Training for periorbital and upper face treatment with botox and Juvederm Training for experienced injectors. no rights may be derived from this training

1. Treating the Periorbital and Upper Face Areas

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. 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. Anatomy of the
periorbital region

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. 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. 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. 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. 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. 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

12. 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

13. 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

14. The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery, Rohrich, Rod; Pessa, Jo
Plastic & Reconstructive Surgery 2007.

15. 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.

16. Effects of ageing on the
periorbital region

18. Bone changes
1. Coleman SR et al. Aesthet Surg J 2006;26(1S):S4–9.

19. Bone changes
1. Coleman SR et al. Aesthet Surg J 2006;26(1S):S4–9.

20. 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

21. 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.

22. 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

23. 8 point-lift

24. Treatment options

25. 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.

26. 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

27. VISTABEL®
(Botulinum Toxin Type A)

28. • 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

29. 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

30. 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

31. 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.

32. The Juvéderm®VYCROSS™ Collection

33. 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

34. 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

35. 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

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.
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

37. 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

38. 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

39. 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

40. 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

41. Potential complications

42. 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.

43. 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.

44. 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.

45. 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.

46. 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.

47. Questions?

48. Prescribing information
Vistabel® (botulinum toxin type A) BE-FR
Adverse events should be reported to your local regulatory
authority and Allergan office

49. Prescribing information
Vistabel® (botulinum toxin type A) BE-NL
Adverse events should be reported to your local regulatory
authority and Allergan office

50. Prescribing information
Vistabel® (botulinum toxin type A) NL-NL
Adverse events should be reported to your local regulatory
authority and Allergan office