Peri-Orbital Rejuvenation for the Fourth and Fifth Decades
April 2003
M any patients in their fourth, fifth and later decades start to express concerns about lateral canthal rhytides and accentuation of lower eyelid folds and herniation of fat pads in lower eyelids. The aging process is often accentuated in the periorbital region with the appearance of fat that bulges beneath the orbital membrane/septum into the lower eyelids, producing “bags.” These changes are inherent in the skin, muscularis, orbital septum, underlying fat and lid support structures.
In the last article of this series (January 2003, Skin & Aging), we presented the typical intervention you might use for periorbital upper eyelid aging process in patients in their thirties and forties.1 Here, let’s focus on rejuvenation of the lower eyelids and periocular dynamic rhytides or “crow’s feet.”
Available Techniques
A number of techniques to address the excess skin and bulging fat have been described in the literature,2 including lower eyelid skin flap technique, skin muscle flap technique and transconjunctival technique of blepharoplasty.
While the first two techniques are percutaneous approaches to excise excess skin and/or fat, their main disadvantage is the visible scarring in the infraorbital area. On the other hand, the transconjunctival technique avoids cutaneous scarring, carries a lower incidence of complications and shorter procedure time, thus making it our technique of choice. This approach is ideal for patients with excess fat and minimal excess skin. Patients with excess skin are left with marked skin laxity, rhytides and pigmentation abnormalities.
In our experience transconjunctival blepharoplasty with ultrapulsed CO2 laser resurfacing addresses many of the shortcomings related to the skin excess encountered with transconjunctival approach alone. Similarly, the ultra pulsed CO2 resurfacing of the periorbital area has a dramatic effect on reducing the static rhytides.
Moreover, the dynamic rhytides in the periorbital region can be effectively treated with Botulinum toxin type A (Botox), and provide a youthful appearance to the aging face.
Pre-Operative Evaluation
During a pre-operative consultation, discuss patient’s history, concerns and expectations, and limitations of the procedure. For the physical examination, focus on the degree of bulging fat, skin excess, periorbital rhytides and pigment abnormalities. Use these factors to formulate a customized approach for each patient.
For the blepharoplasty procedure, we require clearance from an ophthalmologist or optometrist with respect to range of motion, tearing and visual fields. If the patient plans to have the surgical procedure done under conscious sedation then the patient should be cleared by their primary care physician. This involves routine lab work, including CBC with differentials, chemistries, coagulation profile, EKG and chest X-ray and any other work-up the patient’s doctor deems appropriate.
After this is completed, the patient is seen in a pre-operative appointment and these evaluations are reviewed, patient’s questions are addressed and photographic documentation is obtained.
Transconjunctival Blepharoplasty Technique
Prior to surgery, examine the patient while he or she is in a seated position and mark the fat pockets. The procedure can be done under local anesthesia or conscious sedation, which we prefer. If local anesthesia is preferred, use several drops of Tetracaine 0.5% ophthalmic solution (Cetacaine) to anesthetize the conjunctiva and cornea, and gently place a medium sized corneal shield well lubricated with bacitracin ointment (AK-Spore) to protect the cornea during the blepharoplasty procedure.
During this procedure, your assistant should expose the fat with gentle pressure. The assistant should stretch the upper eyelid at the medial and lateral canthi gently to protect the cornea and put gentle pressure on the globe while everting the lower eyelid with the other hand. This maneuver bulges the lower eyelid conjunctiva with underlying fat pads transconjunctivaly.
Injection of local anesthesia into the exposed conjunctiva follows. Inject lidocaine 1% with 1:100,000 epinephrine at the incision site, which should be made approximately 6 mm to 7 mm below the lid margin, or approximately 2 mm below the caudal margin and 4 mm medially below the inferior punctum.
Perform the conjunctival incision with a No. 15 blade, battery operated cautery, CO2 laser or Ellman radiosurgical needle. The benefits of the last two are that bleeding is controlled while cutting. A central incision exposes all three fat pads.
Identification of the fat pockets and inferior oblique, at times, can be difficult. Light globe pressure will cause the fat to bulge and aid in proper identification. The fat pads lay just above the inferior oblique muscle.
Carefully examine medial and central fat compartments prior to cutting and cauterizing to avoid damage to inferior oblique muscle. The fat should be removed in a lateral to medial order. You can aid the fat removal by gently lifting the fat above the intraorbital rim with forceps and dissection cautery resection, clamping and cutting the fat with cold steel, followed by cauterization of the stalk, coagulation, radiowave, or CO2 laser.
Hemostasis must be achieved meticulously to avoid retrobulbar bleeding, which can result in blindness. At the end of the procedure, irrigate the field with bacteriostatic saline. No sutures are needed. Check the apposition at the conjunctival and return the lower eyelid to its natural position. After fat resection, assess the symmetry.
Blindness, as mentioned above, is a rare but serious complication.3 It occurs at a frequency of about 0.04%.4 The blindness may be caused by the retrobulbar hemorrhage compromising the vascular supply to the optic nerve. Signs and symptoms include onset of acute and severe pain, progressive swelling and ecchymosis, proptosis and visual impairment. Seek immediate ophthalmologic consultation if you encounter this complication.
Other complications include diplopia, caused by injury to inferior oblique or inferior rectus muscles, excess fat removal, residual fat, lid malposition and dry eye syndrome.
Skin Flap and Skin Muscle Flap Techniques
Although not favored by us, some surgeons still use these techniques to address the excess skin and bulging lower eyelid fat pads. Both techniques involve a cutaneous incision about 1.5 mm to 2 mm below the lower lid margin that extends from just lateral to the punctum to about 2 mm beyond the lateral canthus and then slightly downward to end at the orbital rim in a smile line.
After the incision is made, undermine the skin in the plane superior to the orbicularis muscle up to the orbital margin and any fat pads that need to be removed, excise by making an incision in the orbicularis muscle just superior to the inferior orbital rim. In the skin muscle flap technique, use blunt-tipped scissors to penetrate the orbicularis muscle to the sub-orbicularis space and bluntly dissect the muscle from the orbital septum to the orbital rim. Remove the fat, as described. Excise the excess skin in skin flap techniques, and the excess skin and muscle in the skin muscle flap technique. Use a 6-0 nylon suture to close the wound. Don’t excise too much skin — it will result in ectropion.
CO2 Resurfacing
We routinely perform CO2 laser resurfacing of the lower eyelid following lower eyelid fat pad resection. We prefer the ultrapulsed CO2 laser over any other resurfacing modality because of its ability to tighten the underlying skin, it’s precision, simplicity and safety profile.5 The technique was detailed in the last article of this series.1 The excellent ability of ultrapulsed CO2 laser to tighten the redundant skin after the fat pad removal makes it a valuable adjunct to transconjunctival blepharoplasty.
Botox
Patients with markedly deep rhytides/muscle bundling with smiling at the lateral canthi, can benefit from Botox. Despite its FDA approval for glabellar lines, it’s most useful for its ability to markedly reduce the lateral canthal folds/kinetic rhytides (crow’s feet).
Botox Cosmetic is available in a 100 U vacuum-dried form. Using preservative-free normal saline, a dilution of 2.5 ml is recommended by the manufacturer, but a range of dilutions are effective.6 After the product is reconstituted, the manufacturer recommends using it within 4 hours, although many physicians use it within 24 hours, and some claim it to remain effective up to a week if refrigerated.7
Don’t treat patients with a history of neuromuscular disorder or who are pregnant or lactating, or anyone with a sensitivity to albumin with Botox. Since aminoglycosides can potentiate the effects of Botox, use caution when using these antibiotics with Botox.
The dosages of Botox usually recommended can be found elsewhere.7 Botox should be injected into the muscles causing the skin lines.
For the glabellar area, treat by injecting into procerus, medial corrugators and orbicularis oculi muscles. Treat crow’s feet by injecting the toxin into lateral periorbital orbicularis oculi muscle, 1.5 cm lateral to orbital rim at the level of canthus and slightly medial and inferior to previous injection. This muscle can be localized if the patient squints. Forehead lines can be treated if the patient raises his/her eyebrows and you inject the muscle creases with multiple, equal, small injections about hairline to 1 cm above the eyebrows. You may have to modify this in patients with brow ptosis.
The recent availability of botulinum toxin B (Myobloc) apparently has no advantage. In fact, Botox is less painful, about 100 times more potent on a unit to unit basis and longer lasting.8 In our opinion, the only situation where Myobloc may find a use, is in cases where Botox has lost its effectiveness due to antibody production in response to repeated use of botulinum toxin A.
Choosing the best option
In many younger patients with slight laxity of the lower eyelid skin, only ultrapulsed CO2 laser resurfacing may defer the need for lower blepharoplasty. On the other hand, in patients with marked lower eyelid fat pad herniation, transconjunctival blepharoplasty combined with CO2 laser resurfacing affords the patients with excellent cosmetic results.
M any patients in their fourth, fifth and later decades start to express concerns about lateral canthal rhytides and accentuation of lower eyelid folds and herniation of fat pads in lower eyelids. The aging process is often accentuated in the periorbital region with the appearance of fat that bulges beneath the orbital membrane/septum into the lower eyelids, producing “bags.” These changes are inherent in the skin, muscularis, orbital septum, underlying fat and lid support structures.
In the last article of this series (January 2003, Skin & Aging), we presented the typical intervention you might use for periorbital upper eyelid aging process in patients in their thirties and forties.1 Here, let’s focus on rejuvenation of the lower eyelids and periocular dynamic rhytides or “crow’s feet.”
Available Techniques
A number of techniques to address the excess skin and bulging fat have been described in the literature,2 including lower eyelid skin flap technique, skin muscle flap technique and transconjunctival technique of blepharoplasty.
While the first two techniques are percutaneous approaches to excise excess skin and/or fat, their main disadvantage is the visible scarring in the infraorbital area. On the other hand, the transconjunctival technique avoids cutaneous scarring, carries a lower incidence of complications and shorter procedure time, thus making it our technique of choice. This approach is ideal for patients with excess fat and minimal excess skin. Patients with excess skin are left with marked skin laxity, rhytides and pigmentation abnormalities.
In our experience transconjunctival blepharoplasty with ultrapulsed CO2 laser resurfacing addresses many of the shortcomings related to the skin excess encountered with transconjunctival approach alone. Similarly, the ultra pulsed CO2 resurfacing of the periorbital area has a dramatic effect on reducing the static rhytides.
Moreover, the dynamic rhytides in the periorbital region can be effectively treated with Botulinum toxin type A (Botox), and provide a youthful appearance to the aging face.
Pre-Operative Evaluation
During a pre-operative consultation, discuss patient’s history, concerns and expectations, and limitations of the procedure. For the physical examination, focus on the degree of bulging fat, skin excess, periorbital rhytides and pigment abnormalities. Use these factors to formulate a customized approach for each patient.
For the blepharoplasty procedure, we require clearance from an ophthalmologist or optometrist with respect to range of motion, tearing and visual fields. If the patient plans to have the surgical procedure done under conscious sedation then the patient should be cleared by their primary care physician. This involves routine lab work, including CBC with differentials, chemistries, coagulation profile, EKG and chest X-ray and any other work-up the patient’s doctor deems appropriate.
After this is completed, the patient is seen in a pre-operative appointment and these evaluations are reviewed, patient’s questions are addressed and photographic documentation is obtained.
Transconjunctival Blepharoplasty Technique
Prior to surgery, examine the patient while he or she is in a seated position and mark the fat pockets. The procedure can be done under local anesthesia or conscious sedation, which we prefer. If local anesthesia is preferred, use several drops of Tetracaine 0.5% ophthalmic solution (Cetacaine) to anesthetize the conjunctiva and cornea, and gently place a medium sized corneal shield well lubricated with bacitracin ointment (AK-Spore) to protect the cornea during the blepharoplasty procedure.
During this procedure, your assistant should expose the fat with gentle pressure. The assistant should stretch the upper eyelid at the medial and lateral canthi gently to protect the cornea and put gentle pressure on the globe while everting the lower eyelid with the other hand. This maneuver bulges the lower eyelid conjunctiva with underlying fat pads transconjunctivaly.
Injection of local anesthesia into the exposed conjunctiva follows. Inject lidocaine 1% with 1:100,000 epinephrine at the incision site, which should be made approximately 6 mm to 7 mm below the lid margin, or approximately 2 mm below the caudal margin and 4 mm medially below the inferior punctum.
Perform the conjunctival incision with a No. 15 blade, battery operated cautery, CO2 laser or Ellman radiosurgical needle. The benefits of the last two are that bleeding is controlled while cutting. A central incision exposes all three fat pads.
Identification of the fat pockets and inferior oblique, at times, can be difficult. Light globe pressure will cause the fat to bulge and aid in proper identification. The fat pads lay just above the inferior oblique muscle.
Carefully examine medial and central fat compartments prior to cutting and cauterizing to avoid damage to inferior oblique muscle. The fat should be removed in a lateral to medial order. You can aid the fat removal by gently lifting the fat above the intraorbital rim with forceps and dissection cautery resection, clamping and cutting the fat with cold steel, followed by cauterization of the stalk, coagulation, radiowave, or CO2 laser.
Hemostasis must be achieved meticulously to avoid retrobulbar bleeding, which can result in blindness. At the end of the procedure, irrigate the field with bacteriostatic saline. No sutures are needed. Check the apposition at the conjunctival and return the lower eyelid to its natural position. After fat resection, assess the symmetry.
Blindness, as mentioned above, is a rare but serious complication.3 It occurs at a frequency of about 0.04%.4 The blindness may be caused by the retrobulbar hemorrhage compromising the vascular supply to the optic nerve. Signs and symptoms include onset of acute and severe pain, progressive swelling and ecchymosis, proptosis and visual impairment. Seek immediate ophthalmologic consultation if you encounter this complication.
Other complications include diplopia, caused by injury to inferior oblique or inferior rectus muscles, excess fat removal, residual fat, lid malposition and dry eye syndrome.
Skin Flap and Skin Muscle Flap Techniques
Although not favored by us, some surgeons still use these techniques to address the excess skin and bulging lower eyelid fat pads. Both techniques involve a cutaneous incision about 1.5 mm to 2 mm below the lower lid margin that extends from just lateral to the punctum to about 2 mm beyond the lateral canthus and then slightly downward to end at the orbital rim in a smile line.
After the incision is made, undermine the skin in the plane superior to the orbicularis muscle up to the orbital margin and any fat pads that need to be removed, excise by making an incision in the orbicularis muscle just superior to the inferior orbital rim. In the skin muscle flap technique, use blunt-tipped scissors to penetrate the orbicularis muscle to the sub-orbicularis space and bluntly dissect the muscle from the orbital septum to the orbital rim. Remove the fat, as described. Excise the excess skin in skin flap techniques, and the excess skin and muscle in the skin muscle flap technique. Use a 6-0 nylon suture to close the wound. Don’t excise too much skin — it will result in ectropion.
CO2 Resurfacing
We routinely perform CO2 laser resurfacing of the lower eyelid following lower eyelid fat pad resection. We prefer the ultrapulsed CO2 laser over any other resurfacing modality because of its ability to tighten the underlying skin, it’s precision, simplicity and safety profile.5 The technique was detailed in the last article of this series.1 The excellent ability of ultrapulsed CO2 laser to tighten the redundant skin after the fat pad removal makes it a valuable adjunct to transconjunctival blepharoplasty.
Botox
Patients with markedly deep rhytides/muscle bundling with smiling at the lateral canthi, can benefit from Botox. Despite its FDA approval for glabellar lines, it’s most useful for its ability to markedly reduce the lateral canthal folds/kinetic rhytides (crow’s feet).
Botox Cosmetic is available in a 100 U vacuum-dried form. Using preservative-free normal saline, a dilution of 2.5 ml is recommended by the manufacturer, but a range of dilutions are effective.6 After the product is reconstituted, the manufacturer recommends using it within 4 hours, although many physicians use it within 24 hours, and some claim it to remain effective up to a week if refrigerated.7
Don’t treat patients with a history of neuromuscular disorder or who are pregnant or lactating, or anyone with a sensitivity to albumin with Botox. Since aminoglycosides can potentiate the effects of Botox, use caution when using these antibiotics with Botox.
The dosages of Botox usually recommended can be found elsewhere.7 Botox should be injected into the muscles causing the skin lines.
For the glabellar area, treat by injecting into procerus, medial corrugators and orbicularis oculi muscles. Treat crow’s feet by injecting the toxin into lateral periorbital orbicularis oculi muscle, 1.5 cm lateral to orbital rim at the level of canthus and slightly medial and inferior to previous injection. This muscle can be localized if the patient squints. Forehead lines can be treated if the patient raises his/her eyebrows and you inject the muscle creases with multiple, equal, small injections about hairline to 1 cm above the eyebrows. You may have to modify this in patients with brow ptosis.
The recent availability of botulinum toxin B (Myobloc) apparently has no advantage. In fact, Botox is less painful, about 100 times more potent on a unit to unit basis and longer lasting.8 In our opinion, the only situation where Myobloc may find a use, is in cases where Botox has lost its effectiveness due to antibody production in response to repeated use of botulinum toxin A.
Choosing the best option
In many younger patients with slight laxity of the lower eyelid skin, only ultrapulsed CO2 laser resurfacing may defer the need for lower blepharoplasty. On the other hand, in patients with marked lower eyelid fat pad herniation, transconjunctival blepharoplasty combined with CO2 laser resurfacing affords the patients with excellent cosmetic results.
M any patients in their fourth, fifth and later decades start to express concerns about lateral canthal rhytides and accentuation of lower eyelid folds and herniation of fat pads in lower eyelids. The aging process is often accentuated in the periorbital region with the appearance of fat that bulges beneath the orbital membrane/septum into the lower eyelids, producing “bags.” These changes are inherent in the skin, muscularis, orbital septum, underlying fat and lid support structures.
In the last article of this series (January 2003, Skin & Aging), we presented the typical intervention you might use for periorbital upper eyelid aging process in patients in their thirties and forties.1 Here, let’s focus on rejuvenation of the lower eyelids and periocular dynamic rhytides or “crow’s feet.”
Available Techniques
A number of techniques to address the excess skin and bulging fat have been described in the literature,2 including lower eyelid skin flap technique, skin muscle flap technique and transconjunctival technique of blepharoplasty.
While the first two techniques are percutaneous approaches to excise excess skin and/or fat, their main disadvantage is the visible scarring in the infraorbital area. On the other hand, the transconjunctival technique avoids cutaneous scarring, carries a lower incidence of complications and shorter procedure time, thus making it our technique of choice. This approach is ideal for patients with excess fat and minimal excess skin. Patients with excess skin are left with marked skin laxity, rhytides and pigmentation abnormalities.
In our experience transconjunctival blepharoplasty with ultrapulsed CO2 laser resurfacing addresses many of the shortcomings related to the skin excess encountered with transconjunctival approach alone. Similarly, the ultra pulsed CO2 resurfacing of the periorbital area has a dramatic effect on reducing the static rhytides.
Moreover, the dynamic rhytides in the periorbital region can be effectively treated with Botulinum toxin type A (Botox), and provide a youthful appearance to the aging face.
Pre-Operative Evaluation
During a pre-operative consultation, discuss patient’s history, concerns and expectations, and limitations of the procedure. For the physical examination, focus on the degree of bulging fat, skin excess, periorbital rhytides and pigment abnormalities. Use these factors to formulate a customized approach for each patient.
For the blepharoplasty procedure, we require clearance from an ophthalmologist or optometrist with respect to range of motion, tearing and visual fields. If the patient plans to have the surgical procedure done under conscious sedation then the patient should be cleared by their primary care physician. This involves routine lab work, including CBC with differentials, chemistries, coagulation profile, EKG and chest X-ray and any other work-up the patient’s doctor deems appropriate.
After this is completed, the patient is seen in a pre-operative appointment and these evaluations are reviewed, patient’s questions are addressed and photographic documentation is obtained.
Transconjunctival Blepharoplasty Technique
Prior to surgery, examine the patient while he or she is in a seated position and mark the fat pockets. The procedure can be done under local anesthesia or conscious sedation, which we prefer. If local anesthesia is preferred, use several drops of Tetracaine 0.5% ophthalmic solution (Cetacaine) to anesthetize the conjunctiva and cornea, and gently place a medium sized corneal shield well lubricated with bacitracin ointment (AK-Spore) to protect the cornea during the blepharoplasty procedure.
During this procedure, your assistant should expose the fat with gentle pressure. The assistant should stretch the upper eyelid at the medial and lateral canthi gently to protect the cornea and put gentle pressure on the globe while everting the lower eyelid with the other hand. This maneuver bulges the lower eyelid conjunctiva with underlying fat pads transconjunctivaly.
Injection of local anesthesia into the exposed conjunctiva follows. Inject lidocaine 1% with 1:100,000 epinephrine at the incision site, which should be made approximately 6 mm to 7 mm below the lid margin, or approximately 2 mm below the caudal margin and 4 mm medially below the inferior punctum.
Perform the conjunctival incision with a No. 15 blade, battery operated cautery, CO2 laser or Ellman radiosurgical needle. The benefits of the last two are that bleeding is controlled while cutting. A central incision exposes all three fat pads.
Identification of the fat pockets and inferior oblique, at times, can be difficult. Light globe pressure will cause the fat to bulge and aid in proper identification. The fat pads lay just above the inferior oblique muscle.
Carefully examine medial and central fat compartments prior to cutting and cauterizing to avoid damage to inferior oblique muscle. The fat should be removed in a lateral to medial order. You can aid the fat removal by gently lifting the fat above the intraorbital rim with forceps and dissection cautery resection, clamping and cutting the fat with cold steel, followed by cauterization of the stalk, coagulation, radiowave, or CO2 laser.
Hemostasis must be achieved meticulously to avoid retrobulbar bleeding, which can result in blindness. At the end of the procedure, irrigate the field with bacteriostatic saline. No sutures are needed. Check the apposition at the conjunctival and return the lower eyelid to its natural position. After fat resection, assess the symmetry.
Blindness, as mentioned above, is a rare but serious complication.3 It occurs at a frequency of about 0.04%.4 The blindness may be caused by the retrobulbar hemorrhage compromising the vascular supply to the optic nerve. Signs and symptoms include onset of acute and severe pain, progressive swelling and ecchymosis, proptosis and visual impairment. Seek immediate ophthalmologic consultation if you encounter this complication.
Other complications include diplopia, caused by injury to inferior oblique or inferior rectus muscles, excess fat removal, residual fat, lid malposition and dry eye syndrome.
Skin Flap and Skin Muscle Flap Techniques
Although not favored by us, some surgeons still use these techniques to address the excess skin and bulging lower eyelid fat pads. Both techniques involve a cutaneous incision about 1.5 mm to 2 mm below the lower lid margin that extends from just lateral to the punctum to about 2 mm beyond the lateral canthus and then slightly downward to end at the orbital rim in a smile line.
After the incision is made, undermine the skin in the plane superior to the orbicularis muscle up to the orbital margin and any fat pads that need to be removed, excise by making an incision in the orbicularis muscle just superior to the inferior orbital rim. In the skin muscle flap technique, use blunt-tipped scissors to penetrate the orbicularis muscle to the sub-orbicularis space and bluntly dissect the muscle from the orbital septum to the orbital rim. Remove the fat, as described. Excise the excess skin in skin flap techniques, and the excess skin and muscle in the skin muscle flap technique. Use a 6-0 nylon suture to close the wound. Don’t excise too much skin — it will result in ectropion.
CO2 Resurfacing
We routinely perform CO2 laser resurfacing of the lower eyelid following lower eyelid fat pad resection. We prefer the ultrapulsed CO2 laser over any other resurfacing modality because of its ability to tighten the underlying skin, it’s precision, simplicity and safety profile.5 The technique was detailed in the last article of this series.1 The excellent ability of ultrapulsed CO2 laser to tighten the redundant skin after the fat pad removal makes it a valuable adjunct to transconjunctival blepharoplasty.
Botox
Patients with markedly deep rhytides/muscle bundling with smiling at the lateral canthi, can benefit from Botox. Despite its FDA approval for glabellar lines, it’s most useful for its ability to markedly reduce the lateral canthal folds/kinetic rhytides (crow’s feet).
Botox Cosmetic is available in a 100 U vacuum-dried form. Using preservative-free normal saline, a dilution of 2.5 ml is recommended by the manufacturer, but a range of dilutions are effective.6 After the product is reconstituted, the manufacturer recommends using it within 4 hours, although many physicians use it within 24 hours, and some claim it to remain effective up to a week if refrigerated.7
Don’t treat patients with a history of neuromuscular disorder or who are pregnant or lactating, or anyone with a sensitivity to albumin with Botox. Since aminoglycosides can potentiate the effects of Botox, use caution when using these antibiotics with Botox.
The dosages of Botox usually recommended can be found elsewhere.7 Botox should be injected into the muscles causing the skin lines.
For the glabellar area, treat by injecting into procerus, medial corrugators and orbicularis oculi muscles. Treat crow’s feet by injecting the toxin into lateral periorbital orbicularis oculi muscle, 1.5 cm lateral to orbital rim at the level of canthus and slightly medial and inferior to previous injection. This muscle can be localized if the patient squints. Forehead lines can be treated if the patient raises his/her eyebrows and you inject the muscle creases with multiple, equal, small injections about hairline to 1 cm above the eyebrows. You may have to modify this in patients with brow ptosis.
The recent availability of botulinum toxin B (Myobloc) apparently has no advantage. In fact, Botox is less painful, about 100 times more potent on a unit to unit basis and longer lasting.8 In our opinion, the only situation where Myobloc may find a use, is in cases where Botox has lost its effectiveness due to antibody production in response to repeated use of botulinum toxin A.
Choosing the best option
In many younger patients with slight laxity of the lower eyelid skin, only ultrapulsed CO2 laser resurfacing may defer the need for lower blepharoplasty. On the other hand, in patients with marked lower eyelid fat pad herniation, transconjunctival blepharoplasty combined with CO2 laser resurfacing affords the patients with excellent cosmetic results.
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