Treatment Protocols & Assessment of the face

Treating Glabella Area (Frown Lines)

 

 

Neurotoxins are commonly used to treat the vertical lines between the brows. This is the only area currently FDA (Food and Drug Administration) approved for treatment with botulinum toxin A

 

The vertical lines of the glabella are produced by contraction of the paired corrugator muscles, and the horizontal lines (eleven lines) are caused by contraction of the centrally located procerus muscle. The corrugators originate on the supraorbital ridge of the frontal bone and insert on the skin above the middle third of the eyebrow. The procerus muscle originates on the nasal bone and inserts onto the skin of the glabella or midforehead. Although this anatomy seems straightforward, there are subtle anatomic variations that can be visualized during facial animation. We have noted two distinct patterns of corrugator positioning: either straight along the brow, or more vertically oriented in a V shape. For this reason, the injector should not rely on only one technique in this area. The injector should “look through” the skin to imagine the location of the muscles and their contribution to the wrinkles produced during movement.

 

Prior to injecting the client we would always ask that they frown their brow. Attempt to look through the skin to determine the size, strength, and location of the procerus and corrugator muscles. Injections must be placed 1 cm above the superior orbital rim to reduce the risk of upper eyelid ptosis. Injections are placed in the muscle belly. Try not to “bump” the periosteum, as this occasionally can be associated with post injection headache.

 

Ask the your client to again to frown as you assess the size and shape of the muscle. Tailor the treatment to the anatomy. Filler injections may be necessary for deep rhytids in this region. Consistent retreatment of the glabella may result in the patient “unlearning” to move the brow, and thus not only improve the rhytids but also extend the time required between injections.

 

The glabella accounts for ONE area. This can be an area injected on its own or, in conjunction with either the frontalis or the orbicularis oculi (crows feet) or, both.

The glabella consists of 5 injections. one directly in the middle of the procerus muscle and one at the beginning and tail of the corrugator muscles on each side. These injection points can be seen on the diagram above and must be 1cm apart.

 

Precautions

 

Upper lid ptosis can occur should too many units be injected into this area, or should the product unfavourably migrate , which can be seen up to 2 weeks after injection and may last 2 to 4 weeks post-injection.

 

Ptosis can be present at birth, but people can also acquire it later in life due to:

 

  • Injury or stretching of eyelid muscles or ligaments
  • Damage to the nerve controlling the eyelid muscles
  • Ageing
  • A complication of eye surgery
  • A complication of Botox injections

 

Ptosis does not lead to any health issues, in most cases, and is easily manageable

 

What causes droopy eyelids after Botox? When Botox migrates to one or both of two specific areas, Botox injections can result in a droopy eyelid — also called ptosis.

 

These two areas are the forehead and between the eyes.

 

Post procedure Instructions

 

There is no clinical data to suggest that giving patients post-treatment instructions decreases ptosis or improves results, however it could minimise the chances of a negative result.

As part of after care we ask our patients/clients not to bend over, push on the injection sites, or lie down for 4 hours. It is also recommending the patient refrain from exercise that day and to actively move the injected muscles for 90 minutes in the basal layer is a protein that aids in protecting the skin against invasion.

Risks – Diffusion of product into the eyelid may affect the levator palpebrae superioris muscle and result in a transient ptosis.

 

Treatment of Frontalis    Transverse wrinkles of the forehead

 

Contraction of the paired frontalis muscles raises the eyebrows and upper eyelids, which produces transverse creases in the forehead. These muscles originate on the galea aponeurotica of the cranium and insert into the skin of the eyebrows. The frontalis muscles are often described as paired muscles that do not meet centrally. However, clinically, the central position of the forehead is not devoid of wrinkles. Therefore, treatment of the forehead should include injections in the central aspect of the forehead. The upper face must be assessed both in animation and at rest prior to injection. In women, the brow should lie at or just above the superior orbital rim. In men, it should lie at the bony rim. Have the patient raise and lower the brow and assess the extent of muscle movement. The frontalis muscles are located superficially, so the injections should be placed in the superficial subcutaneous tissue. We treat the entire forehead from medial to lateral. As with all toxin injections, male patients may require a higher dose.

More than with any other area, it is imperative to observe the patient contracting and relaxing the frontalis muscles while the injector plans the injection sites. If the rhytids extend up to the hairline, make sure the injections extend to this area, or it will result in a smooth forehead with a ridge of wrinkles superiorly. Also be sure to assess the lateral brows; occasionally these rhytids are undertreated, and deep crescent shaped creases will be seen just above the lateral brow. A unilateral forehead resting contraction may be compensation for upper eyelid ptosis. Assess these areas carefully prior to injecting the patient.

Unlike the glabella, frontalis cannot be treated on its own. It must be paired with the glabella. Glabella can be treated alone however frontalis must be treated with glabella. This is because the frontalis is an elevator. If completely relaxed it will cause the brow to drop. the glabella is a depressor and will therefore even it out causing less chance of a brow drop.

The frontalis consists of 6 injections at leased 1cm apart.

Precautions 

The forehead is often described as the most difficult area to inject well. Although treatment of the forehead seems intuitively simple, common errors include overtreatment or poor injection planning. The most important rule of injection is to assess the position of the brows at rest, prior to injection of neurotoxin. Two important conditions of this region must be predetermined: the presence of brow ptosis; and increased resting tone of the muscles, which can mask brow ptosis.

In some patients, horizontal forehead creases are the result of compensation for brow ptosis. These patients often request neurotoxins to improve their deep forehead rhytids. It is important to remember that the frontalis muscles are the only muscles that elevate the brows. If the brow is ptosis we do not inject the frontalis muscles, as this will worsen the brow ptosis. If injection must be performed on a patient with brow ptosis, plan the injections high in the forehead, at leased 2cm above the orbital rim so that the patient retains some brow elevation movement, or consider undertreating this entire area. In addition, the frontalis muscles can sometimes show a resting tonic contraction that must be relaxed to determine the resting position of the brow. This may even require the injector to “smooth out” the forehead manually to encourage relaxation of the muscles. Having the client close his/her eyes can help relax the frontalis muscles. Once the frontalis muscles are at rest we can assess the brow position to determine if the frontalis contraction was masking brow ptosis. Poor technique in this area can produce an odd-shaped brow. Do not limit the injections to the central brow. Do not assume that the injections cannot extend laterally. If only the centre of the brow is treated, the brow will drop medially and elevate laterally, which produces an odd-appearing slanted look, sometimes referred to as the  as Spock brow. A lateral browlift can be obtained by using this technique but proceed with caution in this area to avoid an overly slanted medial brow.

Risks 

Ptosis of the upper eyelid and unmasking brow ptosis are the major risks of this procedure. Minor risks include inappropriate injection planning, which may result in unnatural-appearing brows.

Crows Feet

 

he Smile lines and crow’s feet are two of the most commonly sought-after areas for treatment with to9xin .To soften or eliminate wrinkles around the lateral and inferior orbit, injection of the orbicularis oculi muscles can prevent movement-related creasing of the overlying skin associated with expression and baseline muscle tension. Neurotoxin injection will not improve static wrinkles or deep creases due to photoaging. The orbicularis oculi muscle surrounds the eye and is separated into three divisions: pretarsal, preseptal, and orbital. The orbital portion extends laterally and is intimately adherent to the overlying skin. Contraction of this muscle results in lines extending radially from the lateral canthus. As the overlying skin thins and ages, crow’s feet become visible in the skin from repeated muscle contractions.

Three  injections of Botulinum Toxin Type A are placed radially in the area of the crow’s feet.  Care should be taken to inject 1 cm lateral to the bony orbital rim, especially above the canthal angle, as upper lid lag can occur.

It is helpful to place a finger of the non injecting hand at the lateral orbital rim as a guide. The muscle is superficial, so the needle does not need to be placed deep into the subcutaneous tissue and because of the wide zone of effect for, Botulinum Toxin Type A a superficial dermal injection will minimize bruising without compromising clinical results.

 

It is acceptable to have some movement with full expressive action of the muscle.

Precautions 

 

The periocular area often has many superficial and deep venous structures that may or may not be visible through the surface of the skin. Trying to avoid them will keep the toxin from being washed away and also prevent bruising.

Risks 

Extending the injections too far inferiorly and too deep under the orbicularis can affect the zygomaticus major muscle and result in an upper lip droop or asymmetric smile. Patients should be made aware that injections cannot be extended too inferiorly in this area. Some patients will note an accentuation of lines in this region once the lateral lines have been treated.

Post Procedure Advice 

This is a highly vascular area, so bruising is possible. If a vessel is injured, hold firm pressure for a minute or two to minimise bruising.