Periocular Injectables with Hyaluronic Acid and Calcium Hydroxyapatite

370 R.A. Glasgold and S.M. Lam

injection minimizes the risk of intra-arterial injection. In addition, injection is performed only during needle withdrawal, watching for bleed ashback into the syringe. Any duskiness or skin color change that suggests vascular compromise is treated with topical nitropaste. Always have a supply of nitropaste at hand in the event of this unlikely

complication.

Contour irregularities can arise due to technical error with injection method. Deeper placement (suborbicularis), steady injection, and vigorous massage are the principal methods to avoid a contour problem.

Hyaluronic Acid (HA)

HA has become one of the most popular choices as a soft tissue filler for facial enhancement. HA can be used effectively in the entire periocular region, including the glabellar rhytids, superior orbital rim depression, inferior orbital rim hollow, and the nasojugal trough (Figure 122.1).

To avoid contour problems, HA should be injected smoothly with a linear threading or crosshatch technique while minimizing serial punctures. The slow and deliberate injection into the suborbicularis oculi plane achieves a more uniform contour. Digital massage and manipulation smoothes out remaining contour problems and is routinely performed in the periocular region. Massage is less critical in the perioral region, but it is beneficial in the unforgiving thin skin of the periocular region.

The best candidates for periocular filling are those with limited defi ciencies that can be corrected with one or two 1-ml syringes of HA. Greater contour deficiencies are better managed with autologous fat transfer. Larger volumes of HA risk contour irregularities and are cost prohibitive. Trying to camouflage a pronounced prolapse of fat in the lower eyelid using HA (or any other filler for that matter) along the bony rim can contribute to an unsightly bulge and compound the problem. The best candidates are those who exhibit mild to moderate isolated deficiencies of the nasojugal trough with or without some extension of hollowing in the remaining inferior orbital rim (Figure 122.1).

The patient should be seen 1 week after treatment when it is still relatively easy to massage out contour problems. After the second week, manipulation of the material becomes ineffective. In these cases, use of hyaluronidase can be instrumental to dissolve the HA in a matter of a few hours. This potential reversibility is a compelling reason to use HA for periocular purposes.

Calcium Hydroxyapatite

CH can provide superb enhancement in the periocular region (Figure

122.2). In several cases that we have observed, CH elicits a persistent cutaneous erythema in the nasojugal trough recalcitrant to treatment but that dissipates after many months. We have restricteded the use of CH in the nasojugal trough despite early successes. The superior orbital rim may also be a difficult area to contour.

Chapter 122 Periocular Injectables with Hyaluronic Acid and Calcium Hydroxyapatite 371

The remaining inferior orbital rim can be enhanced but should be approached in the immediate supraperiosteal plane, i.e., deeper than just below the orbicularis oculi where HA is injected. Doing so limits contour problems with CH due to its higher viscosity. As a general rule, CH works exceptionally well in the adjacent malar depression since it provides a more potent volumetric enhancement per ml than HA and also because it comes packaged in a larger syringe (1.3 ml vs. just 1 ml with HA).When filling a complex contour deficit, it is always wiser to approach that area with a crosshatch method that facilitates a seamless result where the borders of augmented soft tissue are not seen.

A

B

Figure 122.1. Pre- (A) and posttreatment (B) photos following Restylane injections to the nasojugal groove and inferior orbital rim depression.

372 R.A. Glasgold and S.M. Lam

A

B

Figure 122.2. Pre- (A) and posttreatment (B) photos following Radiesse injections to the nasojugal groove and inferior orbital rim depression.

374 S.L. Matarasso

that is often omitted and should be discussed with patients is their goals and the degree of the expected cosmetic improvement. It should be stressed that the mimetic lines will be reduced for approximately 3–4 months and that with each subsequent treatment the results may last longer and the lines may not be as deep, but deeply etched-in lines often require additional therapy. For complete rhytid effacement, if cost permits, patients may often require additional adjunctive therapy. An ideal combination is the administration of Botox to relax the muscles of facial expression and maximally reduce the dynamic lines and the subsequent use of a lling agent to further reduce the remaining static lines. Not only does this optimize the ultimate aesthetic result, the decreased muscle activity increases the durability of the filling substance.3

1.Patients who elect to undergo a procedure for facial enhancement often do not have the same expectations as those who present for medical indications. While bruising and edema are acceptable sequelae for many therapeutic procedures, they are often ill tolerated with cosmetic procedures. Patients must be made aware of these normal consequences and the associated morbidity (downtime). To reduce the incidence of bruising, medications that can interfere with the clotting mechanism (aspirin, nonsteroidal anti-in ammatory drugs) should, if medically appropriate, be discontinued for 10–14 days prior to treatment. There may also be an increased incidence of eccyhmosis as most facial injectables require a 30-gauge needle-and aspiration prior to injection to ensure appropriate cutaneous (as opposed to intravascular injection) placement is not tenable.

2.The results of Botox can be dramatic and muscle immobilization can be objectively appreciated—conversely the results of a filler can be more subtle and subjective. Standardized preoperative photographs assume an important role with soft tissue augmentation. For the physician they are a valuable learning tool as they reinforce proper technique and placement. For the patient they are more important—it is not atypical to forget the pretreatment appearance of a wrinkle, and baseline photography is unequivocal documentation.

3.Ideally, Botox should be administered initially and allow 3–4 days for the maximal effect to take place. The remaining soft tissue defect will require a smaller quantity of filler and hence lowers the total cost of the combined procedures. However, for patient convenience Botox and fillers can be done simultaneously. There is no scientific documentation of which should be injected first. Theoretically as they are placed at different levels—Botox is intramuscular and fillers are intradermal—it should not be clinically relevant. Some physicians do prefer to inject the

ller before the toxin. This sequence may theoretically prevent the spread of toxin with subsequent percutanous injections and unwanted diffusion into adjacent areas with unintentional muscle weakness.

4.The selection of the filler depends upon the depth and location of the remaining rhytid and the quantity needed. The thinner, superficial llers, those that are noncrosslinked, such as Zyderm I and II and CosmoDerm 1 and 2, are preferable. These agents contain a high saline content that is rapidly reabsorbed and therefore upon injection into the

Chapter 123 Pearls and Pitfalls of Botox and Filler Substances 375

super cial papillary dermis require overcorrection with visible blanching of the skin. As small amounts of filler are required to complement the Botox, the collagen that is commercially available in the smallest volume (0.5 cc) is recommended. Collagens notoriously have a brief longevity; using the longer-lasting hylauronans (Restylane or Juvederm) is acceptable. The tradeoff is that they do not contain local anesthesia and are more painful to inject, are associated with more edema and bruising, and are thicker and so must be placed deeper in the papillary dermis.

5.There are two primary injection techniques for dermal fillers: serial puncture and linear threading. With the former, small aliquots of a ller are sequentially deposited immediately anterior to the previous injection. This is often the preferred method, although it requires multiple entries into the skin, is more precise, and is not blinded, and therefore, unlike linear threading, there is less chance of intravascular embarrassment.

6.Patients should be placed in an upright/dependent position to accentuate rather than blunt the rhytid. Overhead lighting and magnification assist not only in appreciating the depth of the defect, but also in locating vessels that should be avoided upon injection.4

7.Injections into glabrous skin can be painful. To reduce the discomfort and make it a nonthreatening experience for the patient, the use of a topical anesthesia for 15–30 minutes is beneficial. Despite adequate anesthesia with cream preparations, repeated injections can dull the 30gauge 1/2 needle and increase the pain. Not only can changing the needle as needed diminish the pain, but also injecting the material slowly is helpful.

8.After successful treatment with Botox into the orbicularis oculi muscle (crow’s feet), there may be residual lines laterally and in the infraocular sulcus. The lines that radiate laterally are superficial and

therefore well suited to very fine llers such as Zyderm I or CosmoDerm 1. When using bovine products it is the standard of care to have two negative skin tests documented to reduce the risk of hypersensitivity reactions.5 The infraocular sulcus is the result of loss of subcutaneous tissue and therefore will not be responsive to Botox or a superficial filler. Soft tissue augmentation in this area restores the convexity of youth. The collagen products tend to “bead” in this area and do not provide a sustainable augmentation. More viscous products such as the hyalutonic acids (Restylane and Juvederm) are recommended in this area. This area can be approached laterally from the canthal region or inferiorly just above the bony zygomatic arch. The skin in this area is thin and very prone to eccyhmosis and contour irregularities. Placing these products deep in the submuscular plane seems to produce longer-lasting augmentation and reduce contour irregularities. The anterior threading (“push along”) method acts like blunt dissection and creates a submuscular space. To reduce the potential risk of intravascular placement it may be warranted to inject in a lateral direction, away from the eye, as opposed to towards the peri-orbita. (Figure 123.1)

9. Perhaps the sine-qua-non stigma of treatment with Botox in the frontailis muscle is the intact inferior muscle fibers located immediately above the lateral eyebrow. They can on occasion be treated

376 S.L. Matarasso

conservatively with very small amounts of Botox (1.0–2.0 units).

However, completely inactivating the sole brow elevator muscle may cause ptosis with lateral hooding. To avoid this it is advisable not to treat the most inferior horizontal rhytids with Botox (approximately 1.5– 2.0 cm above the superior orbital rim). This does predictably result in what has been commonly known as the “Mr. Spock” or quizzical brow.

A reliable remedy of these infero-lateral furrows is the use of a filler. Selection of the filler is predicated upon the depth of the wrinkle, and most dermal fillers would be acceptable in this suprabrow location.

10. Most llers approved by the FDA are for the temporary “improvement of soft tissue contour folds and wrinkles, such as the nasolabial fold.” When used above the zygomatic arch, they are considered offlabel. The most significant absolute contraindication for the use of fillers lies in the glabellar region. There is a high risk of intravascular injection with fillers with consequent tissue necrosis, slough, and cicatrix formation. To avoid this complication, fi llers that are robust (crosslinked with gluteraldehyde-Zyplast and CosmoPlast) should be strictly prohibited in this area. Thin agents (Zyderm I and Cosmoderm 1)are indicated for any dermal lines in this area. Even with slow deliberate superficial placement of a ller vascular occlusion can occur. This will be manifested by unexpected blanching and pain. If this occurs it can be responsive to topical vasodilator nitroglycerin paste. It may be prudent to keep this cream readily available in treatment rooms.

11.As the uses of injectables evolve, an era of facial shaping is becoming a standard practice. This is especially apparent in the brow area. Treating the glabellar complex with Botox relaxes the brow depressor muscles and by definition will produce lateral “chemical brow lift” of 2.0–3.0 mm by unopposed action of the frontalis muscle. To further accentuate elevation of the brow, a filler can be placed along the lateral tail of the eyebrow. A hylauronan can be injected in a threading manner along the superior orbital rim. Very small amounts, 0.2 cc per side, can be placed one third to one fourth of the length of the eyebrow. It may be slightly uncomfortable, but patients report an immediate lift of the brow.

12.Postinjection massage is not a universal practice, but it does locate any skip areas that have not been adequately addressed with a filler as well as reduce postinjection edema. Similarly, brief application of cool compresses or ice can be helpful in minimizing patient discomfort and erythema.