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Training for periorbital and upper face treatment with botox and Juvederm

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Training for periorbital and upper face treatment with botox and Juvederm

Training for experienced injectors.

no rights may be derived from this training

Published in: Health & Medicine
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Training for periorbital and upper face treatment with botox and Juvederm

  1. 1. Treating the Periorbital and Upper Face Areas
  2. 2. Contents: Treating the periorbital region Introduction Anatomy of the periorbital region Effects of ageing on the periorbital region Treatment overview Potential complications Injection techniques
  3. 3. The periorbital features are the most scrutinised of the face1 • The upper face is:1,2 - The aesthetic centre of the face - Where we look to estimate age - The region we use to judge a person’s emotional state • The periorbital region is one of the first to show the effects of ageing3 1. Massry GG et al (eds). Master Techniques in Blepharoplasty and Periorbital Rejuvenation. Tan KS Chapter 2. Springer 2011. 2. Perlman SB et al. PLoS One 2009;4(6):e5952. 3. Kranendonk S & Obagi S. Dermatol Surg 2007;33:572–8.
  4. 4. Anatomy of the periorbital region
  5. 5. The skin around the orbita is the thinnest of the face1 • In general, facial skin is thinner in the upper face compared with the lower face region2 • During ageing, skin thickness increases on the forehead and cheeks but decreases in infraorbital areas2 1. Ha RY et al., Plast Reconstr Surg. 2005 May;115(6):1769-73. 2. Pellacani G & Seidenari S, Acta Derm Venereol. 1999 Sep;79(5):366-9. 2.85 1 1 2.192.19 2.78 2.78 3.232.97 3.30 2.02 2.26 2.26 3.14 Skin thickness measurements relative to the upper eyelid1 2.26 *Skin thickness measurements taken from three adult cadavers, two female and one male, aged 51–82 years.1
  6. 6. Facial appearance is influenced by the underlying facial bones1,2 • In general masculine faces have3: – More prominent brow ridges – Differently-shaped orbital rims Frontal bone Nasal bone Zygomatic bone Maxilla 1. Shiffman MA & Di Giuseppe A (eds). Cosmetic Surgery: Art and Techniques. Prendergast PM. Chapter 2. Springer 2012. 2. Standring S et al. Gray’s Anatomy Fortieth Edition (p473–474). Elsevier 2008. 3. Mendelson B & Wong CH. Aesthetic Plast Surg 2012;36(4):753–60.
  7. 7. Repeated action of facial muscles over time leads to development of rhytides1 Frontalis Temporalis Procerus Nasalis Orbicularis oculi Levator labii superioris Zygomaticus minor Zygomaticus major Depressor septi Risorius Orbicularis oris Masseter Depressor anguli oris Mentalis Platysma Corrugator Depressor septi nasi Levator labii superioris aleque nasi Depressor labii inferioris 1. Coleman SR et al. Aesthet Surg J 2006;26(1S):S4–9. 2. Shiffman MA & Di Giuseppe A (eds). Cosmetic Surgery: Art and Techniques. Prendergast PM. Chapter 2. Springer 2013.Figure adapted from Shiffman 20132
  8. 8. Subcutaneous facial fat exists in distinct anatomical compartments1 Lateral orbital compartment Middle forehead compartment Central forehead compartment Nasolabial compartment Lateral temporal-cheek compartment Middle cheek compartment Superior orbital compartment Inferior orbital compartment Medial cheek compartment 1. Rohrich RJ & Pessa JE. Plast Reconstr Surg 2007;119:2219–27. 2. Alghoul M & Codner MA. Aesthet Surg J 2013;33(6):769-82. Image adapted from Alghoul & Codner 20132
  9. 9. Temporaal fat pad Lateraal orbital fat pad Frontaal fat pad Malar fat pad Prejowl fat pad Superieur orbital fat pad Inferieur orbital fat pad Nasolabial fatpad
  10. 10. Temporaal fat pad Lateraal orbital fat pad Frontaal fat pad Malar fat pad Prejowl fat pad Superieur orbital fat pad Inferieur orbital fat pad Nasolabial fatpad
  11. 11. The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery, Rohrich, Rod; Pessa, Jo Plastic & Reconstructive Surgery 2007. inferior temporal septum superior cheek septum
  12. 12. Temporaal fat pad Lateraal orbital fat pad Frontaal fat pads Malar fat pad Prejowl fat pad Superieur orbital fat pad Inferieur orbital fat pad Nasolabial fatpad
  13. 13. The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery, Rohrich, Rod; Pessa, Jo Plastic & Reconstructive Surgery 2007.
  14. 14. Inspection of the vascular structures prior to injecting Superficial temporal vein (parietal branch) Superficial temporal artery (parietal branch) External carotid artery Submental vein Submental artery Mental vein Mental artery Facial vein Facial artery Superficial temporal vein (front branch) Superficial temporal artery (frontal branch) Angular artery Angular vein Transverse facial vein Transverse facial artery Infraorbital artery Infraorbital vein Supratrochlear artery Supratrochlear vein Supraorbital artery Supraorbital vein Standring S et al. Gray’s Anatomy Fortieth Edition (p490). Elsevier 2008.
  15. 15. Effects of ageing on the periorbital region
  16. 16. Bone changes 1. Coleman SR et al. Aesthet Surg J 2006;26(1S):S4–9.
  17. 17. Bone changes 1. Coleman SR et al. Aesthet Surg J 2006;26(1S):S4–9.
  18. 18. The facial muscles are concealed by subcutaneous fullness in youth1 1. Coleman SR et al. Aesthet Surg J 2006;26(1S):S4–9. During ageing, significant loss of subcutaneous volume accentuates the underlying bone and muscle structures1
  19. 19. Eyebrow fat volume increases with age1 • Major component of eyebrow volume is soft tissue/muscle1 • Only 18% of eyebrow volume consists of fat1 • Decrease in soft tissue/muscle volume1 • Significant increase in galeal fat pad1 • 81% of eyebrow volume consists of fat1 21-year-old female* 76-year-old female* * 3D reconstruction analysis using CT scan of the face Image reproduced with permission: Papageorgiou KI et al. Aesthet Sur J 2012;32(1):46-57, published under the Creative Commence license 2.0 CC-BY. 1. Papageorgiou KI et al. Aesthet Sur J 2012;32(1):46-57.
  20. 20. Volume loss is the predominant cause of tear trough deformity1 • Tear trough deformity is a hollow ridge below the eye, which results in a fatigued appearance1 • The underlying cause of tear troughs can be multifactoral, including:1 – Volume loss – Skin laxity 1. Sadick N et al. J Cosmet Dermatol 2007;6(4):218–22. In some patients, dark circles under the eyes can also develop due to prominent subcutaneous venous pooling, pigmentation and changes in skin thickness1
  21. 21. 8 point-lift
  22. 22. Treatment options
  23. 23. Upper facial assessment1,2 • Evaluate at rest and during animation • Assess: – Dynamic and static lines – Position and mobility of brow, eyelid function, and presence of excess skin – Volume loss in the upper face 1. de Maio M, Rzany B. Injectable Fillers in Aesthetic Medicine. 2006. 2. de Maio M, Rzany B. Botulinum Toxin in Aesthetic Medicine. 2009.
  24. 24. BNL/0133/2014|Date of preparation: March 2014 * Treatment of Infraorbital region should start with assessment and treatment of midface region **Juvéderm® VOLUMA® with Lidocaine may also be used to treat the malar groove † with Lidocaine; # Safety must be considered; ‡ Consult DFU for contraindications; § For lines and wrinkles only Midface**: Juvéderm® VOLIFT®† Juvéderm® VOLUMA®† Juvéderm® VOLBELLA®†§ Treatments for the upper face Eyebrows: Juvéderm® VOLIFT®† Forehead: Juvéderm® VOLBELLA®† Juvéderm® VOLIFT®†‡ Glabellar Lines: Juvéderm® VOLBELLA®† Temples: Juvéderm® VOLBELLA®† Juvéderm® VOLUMA®† Juvéderm® VOLIFT®†# 1. DFU for Juvéderm® VOLUMA® with Lidocaine 72475JR11 Revision 2012-09-19. 2. DFU for Juvéderm® VOLIFT® with Lidocaine 72383JR11 Revision 2012-09-24. 3. DFU for Juvéderm® VOLBELLA® with Lidocaine 72526JR10 Revision 2012-12-21. Crow’s feet lines: Juvéderm® VOLBELLA®† Infraorbital*: Juvéderm® VOLBELLA®†, delivered by specialist injectors only1 Diagram for illustrative purposes only
  25. 25. VISTABEL® (Botulinum Toxin Type A)
  26. 26. • Depth with a 30 G ½” needle: – Half needle – Full needle – Upper 1/3 of needle • Dose per point: – 4 U VISTABEL® • Total dose range for area: – 20 U VISTABEL® • Action2: – Procerus muscle: Lowers the medial aspect of the eyebrow; responsible for the horizontal lines – Corrugator muscle (Green medial; yellow lateral): Draws down the medial aspect of the eyebrow; responsible for vertical lines 1. ALFA Injection Guide Consensus, 2013. 2. de Maio M, Rzany B. Botulinum Toxin in Aesthetic Medicine. 2009. VISTABEL: Glabellar lines1 Diagram for illustrative purposes only
  27. 27. BNL/0133/2014|Date of preparation: March 2014 Procerus Depth: Half needle Medial corrugator: Depth: Full needle Lateral corrugator Depth: Upper 1/3 of needle Technical injection recommendations1,2 • Pinch the skin during the injection • Injections angled up and lateral • Glabellar treatment with BOTOX may cause ptosis of the eyelid 1. ALFA Injection Guide Consensus, 2013. 2. Raspaldo H et al. J Cosmet Dermatol. 2011;10:36–50. VISTABEL: Glabellar lines1
  28. 28. VISTABEL: Crow’s Feet Lines1 • Depth with a 30 G ½” needle: – Upper ⅓ of needle • Dose per point: – 4 U VISTABEL® • Total dose range for area: – 24 U VISTABEL® (12 U per side) • Action2: – Orbicularis oculi muscle (orbital part): Protrusion of the eyebrows and voluntary eyelid closure 1. ALFA Injection Guide Consensus, 2013. 2. de Maio M, Rzany B. Botulinum Toxin in Aesthetic Medicine. 2009. Pattern 1 Diagram for illustrative purposes only
  29. 29. VISTABEL: Crow’s Feet Lines1 Technical injection recommendations1,2 • Keep patient’s eyes closed • Avoid superficial vessels • Inject superficially • Avoid inadvertent injection into the upper eyelid • Protect the upper eyelid with your finger • Avoid directing the needle towards the eye All injections in the orbicularis oculi Upper ⅓ of needle 1. ALFA Injection Guide Consensus, 2013. 2. Raspaldo H et al. J Cosmet Dermatol. 2011;10:36–50.
  30. 30. The Juvéderm®VYCROSS™ Collection
  31. 31. VYCROSS™ technology Proprietary mixture9 of1–4: Mostly low molecular weight HA (<1 million Da) Some high molecular weight HA (>1 million Da) The science behind VYCROSS™ Juvéderm® ULTRA range Mostly high molecular weight HA (>1 million Da)*3 *Juvéderm® Ultra range (2, 3, 4 & SMILE) contains small amounts of low molecular weight hyaluronic acid (HA) Cohesivity and gel hardness1,3,8 Before After Crosslinking Before After Crosslinking Water Water BDDE BDDE The tight hyaluronic acid (HA) network results in: • Greater resistance to degradation, delivering longer durationᵻ1,2,5,6 • Minimal gel swelling due to the low water uptake coupled with the lower HA concentration2,3,7 1. Muhn C et al. Clin Cosmet Investig Dermatol. 2012;5:147-158. 2. Callan P et al. Clin Cosmet Investig Dermatol. 2013;6:81-89. 3. Bernardin A et al. Presented at AMEC EMAA 2013. 4. Borrell M et al. J Cosmet Laser Ther. 2011;13:21-27. 5. Raspaldo H. J Cosmet Laser Ther. 2008;10:134-142. 6. Eccleston D, Murphy DK. Clin Cosmet Investig Dermatol. 2012;5:167-172. 7. Data on file. Allergan, Inc., Lab book references RE1301025. 8. Shumate G et al. Presented at ASDS 2013. 9. WO2004/092222A2 patent. ᵻBased on clinical studies showing duration of Juvéderm® VOLUMA®5,2 and Juvéderm® VOLBELLA® with Lidocaine6
  32. 32. Products in the VYCROSS™ Collection can be applied with a low uniform extrusion force1 1. Bernardin A et al. VYCROSS™: An innovative dermal filler technology; poster presentation at AMEC 2013. 2. DFU for Juvéderm® VOLUMA® with Lidocaine 72475JR11 Revision 2012-09-19. 3. DFU for Juvéderm® VOLIFT® with Lidocaine 72383JR11 Revision 2012-09-24. 4. DFU for Juvéderm® VOLBELLA® with Lidocaine 72526JR10 Revision 2012-12-21. Smooth consistency and low extrusion force Juvéderm® Ultra 3 (TSK 27G1/2”) Juvéderm® VOLBELLA® with Lidocaine (TSK 30G1/2”)4 Competitor (30G1/2”) Juvéderm® VOLIFT® with Lidocaine (TSK 30G1/2”)3 Juvéderm® VOLUMA® with Lidocaine (TSK 27G1/2”)2 Extrusion force measured at 50 mm/min. Tests run with recommended needle for product. Displacement (mm) Extrusionforceat50mm/min(N) 0.00 2.00 4.00 6.00 8.00 10.0 12.00 70 60 50 40 30 20 10 0 * Juvéderm® VOLUMA® with Lidocaine7 and Juvéderm® VOLIFT® with Lidocaine8 are contraindicated for treatment of the glabellar lines, crow’s feet lines, tear trough and infraorbital crease.2,3
  33. 33. BNL/0133/2014|Date of preparation: March 2014 • 1 Injection site; 27 G ½” needle − Single bolus; supraperiosteal • Volume range − 0.5–1.0 mL per side − Severe volume loss may require up to 2 mL per side • Technical tips − Avoid the superficial vessels2 − Single bolus requires digital pressure along hairline − Do not inject lower or posterior fossa with the bolus technique 1 1. ALFA Injection Guide Consensus, 2013. 2. Raspaldo H et al. J Cosmet Dermatol. 2012;11:279-289. Temples: Juvéderm® VOLUMA® with Lidocaine Diagram for illustrative purposes only
  34. 34. BNL/0133/2014|Date of preparation: March 2014 1. ALFA Injection Guide Consensus, 2013. 2. Raspaldo H et al. J Cosmet Dermatol. 2012;11:279-289. Temples: Juvéderm® VOLUMA® with Lidocaine Technical injection recommendations1,2 • Digital pressure along hairline for single bolus • Observe visual response • Massage • Subcutaneous injections may lead to irregularities and visible vein congestion after the treatment Injection1: Need to reflux; slow steady injection
  35. 35. BNL/0133/2014|Date of preparation: March 2014 • 2 Injection sites; 30 G ½” needle − Small bolus; deep dermis • Volume range − 0.1–0.2 mL per injection • Technical tips − Be careful of the supraorbital foramen with medial injection − Avoid inadvertent injection into the intraorbital cavity 2 1 ALFA Injection Guide Consensus, 2013. Eyebrow reshape: Juvéderm® VOLIFT® with Lidocaine
  36. 36. BNL/0133/2014|Date of preparation: March 2014 1. ALFA Injection Guide Consensus, 2013. 2. Raspaldo H et al. J Cosmet Dermatol. 2012;11:279-289. Eyebrow reshape: Juvéderm® VOLIFT® with Lidocaine Technical injection recommendations1,2 • Remember to palpate the orbital rim • Protect with the finger to avoid migration into the upper eyelid • Avoid overcorrection of the eyebrow with filler Injection1: Need to reflux; inject slowly; massage upwards
  37. 37. BNL/0133/2014|Date of preparation: March 2014 • 6 Injection sites; 30 G ½” needle − Very small bolus; mid-dermis • Volume range − Up to 0.1 mL per site • Technical tips − Inject at least 1 cm above the eyebrow − Be vigilant to avoid the subcutaneous vessel bundles 1 2 3 4 5 6 ALFA Injection Guide Consensus, 2013. Forehead contour: Juvéderm® VOLBELLA® with Lidocaine Diagram for illustrative purposes only
  38. 38. ALFA Injection Guide Consensus, 2013. Forehead contour: Juvéderm® VOLBELLA® with Lidocaine Technical injection recommendations • Massage is mandatory to deliver a uniform result • Apply pressure for bleeding points Injection 1 Be vigilant to avoid the temporal vessels and nerves Injection 2 Be vigilant to avoid the supraorbital and supratrochlear vessel bundles
  39. 39. Potential complications
  40. 40. Avoiding complications when treating the periorbital region • Excellent knowledge of facial anatomy1,2 • Comprehensive history1 • Assessment of individual’s unique anatomy, under dynamic and resting conditions2 • Appropriate hygiene during treatment • Counselling patient about after- treatment care1 1. Nettar K. Maas C. Facial Plast Surg 2012;28(3):288-93. 2. Carruthers JA et al. J Plast Surg 2008;121;(Suppl)1S-36S.
  41. 41. Danger zone: the infraorbital region1 Infraorbital nerve Facial artery / vein Infraorbital artery / vein Nerves Blood vessels Nerves illustrated in yellow Arteries illustrated in red Veins illustrated in blue Orbicularis oculi muscle Muscles 1cm 1. Vartanian AJ & Dayan SH. Facial Plast Surg Clin N Am 2005;13:1-10.
  42. 42. Glabellar necrosis • Obstruction due to direct injection into vessel1 • Interruption of supply due to compression1 • Glabellar at greatest risk due to small-caliber vessels1 1. Cohen J. Dermatol Surg 2008;34(Suppl 1):S92-9. 2. Weinberg MJ et al. Facial Plast Surg 2009;25(5):324-8. 3. Allergan. VISTABEL® Summary of Product Characteristics, 2014. Image sourced from Cohen J. Dermatol Surg 2008;34(Suppl 1):S92-9. If impending necrosis is suspected: • Immediately treat with hyaluronidase*1 • Massage area to restore blood supply1,2 • Apply warm compresses 1,2 • Begin aspirin + anti-acid2 • Low molecular weight heparin1 Potential complications when treating the periorbital region with neurotoxin include ptosis, eyebrow winging and blurred vision3 * Hyaluronidase is not an Allergan product and is not authorised in all countries.
  43. 43. Tyndall effect • Presents as a bluish hue 1,2 – Visual refraction to the filler through the skin produces bluish hue – Superficial injection with too great a volume 1. Lowe NJ et al. Dermatol Surg 2005;31:1616-25. 2. Weinberg MJ et al. Facial Plast Surg 2009;25(5):324-8. Image sourced from Weinberg MJ et al. Facial Plast Surg 2009;25(5):324-8. Treatment: Administer hyaluronidase* or manually remove the product2 * Hyaluronidase is not an Allergan product and is not authorised in all countries.
  44. 44. Nodules • Superficial injection can lead to hyaluronic acid-related lumps under the skin1 • Injection in areas of previously treated with non-licensed, late or minimally biodegradable products, might also induce nodule or even granuloma formation2 1. Winslow CP. Facial Plast Surg 2009;25(2):124–8. 2. Personal communication: Dr Koenraad De Boulle, Consultant Dermatologist, Belgium. Nodules: Image sourced from Lemperle G et al. Plast Reconstr Surg 2009;123:1842-63. Treatment:2 Consider hyaluronidase* and antibiotic therapy for persistent nodules * Hyaluronidase is not an Allergan product and is not authorised in all countries.
  45. 45. Questions?
  46. 46. Prescribing information Vistabel® (botulinum toxin type A) BE-FR Adverse events should be reported to your local regulatory authority and Allergan office
  47. 47. Prescribing information Vistabel® (botulinum toxin type A) BE-NL Adverse events should be reported to your local regulatory authority and Allergan office
  48. 48. Prescribing information Vistabel® (botulinum toxin type A) NL-NL Adverse events should be reported to your local regulatory authority and Allergan office

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