Steve Yoelin MD Private Practice

Newport Beach, California

Disclosures Consulting Fee: Allergan Speakers’ Bureau: Allergan; Medicis Pharmaceutical Contracted Research: Allergan

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.

Facial Aging: Changes in the Midface

Nasojugal Fold

Nasal Dorsum/Tip

Arcus Marginalis

Malar Smile Lines

Orbital/Malar Groove

Malar Projection

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.

Reprinted with permission. Carruthers JD, Glogau RG, Blitzer A; Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies--consensus recommendations. Plast Reconstr Surg. 2008;121(5 Suppl):5S-30S.

Age-Related Changes in the Lower Face Reduced display of upper

teeth and increased display of lower teeth

Decreased vermilion show Hyperfunctional perioral

rhytides

Chin ptosis Jowling Upper lip elongation Lateral commissures droop

Lips

Perioral Rhytides Oral Commissures

Prejowl Sulcus

Mentalis/Chin

Marionette Lines

Platysmal Bands

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.

FDA Recommendations for Health Professionals Using Botulinum Toxins

Understand that dosage strength (potency) in “units” is different among the botulinum toxin products and that clinical dosages expressed in units are not interchangeable from one product to another

Educate patients and caregivers about possible effects following administration of botulinum toxins such as Unexpected loss of strength or muscle weakness Trouble swallowing or breathing Double or blurred vision or drooping eyelids

Understand such effects may present from hours to weeks after injection

Advise patients to seek medical attention for any of these symptoms

Patient Medication Guide To be provided to all patients receiving botulinum

toxin injections Contains description of drug, injection method Spells out potential serious side effects, including

those due to spread of toxin’s effect Incorporates warnings and precautions, including

allergies, concurrent medical conditions and medications

Important Safety Information (class labeling)

Botox Cosmetic, Dysport, and Xeomin (botulinum toxin) may cause serious side effects that can be life threatening. Call your doctor or get medical help right away if you have any of these problems any time (hours to weeks) after injection of Botulinum toxin:

Problems swallowing, speaking, or breathing, due to weakening of associated muscles, can be severe and result in loss of life. You are at the highest risk if these problems are pre-existing before injection. Swallowing problems may last for several months.

Spread of toxin effects. The effect of botulinum toxin may affect areas away from the injection site and cause serious symptoms including: loss of strength and all-over muscle weakness, double vision, blurred vision and drooping eyelids, hoarseness or change or loss of voice (dysphonia), trouble saying words clearly (dysarthria), loss of bladder control, trouble breathing, trouble swallowing.

There has not been a confirmed serious case of spread of toxin effect when botulinum toxin has been used at the recommended dose to treat frown lines

It is strongly recommended that you obtain a written acknowledgement/informed consent from your patient concerning the “Important Safety information

Botulinum Toxins Pre-Existing 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 Soft Tissue Fillers Collagen Stimulator

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®

Frontalis Before After

At Rest

Animated

= 2.5units AbobotulinumtoxinA = 1.5units AbobotulinumtoxinA

Chemical Brow Lift

Before After

50 U onabotulinumtoxinA = 4U injection site = 2U injection site

Crow’s Feet

15

15 15

Before After (smiling)

45 U of abobotulinumtoxinA

Crow’s Feet (Male)

Before After

3.5 U of onabotulinumtoxinA per dot 10.5 U per side

Jelly Roll (Pretarsal Orbicularis)

Photos courtesy of Timothy Greco, MD

Before Photos courtesy of Timothy M. Greco, MD

Before After After

= 2.5 U onabotulinumtoxinA per side

Complications: 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

Tear Troughs

Before After

0.5 cc of Juvedérm Ultra Plus XC per side

Photos courtesy of Charles Boyd, MD

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.

Earlobes

Before After

1 syringe filler in each earlobe

Lip Augmentation

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.

Prevention of Complications Secondary to Dermal Filler Injection - 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.

6 hours post-injection

3 days post-injection

5 days post-injection

11 days post-injection

30 days post-injection (acne bumps apppear)

Patient received .4cc of Calcium hydroxylapatite mixed with 2% xylocaine to her malar region. Discoloration apparent in minutes, injector attributed to xylocaine.

Nitropaste and massage applied a few hours later,

Hyperbaric oxygen for 1 month

Treated with clindamycin 300 qid, empiric valtrex, Xeroform

2 months post injection prescribed cleocin-T and doxycycline

Multiple laser treatments at 3 months post-injection.

Ischemia resolved with minor redness at alar groove

6 months post-injection

2 yrs 4 months post-injection

Occluded Artery from Dermal Filler Injection

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 Soft 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.

Management of Expectations Establish realistic goals (aesthetic and budgetary) Discuss effects of change in one area on other areas of face Photograph all areas of face, not just those undergoing treatment

(standard target and global photographs) Review post-procedure expectations

Bruising, swelling, discomfort, etc Schedule follow-up post-care visit (2 weeks) Pre- and post-treatment photos are invaluable to evaluating

results

Thank you!