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HOW IS DONE (Techniques, Surgical anatomy, Indications)
Chemical denervation, Dermal fillers
Constantinos Laskarides DMD, DDS, PharmD, FICD ORAL & MAXILLOFACIAL SURGERY
Assoc iate P ro fessor , TUFTS UNIVERSITY
Attending Surgeon, TUFTS MEDICAL CENTER
Diplomate , Amer ican Board o f Oral & Max i l lo fac ia l Surgery
Fe l low, Amer ican Assoc iat ion o f Ora l & Max i l lo fac ia l Surgeons
Fe l low, Amer ican Co l lege o f Ora l & Max i l lo fac ia l Surgeons
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American Society for Aesthetic Plastic Surgery
2012 Statistics
Most popular nonsurgical
procedures (Doctors)
• Botulinum Toxin Type A: 3,257,913
• Hyaluronic Acid: 1,423,705
• Laser Hair Removal: 883,893
• Microdermabrasion: 498,821
• Chemical Peel: 443,824
Most popular nonsurgical procedure
(TOTALS: Drs, PAs, RNs)
• Botulinum Toxin Type A: 4,125,179
• Hyaluronic Acid: 1,806,806
• Laser Hair Removal: 1,224,920
• Chemical Peel: 718,465
• Microdermabrasion: 672,430
Cosmetic surgical procedures
• Breast Augmentation: 330,631
• Liposuction: 313,011
• Abdominoplasty: 156,508
• Eyelid surgery: 153,171
• Rhinoplasty: 143,801
$6.7 billion - surgical procedures
$2 billion - injectables procedures
$1.8 billion - skin rejuvenation procedures
$483 million - other nonsurgical procedures (laser
hair removal and laser treatment of leg veins)
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Surgical Anatomy Forehead and Periocular Region
• Frontalis • Origin-epicranial aponeurosis at level of coronal suture
• Lifts the eyebrows
• Surprise, fear
• Nerve-temporal branches of facial nerve
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• The frontalis also inserts onto fibers of the procerus, corrugator, and orbicularis oculi muscles
• This muscle group is responsible for the horizontal wrinkles of the forehead as well as for elevation of the brow.
• The frontalis muscle should not be completely paralyzed, which will result in inadvertently depressing the brow
Surgical Anatomy Forehead and Periocular Region
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• Only small amount of Botox should be injected into the lower fibers of the frontalis to avoid brow ptosis
• Avoid injecting close to the lateral brow to avoid lateral brow ptosis
• Aware of the hyperfunctional frontalis muscle that actually supports a ptotic upper eyelid
Surgical Anatomy Forehead and Periocular Region
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• margin fold distance (MFD)
• margin reflex distance 1 (MRD-1) 4-4.5mm
• margin reflex distance 2 (MRD-2)
Blepharoptosis (Upper eyelid ptosis)
• palpebral fissure (PF [MRD-1 + MRD-2]) ~10
• horizontal fissure distance (HF)
• intercanthal distance (ICD).
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• Inadvertent involvement of levator palpebrae superioris by Botox causes lid ptosis
Surgical Anatomy Forehead and Periocular Region
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The corrugator muscle
• Brow adductor. Compresses the skin between the eyebrows
• Frown, concern, concentration (glabella crease)
• Deep to both the procerus and frontalis muscles. Injection of this muscle will inevitably paralyze some of the fibers of the other 3 muscles.
• Nerve - Zygomatic and temporal branches of facial
Surgical Anatomy Forehead and Periocular Region
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Procerus muscle
•Transverse wrinkles
•Angry scowl
•paralysis will relax the “snout” contraction
•Nerve - Zygomatic and temporal branches of facial
Surgical Anatomy Forehead and Periocular Region
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Orbicularis Oculi
• Function-Sphincter of eyelids; palpebral part involuntary
• Squinting, smiling, winking
• Nerve - Temporal and zygomatic branches of facial
Surgical Anatomy Forehead and Periocular Region
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Levator Labii Superioris Alaeque Nasi
• Dilates the nostril and elevates the upper lip
• Sneering, “bunny lines”
• Nerve - Buccal branch of facial nerve
Surgical Anatomy Nasal Region
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Depressor anguli oris
• Pulls the corner of the mouth downward
• Injection will lift corners of mouth
• Nerve - Mandibular branch of facial nerve
Surgical Anatomy Lower Face
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Depressor Labii Inferioris
• Pulls the lower lip down and out
• Medial injections may cause inward curl of lower lip
• Nerve - Mandibular branch of facial nerve
Surgical Anatomy Lower Face
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Orbicularis oris
• Sphincter of mouth, purses lips and puckers lip edges.
• “smoker lines”
• Nerve - lower zygomatic, buccal, and mandibular branches of the facial nerve
Surgical Anatomy Lower Face
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Platysma
• Flat, superficial neck muscle
• Forms longitudinal bands
• Nerve - cervical branch of the facial nerve
Surgical Anatomy Neck
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Indications
• Dynamic rhytides occur in areas of dynamic motion, and these types of lines may be improved with botulinum toxin.
• Relaxation of muscles that will result in enhanced esthetics
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Indications
•Upper face
– Glabellar rhytids
– Lateral canthal rhytids (crow’s feet)
– Upper nasal rhytids (bunny lines)
– Horizontal forehead rhytids
– Lateral eyebrow lift
– Asymmetric brows
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Glabella
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Forehead
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Lateral eyebrow lift
• off label
• usually females
• 2 units
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Crow’s feet
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Indications
• Midface
– Lower nasalis rhytids (nasal flare)
– Perioral rhytids (lipstick lines)
– Facial asymmetry
• Lower face
– Melomental folds, drooping labial commisure
– Peau d’orange chin (mentalis strain)
– Gummy smile
– Lower facial asymmetry
• Neck
– vertical platysmal folds
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bevel tip up
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Treatment strategy
Area glabella forehead upper lat.
periocular
middle lat.
periocular
lower lat.
periocular
Muscles
involved
Corrugator &
procerus
Frontalis upper lat.
Orbicularis
oculi
middle lat.
Orbicularis
oculi
lower lat.
Orbicularis
oculi
No. Units 15 - 20 10 - 15 5 - 7 5 - 7
5 - 7
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Other uses
• Use of intradermal Botulinum toxin to reduce sebum production and facial pore size. AR Shah
J. Drugs in Dermatology, 2008 7:9, 847-850
(sebum production affected by acetylcholine, parasympathetic muscle relaxes arrector pili muscles)
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Treatment planning
• understanding of patient desires and expectations
• evaluate the area to be treated, prior treatments, medical
history, allergies, pain tolerance.
• evaluate the wrinkle, depth of the fold or groove to be treated,
volume of filler needed, skin type, as well as any pre-existing
asymmetry.
• choose the correct filler
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Treatment
• Photographs
• Face is cleansed with disinfectant
• Patient seated in an upright position. Lying down may alter
effects of gravity
• Magnification can be useful to aid in the appreciation of subtle
contour abnormalities.
• Ice packs, topical anesthetics, field block, and peripheral nerve
block possible
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Treatment
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Treatment
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Treatment
The outer diameter of a 26-gauge needle is 0.45 mm.
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Treatment
Thickness of dermis in
different areas of face
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Lips
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Oral Glabella
Scars
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Nasolabial folds
Keep injection under and
medial to the fold
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Tear troughs
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Mesotherapy for skin rejuvenation
• smooth formulation of HA without particles, which helps it distribute evenly and smoothly under the skin
• replenish the hyaluronic acid lost through ageing
• hydrates the skin and improves its elasticity and tone
• micro-puncture technique that involves injecting very small amounts into the superficial papillary dermis, about 1- 2cm apart
• Restylane Vital, Juvederm Hydrate