Mr Taimur Shoaib, faculty member of the Allergan Medical Institute, discusses the treatment protocol and the training on offer
2014 has been dubbed ‘the year of the eye’ by Allergan, and at the 12th Anti-Aging Medicine World Congress in Monte-Carlo this April, the company will launch a unique new treatment protocol for the periorbital area. Designed to rejuvenate the entire area, safely, effectively and using scientifically proven techniques, this combination approach of botulinum toxin and dermal filler treatments was developed in consultation with twelve leading medical aesthetics practitioners from across Europe. It brings a holistic, individualised and stepwise approach to revitalisation of this most delicate, expressive and important area of the face. A training programme in how to use the new protocol will now be rolled out to over 15,000 medical practitioners across Europe. As a faculty member of the Allergan Medical Institute I am involved in the company’s medical education, and over the course of the next few months I will be conducting training sessions in Scotland and the North of England. There is a clear demand from patients for eye rejuvenation. In a recent survey by Allergan, crow’s feet lines were identified as the most desired area for a facial injectable treatment, with under-eye bags and frown (glabellar) lines ranking closely behind in the top six areas of ageing concern.
Yet treating this area has often been linked with complications. With its thin skin, complex anatomy and intricate nerve structure, the periocular area can be an unforgiving area for treatments with Botox and fillers. As part of the training provided with this new protocol, we will endeavour to show practitioners a safe and effective way of rejuvenating this delicate area. This will include expert guidance on periorbital anatomy, patient assessment, treatment with Allergan’s portfolio of Botox and the Juvéderm Vycross collection, as well as how to avoid complications. Key to the protocol is spreading the treatment over two appointments, with the eye area first treated with Botox followed two to four weeks later with dermal fillers. Allergan’s Botox is the only botulinum toxin now approved for the treatment of moderate-to-severe glabellar lines and crow’s feet lines, either alone or simultaneously, while Vycross is a versatile range of HA dermal fillers which can be used in a tailored way to treat the mid-face, infra-orbital and eyebrow areas. Volbella’s fine texture makes it suitable for the infra-orbital area, while Volift is suitable for mid- deep contouring in the eyebrow or temple. The mid-face deep fat pads can also be safely treated by gentle volumising using Juvéderm Voluma.
Before any treatment, it’s crucial to establish a comprehensive history of the patient. The two most important things we need to discover from our patients is what don’t they like about themselves, and what they are hoping to achieve. I take a full, relevant medical history
too. Have they had treatments before? What treatments have they had? What have the results been like from this treatment? Do they have any allergies, are they otherwise fit and healthy? Are they on any medications? Do they smoke? I will then move on to examine the patient’s periocular area, starting at the forehead and moving down to the eyebrows and then into the eyelid region, moving down to the lower eyelid-cheek junction and down to the midface where the cheek fat pads lie. I then examine the area in the lateral area of the periocular region where there are crow’s feet and the temporal fossa, where our temporal fat pads undergo atrophy as the ageing process occurs. Following this, I will then come up with a tailored programme to address these main areas. On day one, Botox is administered into the glabella at five injection points, with four units given in each of these five injection points, giving a total of 20 units of Botox. One injection is given to the procerus muscle and two injections are given to the corrugator supercilii muscle, one on the left and one on the right: five injection points in total, with each injection approximately 1cm apart.
Botox is also then given to the crow’s feet area, 24 units at three injection points into the lateral vertical fibres of the orbicularis oculi muscle, inferior to the tail of the brow, each injection approximately 1cm apart. Botox starts working after a few days, and has its maximal effect after a couple of weeks. According to Allergan’s clinical studies on the eye area, 59% of subjects were rated by investigators at Day 30 as having none or only mild wrinkles. 87.9% of subjects were rated by investigators as having a 1 grade or more improvement on the Facial Wrinkle Scale at maximum smile on Day 30. Patients continued to show significant improvement at 4 months.
Two weeks later I review the patient and begin the filler treatment. The majority of people benefit from a brow lift and volume restoration in their midface region at the deep malar fat pads. They also benefit from an enhancement of their orbital rim at the inferior border; the tear trough region. Some patients may also require temple fillers to treat temple hollowing. My approach in this case would be to lift the eyebrows using Volift – giving 0.5cc of Volift into the lateral brow region – which would lift the brow by 0.25-0.5cm. I would then administer Voluma into the deep malar fat pads in the mid face, in the cheek region, and Volbella into the tear trough region. Often I would give five injection points of 0.1cc just inferior to the orbital rim. We don’t want to inject into the eyelids as we don’t want to inject into the deeper structures of the periocular region. These exact injection points will be something we’ll show people during the training courses.
I don’t like to give Botox and filler into the same area at the same time. It’s safer to administer these separately as there’s a danger of overfilling or underfilling the areas or seeing too much or too little by way of brow lifting. I also want to see separately the effects of Botox into the muscles around these regions and filler into the fat pads. Following the treatment the patient then needs reviewing again, to ensure the results meet our expectations, and that the patient has no complications. With this protocol we expect the vast majority will have none whatsoever. However, later complications may occur, such as product migration, swelling, product palpability, and product visibility. Dealing with these is addressed as part of the training. Knowledge of the anatomy of the nerves is crucial to avoid injecting into and around the nerves. Knowledge of the blood vessels and what to do if a blood vessel is inadvertently punctured is also vital to avoid bruising. Training is also given in these aspects. Training for the protocol is delivered to a maximum of five participants at a time. Each session begins with presentations on the entire protocol, followed by a demonstration which I would carry out on a model. Participants bring in their own models in order to deliver the treatment themselves.
Patients involved in Allergan’s clinical studies on the eye area claimed that at day 30 they felt they looked younger, more attractive and less tired when treated for crow’s feet lines and glabellar lines simultaneously, versus patients treated for crow’s feet lines alone. I’m very confident that we will be able to train practitioners in the safe and effective delivery of these treatments, minimising side effects and maximising outcomes.
The complementary use of Botox/Vistabel alongside the Vycross filler collection produces soft, natural and elegant results both at rest and during animation. This unique effect is possible due to optimum tissue integration and the mechanical blocking of dynamic lines. This has been shown to be desirable to our patients with high levels of satisfaction. When treating the periorbital region the patient must have a detailed consultation regarding the strategy and possible risks and complications. I usually apply topical anaesthetic cream and use a 32G needle at the tear trough and lid/cheek junction or a 30G cannula when gently subcising the orbicularis retaining ligament. I normally correct to 80-90% of the desired volume to allow for any post-injection swelling or hydrophilic rebound which I would touch up and perfect at two weeks.
The results our patients can expect to enjoy following injection using the periorbital strategy can be summarised in the following endpoints:
Overall we can expect to see a 360 degree improvement in the beauty of the eye and periorbital area.
We are delighted to share this new periorbital protocol and hope that this will enable injectors of all levels to deliver exceptional results using indirect and direct techniques, depending on their personal skill and experience in this area. We now have such sophisticated and versatile products and techniques to help us deliver optimum results whilst significantly reducing adverse events.
I have been involved in training delegates in periorbital injection techniques using the Juvederm filler portfolio over the last four years. The subsequent development in Vycross technology provided the perfect solution for volume correction and lift in this delicate anatomical region. After producing the first tear trough injection strategy, I was given the opportunity to lead the first large scale tear trough study in France alongside Allergan key opinion leaders. This was the foundation for my periorbital injection protocol. To accompany the protocol, we have also filmed an injection video which will be available via the Allergan Facial Anatomy App. The periorbital area is the aesthetic centre of the face and has become a huge focal point of concern for patients. It is where we first show the signs of facial ageing due to changes in the skin, muscle, fat and bony orbit. It is also where we estimate age and assess emotion in others. The challenges when treating the periorbital region are based on the sensitive anatomy and critical structures in this area. In particular, thin fragile skin, orbicularis oculi and it’s retaining ligament, complex vascularity, lacrimal apparatus, lymphatic channels and of course the orbital septum which must never be breached. Side effects such as bruising and swelling are more common here however significant adverse events such as Tyndall, lymphoedema, vascular and visual compromise must be avoided at all costs.
Patient selection is key. I recommend a simple grading tool (mild, moderate, severe). This helps to build an appropriate treatment plan including product selection and appropriate volumes. The protocol starts with the licensed use of Botox / Vistabel in the glabella and crows feet to promote a more open and refreshed orbital show. Two weeks later we follow with the Vycross collection in the following points:
This case study shows a 29-year-old actress and model who takes good care of her face and body. The patient had noticed for 12 months that she had dark circles and sunken eyes. This affected her casting and modelling, despite using different eye make-up products. Simple, accurate and low volume treatment has given her full correction of the tear trough. The patient now comments that she looks better without make-up.
This case study shows a 31-year-old who had a six- month-old baby at the time. The patient complained of “tired eyes” due to lack of sleep, despite always being complimented on being very beautiful. Her treatment opened the orbital show and gives a look of serenity and being rested, which has restored her confidence.
This case study shows a 35-year-old (then) bride-to-be. The patient had experienced ‘eye bags’ since childhood, but had noticed them worsening over the past three years. The patient had previously been for a blepharoplasty consult but was told she was too young. The patient was getting married in six months and wanted to look her best. Careful strategic placement of product in the cheek, tear trough and lid cheek junction masks the presence of the eye bag by ‘raising the sea level around the island’.
This case study shows a 37-year-old sportsman. The patient has an athletic physique with low body fat percentage. Facial fat is minimal and gives a gaunt appearance. This was a complex case using sequential treatment to delicately restore midfacial and periorbital volume to promote a healthy and vibrant look.