Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers

Focus on the Upper Face

Maurício de Maio, M.D.; Arthur Swift, M.D.; Massimo Signorini, M.D.; Steven Fagien, M.D.

Disclosures

Plast Reconstr Surg. 2017;140(2):265e-276e. 

In This Article

Neuromodulator Injection Technique for Indications in the Upper Face

Forehead Lines

The frontalis muscle elevates the eyebrow (e.g., during expressions of surprise and fright) and is the only elevator muscle in the upper face.[13] Contraction of the frontalis muscle leads to the development of horizontal forehead lines. Injections of onabotulinumtoxinA for treatment of horizontal forehead lines are performed at five sites (Figure 4, left). Treatment at two additional sites is optional. The dosing and injection pattern reflects the aesthetic objective of treatment, degree of muscle activity, and prior treatment in the area. Injections of onabotulinumtoxinA are made in the frontalis muscle. Gently pinch the skin above the frontalis muscle until a papule is seen and then insert the needle angled upward to one-third its depth (Figure 4, right). Check eyebrow height, frontalis strength, and skin elasticity before injection, and also check for asymmetry. Careful selection of patients for treatment with fillers (i.e., more severe dynamic and static lines at rest, as described above) or neuromodulators is essential to achieve optimal outcomes and avoid potential complications. Overinjection in the forehead should be avoided, especially in female patients who present with low and flat eyebrows. In addition, overinjection of onabotulinumtoxinA may lead to a frozen appearance of the forehead, brow asymmetry, or medial and/or lateral eyebrow ptosis.[10,13] In addition, extend the injection sites far enough laterally to avoid excessive elevation of the lateral part of the eyebrow, termed the "Mephisto" or "Spock" appearance.[13] To avoid eyebrow ptosis, it is important to also treat the depressors of the glabellar complex and the lateral periorbital lines.

Figure 4.

Treatment of horizontal lines with onabotulinumtoxinA. Injections are made at five sites, with the option of injecting at two additional sites (designated by circles) (left). Asterisks indicate one-third needle injection depth. For each injection, gently pinch the skin until a papule is seen and then insert the needle angled upward to one-third of its depth (right).

Glabellar Lines

Glabellar or frown lines may develop because of natural aging and photoaging of the skin in conjunction with ongoing contraction of the procerus and corrugator muscles. Contraction of the procerus muscle lowers the medial aspect of the eyebrow and is the main contributor to the horizontal lines, whereas contraction of the corrugator muscle draws down the medial aspect of the eyebrow and is primarily responsible for vertical lines.[10] Once considered an independent indication, treatment of glabellar lines is now viewed as an integral part of harmonization of the brow shape and eyebrow position.[14] OnabotulinumtoxinA treatment is indicated for temporary improvement in the appearance of glabellar lines both during active contraction and at rest.[15] Injections of onabotulinumtoxinA for treatment of glabellar lines involve five injection sites. Injections are made into the procerus muscle (one site) and the medial and lateral corrugator muscles (two sites per side) (Figure 5, left). For injections into the procerus muscle, pinch the skin to help guide the injection and insert the needle to half its depth while angled upward (Figure 5, above, right). Injection into the medial corrugator muscle is made (bilaterally) by gently pinching the skin and inserting the needle to full depth while angled laterally upward (Figure 5, below, right). Injection into the lateral corrugator muscle (because of its more superficial location compared to the medial corrugator muscle) can be facilitated by pinching the skin and inserting the needle to one-third of its depth while angled laterally upward. Treatment of glabellar lines with onabotulinumtoxinA may cause ptosis of the eyelid and eyebrow if an incorrect angle or depth of injection is used.

Figure 5.

Treatment of glabellar lines with onabotulinumtoxinA. Injections are made at five sites (left). Observe that the different symbols used here indicate different depths of injection as follows: squares indicate full-needle depth; X indicates one-half needle depth; and asterisks indicate one-third needle depth. For injection in the procerus muscle, pinch the skin and insert the needle to one-half its depth angled upward (above, right). For injections into medial corrugators, pinch the skin and insert the needle to its full depth angled laterally upward (below, right). For injections into lateral corrugators, pinch the skin and insert the needle to one-third its depth angled laterally upward.

Crow's Feet Lines

Repeated contraction of numerous facial muscles involved in smiling and squinting, notably the orbicularis oculi muscles, leads to formation of lateral canthal lines, also known as crow's feet lines. These lines radiate from the lateral canthus and initially appear on smiling but may become static because of aging, photodamage, and skin remodeling.[16] The orbital part of the orbicularis oculi muscle causes protrusion of the eyebrows and voluntary eyelid closure; it is also responsible for crow's feet lines.[10] In addition to its indication for temporary improvement in glabellar lines, onabotulinumtoxinA has been more recently approved for temporary improvement of crow's feet lines associated with orbicularis oculi activity.[15] Successful treatment of crow's feet lines in most situations can be accomplished by injections at three sites per side. Two patterns of injection are recommended: pattern 1 is more appropriate for patients with low eyebrows (Figure 6, above, left), whereas pattern 2 is more appropriate for those with high eyebrows (Figure 6, above, right). Insert the needle to one-third its depth and inject onabotulinumtoxinA superficially into the lateral fibers of the orbicularis oculi muscle (Figure 6, below) or at times more superficially in the subdermal space. Keep the patient's eyes closed. Use a finger to protect the upper eyelid, and avoid inadvertent injection into the upper eyelid. Helpful tips to facilitate optimum technique include directing the needle away from the eye (laterally) whenever possible and also avoiding the superficial blood vessels in the area.[14] This area is prone to bruising because of its high vascularity. Depending on the patient's ethnicity and the severity of the crow's feet lines, the total dose of onabotulinumtoxinA may vary. It should be kept in mind that treatment will not eliminate all crow's feet lines in many patients. Dynamic lines related to muscle contraction respond well to neuromodulators. However, static lines caused by photodamage and loss of underlying fat and structural support become more prominent with age and are less responsive to treatment.[17]

Figure 6.

Treatment of crow's feet lines with onabotulinumtoxinA. Injections are made at three sites per side using pattern 1 for patients with low eyebrows (above, left) or pattern 2 for patients with high eyebrows (above, right). For each injection, insert the upper one-third of the needle, as indicated by asterisks (below, left). Protect the upper eyelid with a finger, and avoid directing the needle toward the eye (below, right).

Eyebrow Lifting

Because the orbital portion of the orbicularis oculi protrudes and depresses the eyebrows and allows for voluntary eyelid closure, the presence of crow's feet lines leads to lowering of the lateral aspect of the eyebrow. OnabotulinumtoxinA may be used for eyebrow lifting by treating both glabellar and crow's feet lines. Injections of onabotulinumtoxinA are made at five glabellar sites as described above. Treatment of the lateral aspect of the orbicularis oculi is made at three to four sites on each side of the face (Figure 7, left). Although techniques to produce maximal lifting effect in the eyebrow may vary, one should block the eyebrow depressors (corrugator, procerus, and orbicularis oculi muscles). Two upper lateral sites (one on each side) in the frontalis muscle may be injected to prevent development of the Mephisto or Spock eyebrow. Depending on the patient's ethnicity and severity of eyebrow lowering, the total dose of onabotulinumtoxinA may vary. The techniques for injecting the glabellar and crow's feet sites are described in the preceding sections (Figure 7, right).

Figure 7.

Eyebrow lifting with onabotulinumtoxinA. Injections are made at five glabellar sites and eight crow's feet line sites (four on each side) (left). Observe that the different symbols used here indicate different depth of injection as follows: squares indicate full-needle depth; X indicates one-half needle depth; and asterisks indicate one-third needle depth. The technique for injecting the glabellar sites is shown in Figure 5; the technique for injecting two optional sites in the forehead is shown in Figure 4; and the technique for injecting the orbicularis oculi is shown in Figure 6. Use fingers to protect eyes (right).

Eye-Aperture Widening

The palpebral part of the orbicularis muscle closes the eyelid during blinking and is subdivided into preseptal and pretarsal portions.[10] The presep tal fibers run anterior to the orbital septum; with aging, they are responsible for lower eyelid lines and narrowing of the palpebral aperture.[10] Widening of the eye aperture with onabotulinumtoxinA is performed at one site on each side inferior to the lower eyelid and lateral to the midpupil line (Figure 8, left). Besides promoting widening of the eye aperture with these injections, the use of pretarsal injections may also reduce the horizontal rhytides (fine lines). Perform the snap test before injection to verify lower lid functional recovery. Do not treat this area with onabotulinumtoxinA in patients with scleral show, eye bags, or a poor snap test. Insert only the bevel of the needle for a very superficial injection. Keep the needle parallel to the skin and observe for papule formation (Figure 8, right). Keep the patient's eyes closed, and use fingers to protect the eye.

Figure 8.

Eye-aperture widening with onabotulinumtoxinA. A very superficial injection is made at one site on each side inferior to the lower eyelid (left). Insert the needle to the depth of the bevel, and keep lateral to the midpupil line. Keep the needle parallel to the skin; inject after a papule is observed. Use fingers to protect eyes (right).

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