2 Nonsurgical Cervicofacial Rejuvenation of a Traditional Surgical Candidate

2.1 Introduction

The use of injectable bioactive agents including neuromodulators and soft tissue fillers has continued to increase in cosmetic surgery practices as a result of the greater demands from patients for aesthetic improvement without surgery.1,2,3,4,5,6,7 This is due to the growing indications and availability of neuromodulators and soft tissue fillers, along with the desire for rejuvenation from a wider patient population among varying ages and ethnicities.¹ The last decade has seen a dramatic increase in the number of facial fillers approved by the U.S. Food and Drug Administration (FDA) in response to the growing popularity of minimally invasive procedures.⁸ According to The American Society of Plastic Surgeons (ASPS), 15.6 million cosmetic procedures, including both minimally invasive and surgical procedures, were performed in the United States in 2014. Of those 15.6 million cosmetic procedures, injectable treatments comprise 9 million, which is a 4% increase from 2013.⁸

A new category of injectable agents is lipolytic therapies. Currently this category is limited to one product, Kybella (deoxycholic acid, Allergan, Inc.). Kybella is a cytolytic drug indicated for improvement in the appearance of moderate to severe fullness associated with submental fat in adults (see Product Index (p. 170)). In 2015, deoxycholic acid subcutaneous injections received approval from the FDA for the treatment of submental liposis.

Other noninvasive devices for facial rejuvenation that merit mention include Ulthera (Ulthera, Inc.) and numerous lasers and “laserlike devices” (ablative and nonablative lasers in both fractionated and unfractionated forms as well as RF technologies).

These products and devices are an attractive office procedure for providers because of their ease, cost, and minimal discomfort involved in treatment. With all the various products and devices now available, it can be anticipated that both demand and use will continue to increase, because the variety of options affords clinicians and patients greater versatility in tailoring therapy to individual needs and goals.

It is important to select patients carefully and to discuss expected benefits and limitations prior to treatment to avoid patient disappointment, because many aspects of facial rejuvenation still require surgical intervention.

This chapter will discuss how the blending of the previously mentioned technologies offers an excellent means of facial rejuvenation, may significantly enhance surgical results, and/or may delay the need for surgery in the proper patient.

2.2 Technologies for Rejuvenation: A Review

2.2.1 Neuromodulators

Botulinum neuromodulator (BoNT), first used for the management of strabismus in the 1980s by Dr. Allen Scott in San Francisco, is the workhorse of injectable agents for facial rejuvenation.9 The neuromodulator’s biologic action occurs at the neurosynaptic cleft responsible for muscle contraction by cleaving proteins involved in the active transport of acetylcholine.^10,11 Originally these proteins were described as toxins due to the illness botulism, which was associated with consuming large amounts of Clostridium botulinum–contaminated food. Their desired action is selective weakening, relaxation, or paralysis of treated muscles. As a result, unwanted lines and socially undesirable facial expressions can be suppressed or eliminated.

There are seven serotypes of BoNT (A-G), and only A and B have been developed for routine clinical use. The B serotype neuromodulator Myobloc (rimabotulinumtoxinB, Solstice Neurosciences) is less suitable for cosmetic use because of its shorter duration of effect and injection discomfort associated with its acidity (pH of 5.6).12,13 The A serotype of botulinum neurotoxin (BoNTA) has demonstrated the longest duration of effect (90–120 days) and least discomfort with injection. Three formulations of BoNTA have been studied and used extensively for cosmetic and therapeutic indications (see Product Index (p. 167)): Botox Cosmetic, Dysport, and Xeomin. Botox (botulinum toxin type A) Cosmetic (Allergan, Inc.), approved for the reduction of hyperfunctional glabellar lines in 2002, set the standard for neuromodulators by demonstrating a proven safety and efficacy record. Dysport (abobotulinumtoxinA, Galderma Laboratories, L.P.) became FDA approved in 2009, followed by Xeomin (incobotulinumtoxinA, Merz, Inc.) in July 2011 (see Product Index (p. 169)). Although these three formulations are not interchangeable, and reportedly cannot be substituted by one another by any fixed-dose conversion ratio, most agree that the ratio is 2.5 to 3 units of Dysport to 1 unit of Botox and 1 to 1.3 units of Xeomin to 1 unit of Botox.^14,15

Patient Selection

Proper patient selection is important to having satisfied patients and reducing undesired outcomes. A thorough review of the patient’s history is the first step in this process, and it is important to know that the patient has realistic expectations. Allergies or hypersensitivities to any of the formulation ingredients (BoNTA, sodium chloride, human albumin) are contraindications for BoNT treatment. Neurodegenerative and neuromuscular disorders are typically absolute contraindications to therapy. Patients and providers should be made aware of any preexisting lid or brow ptosis if they are present and educated on the risk of exacerbation.¹⁵

2.2.2 Soft Tissue Fillers

Initially utilized for the treatment of fine lines and wrinkles, manufactured or commercially available fillers have expanded to include the correction of volume loss and augmentation of the aging face.16 Since bovine collagen (Zyderm, Inamed Corp.) was introduced as an injectable filler in the early 1970s, several other products have been developed for soft tissue augmentation, particularly in the last decade. The ideal soft tissue filler is¹⁷

• Effective.

• Nonimmunogenic.

• Nontoxic.

• Noncarcinogenic.

• Nonmigratory.

• Easily applied.

• Nonpalpable.

• Painless.

• Long-lasting.

Currently available fillers can be broadly classified into the following three different categories: hyaluronic acid (HA) derivatives, synthetic fillers, and autologous fat ( Table 2.1).

Hyaluronic Acid Fillers

The currently available HA fillers in the United States are Restylane, Restylane Lyft, Juvéderm XC, Juvéderm Voluma, Belotero Balance, and Restylane Silk (see Product Index (p. 167)). HA is a naturally occurring substance in the human body and serves as the ground substance of dermis, fascia, and other tissues. There are several advantages in using the HA fillers, including the immediate reversibility with hyaluronidase and the lack of antigenic specificity, decreasing the risk of allergic response. Another property that makes these products useful clinically is the hydrophilic nature, allowing 1 g HA to bind up to 6 L water (Video 2.1).^16,18

Properties of HAs that are important in determining their clinical performance include the concentration of HA and the degree of cross-linking, which affect longevity and stability; gel hardness (G’), which helps determine flow properties, the extrusion force required, and the structure and stiffness of the finished product; and the degree of gel swelling, or the ability to resist dilution, which also influences longevity.19 The stiffer the material then the higher the G’. This is determined by the degree and strength of interaction in the cross-linking HA as well as the HA concentration.¹⁶

HA typically must be cross-linked to avoid rapid degradation by hyaluronidase, temperature, or free radicals, and different HA fillers vary by the cross-linking density and resultant stiffness. HA fillers with a higher cross-linking density can be used for deep wrinkles, whereas HA fillers with a lower cross-linking density are preferable for fine lines.¹⁶

The Restylane family (Galderma Laboratories, L.P.) maintains an HA concentration of 20 mg/mL and includes Restylane, Restylane Lyft, and Restylane Silk ( Table 2.1, Video 2.1). Restylane was introduced in 1996 as the first non–animal-stabilized HA. Derived from the fermentation of Streptococcus species, the molecules are cross-linked by the addition of 1, 4-butanediol diglycidyl ether to increase surface area and slow down the natural breakdown of the product.¹⁸

Restylane Lyft is similar to Restylane but has a larger particle size. Because of the larger particle size, Restylane Lyft is better suited for deeper levels of injection such as treatment for deep cutaneous depressions, whereas Restylane can be used for these applications and more superficially. Overall, both Restylane and Restylane Lyft have a higher G’, and therefore more firmness with less spreading of the product, making it better suited for placement in the subdermal level. Restylane Lyft needs to be injected through a 27-gauge needle compared with a 30-gauge needle used for Restylane.¹¹ Restylane Silk, FDA approved in June 2014, can be differentiated from other products in the Restylane family by its smaller particle size. It is intended for lip augmentation and correction of perioral rhytids. Restylane Silk is injected intradermally with a 31-gauge needle due to the small particle size for the correction of fine lines.^6,16,18

Juvéderm (Allergan, Inc.) is currently available in two types: Juvéderm XC and Juvéderm Voluma, with an HA concentration of 24 and 20 mg/mL, respectively ( Table 2.1, Video 2.2). Both of the Juvéderm products have an intermediate G’ and viscosity, which leads to a higher likelihood of spreading after implantation and a softer feel.^16,20 Because Juvéderm XC has a lower G’ and viscosity than Juvéderm Voluma, it is ideal for areas where palpability is less desirable, such as medium-depth wrinkles (forehead and glabellar lines, nasolabial folds, and moderate nasal furrows).^16,20,21 Juvéderm Voluma, FDA approved in October 2013, consists of a low- and high-molecular-weight HA, which allows for efficient cross-linking, resulting in a highly cohesive gel with greater hardness (G’) than other Juvéderm products, greater lift capability, and long in vivo duration optimized for midface volumizing.^22,23

Two other HA fillers currently available in Europe that will likely be on the market in the Unites States include Juvéderm Volbella and Volift (Allergan, Inc.). Juvéderm Volbella has a much lower concentration at 15 mg/mL, and a lower G’ and cohesivity, allowing it to be used in a more superficial spreading fashion for the lips, rhytids, and more subtle depressions. Volift at 17.5 mg/mL HA allows more subtle lift capacity but retains an element of spread, making it a useful agent for the perioral region and in the treatment of fine lines.

Belotero (Merz North America) is a HA gel filler that was FDA approved in 2011 for treatment of moderate-to-severe nasolabial folds and wrinkles.²⁴ Belotero has a higher concentration of non–cross-linked HA, and is considered poly-densified because the cross-linking is not uniform throughout.²⁵ This results in a low viscosity and the lowest G’ (gel hardness) of the currently available HA fillers.²⁴ With these properties, Belotero is utilized mainly in areas for superficial intradermal or subdermal injection, because it is a softer product (due to the low G’) that allows it to spread more evenly because of its low viscosity. Clinically, Belotero is useful for very fine lines such as the forehead, vermilion border, and tear trough.^16,24,25

Synthetic Fillers

In addition to HA fillers, two other classes of fillers merit mention. Calcium hydroxylapatite (Radiesse, Merz, Inc.) and poly-Llactic acid (Sculptra, Galderma Laboratories, L.P.) are larger molecule fillers, ranging from 25 to 63 um in particle size (see Product Index (p. 173)).¹⁸ These products work primarily by causing foreign body reaction and an increase in fibroblasts and collagen deposition. Radiesse is composed of calcium hydroxylapatite (CaHA) particles suspended in a carboxymethylcellulose gel, and should be injected subdermally near or well below the dermal-subcutaneous junction.¹⁸ Injection too superficially can lead to visibility of the white material and nodularity.²⁶ After injection, the carrier gel that fills the interstitial space eventually dissipates and is replaced with soft tissue ingrowth, with the CaHA acting as a scaffold.^27,28 Sculptra (Galderma Laboratories, L.P.) is an injectable form of poly-L-lactic acid, a compound that has been used in absorbable suture material for over 40 years.¹⁶ The microspheres eventually gets dissolved into carbon dioxide (CO₂) and water. Sculptra was approved in the treatment of shallow to deep nasolabial folds, facial wrinkles and lines, and improvement of the contour deficiencies with placement recommended subcutaneously.^16,29

Injection techniques include serial puncture, linear threading, fanning, and cross-hatching, with fanning and cross-hatching being used primarily for facial contouring ( Fig. 2.1). All four techniques can be used to create a layered approach, with relatively thin product being used superficially and thicker, larger particle filler being used deeper.

Patient Selection

As with any procedure, it is important to ensure that the patient has realistic expectations. A history of excessive bleeding, bruising, or abnormal scar formation should be documented, and the patient should be aware that this may occur as a result of dermal filler injection. History of anaphylactoid reactions and lidocaine hypersensitivity should be elicited from the patient.

Fig. 2.1 (a-d) Various filler injection techniques. (From Codner MA and McCord CD. Eyelid & periorbital surgery, ed 2, 2016. Thieme, St. Louis)

2.2.3 Kybella

Kybella contains sodium deoxycholate, a naturally occurring bile acid that solubilizes dietary fat in humans and other animals, thereby aiding in its digestion. Deoxycholate induces pores in cellular membranes, producing leakage of cytoplasmic contents, membrane destabilization, and subsequent lysis. These lytic effects occur within minutes and account for the brisk, localized inflammatory response after injection. Replacement of grossly injured adipose tissue with fibrosis may account for subsequent fat reduction and skin retraction observed after treatment.30,31,32

Four large multicenter, randomized, double-blind Phase III trials confirmed the efficacy of Kybella subcutaneous injections to reduce submental fat and improve submental profile and skin laxity.^{30,31,32,33,34,35,36,37} Kybella is a promising, less invasive alternative to liposuction for the reduction of submental fat.

Patient Selection

Kybella is indicated for improvement in the appearance of moderate to severe convexity or fullness associated with submental fat in adults. Careful consideration must be given for the use of Kybella in patients with excessive skin laxity or prominent platysmal bands for which the reduction of submental fat may result in an aesthetically undesirable outcome. Kybella is contraindicated in the presence of infection at the injection sites.

2.2.4 Ulthera

Ultrasound use as a therapeutic modality has evolved from its early neurologic applications in the 1950s.38,39 The application for facial rejuvenation utilizes thermal injury through intense focused ultrasound. This is accomplished through a shorter pulse duration of 50 to 200 ms, a higher frequency of 4 to 7 MHz, and a decreased energy quantity of 0.5 to 10 J.⁴⁰ This technology was commercialized as the Ulthera System in 2004, and several clinical studies refined the device and supported its ability to create thermal coagulation points (TCPs) at specific tissue depths (see Product Index (p. 185)).^41,42,43,44 Intense focused ultrasound energy is delivered through the skin’s surface with the selective creation of thermal injury zones in the superficial musculoaponeurotic system (SMAS), heating the fascia in a pinpoint way, resulting in contraction of the fascia. This results in lifting and tightening of the skin on the neck, under the chin, along the jawline, and on the brow.⁴⁵

In 2009, a study by Alam et al⁴⁶ resulted in FDA approval for a brow lift indication. Kenkel⁴⁷ demonstrated improvement in the neck, giving the device an FDA-approved neck lift indication.

Patient Selection

An ideal patient is usually younger with a robust wound healing response, mild lipoptosis, and good skin elasticity. Ulthera is also a nice option for patients who have already had a facelift and need a “touch-up” procedure. An older patient with extensive photoaging, severe skin laxity, marked platysmal banding, and a very heavy neck is generally not an ideal candidate.⁴⁵

2.2.5 Laser Skin Resurfacing (Ablative and Nonablative)

The introduction of ablative laser skin resurfacing techniques with high-energy, pulsed CO₂ and erbium-doped yttrium aluminum garnet (Er:YAG) devices was met with great enthusiasm because of their excellent clinical outcomes in the treatment of scars and photodamaged facial skin, but the prolonged recovery and the risk of potential side effects made them less attractive treatment alternatives. The subsequent development of nonablative laser devices improved recovery and tolerability, although limited clinical efficacy was associated with these less invasive treatments.48,49

The concept of fractional photothermolysis, coined by Manstein and colleagues,⁵⁰ has revolutionized the field of laser skin resurfacing by providing the ability to obtain significant clinical results with minimal posttreatment recovery. Advantages of fractional over fully ablative lasers include faster re-epithelialization after treatment, shorter posttreatment skin care, less frequent acneiform eruptions, and quicker resolving postoperative erythema.^51,52

In fractional technology, the laser beam creates microscopic treatment zones (MTZs) of controlled width, depth, and densities in the skin.⁵⁰ Only fractions of skin are treated by inducing small zones of thermal damage, resulting in an improved safety profile and shortened recovery times. Collateral damage is controlled and healing is rapid, because the tissue surrounding each tiny wound is undamaged and the keratinocytes have only short distances to migrate during re-epithelialization. Collagen contracts and neocollagenesis is initiated.^50,53

Fractionated technology has led to the development of a number of nonablative and ablative devices ( Table 2.2). For patients with severely photodamaged skin, ablative resurfacing is the best treatment. Texture, tone, dyschromias, and mild to moderate wrinkles can all be improved after a single treatment.

CO₂ lasers emit light at 10,600 nm in the far infrared electromagnetic spectrum. The emitted energy is preferentially absorbed by intracellular water, which leads to rapid heating and vaporization of tissue. CO₂ lasers were introduced in the 1960s and were initially used in the continuous wave (CW) mode for cutting tissue. These CW systems produced significant thermal damage to the surrounding tissue and led to the development of high-energy pulsed and scanned systems in the early 1990s. The pulsed CO₂ lasers caused discrete areas of tissue vaporization while minimizing collateral thermal injury that was associated with fewer unwanted side effects such as scarring and hypopigmentation.^54,55

The Er:YAG laser was approved for skin resurfacing by the FDA in 1996. Its 2940-nm wavelength is absorbed 12 to 18 times more efficiently than is the CO₂ laser, allowing more superficial absorption with less penetration. This allows even less collateral damage. At typical Er:YAG treatment parameters, dermal heating is limited with subsequent reduced effect on tissue tightening, but postoperative healing times are shortened compared with CO₂ lasers.⁵⁴

Numerous studies using CO₂ and Er:YAG lasers have been performed to evaluate the efficacy and safety of ablative resurfacing. Most studies demonstrated marked (80% or greater) improvement in treated areas, with the periorbital and perioral regions showing the best results and areas of dynamic wrinkling, such as the glabella, showing the least^{55,56,57,58,59,60,61} ( Table 2.3).

Nonablative laser technology was subsequently developed in an attempt to limit the prolonged postoperative recovery period associated with ablative laser skin resurfacing. Nonablative remodeling rejuvenates skin without superficial epidermolysis by targeting tissue beneath the surface. A direct dermal wound with new collagen formation effacing wrinkles and acne scarring is the goal. Some nonablative lasers also target irregular pigmentation, abnormal blood vessels, and telangiectasias.⁵⁵ Because nonablative lasers have limited thermal tissue effect, treatments are commonly delivered in a series of three or more monthly sessions to produce mild clinical results. Most studies reported clinical improvement averaging 30% to 50% after a series of treatments.^{55,62,63,64,65,66,67,68} Severely photodamaged patients with advanced wrinkles are better candidates for ablative resurfacing.

There is minimal to no downtime with nonablative lasers. Some edema and erythema may last for a few days, but it can usually be covered with makeup. Each system has specific parameters for the number and duration of treatments ( Table 2.4).

Fractionated technology has led to the development of a number of nonablative and ablative devices, and it has virtually replaced pulsed and scanned systems due to their excellent clinical effects and low risk profiles.

Significant improvement of facial rhytids, scars, and dyspigmentation has been demonstrated in several published studies of nonablative fractionated lasers. By increasing the energy delivered, greater depth of dermal penetration (and tissue effect) is achieved. Increasing the density (or area of coverage) also serves to increase the clinical effect without significantly altering postoperative recovery. Clinical assessment scores corresponding to 50% to 75% improvement or more are typically reported after a series of three or more treatments on facial rhytids.^55,69 Atrophic acne scars have shown improvement (50% and higher) after a treatment series using either a 1550-nm erbium-doped fiber laser or a number of other fractionated diode and Nd:YAG lasers (1410–1540 nm).^70,71,72

The Clear + Brilliant (Solta Medical, Inc.) fractionated diode laser comes in two different handpieces: Original and Perméa. The Original handpiece utilizes a 1440 nm wavelength that is absorbed by the water in the skin. The stratum corneum remains functionally intact, which translates into a safe, lowrisk treatment that heals quickly. Because the handpiece depth is 200 to 300 μm, it effectively targets the layers of the skin most compromised by early signs of aging such as uneven pigmentation, fine lines, and textural changes. On the other hand, the Clear + Brilliant Perméa handpiece utilizes a 1927 nm wavelength that has a significantly higher absorption coefficient than the Original. Although the stratum corneum remains intact, the Perméa handpiece creates wider and shallower lesions, causing greater superficial disruption, which increases skin permeability. The Perméa handpiece depth is fixed at 170 μm. Clear + Brilliant is safe on all skin types, because its longer wavelength penetrates to the dermis and avoids epidermal melanin absorption⁵⁵ ( Table 2.5). The stackable treatment approach is a combination of botulinum toxin injections and dermal fillers to smooth out wrinkles, along with energy-based tools such as laser skin resurfacing (Video 2.3). Stackable treatments and HA fillers can be used to restore volume to the cheeks, with nonsurgical lifting of the face and neck, and then simultaneously combine laser skin resurfacing.

The popularity of this approach was reflected in the 2015 cosmetic surgery data from the American Society for Aesthetic Plastic Surgery (ASAPS), which showed that the use of injectables (dermal fillers and botulinum toxin) increased by 21% from the previous year while laser skin resurfacing remained 1 of the top 10 nonsurgical treatments.8

Even more impressive improvement of photoaged skin has been demonstrated with ablative CO₂ and Er:YAG fractionated laser technology compared with the nonablative fractionated devices.^55,73,74,75 Previous studies have shown good long-term clinical results 5 years after fractional CO₂ laser skin resurfacing in the treatment of facial photoaging.⁴⁹

The UltraPulse Encore (Lumenis) is an advanced fractional CO₂ laser system with three modes of delivering the laser’s energy.⁷⁶ The first, ActiveFX, uses a 1.3-mm spot size that ablates the superficial tissue and is useful for treating fine lines and actinic keratosis. The second, DeepFX, focuses the lasers energy into a 0.12-mm spot size and allows for deep ablation that is useful for treating deep rhytides. DeepFX is particularly useful for treating perioral and periocular fine lines, and scars. This mode can ablate up to 2 mm into the tissue. The TotalFX mode uses both the ActiveFX and DeepFX modes simultaneously and is useful for treating scars and rhytides.⁷⁶ Modest power settings are important when treating around the eyelids and the neck. For superficial areas on the face and neck, the ActiveFX component of the UltraPulse is most commonly used with the following parameters: 90 to 125 mJ, 100 Hz, scan size 4 to 8, density 3 to 4. For deeper areas, the DeepFX component is most commonly used with the following parameters: 17.5 to 20 mJ, 300 Hz, scan size 4 to 8, density 15 to 20% ( Fig. 2.2).

Fig. 2.2 (a) Before and (b) after photographs of upper blepharoplasty, facelift, and fractional CO₂ laser skin resurfacing of the face and neck.

The Fraxel re:pair fractional CO₂ laser system (Solta Medical, Inc.) works much like the UltraPulse Encore’s DeepFX mode. The pulse duration on this laser can range from 0.15 to 3 ms. By using a short pulse duration, the laser system can deliver more energy quicker and ablate deeper. By combining its small 0.14-mm spot sizes and a short 0.15-ms duration, this laser ablates to depths of 1.6 mm. Fractional technology can be applied to Er:YAG lasers in much the same way that it was developed for CO₂ lasers76 ( Table 2.6).

RF systems are unique in that they are thermal heating systems, working more like microwaves rather than lasers. They have the advantage of having a higher penetration depth, while aiming for collagen shrinkage and skin tightening. The RF largely passes through the skin surface, sparing it from heating.⁷⁶ Much like the laser systems, the RF systems achieve results by denaturing existing collagen and stimulating the production of newer and shorter collagen, leading to lasting tissue tightening.^76,77 This modality is often combined with other modalities to achieve a synergistic effect. For example, RF has been combined with diode systems (Polaris WR, Syneron Candela). A major limitation of this modality is that currently there is not enough published data regarding the optimal temperature and duration of treatment at that temperature to obtain ideal results. In fact, most data is currently anecdotal, and further research is necessary to determine the optimal parameters for this treatment modality.

Patient Selection

Patients should be educated about the course and importance of their postoperative care and potential complications. Indications for laser skin resurfacing include improvement in sun-damaged skin, facial rhytids, dyschromias, and scar revision. The senior author routinely performs ablative fractional laser skin resurfacing on patients of all skin types (Fitzpatrick I-VI).

Table 2.6 Radiofrequency Systems

Patients with darker skin phototypes (Fitzpatrick III-VI) have a higher likelihood of developing postinflammatory hyperpigmentation (PIH), although this has never been permanent in the senior author’s experience, and is easily treated with topical creams. PIH is much less frequent with fractional laser skin resurfacing than with other ablative procedures.78 These patients should be informed about PIH, with treatment initiated when indicated. Any factors that may affect the pilosebaceous glands, such as previous facial radiation or the use of oral retinoids for 1 year in advance, can increase the risk for poor healing after treatment. Other contraindications include active skin infections, vitiligo, and a history of keloids or hypertrophic scars. Antivirals should be started 1 day prior to the procedure and continued for 1 week.⁷⁹

2.2.6 Nonsurgical Blepharoplasty and Browplasty

2.3 Treatment Plans and Results

2.3.1 Neuromodulators

Studies have demonstrated the effect of BoNTA treatment of the lateral orbicularis oculi on brow position (also known as a chemical browlift).80,81 Because the lateral orbicularis oculi muscle acts as a sphincter, careful attention must be paid to the vectors of force during contraction. The contraction vectors at 12 and 6 o’clock are predominantly horizontal, whereas the vectors at 3 and 9 o’clock are primarily vertical. With BoNTA treatment, the lateral frontalis muscle is now unopposed and will create a brow elevation. The medial brow position can be manipulated as well through treatment of the corrugator supercilii muscle. The crow’s-feet wrinkles are treated by injecting the lateral orbicularis oculi at several sites lateral to the orbital rim. A typical dose is 10 units of Botox/Xeomin or Dysport equivalent per side, divided into 4 or 5 aliquots ( Fig. 2.3).

Glabellar Complex

The vertical glabellar lines are primarily formed by the actions of the paired corrugator supercilii muscles. The corrugator supercilii originates from the procerus medially and inserts laterally into the orbicularis oculi muscle and the soft tissue at and slightly above the medial eyebrow. This muscle is nearly horizontal in most individuals; thus, contraction of the corrugator supercilii produces a vertical wrinkle. It is crucial that BoNTA be injected properly into the corrugator supercilii muscle. A common mistake is to inject the corrugator supercilii too far superiorly and thus actually treat the frontalis. The frontalis relaxation may cause a mephisto, or “Spock-like,” unattractive appearance ( Fig. 2.4). The correct placement of BoNTA into the corrugator supercilii muscle is just at or slightly above the medial clubhead of the eyebrow. A second small dose is given 3 to 5 mm lateral to the first injection to treat the entire length of the corrugator muscle. Typically, 10 units of Botox/Xeomin or Dysport equivalent is injected per side.

Furrows created at the base of the nose are created by the procerus muscle. If a patient has transverse furrows, 3 to 5 units of Botox/Xeomin or Dysport equivalent is injected into the belly of this muscle in 1 or 2 aliquots.

Frontalis Muscle

The frontalis is a thin, quadrangular muscle originating from the galea aponeurotica superiorly and inserting into the brow inferiorly. It is contiguous with the procerus muscle centrally and interdigitates with the corrugator and orbicularis oculi muscles at the brow. Its fibers are vertical in orientation, and contraction causes elevation of the brow. Hyperfunctional lines in this area cause classic horizontal forehead furrows.

Ten units of Botox/Xeomin or Dysport equivalent, divided into 4 aliquots, are used to treat the frontalis. The location of the injections is critical to achieving optimal results. The patient should raise the brow to better define the forehead lines, and injections immediately above the most inferior horizontal line is recommended. Laterally, the point at which the forehead curves temporally is the lateral injection point. Medially, the medial canthus is the medial injection point. Three additional injection points (2units of Botox/Xeomin or Dysport equivalent) can be added as extension therapy in patients with numerous forehead lines or greater forehead height. One extension therapy injection is added in the midline, whereas the other is added between the medial and lateral injection points bilaterally. It is important to explain to the patient that BoNTA treatment of the frontalis can result in brow ptosis. Therefore, treatment of the frontalis involves walking a fine line between undertreatment of the forehead and persistent lines versus ptosis of the brow ( Fig. 2.3).

2.3.2 Soft Tissue Fillers

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