Aesthetic Fillers and Botulinum Toxin for Wrinkle Reduction

Introduction

A focal point of attraction, the periorbital region, is one of the first areas of the face to manifest early signs of aging. In youth the forehead is high and gently rounded, the brow well defined and of appropriate height and shape, the upper orbit full, with a crisp upper eyelid crease and a lower lid that transitions smoothly to the cheek. Over time, these smooth contours are lost. Bony changes and atrophy of subcutaneous soft tissues lead to a loss of cutaneous support. It is this loss of skeletal and soft tissue support that has the greatest impact on the appearance of the aging face. As the skin repositions itself over the changing landscape of the face, the brow sinks toward the orbital rim, wrinkles bloom between and around the eyes, and the eye itself takes on a hollow, skeletonized appearance.

The multifactorial nature of aging provides the rationale for a combined, panfacial approach that simultaneously targets loss of support and volume and the appearance of wrinkles as indicated. Rejuvenation of the periorbital region using soft tissue fillers and botulinum neurotoxin type A (BoNTA) restores harmony and balance that has been lost during the aging process. However, the highly innervated and vascularized upper face requires a cautious approach and a deft touch. A thorough knowledge of anatomy and the interaction between musculature and the surrounding soft tissue is the key to consistent, favorable outcomes.

Approach to Periorbital Rejuvenation

The periorbital region is prone to early manifestations of aging. The brow lowers progressively because of loss of structural forehead support (bone and fat), a decrease in neocollagenesis in the skin and facial planes, and the repetitive activity of the depressor muscles pulling on the inelastic skin of the forehead. Mimetic musculature leads to the formation of glabellar rhytides and horizontal lines in the forehead that become more pronounced over time and produces lateral canthal and infraorbital rhytides, while the forehead and temples lose soft tissue fullness. Bony resorption widens the orbital cavity, giving the eye a sunken or shadowed appearance. The upper eyelid—the thinnest skin on the body with little to no subcutaneous fat—is prone to further thinning and stretching, whereas the lower lid is subject to fat redistribution, laxity, and weakening of the connective tissue.

The recognition of volume loss as a cardinal feature of aging has had a significant and lasting impact on the approach to facial rejuvenation with injectable agents. The original treatment paradigm—using fillers or BoNTA separately in clearly delineated areas—has shifted toward more equal use of toxin and fillers in all facial zones with the objective of restoring youthful contours and creating facial proportions that more closely approximate the ideals of beauty. When used in combination throughout the face, neuromodulators and fillers work in synergy to produce optimal and durable aesthetic outcomes. It is an ideal marriage: fillers correct volume loss in the periorbital complex and fill deeper folds and static wrinkles that cannot be alleviated by BoNTA alone.

Anatomical Considerations

The upper face is an area of substantial physical variability and is anatomically unforgiving with respect to safety and aesthetic considerations. A thorough knowledge of periorbital musculature, vasculature ( Fig. 12.16.1 ), and innervation is critical in achieving optimal outcomes and avoiding potentially catastrophic adverse events (see “Precautions” section).

Four muscles—the corrugator supercilii, procerus, depressor supercilii, and orbicularis oculi—work together to cause the head of the brow to rotate medially and descend in the frown. The frontalis, the sole elevator muscle, raises the forehead and eyebrows medially and can elevate the eyelid as high as 5 mm at maximal action. Contraction of the frontalis produces horizontal forehead rhytides. The depressor muscles—the procerus and corrugator supercilii—move the eyebrow medially and downward and contribute to the formation of glabellar rhytides. The orbicularis oculi—the sphincter muscle of the eyelids—is a wide, concentric band of muscle responsible for blinking, eyelid closure, and the production of lateral canthal and lower eyelid rhytides. The orbicularis oculi also contributes to glabellar frown lines and helps lower the brow as part of a protective mechanism of the eye.

The Brow and Temple

The forehead, glabella, and temples are often assessed as one aesthetic unit and treated simultaneously with a combined approach using BoNTA for muscle control and soft tissue fillers to improve temporal hollowing and the contours of the forehead.