Using Botox for Periorbital Rejuvenation

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Lecture by Dr. Patrick Treacy to AAAD Mexico 2013

Published in: Health & Medicine

Using Botox for Periorbital Rejuvenation

  1. 1. Rejuvenating the periorbital area with Botox by Dr. Patrick Treacy Medical Director Ailesbury Clinics Dublin Ireland
  2. 2. LECTURE SERIES ON THE COSMETIC USES OF BOTULINUM-A TOXIN ANATOMY OF THE PERIORBITAL AREA CORRECT PATIENT SELECTION HOW TO PROPERLY EVALUATE THE AREA TIPS AND TRICKS
  3. 3. Anatomy of the periorbital area Muscle Anatomy (A) Frontalis (B) Corrugator superciliaris (C) Procerus (D) Orbital Orbicularis (E) Preseptal Orbicularis (F) Pretarsal Orbicularis
  4. 4. ANATOMY OF PERIORBITAL MUSCLES ORBICULARIS OCULI Action:Depresses eyebrows Closes the eyelids Helps drainage of tears Origin Med orbital margin and lacrimal sac(orbital, palpebral and lacrimal parts) Insertion Lat palpebral raphe
  5. 5. Anatomy of Orbicularis Oculi Orbicularis is a curved muscle running from the medial orbital margin to the frontal process of the maxilla. A B C ORBITAL (A) is used in forced closure of the eye PALPEBRAL (B) is used in blinking and voluntary winking
  6. 6. Anatomy of Orbicularis oculi (D) ORBICULARIS OCULI Superficial muscle of facial expression. The muscle is divided into the ORBITAL and PALPEBRAL The PALPAEBRAL is divided into Preseptal (E) Pretarsal (F)
  7. 7. ANATOMY OF FOREHEAD MUSCLES CORRUGATOR SUPERCILII Action: Depresses eyebrows and wrinkles forehead Origin Medial superciliary arch Insertion Skin of medial forehead
  8. 8. ANATOMY OF FOREHEAD MUSCLES FRONTALIS Action: Elevates eyebrows and the skin of the forehead Origin Occipital:highest nuchal line and mastoid process. Frontal: sup fibres of upper facial muscles Insertion Galeal aponeurosis
  9. 9. EVALUATE DEPTH ORBITAL SOCKET IS THE EYE SOCKET DEEP OR SHALLOW? DOES THE PATIENT‟S INFRAORBITAL RIM PROTRUDE? CHECK SKELETAL SUPPORT OF LOWER LID WITH THE „PENCIL‟ TEST IF PENCIL IS CLOSE TO CORNEA THERE IS A GREAT RISK OF INFRAORBITAL CONTENTS BULGING
  10. 10. EVALUATE ORBICULARIS TONE ARE THE WRINKLES DEEP? SPREAD THE SKIN BETWEEN YOUR FINGERS DO THE „TOUCH’ TEST BY PRESSING LIGHTLY ON ZYGOMATIC AND ASK PATIENT TO SMILE THIS SIMULATES THE POTENTIAL ACTION OF BOTOX BY STOPPING ORBICULARIS CONTRACTION
  11. 11. EVALUATE THE AESTHETICS OF THE FACE IDEAL PROPORTIONED BROW SHOULD BE 1/3 FACIAL HEIGHT AS MEASURED FROM HAIRLINE TO GLABELLA WOMEN SHOULD BE GENTLY ARCHING AND SHOULD LIE JUST ABOVE ORBITAL RIM HIGHEST POINT SHOULD LIE BETWEEN LAT LIMBUS AND LAT CANTHUS
  12. 12. EVALUATE THE AESTHETICS OF THE BROW LATERAL BROW ASPECT SHOULD BE HIGHER THAN MEDIAL ASPECT THIS PARALLELS FREE MARGIN OF LAT ASPECT OF EYELID HIGHEST POINT SHOULD LIE BETWEEN LAT LIMBUS AND LAT CANTHUS
  13. 13. EVALUATE FACIAL ASYMMETRIES • SHOW TO PATIENT • DOCUMENT AT TIME • PHOTOGRAPH IT BEFORE PROCEDURE DANGER IS THE POSSIBILITY OF EXACERBATING PRE-EXISTING OR UNDERLYING BROW OR LID PTOSIS
  14. 14. EVALUATE AMOUNT OF HOODING ESTABLISH WHETHER THE PATIENT CAN APPLY MAKE UP PHYSICALLY GRIP SKIN TO SEE AMOUNT OF REDUNDANT TISSUE CHECK TO SEE IF DEEP SET EYES OR LID HOODING PATIENT MAY BE SUITABLE FOR LATERAL BROW LIFT
  15. 15. CASE 1 Patient with assymetrical face post nerve damage
  16. 16. CASE 1 Patient with nerve damage post craniotomy
  17. 17. CASE 1 Placement of Contour Threads
  18. 18. Placement of Contour Threads
  19. 19. CASE 1 Correction with Contour Threads
  20. 20. EVALUATE INFRAORBITAL FAT PADS LOOK FOR A WEAK ORBITAL SEPTUM OR PROTRUDING FAT PADS AVOID INJECTING INFERO- MEDIALLY IN PATIENTS WITH EXCESSIVE SKIN AND FAT. PRETARSAL DRIFT CAUSES TEMPORARY EYEBAGS. ACCESS LEVEL OF UNDERLYING HERNIATION BY PRESSING GENTLY ON „EYEBALL‟
  21. 21. EVALUATE POSITION OF LATERAL ASPECT OF EYEBROW SOMETIMES THIS CAN BE DIFFICULT BECAUSE OF PATHOLOGY SUCH AS HYPOTHYROIDISM BE CAREFUL OF PATIENTS WEARING JEWELLERY
  22. 22. EVALUATE INFRAORBITAL VESSELS BEST SEEN WHEN PATIENT LYING AT ANGLE OR SUPINE PREFERABLE INJECT AS SUBDERMAL BLEB TO AVOID TEMPORAL VESSELS
  23. 23. EVALUATE LEVEL OF WRINKLES THESE PATIENTS OFTEN HAVE „GRID‟ PATTERN OF LINES EXTENDING ALONG LATERAL ORBIT AND CHEEK AREA BE REALISTIC WITH THESE PATIENTS OFTEN RISKS OF PROBLEMS ARE HIGHER IN OLDER PATIENTS USING BOTOX FOR FIRST TIME BE AWARE OF AGING SUNDAMAGE SLEEP LINES
  24. 24. EVALUATE LID LAXITY EVALUATE LID LAXITY WITH A SNAP TEST. LAXITY INDICATES POTENTIAL FOR DEVELOPING LOWER LID PTOSIS AND INJECTIONS SHOULD BE AVOIDED DANGER IS THE POSSIBILITY OF CAUSING ECTROPION “SNAP”
  25. 25. EVALUATE FOR HYPERTROPHIC ORBICULARIS SOME PATIENTS FAVOUR WIDER ROUNDED EYE SMALL AMOUNT OF BTX-A INJECTED INTO THE LOWER PRETARSAL ORBICULARIS OPENS THE PALPEBRAL APETURE AT REST AND AT SMILE
  26. 26. EVALUATE ZYGOMATIC ARCH EXAMINE HEIGHT AND WIDTH OF ZGYOMATIC ARCH DOES ORBICULARIS MUSCLE SAG BETWEEN CHEEKBONE AND EYE AREA WILL DEVELOP A HOLLOW APPEARANCE IF ORBICULARIS WEAKENED BY INJECTION
  27. 27. CAREFUL OF NEUROTIC PATIENTS BE EVER WATCHFUL FOR PATIENTS TESTING YOU WITH SCARS BE CAREFUL OF PATIENTS WHO TALK ABOUT OTHER DOCTORS BE CAREFUL OF PATIENTS WHO HIDE PROCEDURES BE CAREFUL OF PATIENTS WITH DEPRESSION
  28. 28. EVALUATE POSITION OF INFERIOR ASPECT OF EYE AREA CORRECTION OF RHYTIDS EXTENDING OVER ZYGOMATIC ARCH INTO MALAR AREA HOLD FINGER OVER THE INFEROLATERAL TO LATERAL CANTHUS TO CHECK ON FINAL EFFECT . ...
  29. 29. EVALUATE POSITION OF INFERIOR ASPECT OF EYE AREA CORRECTION OF RHYTIDS EXTENDING OVER ZYGOMATIC ARCH INTO MALAR AREA EXTRA INJECTION INFEROLATERAL TO LATERAL CANTHUS . ...
  30. 30. BE CAREFUL OF PATIENTS WITH PREVIOUS SURGERY CAUTION WITH PATIENTS THAT HAVE HAD PREVIOUS SURGERY i.e. BLEPHAROPLASTY. THIS LEADS TO AN ALTERED PERIORBITAL ANATOMY. BE CAREFUL OF VISION REFRACTIVE PROCEDURES i.e. (LASIK) LASER ASSISTED IN SITU KERATOMILEUSIS
  31. 31. LATERAL CANTHAL INJECTIONS PERFORM 3 or 4 subcut INJECTIONS ABOUT 1 cm lat TO ORBITAL RIM 2-3 U per injection site ( total 6-12 U per side). SPACE 0.5-1 cm APART IN ARCHING LINE PLACE OUTSIDE BONY ORBITAL MARGIN
  32. 32. INJECTING PERIORBITAL X= CROWS FEET Y= LATERAL BROW LIFT Z= RELAX INFRAORBITAL FOLDS WIDER OCULAR APETURE O X X X AILESBURY CLINIC 2004 BROW LIFT
  33. 33. INJECTING PERIORBITAL X= CROWS FEET Y= LATERAL BROW LIFT Z= RELAX INFRAORBITAL FOLDS WIDER OCULAR APETURE O X X X AILESBURY CLINIC 2004 LOWER EYELID
  34. 34. REMEMBER brow POSITION is maintained by a BALANCE between DEPRESSORS and ELEVATOR PROCERUS MUSCLE CORRUGATOR MUSCLE ORBICULARIS OCULI FRONTALIS FINAL BALANCE DEPENDS ON YOUR SKILL
  35. 35. IF YOU OVERTREAT FRONTALIS YOU PAY THE PRICE NOW! HOW DO I GET BACK UP?
  36. 36. INJECTING THE GLABELLA X=NORMAL INJECTION POINTS IN MOST PATIENTS Y=LATERAL BROW LIFT SOMETIMES REQUIRED Z= ADDITIONAL INJECTION POINT TO FLATTEN BROW
  37. 37. AVOID INJECTING LACRIMAL PUMP LACRIMAL PUMP CONTAINS FIBRES OF ORBICULARIS THAT INSERT INTO LACRIMAL SAC. PROCEED WITH CAUTION TREATING PATIENT WITH HISTORY OF DRY EYES
  38. 38. AVOID OVER-INJECTING BUNNY LINES AVOID INJECTING LEVATOR LABII ALAEQUE NASI AND LEVATOR LABII SUPERIORIS TO PREVENT DROOPING OF UPPER LIP DO NOT MASSAGE AREA AFTER TREATMENT BE CAREFUL OF UPPER LIP PTOSIS
  39. 39. LEARNING THE INJECTION POINTS GLABELLAR: INJECT 3-5 SITES ON EACH SIDE OF THE MIDLINE ABOUT 3-6U VOLUME BTX-A PER SITE DANGER: AVOID INJECTING 1CM ABOVE MID-PUPILLARY LINE SEPARATE INJECTION SITES BY 1-2CMS
  40. 40. Remember to inject BTX-A in the GLABELLAR area in a V-formation
  41. 41. INJECTION OF THE GLABELLAR AREA 1. Place the first injection into the belly of the corrugator muscle 2. Advance the needle within the belly of the muscle upward and lateral as far as the medial 1/3 of the eyebrow, 1 cm superior to the orbital rim 3. Inject 1 cm above the upper medial aspect of the supraorbital ridge
  42. 42. INJECTING THE FRONTALIS AREA FRONTALIS: INJECT 3-5 SITES ON EACH SIDE OF THE MIDLINE ABOUT 1-4U VOLUME BTX-A PER SITE DANGER: AVOID INJECTING 1CM ABOVE MID-PUPILLARY LINE SEPARATE INJECTION SITES BY 1-2CMS

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