up to 2 years, opinion in Europe and USAis mixed. Multiple repeat injections, spaced months apart, are required to achieve desired enhancement. Granulomas, nodule formation, and drainage have been reported, and these can be difficult to manage [9]. The use of Sculptra™ and Radiesse™ is limited in the periocular region. Wrinkles in the periorbital area are generally fine to moderate, and these products are more suitable for treating deeper depressions, such as the nasolabial fold. Using these products to treat the typical periorbital wrinkles risks undesirable consequences.

25.3Treatments

25.3.1 Lateral Orbital Rhytids (Crow’s Feet)

The orbicularis oculi muscle is a flat, wide muscle that encircles each orbit and extends into the eyelids (Fig. 25.1). The muscle has been arbitrarily divided into two parts: orbital and palpebral. The palpebral portion is further subdivided into a preseptal and pretarsal segment. The orbital portion consists of the outermost part of the muscle overlying the orbital margins. The preseptal portion overlies the orbital septum. It originates from the medial canthal tendon and lacrimal diaphragm and passes across the lid, meeting at the lateral canthal tendon. The pretarsal portion is the innermost portion of the muscle that overlies the superior and inferior tarsal plates. The pretarsal orbicularis has a lacrimal portion that inserts into and around the medial canthal tendon. The part of the orbicularis oculi that is located along the lateral orbit is responsible for creating the lateral radial lines, known as “crow’s feet.” In addition, the orbital segment of the orbicularis oculi is a depressor of the lateral brow.

The most common treatment for lateral orbital rhytids is BoNTA. The use of BoNTA should keep two goals in mind:

(1)relaxing the radial crow’s feet lines by targeting the lateral, vertically oriented portion of the orbicularis oculi and

(2)providing brow elevation by neuromodulation of the brow depressor function by treating the entire length of the lateral orbicularis oculi. Studies have demonstrated the effect of BoNTA treatment of the lateral orbicularis oculi on brow position [10, 11]. Since this 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, while the vectors at 3 and 9 o’clock are primarily vertical. The crow’s feet wrinkles are treated by injecting the lateral orbicularis oculi at several sites lateral to the orbital rim. This reduces the risk of orbital complications. A typical dose of 10 units of BotoxCosmetic™ or 30 units of Dysport™ per side is injected, divided into four or five aliquots (Fig. 25.2). The injections should be placed carefully to achieve maximum effect on the orbicularis oculi, and avoid injecting or injuring any superficial blood vessels.

Fillers have a limited role in the thin skin of the lateral orbital area. Most patients have fine to moderate lines due to orbicularis oculi overactivity and respond well with BoNTA. More severe rhytids are difficult to efface with BoNTA and may be better addressed with skin resurfacing, such as chemical peels or laser resurfacing. Collagen fillers such as Cosmoderm can be considered to fill in persistent fine lines. When using Cosmoderm, the injections are delivered in more superficial levels of the mid to upper dermis. The serial puncture technique, whereby small aliquots of filler are given to achieve even distribution over a two dimensional area, is particularly effective in accurate filler placement.

25.3.2 Glabellar Complex

The vertical glabellar lines are primarily formed by the actions of the paired corrugator supercilii muscles. The inferior aspect of these vertical wrinkles may have an oblique or horizontal component caused by the procerus muscle. The corrugator supercilii originates from the procerus medially and insert, laterally, into the orbicularis oculi muscle and the soft tissue at and slightly above the medial eyebrow (Fig. 25.1). This muscle is nearly horizontal in most individuals; thus, contraction of the corrugator produces a vertical wrinkle. In some patients (<10%), the corrugator supercili muscle is oriented more diagonally; its contraction may result in an oblique wrinkle. It is crucial that BoNTA be injected properly in the corrugator supercili muscle to create a smoothing effect. More importantly, proper placement avoids any unnatural facial appearances. Many textbooks erroneously depict the corrugator supercilii muscle as a

long vertically oriented muscle that inserts into the frontalis muscle in the mid forehead. Consequently, a common mistake is to inject the corrugator supercilii too far superiorly and actually treat the frontalis. The frontalis relaxation may cause a mephisto, or “Mr. Spock-like,” unattractive appearance (Fig. 25.3). The correct placement of BoNTA into the corrugator supercilii muscle is more inferior, just at or slightly above the medial clubhead of the eyebrow. A second small dose is also given about 3–5 mm lateral to the first injection to treat the entire length of the corrugator muscle. Typically, 10 units of BotoxCosmetic™ or 30 units of Dysport™ to each side are employed (Fig. 25.2).

Furrows created at the base of the nose are created by the procerus muscle (Fig. 25.1). This muscle is anatomically larger in women than men [12]. It can be a powerful “wrinkler” of the nose. With chronic activity, the procerus can create deep furrows. Careful evaluation of the glabellar complex is important because many patients seeking treatment for the

vertical glabellar furrows have very limited or nonexistent transverse lines. These patients, thus, do not need any treatment. Not all patients are the same; treatment formulas that are universal are wasteful and unnecessary. If a patient has transverse furrows, 3–5 units of BotoxCosmetic™ or 9–15 units of Dysport™ in one or two aliquots directed at the belly of this muscle are sufficient for most patients to achieve a satisfactory reduction in procerus activity (Fig. 25.2).

Occasionally, some superficial lines persist after BoNTA treatment to the glabellar area. It is wise to advise patients of the potential need for supplemental fillers if they present for neuromodulator treatment and have deeply ingrained dermal lines at rest. These lines are excellent candidates for correction with Cosmoderm [13]. Alternatively, Prevelle Silk™ can be used to treat superficial lines. In cases with deeper furrows, HA products can be used. When injecting HA product, one must stay superficial to the mid dermis. Ischemic necrosis of the glabellar skin, a rare and disastrous complication, can occur if any filler is injected intravascularly [14–17] (see Sect. 25.4). If combining BoNTA and filler, it is advisable to stage the treatment, particularly for new patients. Most experienced injectors will use BoNTA first; this allows for evaluation of residual lines or folds after BoNTA has taken effect [3]. Afterward, a better determination of filler application can be made.

25.3.3 Frontalis Muscle

The frontalis is a thin, quadrangular muscle originating from the galea aponeurotica below the coronal suture superiorly and inserting into the brow inferiorly (Fig. 25.1). While it has no bony attachments, 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. As such, hyperfunctional lines in this area cause classic horizontal forehead furrows.

BoNTA treatment of the frontalis muscle offers an excellent treatment for mild and moderate forehead lines. Ten units of BotoxCosmetic™ or 30 units of Dysport™, divided into four aliquots are used to treat the frontalis. The location of injections is critical to optimum results. To best identify appropriate injection placement, it is important to have the patient raise their brow to better define the forehead lines. Injecting 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 (Fig. 25.4). Three additional injection points (2 units BotoxCosmetic™/6 units Dysport™) can be added as extension therapy in patients with numerous forehead lines, or those with greater forehead height. One extension therapy injection is added in the midline, while the other is added between the medial and

Fig. 25.4 Standard injection sites for treating the frontalis muscle. Injecting 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 can be added as extension therapy in patients with numerous forehead lines, or those with greater forehead height. One extension therapy injection is added in the midline, while the others are added between the medial and lateral injection points bilaterally. X, standard injection sites; E, extension therapy

lateral injection points bilaterally (Fig. 25.4). When counseling a patient, it is important to explain 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.

With the advent of BoNTA, soft-tissue fillers have a more limited role in the treatment of horizontal forehead lines. It is important to distinguish between dynamic and nondynamic lines of the forehead. While the former is better treated with BoNTA, the latter, particularly in superficial lines caused by actinic damage, qualify for treatment with soft-tissue filling agents. Cosmoderm™, a human collagen agent, and Prevelle Silk™, an HA, offer the most superior results for these superficial lines without the risk of Tyndall effect.

25.3.4 Nasojugal Groove/Tear Trough

Contemporary periorbital rejuvenation techniques focus on improving the lower eyelid-mid-face contour [18]. As one ages, the mid-face structures become ptotic and expose the nasojugal groove and orbital rim. Often, pseudoherniation of orbital fat is also present, which accentuates the lower eye- lid–cheek complex. Surgical options include blepharoplasty and mid-face lifts. However, volume replacement can be an effective option or supplement for patients with mild to moderate deformities [18]. Choices for volume replacement