Steve  Yoelin  MD  Private  Practice  

Newport  Beach,  California    

Zones  of  the  Face  

� Upper  zone–Anterior  hairline  to  glabella  

� Middle  zone–Glabella  to  nasolabial  angle  

�  Lower  zone–Nasolabial  angle  to  mentum  

Based on Leonardo Da Vinci’s rule of 3s of the face

Age-­‐Related  Changes  in  the  Face  

Zimbler MS et al. Facial Plast Surg Clin North Am. 2001;9:179–187.

Frown Lines

Nasolabial Fold

Jowl (Broken Jaw line)

Obtuse Cervical Angle

Wide, Deep Orbit

Midface Resorption

Jaw Resorption

Corrugator supercilii

Orbicularis Oculi m.

Cheek Fat

Platysma m.

Platysma Plus Fat

CT  Scan  Shows  Age-­‐Related  Decreases  in  Mean  Angular  Measurements  

Reprinted with permission. Shaw RB Jr, Kahn D. Aging of the Midface Bony Elements: A Three-Dimensional Computed Tomographic Study Plast Reconstr Surg. 2007;119(2):675-681.

Female, 25 to 44 years old Female, ≥65 years old Glabellar

Angle 77.1° Glabellar

Angle 71.4°

Pyriform Angle 56.9°

Maxillary Angle 53.6°

Nasal Area 610.4 mm2 Nasal Area

669.8 mm2

Pyriform Angle 60.5°

Maxillary Angle 64.4°

Adapted from Zimbler MS et al. Facial Plast Surg Clin North Am. 2001;9:179–187.

The  Triangle  of  Youth    Becomes  the  Pyramid  of  Aging…  

Gravitational changes lead to descent of underlying muscle and soft tissue

Carruthers JD et al. Plast Reconstr Surg. 2008;121(5Suppl.):5S–30S.

General  Principles  for  the  Upper  Face  

� Hyperfunctional  rhytides  are  the  most  prominent  feature  in  the  upper  face  � Botulinum  toxin  has  become  the  standard  of  care  for  nonsurgical  upper  facial  rejuvenation  

� Volume  changes  in  the  upper  face  include  deflation  of  the  brow  and  hollowing  of  the  temples    

Elevator/Depressors/Abductors  of  Brows  

Facial muscles responsible for vertical and horizontal glabellar rhytides, forehead rhytides, and brow depression and elevation

Adapted with permission. Fedok FG. Advances in minimally invasive facial rejuvenation. Curr Opin Otolaryngol Head Neck Surg. 2008;16(4):359-368.

Corrugator

Orbicularis Oculi

Procerus

Depressor Supercilii

Frontalis

Carruthers JD et al. Plast Reconstr Surg. 2008;121(5 Suppl):5S–30S.

General  Principles  for  the  Midface  � Key  to  midface  rejuvenation  is  volume  restoration  � Dermal  fillers    � Panfacial  volumizing  agents  

� Malar  contour  should  be  restored  � Treatment  of  malar  area  improves  surrounding  areas,  such  as  NLF  

NLF, nasolabial fold.

Carruthers JD et al. Plast Reconstr Surg. 2008;121(5 Suppl):5S-30S.

 General  Principles  for  the  Lower  Face:  Restoring  Volume    

�  The  primary  goals  are  to  restore  volume,  control  muscle  hypermobility,  and  treat  for  rhytides  

�  View  and  treat  the  lower  face  as  a  whole  rather  than  as  individual  regions  

�  Treatment  with  fillers  is  considered  standard  of  care  �  However,  consider  combination  treatment  with  botulinum  toxin  and  dermal  filler  where  appropriate    

� When  treating  the  lips,  it  is  important  to  consider  shaping  as  well  as  volumizing    

� When  treating    the  perioral  area  with  botulinum  toxin,  avoid  overtreatment  to  prevent  mouth  incompetence  

Carruthers JD et al. Plast Reconstr Surg. 2008;121(5 Suppl):5S-30SC.

Injectable  Botulinum  Toxins    �  Produced  by  various  strains  of  Clostridium  botulinum  �  Seven  known  serotypes  

�  Serotypes  A  and  B  developed  for  clinical  use  �  Serotype  A  

�  OnabotulinumtoxinA  =  BOTOX®  Cosmetic    

�  AbobotulinumtoxinA  =  Dysport™  

 �  IncobotulinumtoxinA  =  Xeomin  ®      

�  Serotype  B  �  rimabotulinumtoxinB  =  MYOBLOC®    

OnabotulinumtoxinA, AbobotulinumtoxinA and IncobotulinumtoxinA are FDA approved for cosmetic use (glabellar lines).

Botulinum  Toxin  Overview  of  products  Product OnA(Botox) AboA (Dysport) IncA (Xeomin) Manufacturer Allergan Ipsen (Europe)

Medicis (USA) Merz Pharmaceuticals

Units per vial 50 or 100 Botox Units (BU) 300 Dysport Units (DU) 50 or 100 Xeomin Units (XU)

Active ingredient (molecular weight)

Botulinum toxin serotype A Complex (900 kDa)

Botulinum toxin serotype A Complex (500-900 kDa)a

Uncomplexed Botulinum toxin serotype A (150 kDa)

Total toxin protein per vial (active toxin + NAPsb)

5 ng 2.61 ng 0.6 ng (in 100 units)

Excipients Human serum Albumin 500 µg NaCl 0.9 mg

Human serum Albumin 125 µg Lactose 2.5 mg

Human Serum Albumin 1 mg Sucrose 4.7 mg

Bacterial Source Clostridium botulinum, Hall strainc

Clostridium botulinum, Hall strainc

Clostridium botulinum, Hall strainc

Storage conditions 2-8°C 2-8°C Up to 25°C Purification process Dialysis and acid

precipitation then vacuum dried

Column chromatography then freeze dried (lyophilized)

Column chromatography then freeze dried (lyophilized)

Cartee, TB, Monheit, G. Clin Plastic Surg 38 (2011) 409–426 a Molecular weight of AboA is not firmly established b Neurotoxin-associated proteins. c There are numerous Hall strains and the manufacturers do not necessarily use identical bacteria.

Botulinum  Toxins  Pre-­‐ExisPng  Neuromuscular  Disorders    

�  Individuals  with  peripheral  motor  neuropathic  diseases,  amyotrophic  lateral  sclerosis,  or  neuromuscular  junctional  disorders  (e.g.,  myasthenia  gravis  or  Lambert-­‐Eaton  syndrome)  should  be  monitored  particularly  closely  when  given  botulinum  toxin    

� Patients  with  neuromuscular  disorders  may  be  at  increased  risk  of  clinically  significant  effects  including  severe  dysphagia  and  respiratory  compromise  from  typical  doses  of  Botox  Cosmetic,  Dysport,  Xeomin  and  Mybloc  

Commonly  Used    Hyaluronic  Acid–Based  Fillers  

Manufacturer/ Distributor

Trade Name Syringe Size

Q-Med/Medicis Aesthetics

Restylane® Restylane®/-L* Perlane®/-L*

0.4 mL,1.0 mL, 2.0 mL 0.5 mL, 1.0 mL

1.0 mL

Allergan Juvéderm® Ultra Plus/XC* Juvéderm® Ultra/XC*

1.0 mL 1.0 mL

Mentor Corporation Prevelle® SILK*

0.9 mL

Anika Therapeutics Hydrelle™*

1.0 mL

All HA fillers approved for NLFs. Restylane approved for submucosal implantation for lip augmentation in patients over 21. *Preparation with lidocaine.

FDA Consumer Health Information. June 26, 2008. Sapijaszko MJA. Skin Ther Lett 2007;12(8):4-7. Sculptra Aesthetic [prescribing information]. Bridgewater, NJ: Sanofi-Aventis; 2009. Narins RS. Dermatol Surg 2008;34:S100-S104. Rossner F et al. Journal Cosmetic Dermatology 2009.14-18 Radiesse Prescribing Information. San Mateo, Calif: BioForm Medical Inc.; 2006 .

Non-­‐HA  SoT  Tissue  Fillers  Collagen  SPmulator  

� Calcium  hydroxylapatite  (Ca  HA)  –  Radiesse  �  Manufactured  by  Merz  Aesthetics  �  Major  mineral  constituent  of  bone  �  >10  years  of  use  in  dentistry  and  reconstructive  surgery  �  Injected  Ca  HA  particles  act  as  a  scaffold  for  new  collagen  �  No  animal-­‐based  ingredients;  skin  testing  is  not  required  �  Over  time,  Ca  HA  particles  slowly  dissolve  into  calcium  and  

phosphate  ions  through  normal  metabolic  processes  

� Indications  �  Moderate  to  severe  facial  wrinkles  (NLF)  �  HIV-­‐associated  lipoatrophy  

 Ca HA = RADIESSE®; PLLA = SCULPTRA®

ComplicaPons:  Botulinum  Toxin  Complication Prevention Treatment

Brow ptosis Avoid treating lower portion of frontalis

Treat brow depressors

Eyelid ptosis Proper injection technique (avoid placement deep and medial to lateral orbital rim)

iopidine drops 0.5%, naphazoline, (Vasocon-A, Naphcon-A, Opcon-A) 1 drop to affected eye for 4–6 hrs as needed

Headache Avoid injection below periosteum

NSAIDs, ibuprofen

Bruising (Hematoma)

Avoid blood vessels Wear magnification when injecting

Glabellar  Necrosis  

Cohen JL. Understanding, Avoiding, and Managing Dermal Filler Complications. Dermatol Surg. 2008;34(S1):S92–S99. Copyright © 2008 by the American Society for Dermatologic Surgery, Inc. Reprinted with permission from John Wiley and Sons.

1 – supratrochlear artery 2 – supraorbital artery 3 – dorsal nasal artery 4 – superficial temporal artery

– infraorbital artery

Tear  troughs  Inappropriate  placement  of  dermal  filler  

�  Nodule  of  filler  product  is  visible  under  this  patient’s  right  eye,  resulting  from  superficial  placement  of  HA*  

�  Superficial  small  linear  threads  of  filler  are  apparent  at  the  left  lower  lid  

Bailey SH, Cohen JL, Kenkel JM. Aesthet Surg J. 2011;31(1):110-121. Copyright © 2011 by The American Society for Aesthetic Plastic Surgery, Inc. Reprinted by Permission of SAGE Publications.

*Restylane

Lip  AugmentaPon  

�  Enhancement  of  vermilion  border  �  Volume  (plumping)  

�  Enhancement  of  tubercles  (upper  lip,  3;  lower  lip,  2)  �  Eversion  

�  Enhancement  of  lip  above  gingivolabial  sulcus  

Cummings CW et al. Cummings Otolaryngology: Head and Neck Surgery. 4th ed. Philadelphia, PA: Elsevier Health Sciences; 2004.

Philtrum Dimple

Philtrum Column

Labial Tubercle Vermilion Border

Labiomental Crease

Labial Commissure

Preven&on  of  ComplicaPons  Secondary  to    Dermal  Filler  InjecPon  -­‐  Ischemia  

�  Inject  slowly  (<0.3  mL/min)  and  with  low  pressure  �  Consider  the  use  of  a  blunt  cannula,  rather  than  syringe  needle  to  prevent  embolic  event  

� Watch  for  danger  signs  such  as  sudden  or  delayed  pain  or  blanching  

                                                 KNOW  YOUR  ANATOMY!  

Carruthers JD et al. Plast Reconstr Surg. 2008;121(5 Suppl):5S–30S. Cohen J. Dermatol Surg. 2008;34:S92–S99. Shanz S et al. Br J Dermatol. 2002;146:928–929. Permission Pending. Kim,YJ, Kim, SS, Song WK, Lee SY, Yoon JS. Opthal Plast Reconstr Surg, 2 011; 27(6): 152_155.

INJECTION Apply ice immediately post-injection

BRUISING, SWELLING, PAIN

(severe)

FOLLOWUP & FURTHER MANAGEMENT •  Follow patient daily for further signs of occlusion/necrosis •  Continue hyaluronidase & 2% nitroglycerin paste as needed •  Continue ASA, antacid & topical oxygen therapy until wound has healed •  If edema progresses begin methylprednisone therapy (Medirol Dose pack) •  Consider hyperbaric therapy for necrosis resistant to above-mentioned treatment

options •  If ischemia is not reversed, contact plastic or reconstructive surgeon

DISCONTINUE INJECTIONS

IF OCCLUSION SUSPECTED

ASSESS FOR OCCLUSION

Presentation

Immediate or early blanching followed by a dusky purple discoloration

OBSERVE (Arnica gel)

TREATMENT •  Massage •  Inject 10 – 30U hyaluronidase per 2x2 cm area

•  Massage 2 % Nitroglycerin Paste into area and apply warm compresses •  Begin 325 ASA (enteric coated) and antacid regimen

•  Initiate antibiotic regimen as needed •  Consider application of topical oxygen cosmeceutical therapy BID

BRUISING

Adapted from Dayan, S, Journal of Drugs & Dermatology

Adapted from Kassir, R, Kolluru A, Kassir M. Dermatol Surg. 2011; 10: 224-231.

RESOLVES WITHIN 30 MINUTES

DISCONTINUE INJECTIONS

OBSERVE

Managing Necrosis Secondary to Dermal Filler Injection

HA  SoT  Tissue  Filler    “Eraser”  �  Hyaluronidase    -­‐  Vitrase  ®  

� Distributed  by  ISTA  Pharmaceuticals  �  Purified    preparation  of  ovine  testicular  hyaluronidase  –  protein  enzyme  

� Modifies  the  permeability  of  connective  tissue  through  the  hydrolysis  of  hyaluronic  acid  

�   Inject  just  beneath  the  HA  depot  �   Hyaluronidase  should  not  be  injected  in  an  area  which  has  been  treated  with  botulinum  toxin  within  the  previous  48  hours  (spread  –  function  of  MOA  of  hyaluronidase)  

�  Indication    �  Adjuvant  to  increase  the  absorption  and  dispersion  of  other  injected  

drugs;  for  hypodermoclysis  and  as  an  adjunct  in  subcutaneous  urography  for  improving  resorption  of  radiopaque  agent  

Vitrase Prescribing Information. Irvine, Calif: ISTA Pharmaceuticals; 2006 RzANy, B, Becker-Wegerich, P, et al. J Cosmetic Dermatol. 2009; 8:317-323.

Thank  you!