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BTX may be used in the periorbital region to diminish dynamic rhytides in the lateral canthal region, to weaken eyebrow depressors and thereby elevate or contour the brows, and to treat hypertrophic orbicularis oculi muscle in the lower eyelid20 In any given patient, it may be desirable to accomplish one or more of these goals They are not mutually exclusive and should be considered independently When treating lateral canthal rhytides, the injector must distinguish between the lines caused by the action of the orbicularis oculi muscle, those caused by contraction of zygomaticus major and minor muscles (causing upward movement of the cheek with smiling), and those due to photoaging of the skin Only those lines clearly caused by contraction of the orbicularis oculi muscle should be treated with BTX (Figure 58)22 Attempts to treat too far inferiorly may produce an unnatural appearance when smiling, facial asymmetry, or, in the most extreme circumstance, facial drooping It is usually best to use the least amount of toxin necessary to produce the desired clinical effect while still providing adequate ef cacy
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5: Periorbital Rejuvenation
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Figure 58 (A) Before injection of crow s-feet rhytides with botulinum toxin type A, active (B) 3 weeks after injection of crow s-feet rhytides with botulinum toxin type A, active orbicularis oculi activity is reduced but not eliminated (C) Before injection of crow s-feet rhytides with botulinum toxin type A, passive (D) 3 weeks after injection of crow sfeet rhytides with botulinum toxin type A, passive (Note improvement in rhytides even when in repose)
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Use of too much toxin will minimize the action of the orbicularis oculi muscle to the point where the lateral canthus does not wrinkle at all with smiling and other facial expressions This can signal the appearance of insincerity in some patients, and thus overaggressive injection in the crow s-feet region should be avoided A careful injection record should be kept and rst-time patients are usually followed up 2 weeks after their injection At the follow-up visit, the treatment goals should be reviewed and compared to the clinical results If additional injections are needed to achieve the desired goals, these should be administered at the follow-up visit If the patient has not achieved the best possible outcome,
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careful notes should be made about adjustments that need to be made in dosage, placement, or both BTX can also be used to weaken the pretarsal orbicularis oculi muscle This can reduce the prominent roll that appears with smiling in patients with hypertrophic orbicularis muscle and can also increase the size of the palpebral ssure (the distance between the upper and lower eyelids) While these goals are separate, they are indistinct in that it is dif cult to accomplish one objective without the other That is, treatment of hypertrophic orbicularis oculi muscle will not only reduce the muscle bulk upon smiling but will also make the eyes appear to be open wider Flynn reported this change to be well
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| Regional Approach to Aesthetic Rejuvenation
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strates some typical injection sites on patients with normal and large sized orbicularis oculi muscles When injecting in the lateral canthal region, the risk of toxin diffusion into the orbit increases with proximity to the canthal angle While there a study is yet to be performed to address this issue directly, it seems that injecting at a distance 1 to 15 cm from the lateral canthal angle minimizes the risk of clinical effects of toxin on the extraocular muscles Pain management techniques for periorbital BTX injections range from no anesthesia, to the use of ice packs immediately prior to injection, to the use of topical anesthetic agents Extremely anxious patients may very rarely wish to take a benzodiazepine prior to injection; but in this scenario, transportation arrangements must be made as driving while under sedation cannot be permitted If a topical anesthetic agent is applied, it should be thoroughly removed prior to injection as the small 30 to 32 gauge needles may otherwise become occluded Although brow contouring has been brie y covered in 4 (see Botulinum Toxin by Neuhaus), it is appropriate to make at least a few comments on this topic within the context of periorbital rejuvenation since the brows exert such a strong in uence on eyelid aesthetics The rationale for using BTX-A to change eyebrow position is based on the selective relaxation of brow depressors Centrally, the corrugator, depressor supercilii, and procerus muscles are all important brow depressors Temporal to the papillary midline, the orbicularis oculi muscle is the sole brow depressor The orbicularis oculi muscle is opposed by the frontalis muscle medial to the temporal line of fusion (conjoined tendon) and is unopposed temporal to this landmark (in the region overlying the temporalis muscle) Therefore, relaxation of the temporal brow depressor leads to brow elevation With regard to the placement of these injections, anecdotal reports suggest a variety of options including directly into the tail of the brow, above the tail, and below the lateral brow As long as the orbital orbicularis oculi muscle is affected by the toxin, the exact placement of the injection probably is not critical, provided the diffusion into the inferior aspect of the frontalis muscle is avoided Those injectors using a higher dilution (eg, 4 mL of saline) and thus a greater volume may be well advised to inject relatively more superiorly so as to avoid unexpected diffusion of toxin into the levator muscle As the injections given to contour the brows are administered in the periorbital region, a few general comments in this chapter are warranted First, injections given along the
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accepted by the patients, but lowering of the eyelid after blepharoplasty surgery is generally considered a complication to be avoided23 Further, some patients who complain of bunching of their lower eyelid with smiling or animation actually have either excess eyelid skin or a normal amount of eyelid skin that is compressed into a small area by the upward movement of the cheek associated with strong contraction of the zygomaticus muscles These patients will not bene t signi cantly from BTX injection into the lower eyelid Thus, a careful examination and discussion about realistic goals is needed prior to treatment The dosage of BTX-A injected into the periorbital region should be determined by the treatment goal, the size and strength of the orbicularis oculi muscle, and the position of the globe relative to the orbit As detailed earlier, the size and distribution of the orbicularis oculi muscle may vary dramatically from patient to patient and even within individuals from one side of the face to the other Individuals with the muscle distributed over a large area or with relatively hypertrophic muscle will require larger doses of toxin than may be considered standard Similarly, patients with smaller muscles that do not contract as forcefully should receive relatively lower doses of toxin The dosage should also be reduced when injecting the lower eyelid and inferior lateral canthal region of patients with prominent globes caused by shallow orbits, thyroid eye disease, or myopia (extreme near-sightedness due to a longer than normal eye) as these patients are at higher risk for ectropion or incomplete eyelid closure24 It is more helpful to think in terms of number of units per injection site than the total dose required to treat the entire region As a general rule, 25 to 5 U per site is appropriate in the lateral canthal area When treating the inferior pretarsal orbicularis oculi muscle only 1 to 2 U should be used per site
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