24.10 Conclusion

Fig. 24.28 Wedge (inverted triangle) resection of eyelid

and pull the lid inferiorly. The laser incision is continued in the subor pre-periosteal plane. Dissection continues inferiorly to mobilize the SOOF. The SOOF is then engaged and elevated with two 4-0 vicryl sutures anchored to the external aspect of the lateral orbital rim.

The previously fabricated tarsal strip is engaged with either 4-0 Merseline or Vicryl suture on a 1/2-circle needle (a P-2 needle). The suture is secured to the internal aspect of the lateral orbital rim periosteum in close proximity to

References

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2.Goldman I. Laser treatment of malignant melanoma. In: Goldman I, editor. Laser cancer research. New York: Springer; 1966.

3.Patel CKN. Continuous-wave laser action in vibrational-rotational transitions of carbon dioxide. Phys Rev. 1964;136:A1187–93.

4.Beckman H, Fuller TA, Beman R, Mandell G, Nathan LE. Carbon dioxide laser surgery of the eye and adnexa. Ophthalmology. 1980;87(10):990–1000.

5.David LM, Sanders G. CO2 laser blepharoplasty: a comparison to cold steel and electrocautery. J Dermatol Oncol. 1987;13:110–4.

6.Baker SS, Hunnewell JM, Muenzler WS, Hunter GJ. Laser bleph-

aroplasty: diamond laser scalpel compared to the free beam CO2 laser. Dermatol Surg. 2002;28:127.

7.Ben-Bassat M, Ben-Bassat J, Kaplan I. An ultrastructural study of the cut edges of skin and mucous membrane specimens excised by carbon dioxide laser. In: Kaplan I, editor. Laser surgery II. Jerusalem: Academic; 1976.

8.Biesman BS. Lasers play a useful role in periorbital incisional surgery. Dermatol Surg. 2000;26:883–6.

9.Goldman MP, Fitzpatrick RE. Cutaneous laser surgery. St. Louis: Mosby; 1994.

10. Lieb WE, Klink T, Munnich S. CO2 and erbium YAG laser in eyelid surgery. A comparison [German]. Ophthalmologe. 2000;97: 835–41.

11. Lessner AM, Fagien S. Laser blepharoplasty. Semin Ophthalmol. 1998;13:90–102.

12. Hruza GJ, Dover JS. Laser skin resurfacing. Arch Dermatol. 1996;132:451–5.

13. Wesley RE, Bond JB. Carbon dioxide laser in ophthalmic plastic and orbital surgery. Ophthalmic Surg. 1985;16:631–3.

Key Points

•Hyperfunctional muscular activity, volume loss, and contour irregularities are the anatomic targets for neuromodulation and soft-tissue fillers in periorbital rejuvenation.

•Botulinum toxin A prevents presynaptic release of acetylcholine at the neuromuscular junction conveying temporary muscular paresis and reduction in dynamic rhytids.

•Neuromodulators are very effective in the treatment of lateral orbital rhytids (Crow’s feet), horizontal forehead lines, and glabellar lines (eleven lines).

•Botox® Cosmetic and Dysport™ are the two commercially available neuromodulators in USA. While they function similarly, their reconstitution, dosage, and results differ.

•Dysport™ has been observed to have a slightly greater regional effect, which can be used to its advantage in treating lateral orbital rhytids.

•Complications of neuromodulators include brow or eyelid ptosis, diplopia, and dry eyes, while those of injectable fillers include skin necrosis, Tyndall effect, and heaved rows.

•Hyaluronic acid (HA) is a naturally occurring biopolymer molecule with a uniform structure throughout nature.

•Restylane-L™, Juvederm XC™, and Prevelle Silk™ are the most popular of the hyaluronic HA gel products and are quite effective in the rejuvenation of the periorbital region.

•The linear threading and serial puncture injection techniques are both effective in effacing the nasojugal groove.

•Unwanted side effects of HA fillers can be reversed with the use of injectable hyaluronidase.

C.S. Maas (*)

The Maas Clinic, Associate Clinical Professor, University of California-San Francisco, San Francisco, CA, USA e-mail: drmaas@maasclinic.com

25.1Introduction

The periorbital region is one of the early and more dramatic regions demonstrating signs of facial aging. The appearance of the periorbital area projects impressions regarding one’s health, energy, and emotion. Surgical and nonsurgical options such as blepharoplasty, browplasty, and skin resurfacing remain mainstays for primary management of age-related changes in the eyelids and adjacent areas. However, the authors strongly feel that such interventions can be significantly enhanced by the use of injectable cosmetic agents.

The goal of periorbital rejuvenation employing injectable cosmetic agents can be classified into three basic categories. These include the following:

1. Reduction in hyperfunctional or dynamic muscular activity (and the effects of chronic hypertonicity)

2. Correction of involutional or congenital volume-related contour irregularities

3. Improvement of surface irregularities (fine lines)

While age, gender, and ethnicity impart variation on treatment parameters, the techniques used are generally the same.

The nonsurgical adjuncts to treatment of the periorbital region include neuromodulators as well as injectable fillers. This chapter discusses their use, excluding fat, for the glabella, forehead, lateral orbital, and tear trough areas.

25.2Review of Neuromodulators and Fillers: The Products

Botulinum toxin type A is the primary neuromodulator used today for treatment of lines due to hyperfunctional or dynamic muscular activity. Botulinum toxin, a naturally occurring protein, was originally described as the etiologic agent causing the illness botulism, which is associated with ingestion of large amounts of Clostridium botulinum contaminated food. Botulinum toxin type A (BoNTA) affects the

neuromuscular junction at the presynaptic level and inhibits the release of acetylcholine. Its distinct beneficial action is selective weakening or relaxation of treated muscles or muscle groups. Unwanted facial lines and facial expressions can be suppressed or even eliminated by selective weakening of specific hypertrophic muscles in the face and neck.

There are seven serotypes of botulinum neuromodulator (A–G), and only A and B have been developed for routine clinical use [1, 2]. The B serotype neuromodulator rimabotulinumtoxinB (Myobloc, Solstice Neurosciences, Inc., Malvern, PA) is indicated for the treatment of cervical dystonia. It is less suitable and practical for cosmetic use due to its shorter duration of effect [3] and injection discomfort associated with its acidity (pH of 5.6) [4, 5]. The A serotype has demonstrated the longest duration of effect (90–120 days) and least discomfort with injection. Only two formulations of BoNTA have been studied and used extensively for cosmetic and therapeutic indications [3]. The mechanism of action for onabotulinumtoxinA (BotoxCosmetic™, Allergan Inc., Irvine, CA) and abobotulinumtoxinA (Dysport™, Medicis, Scottsdale, AZ) is the same, but the products differ in the composition of the surrounding hemagglutinins and complex size (BotoxCosmetic™: 900 kDa, Dysport™: 500–900 kDa).

BotoxCosmetic™ set the standard for neuromodulators by demonstrating a proven safety and efficacy record for over 15 years. Dysport™ was licensed for medical use in Europe in 1990 and has been used for cosmetic treatments for many years. In 2009, it received US Federal Drug Administration (FDA) approval for treatment of glabellar lines. While these two formulations are not interchangeable, and reportedly cannot be substituted by one another by any fixed-dose conversion ratio, most experienced investigators believe that a 2.5–3 abobotulinumtoxinA units (AU) to 1 onabotulinumtoxinA unit (OU) [3] can be utilized when comparing the two products. Based on both preclinical and clinical studies, it appears that Dysport™ has a slightly greater regional effect, which can be used to the product’s advantage. Using a slightly higher concentration of Dysport™ provides the same or better benefits with lower volumes of injection. While the injection doses and volumes differ between Botox™ and Dysport™, the injection technique need not be altered.

Bovine collagen (Zyderm™ and Zyplast™, McGhan Medical Corporation, Fremont, CA) was the first commercially manufactured, syringe-supplied injectable approved for use as a soft-tissue filler. The need for skin testing, delay from initial consultation to treatment, and risk of delayed hypersensitivity reactions led to the development of humanderived “tissue engineered” collagen. Cosmoderm™ and Cosmoplast™ (Allergan Inc., Irvine, CA) are the only currently available dermal fillers made from cultured human fibroblasts. The cell lines are obtained from newborn foreskin

and are screened for viruses, tumorigenicity, and other potential pathogens. One advantage compared to Collagen™ is that no skin testing is required. Additionally, Cosmoderm™ is, in the senior author’s opinion, the best commercially available injectable product for the treatment of fine lines. Other fillers including the plethora of hyaluronic fillers currently available are not easily used as intradermal fillers without visible signs such as Tyndall effect and heaved runways elevating the target line. Unfortunately, this product is now being withdrawn from the market for economic reasons.

Hyaluronic acid (HA) fillers have also gained traction in the treatment of volume loss and surface irregularities. HA is a naturally occurring glucosaminoglycan biopolymer molecule made up of linked alternating residues of the monosaccharides D-glucuronic acid and N-acetyl-D-glycosamine, which coil around themselves [6]. This results in an elastic and viscous matrix. HA exhibits no species or tissue specificity, and its chemical structure is uniform throughout nature. The most common sources for HA-based product development are bacterial cultures and heterologous sources (e.g., rooster combs). Although, in theory, there is no potential for eliciting hypersensitiviy or allergic reactions, several case series have reported delayed reactions [7, 8]. These were probably related to residual trace streptococcal proteins from manufacturing.

The most popular HA fillers today are Restylane™, Perlane™ (Medicis, Scottsdale, AZ), Juvederm™ (Allergan Inc., Irvine, CA), and Prevelle Silk™ (Mentor, Santa Barbara, CA). The addition of lidocaine to several of these products (Restylane-L™, Juvederm XC™, Prevelle Silk™) has facilitated their ease of administration.

In addition to HA fillers, two other classes of fillers merit mention, though these products are generally not recommended in periorbital applications. Calcium hydroxylapatite (Radiesse™ , BioForm Medical, San Mateo, CA) and poly- L-lactic acid (Sculptra™, Sanofi Aventis, Bridgewater, NJ) are larger molecule fillers, ranging from 25 to 63 mm in particle size. These products work primarily by causing a foreign body reaction and an increase in fibroblasts and collagen deposition. Radiesse™ is composed of microscopic calcium hydroxyapatite particles suspended in a carboxymethyl-cel- lulose gel. Its mechanism of action is both in volume restoration and to act as a framework for fibroblastic ingrowth in soft tissue. In facial treatments, its duration ranges from 6 to 12 months depending on the site of injection and the technique used [9]. Sculptra™ is an injectable form of poly-L- lactic acid, a compound that has been used in absorbable suture material for over 40 years. It is nontoxic, synthetic, immunologically inactive, and biodegradable. Sculptra™ is supplied as a powdered form that must be reconstituted with sterile water (with or without lidocaine) and must sit for 2 h before injection. While the company advertises results lasting