Steve Yoelin MD Private Practice Newport Beach

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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 Corrugator supercilii Frown Lines

Wide, Deep Orbit Midface Resorption

Orbicularis Oculi m. Nasolabial Fold Cheek Fat Jowl (Broken Jaw line) Platysma m. Obtuse Cervical Angle Platysma Plus Fat

Jaw Resorption

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

CT Scan Shows Age-Related Decreases in Mean Angular Measurements Female, 25 to 44 years old

Female, ≥65 years old

Glabellar Angle 77.1°

Glabellar Angle 71.4°

Pyriform Angle 60.5°

Pyriform Angle 56.9°

Maxillary Angle 64.4°

Maxillary Angle 53.6°

Nasal Area 610.4 mm2

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

Nasal Area 669.8 mm2

The Triangle of Youth Becomes the Pyramid of Aging…

Gravitational changes lead to descent of underlying muscle and soft tissue Adapted from Zimbler MS et al. Facial Plast Surg Clin North Am. 2001;9:179–187.

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

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

Elevator/Depressors/Abductors of Brows Facial muscles responsible for vertical and horizontal glabellar rhytides, forehead rhytides, and brow depression and elevation Corrugator

Frontalis

Orbicularis Oculi

Procerus Depressor Supercilii

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

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.

Facial Aging: Changes in the Midface Nasojugal Fold

Malar Smile Lines

Nasal Dorsum/Tip Malar Projection

Arcus Marginalis Nasolabial Fold

Orbital/Malar Groove

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

Perioral Rhytides Prejowl Sulcus Marionette Lines Mentalis/Chin Platysmal Bands

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.

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 LambertEaton 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 Q-Med/Medicis Aesthetics

Allergan

Trade Name Restylane Restylane/-L* Perlane®/-L Juvéderm Ultra Plus/XC* Juvéderm Ultra/XC*

Syringe Size 0.4 mL,1.0 mL, 2.0 mL 0.5 mL, 1.0 mL 1.0 mL 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.

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 FDA Consumer Health Information. June 26, 2008. Sapijaszko MJA.®Skin Ther Lett 2007;12(8):4-7. ® Ca HA = RADIESSE ; PLLA = SCULPTRA 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 .

Frontalis Before

At Rest

Animated

= 2.5units AbobotulinumtoxinA = 1.5units AbobotulinumtoxinA

After

Chemical Brow Lift Before

= 4U injection site = 2U injection site

After

50 U onabotulinumtoxinA

Crow’s Feet After (smiling)

Before

15 15 15

45 U of abobotulinumtoxinA

Crow’s Feet (Male) Before

3.5 U of onabotulinumtoxinA per dot 10.5 U per side

After

Jelly Roll (Pretarsal Orbicularis) Photos courtesy of Timothy M. Greco, Greco, MDMD

Before

= 2.5 U onabotulinumtoxinA per side

After

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 Photos courtesy of Charles Boyd, MD

Before

0.5 cc of Juvedérm Ultra Plus XC per side

After

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

1 syringe filler in each earlobe

After

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.

Occluded Artery from Dermal Filler Injection

6 hours post-injection

3 days post-injection

5 days post-injection

11 days post-injection

30 days post-injection (acne bumps apppear)

6 months post-injection

 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

2 yrs 4 months post-injection

Managing Necrosis Secondary to Dermal Filler Injection INJECTION Apply ice immediately post-injection

BRUISING, SWELLING, PAIN

OBSERVE (Arnica gel)

BRUISING

DISCONTINUE INJECTIONS

ASSESS FOR OCCLUSION Presentation

(severe)

Immediate or early blanching followed by a dusky purple discoloration

DISCONTINUE INJECTIONS

IF OCCLUSION SUSPECTED TREATMENT

RESOLVES WITHIN 30 MINUTES

• 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

OBSERVE

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

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 Adapted from Dayan, S, Journal of Drugs & Dermatology

.

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

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!