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I would like to introduce you to Mike, who is 32 years young. Let’s start by performing a full face assessment. When we look at the shape of his face, we can see that essentially it is rectangular, which is ideal for a male face shape. However, on closer inspection, we do see that although he has good width at the level of his cheeks, by the time we get down to his jaw, he starts to taper in towards the chin. Ideally, for a man, we should have a jaw width which is the same as the cheek width. We will look at this in closer detail when we analyse the thirds.
So let’s begin by analysing the upper third from the trichion to the glabella, we will notice that at rest we can see some static lines in the forehead and the frown region, between the eyebrows. If we get Mike to animate by first of all raising his eyebrows, we can see that he has some strong dynamic lines, particularly in the central part of his forehead. When he relaxes, we notice that his right eyebrow is asymmetric, in that it is elevated both at rest and on animation. This is a really important sign to pick up, because if we do not pick it up before treatment, we may not adjust our parameters, which means that we could exacerbate the asymmetry by causing a greater elevation on the right and a depression of the eyebrow on the left.
Now let’s get Mike to frown. When he frowns, we will notice that he has a strong and complex frown and he appears to be slightly more dominant on his left side with the left corrugator pushing the brow all the way over into the midline. He also has a strong procerus, causing a transverse crease on the radix of the nose. From the lateral profile we can see he has a good convexity of his forehead, from the trichion all the way down to his glabella region.
Let’s now look at Mike’s midface, from the glabella to the subnasale region. Here we can see, as we would expect in a young man, a youthful fullness from the lateral to the anterior cheek. This is in keeping with his age, and there is no treatment indication in this region. However, when he smiles, we notice he has a very strong contraction of his orbicularis. This results in significant collapse of the lateral orbital region and his palpebral aperture is virtually closed. Accordingly, he would be a very good candidate here for treatment with botulinum toxin to preserve the eye opening.
Muscle anatomy markings
Let’s have a look at some of the surface anatomy of the muscles involved in upper face botulinum toxin treatments. The first muscle we will look at is the frontalis muscle, and frontalis originates from the galea aponeurotica and then inserts into fibres of the procerus, corrugator, and orbicularis oculi muscles near the eyebrows. The action of the frontalis is a brow elevator. It is important to notice that it is the only brow elevator in this region, accordingly if we over treat this muscle, we can get some brow ptosis. In some patients, there is a galea in the midline and an absence of muscle fibres in this location.
In terms of the lateral extent of the frontalis muscle, if we palpate the temporal fusion line, or temple crests, usually found at the outer third of the eyebrow, it’s very rare to have frontalis fibres lateral to this point. Accordingly, we normally inject within the temporal fusion lines on the sides of the face. The next muscle to look at is the procerus. The procerus arises from fascia, arising from the nasal bone and nasal cartilage. The fibres ascend vertically and insert into the lower fibres of the frontalis muscle and also the skin in between the eyebrows. Its action is one of a brow depressor and when it contracts it will bring the heads of the eyebrows down. You will notice the transverse crease across the bridge of the nose, this is due to procerus activity.
The next muscle we have is the corrugator supercilii. The corrugator arises from the superciliary arch of the orbital rim, and the fibres ascend at a 30 degree angle to insert into the dermis after passing through fibres of the frontalis. When we contract the corrugator, we will often see a little dimple near the insertion of the corrugator in the dermis.
Finally, we have the orbicularis oculi muscle. The orbicularis oculi muscle has three parts; a preseptal and pretarsal part, which are involved in involuntary blink movements of the eye, and then there are also the orbital fibres, which are involved in voluntary eye closure. The orbicularis oculi is a very thin muscle just under the skin. If the patient forcibly closes their eyes, you will notice that as the muscle is radially orientated, it forms lateral canthal lines which are perpendicular to the muscle fibres like the spokes of a wheel. We can also get the same lines forming when a patient smiles excessively. Accordingly, we treat the muscle for excessive crow’s feet formation.
We can also see the zygomaticus major muscle here, which originates from the maxilla and inserts into the modiolus and is an elevator of the corner of the mouth. Because the origin of the zygomaticus major is very close to the lower portion of the crow’s feet, we have to be very careful injecting in this area. If we are too deep with our injection, and we do manage to get some migration of product onto the zygomaticus major, the patient may end up with a smile asymmetry where one side will rise normally, and the other side will be affected.
Injection site markings and treatment
I want to show you how we make the markings for our injection points for botulinum treatment in the upper face. Take a line from one medial canthus to the opposite head of brow and repeat on the other side. Where these diagonal lines intersect is the first injection point for the procerus muscle. Next, we need to mark the point for the head of corrugator. We do this by taking a vertical line up from the medial canthus, palpate the muscle above the orbital rim, especially while the patient is frowning, and just a centimetre above the orbital rim we can make a second mark for the head of corrugator. Next, we need to repeat this on the other side, and if we have done this properly, we should usually find that there is an equilateral triangle formed. Finally, we need to make the injection points for the insertion of the corrugator, so palpate along the orbital rim, and just before the mid-pupillary line, we will make two additional markings, approximately a centimetre above the orbital rim. We end up with a ‘v’ shaped configuration for our injection points.
In treating Mike’s forehead lines, we need to remember that his right brow is hyperkinetic. Accordingly, the first treatment point for his frontalis will be lower than the subsequent points. All the remaining points are then drawn in a horizontal line, and this is quite typical in a male patient treatment. This is because we want to preserve the flat, horizontal nature of the brow. In a female patient, we would choose a ‘v’ or an ‘m’ shaped pattern.
Now we move on to the markings for the crow’s feet, for which we can take a reference point from the lateral canthus. Because his crow’s feet extend from inferior right up to the tail of the brow, we will use three points. The first one is just a finger’s breadth outside the lateral canthus, then we have a superior point and an inferior point at an approximately 30 degree inclination. We repeat this on the other side, however, do be aware that patients may have considerable difference from one side to the other.
We will begin by injecting the procerus: I pinch the skin with my thumb and forefinger, and then I will introduce the syringe needle and inject deep. Once I have got the full length of the needle through the skin, I will begin by injecting 6 units in this region. Next we will inject the head of the corrugator, I use my finger to protect the orbital rim and prevent diffusion and pinch the muscle between my finger and thumb, and inject deep onto bone, about 6 units. I will repeat this on the right side. It is important with the head of corrugator injection to ensure that we are injecting sufficiently deep as the muscle has a deep, bony origin. We use 6 units in this location as well.
When we move onto treating the lateral corrugator, or the insertion, we change the orientation so we come in very superficially, and these injections are intradermal blebs. This is because the insertion of the corrugator is into the skin. If we are too deep with these injections, we actually inject the toxin behind the corrugator, affecting the levator palpebrae, which can cause a lid ptosis.
When I treat the frontalis muscle, my preference is to inject at an intradermal depth. This is because the muscle is so adherent to the skin that the Botox can diffuse through easily, and this is more comfortable for the patient. I am injecting 2 units at each one of these dots, and I suspect this may not be enough for Mike as he is a young man with very strong muscle activity, however, I can always add more in at review if I need to. If I inject too much, and he ends up with a frozen forehead, he will not thank me for this.
When we treat the crow’s feet, it is a good idea to stand on the opposite side of the patient, turn the patient’s face, and always angle the needle and syringe away from the eye, that way if there is inadvertent movement, we are always in a safe position, I like to stretch the skin, and you will notice that the angle of entry of the needle is very superficial. These injections ought to be intradermal, as the orbicularis oculi muscle is very closely adherent to the skin in this region. After placing these three injections, we also have to be very careful in the lower pole not to inject deep, because we may affect the zygomaticus major. I now repeat the same treatment on the other side, and you will notice I have changed my position, so I am standing on the opposite side again. As previously, I am stretching the skin, and all my injections are very superficial and I am aiming for intradermal deposition of the Botox. I am using 4 units in each one of these locations, and as with the frontalis, it is highly possible that the dose I am using with Mike will not be enough, but if I need to, I can always add in more when I see him for review approximately 2 weeks after treatment.
Treatment outcome at 6 weeks
This is Mike 6 weeks after his treatment and you can see he has a very fresh look about him, with his static lines diminishing considerably in his upper face. If I ask Mike to frown, you will notice that he still has a flicker of movement, but compared to his frown pre-treatment, it is considerably less complex and less extreme than before treatment. If I get Mike to raise his eyebrows, again, he has good movement, but we will see that compared to before we treated him, he has considerably less dynamic lines. However, he is still maintaining some movement. This is the ideal balance to achieve with botulinum toxin treatment.
Now, we will get him to smile, and you can see he has a very natural and pleasing smile that maintains his eyes in an open position. Prior to treatment, when he had a big smile, he was getting almost collapse, especially of the lateral orbital portion, resulting in his eyes looking practically closed. Now, on full smile, his eyes remain open, which is of course far more pleasing to the eye. Finally, I will look at Mike in the front and turn him to the side, where I am already looking at a very nice definition of his jawline, and a good anterior projection of his chin, therefore compared to pre-treatment, he has a much stronger character and a stronger profile than before we treated him. So, in Mike, we have managed to achieve an impactful yet natural treatment with combination botulinum toxin and fillers. We have also managed to significantly enhance his masculinity.