Steve Yoelin MD Private Practice Newport Beach

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!