Hello. I'm Dr. Kavita Mariwalla, Director of Mohs and Dermatologic Surgery at St. Luke's-Roosevelt and Beth Israel Medical Center and Assistant Professor of Dermatology at Stony Brook University. I practice in New York. I'd like to welcome you to this Medscape video lecture titled Rejuvenation of the Upper Face.

Rejuvenation procedures to obtain a more youthful appearance continue to be immensely popular in the United States. In 2010 alone, over 1.3 million hyaluronic acid (HA) injections and over 2.4 million botulinum toxin type A (BoNTA) procedures were performed.

In my experience, very few patients are looking for a completely paralyzed appearance of the face. Instead they're looking for a natural look through procedures with little downtime. Luckily for healthcare practitioners, fillers and neurotoxins provide the tools to improve folds and hollows and ameliorate and soften lines.

Many of my patients seeking treatment for aging often repeat the same phrase, which is that they look in the mirror and don't recognize themselves; the person staring back at them looks older than they themselves feel. Why is that?

There are a number of factors that lead to an aged appearance. Both intrinsic and extrinsic factors augment the aging process. For example, sun exposure can lead to textural changes of the skin, as can smoking. We know that patients with oily skin tend to look younger for longer than patients with dry skin. Similarly we know that there is underlying bony change that occurs with time, which in turn distorts the soft tissue. There is bone loss in the pyriform aperture, which causes a change in the overlying soft tissue of the central face. In the lower face, we know that the mandible grows away from the face with time, which causes soft tissue changes of the jowls and the chin area.

The most practical way to approach changes associated with aging is to think of the face in facial zones or thirds. In this lecture, we are going to focus on the upper third. We will concentrate on horizontal forehead lines, glabellar lines, crow's feet, bunny lines, and loss of volume in the temples and tear trough.

When evaluating the tear trough, it's important to understand the mechanism behind its formation. In 2007, Pessa and Rohrich^[1] evaluated the facial fat pads of cadavers and found that there is a predictable pattern of aging that ultimately leads to loss of volume in the face. There are actually 9 separate fat pads in the middle and upper third of the face, represented here in blue. The malar fat pad is composed of 3 separate compartments: medial, middle, and lateral-temporal cheek. It is important to understand the anatomy and displacement of these fat pads in order to add volume in a natural way.

The tear trough is seen as a depression running beneath the cheek bone, or zygoma, out towards the side of the face. The key event is the sagging or downward displacement of the cheek into the lower portion of the face, a condition referred to as herniation of the cheek fat pad. The malar fat pad descends into the mid face, leaving a hollow beneath the cheek bone. The arcus marginalis ligament and other ligaments of the cheek tether the skin to the higher cheek bone and contribute to the tear trough deformity. But the descent of facial skin and the malar fat pad are the predominant events. These changes create shadowing and give the impression of being tired. Correction through blepharoplasty is probably the best approach, but you can achieve a partial correction through fillers.

Let's take a moment and review some of the more popular fillers that can be used in the upper third of the face.

As a category, hyaluronans are popular among patients and providers alike. HA is abundant in the human dermis. It's a natural polysaccharide polymer that retains water and forms a matrix upon which collagen and elastic fibers develop. There is no protein component. It is hydrophilic and helps hydrate, lubricate, and stabilize connective tissue. Because the structure of HAs is uniform throughout all species, there is a low risk for immune or inflammatory reactions. As skin ages, cells lose the ability to produce their own HA.

As a filler in its natural form, the half-life of HA is 1-2 days. In order to be stable as a filler, it is complexed with HA fibers with cross-linked hydroxyl groups. The cross-linking confers longevity in the skin -- anywhere from 6-12 months.

As a filler, HA can be molded and has a soft look. The mechanism of action is hydration. Believe it or not, HAs can absorb up to 1000 times their molecular weight in water. One of the advantages of HA fillers is that they are not permanent and can be instantly dissolved with hyaluronidase, making them a very good filler for your first-time patients.

Here is an example of a number of the trade names that are available on the market today. The main differences are HA concentration and particle size. Restylane® and Perlane® (Medicis Pharmaceutical Corporation, Scottsdale, Arizona) are 2 trade names of HA fillers that are medium-sized particles of stabilized HA generated by streptococcal bacteria. As I said before, no allergy testing is required and the HA concentration is 20 mg/mL. It's suspended in a buffer at a pH of 7, so patients may report a slight burning sensation when the product is injected.

Both products attract and bind water molecules to help maintain volume, as with all HAs. For Restylane, the duration is approximately 6 months. Perlane is a more viscous product with a larger particle size, and its duration is 6-9 months. Both are now available premixed with lidocaine.

Juvéderm® Ultra and Ultra Plus (Allergan, Inc., Irvine, California) contain 24 mg/mL of HA. This product line is a homogenous gel with the highest degree of cross-linking of any of the HA products, and, therefore, it has a smooth consistency. It is produced by Streptococcus equi bacteria. Again, no allergy testing is required. Ultra Plus has a higher proportion of cross-linked HA. The duration is anywhere from 6-12 months for the Ultra, and Ultra Plus lasts 9-12 months in the skin.

Hylaform® (Genzyme Corporation, Cambridge, Massachusetts) is another commercially available HA product. There are cross-linked molecules of HA that are derived from an avian source: rooster combs. You'll see here the mg/mL of medium-sized particles of hyalin B. It should be noted that persons with a known allergy to avian proteins should not be treated with this product. Again, just like the other HAs, it binds water to enhance volume. The duration is anywhere from 3-6 months.

PREVELLE® Silk (Genzyme Corporation, Cambridge, Massachusetts) is another commercially available HA. Although approved for moderate to severe facial wrinkles, it's often better suited for fine lines. It attracts and binds water, and the duration of this product is about 6 months.

Some of the most common adverse effects of HAs are erythema, edema, and bruising. These are typically transient. Lumps can form, which can be massaged out in the first 24 hours. You can also get the Tyndall effect, which is a bluish color on the skin that occurs when the HA is injected too superficially.

In addition to HAs, there are several semipermanent and longer lasting fillers on the market. You can see them listed here. Synthetic poly-L-lactic acid is sold as Sculptra® Aesthetic (Valeant Pharmaceuticals, Mississauga, Ontario, Canada). It is reconstituted in sterile water 24 hours before use and then lidocaine is added immediately prior to injection.

Radiesse® (Merz Aesthetics, Inc., San Mateo, California) is synthetic calcium hydroxylapatite. We'll talk more about this product in a few minutes. With this product, the practitioner adds lidocaine to the syringe.

Artefill® (Suneva Medical, Inc., San Diego, California) is synthetic polymethylmethacrylate. There is also synthetic silicone, although it should be noted that this product is not approved for cosmetic use.

Calcium hydroxylapatite, sold as Radiesse, is found in humans as a normal component of bones and teeth. This is a mineral complex with a molecular weight of 502 daltons. It has been used as an implant or coating material in dentistry for more than 20 years and has been used to coat prosthetic joint components to assist in fixation to normal bone. During this time, calcium hydroxylapatite has proved to be an inert, reliable, and well-tolerated material.

As a filler, it's suspended in an aqueous gel carrier composed of carboxy methylcellulose, glycerine, and water, which can pass through a 27-gauge needle. When injected, it provides a scaffolding for native soft tissue infiltration. In 2009 alone, there were over 100,000 treatments with Radiesse. Durable results can be seen for up to 12 months. Again, it is mixed with lidocaine by the injector.

There are a number of muscles in the upper third of the face that contribute to facial lines. They are outlined here: the frontalis, the orbicularis oculi, the nasalis, the procerus, and the corrugator supercilii. Neuromodulators will help ameliorate lines by causing a temporary paralysis of these muscles.

Botulinum toxins are key among the neuromodulators and there are several serotypes. However, type A is the one approved for cosmetic use in the United States. Here is a chart showing the current botulinum toxins that are available in the US market.

Botox® Cosmetic is onabotulinumtoxinA. It comes vacuum dried and was approved by the US Food and Drug Administration (FDA) in 2002 for the treatment of moderate to severe glabellar lines in adult patients less than 65 years of age. It should be noted that all other uses are considered off label. Once reconstituted, Botox Cosmetic should be refrigerated.

Dysport® is another popular neuromodulator. Its [generic name is] abobotulinumtoxinA and it comes in 300-unit vials. It is also FDA approved for the treatment of moderate to severe glabellar lines in patients under the age of 65. Once reconstituted, this product should also be refrigerated.

There are some differences between Dysport and Botox. Although they are the same toxin, each product requires its own dosing strategy. Healthcare practitioners who use both products anecdotally report differences in time to onset, duration, and field of effect, although it can vary and true head-to-head clinical trials are few.

The important thing to note is that the strategy for injecting both toxins is the same. As a rule of thumb from published studies, 2.5-3 units of Dysport are proportional to 1 unit of Botox. The common preparation for both neurotoxins is off label and differs from the package insert. Of note, both are commonly reconstituted with preserved saline. They are refrigerated after reconstitution, and a single vial is used for more than 1 patient. It can be used within 1 week of preparation. Dilution volumes vary by practitioner, and we'll review those in our video series.

This is how I do it. For Botox Cosmetic, I dilute with 2.5 mL of saline with preservative. That gives me a concentration of 4 units per 0.1 mL. I typically use anywhere from 2-4 units per injection site. I remove the top from the bottle so that none of the Botox Cosmetic is left in the bottle and wasted.

For Dysport, I use 3 mL of saline with preservative, which gives me a final concentration of 10 units per 0.1 mL. I use 5-10 units per injection site, and I use a 1-mL tuberculin syringe with a 31-gauge needle.

I always take consent and I take a careful patient history. I check for neuromuscular disorders and allergies, for example, to cow's milk and I make sure that patients are not lactose intolerant. I also ask patients if they are pregnant or breastfeeding. I check for bleeding disorders and I also assess if the patient has any facial weakness, such as Bell's palsy, stroke, or underlying ptosis. I take photographs at baseline and I prep the skin with an alcohol pad. I always hold pressure after I inject.

Just a word on medications. There are certain medications that enhance the effects of neuromodulators. These are aminoglycoside antibiotics, calcium channel blockers, and cyclosporine. There are also medications that diminish the effects of neuromodulators, and these include cholinesterase inhibitors.

Of course, there are medications that increase the risk for bruising and bleeding. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), vitamin E, garlic, fish oil, warfarin, clopidogrel, alcohol intake, and prednisone will all increase bruising risks. I actually ask my patients to stop taking alcohol for 72 hours prior to injection. Unless prescribed by a doctor, I ask them to refrain from aspirin and NSAID use. If they have pain during the 2 weeks before injections, I recommend Tylenol® or acetaminophen.

Frown lines are a good place for botulinum toxin use, and these are the wrinkles, lines, or furrows between the eyebrows. Injections should focus on the glabellar complex, namely the corrugator supercilii, the procerus, and orbicularis oculi. Doing so will decrease or eliminate forehead frown lines. It may even lift the central eyebrows. But overall, the patient will look less angry and less aged.

Here is an example of the glabellar complex. This shows the corrugators, which contribute the most to the vertical glabellar lines.

Here you see the procerus, which can give you horizontal glabellar lines, and it is also one of the muscles contributing to the bunny lines.

Our next slide shows the depressor supercilii, which pulls down the medial brow, and then finally the orbicularis oculi, which pulls down the medial and lateral brow.

Again, these are the muscles that are targeted when treating the glabellar complex.

Here is an example of injection points on a typical female patient. As you can see, there are 5 injection points that I like to target when treating vertical forehead lines.

It is important whenever you're treating the glabellar region to assess muscle mass because treatment should be individualized. This is especially important when looking at people who have small or moderate glabellar mass or those who have large muscle mass, such as the difference between men and women. It's important to change the dose accordingly.

Next let's talk about treating the frontalis and the forehead lines. Horizontal lines in the forehead created by the contraction of the frontalis muscle are what most people find concerning. These can be treated, again, with neuromodulators but also with fillers. The result will make the person look calm and relaxed. It's very important to know that if you use too much neurotoxin the patient will appear frozen or glassy.

Treating the frontalis can alter the shape and position of the brow, so it's very important to use low doses and to go carefully and understand the muscle pattern of the frontalis. Classic anatomy is that there are 2 distinct muscle bands that are separated centrally. More commonly, there is 1 broad muscular band with no separation.

In men, it's important to remember that you want to maintain their brow shape, which is low set. Keep muscle mass in mind and be aware of the hairline because the last thing you want to do is inject the lower portion of the frontalis and miss the lines going on in the upper hairline.

In women, placement will alter eyebrow shape. The gull-wing shape is ideal, so you want to keep your injection points well above the brow. Make sure that when you're assessing the patient you're not recruiting the frontalis to actually elevate the eyebrow. Patients may have a weakened levator palpebrae superioris muscle and use the frontalis to keep their eyebrows up. If you inject the frontalis too heavily, you'll actually get a lid lag. These circles represent areas to inject to prevent winging of the lateral brow and are in smaller dosage than the areas in asterisks.

The crow's feet are caused by contraction of the orbicularis oculi muscle coupled with static skin changes. Typically, crow's feet are dynamic rhytides and treating them can be variable. Crow's feet do occur in conjunction with smiling, so care should be taken to stay outside of the orbital rim because if you go inside the orbital rim, the person will experience blurry vision.

It's also important to realize that when patients smile, crow's feet aren't always their main cause of concern. They may be pointing to lines that occur with dynamic smiling action. If you inject too low on the cheek, the patient can develop a facial droop. You can treat with a single depot, which will diffuse, or serial injection points.

Remember that the orbicularis oculi is very superficial. The lateral orbicularis oculi is the largest part of the muscle and is a powerful brow depressor. The horizontal fibers below the eye can cause a lower eye rhytid. When people complain of this, it is possible to do the injection and we'll review that in a minute.

In this slide, you see placement of a single depot shot to treat crow's feet.

Here is an example of multiple injection points.

The infraorbital crease, as we just discussed, is caused by the orbicularis oculi muscle. This is an advanced injection technique and should only be attempted by experienced injectors. If you place too much toxin in the area, it can cause lid lag and ectropion.

To get rid of this crease, you can inject below the lid margin to increase the aperture of the eye. It will also eliminate the lines there. You need a small dose, such as 1 [Botox] unit, and precise placement is necessary. Before injecting here, you should assess the patient's lid snap. You want to make sure that patients don't have a baseline lid lag before injecting here. This slide shows you the injection points, the midpupillary line within 1 mm of the lower eyelid margin.

Bunny lines are caused by contraction of the nasalis muscle and can be seen if chemodenervation is done to the frontalis and glabellar complex. Patients end up smiling with the nasalis. You only need a small dose, 1-2 [Botox] units on both sides.

In this slide, you see our favorite injection points.

Brow lifting is possible when you inject the brow depressors and allow for unopposed brow elevation. It creates a more open eye and a lighter-feeling eyelid. It also can help create an arch. Beware of the shaped appearance of brows at baseline because people often pluck their eyebrows into different formations that may not be what their native eyebrow shape is.

Here I show the Carruthers brow lift. As you can see, there's an injection point at the procerus and into the lateral orbicularis oculi.

Here are injection points for a brow lift with a narrow forehead.

Compare that with a brow lift in someone with a wide forehead.

There is a risk if you are using fillers in the glabella because you can get glabellar necrosis by accidental injection into a vessel. This is important to note because oftentimes neuromodulators alone will not eliminate forehead vertical lines. A little bit of added filler can help, but you have to inject carefully.

Similarly, you can use fillers for the eyebrow area. You can use fillers underneath the eyebrow to give a relative eye lift. This is done by placing fillers directly underneath the eyebrow. You can also do it for static deep set lines near the frontalis near the eyes. Again, make sure that you inject enough so that in motion the person does not look like they have a ropy appearance and that you do not get any Tyndall effect.

You can use some fillers for the crow's feet. As I said before, you don't want neuromodulators too far down on the cheek because you can cause a facial droop. But if you use fillers there, you can create a relative paralysis without that risk. It also helps to give you a cheek augmentation.

In conclusion, neurotoxins play a key role in rejuvenation of the upper face. When used judiciously and with caution, fillers can be adjunctive to neurotoxins. The goal is to create a relaxed appearance that has some movement but no lines at rest.

Thank you for joining us for this Medscape video lecture. Please be sure to watch the accompanying treatment videos before completing the post-test in order to earn credit for this program.