Classification of periorbital wrinkles and treatment with Botulinum Toxin Type A

Received on: 03/01/2011
Approved on: 10 / 05/2011

This study was carried out at the authors’
private practices in São Paulo, Brazil.

Conflict of interests: none
Financial support: none

Abstract

Introduction: Periorbital wrinkles are an important component of facial aging that can be minimized with botulinum toxin treatment.
Objective: To treat periorbital wrinkles through botulinum toxin injections in the orbicularis muscle, using classic lateral points and additional points in the lower eyelid, which were developed based on the classification of these wrinkles.
Methods: Clinical and photographic data from 530 patients who had periorbital wrin- kles classified and treated between 2002 and 2007 were analyzed.
Results: Thirty percent of patients over 45, and 80% of those under 45, demonstrated complete improvement of the wrinkles after treatment in the classic points. The remaining patients needed treatment in the additional points in the lower eyelids.
Conclusion: The classification of wrinkles helped improve treatment. Despite the considerable benefit offered by injecting in the classic points, the necessity of treating additional points in the lower eyelids with botulinum toxin was verified. The presence of subcutaneous cellular tissue and the patient''''''''s age should also be taken into consideration.

Keywords: AGING, EYELIDS, CLASSIFICATION

INTRODUCTION

Dynamic wrinkles, which result from the muscular activi- ty linked to facial mimicry, are an important component of facial aging, along with photoaging, cutaneous sagging and vol- ume alterations caused by osseous and subcutaneous tissue reab- sorption. 1,2

The systems and scales classifying and standardizing facial wrinkles have been useful not only in assisting in the choice for the best individualized treatment, but also in comparing results among different treatments that are also used in the preparation of scientific investigation protocols. 3

With regard to dynamic wrinkles, several studies have been published suggesting classification systems for the glabellar, 4 nasal, 5 and frontal 6 regions.

Dynamic palpebral wrinkles are a frequent complaint from patients. They are mainly caused by the hyperactivity of the orbicularis oculi muscle of the eyelid, whose contraction can be effectively prevented by using botulinum toxin type A (BoNTA), a neurotoxin produced by the Clostridium botu- linum bacterium which blocks the release of acetylcholine in the neuro-muscular junction. 7

The classic application points for treating periorbital wrin- kles using (BoNTA) are well known. (BoNTA) administration using the classic application points mainly acts on the orbicularis oculi muscle, lateral to the external canthus. According to Carruthers and other authors, 8,9 three classic points are utilised for the application of BT in this region. Such points are distrib- uted between the brow and the zygomatic arch, the distance between each being 0.5–1 cm. They are located between 1 and 2 cm from the bone border, forming a semi-circle.

Notwithstanding, the orbicularis oculi eye muscle is circu- lar and the majority of its insertion points are located in the soft tissues, which allow it to work as the sphincter muscle of the eyelids. Therefore, unlike other muscles which have osseous insertion points that can be fully relaxed with only one applica- tion point, the orbicularis oculi muscle will not be fully relaxed if only one of its insertion points is blocked. As a result, addi- tional application points of BT into this muscle – in addition to those in the lateral region – have been developed over the last few years.

Based on some of the common features of palpebral wrin- kles and with the objective of obtaining better aesthetic results from the application of BT, the authors devised a treatment for the orbicularis oculi muscle, based on a classification system for periorbital wrinkles, which includes the classic lateral points together with additional ones located in the lower eyelid.

METHODS

A prospective, longitudinal, analytical study was carried out. The effects of BoNTA on the wrinkles of the periorbital region were assessed by means of clinical examination and pho- tographic documentation in 530 patients treated at the authors'''''''' private practices from 2001 to 2007. The study was carried out in accordance with the ethical principles set out in the Declaration of Helsinki 2000.

A detailed understanding of the regional anatomy, particu- larly of the orbicularis oculi muscle, was instrumental for the study''''''''s objective. This anatomical structure is located immedi- ately below the epidermis, in an area where subcutaneous tissue is either scarce or absent. It has the shape of an elliptical muscu- lar sheet subdivided into three parts: (a) the pars orbitalis arises in the frontal process of the maxilla and in the nasal process of the frontal bone, and surrounds the opening of the orbit and inserts close to the origin. It covers the orbital margin and con- nects to several fibers of the frontalis muscle; (b) the pars palpe- bralis begins in the medial palpebral ligament, passes through each eyelid and inserts into the lateral palpebral raphé; (c) the pars lacrimalis (or Horner''''''''s muscle) arises in the posterior lachrymal crest, in the pre-septal medial portion, passing behind the medial palpebral ligament and crossing the lachrymal sac to join the palpebral portions (Figure 1). Other authors subdivide this muscle into two parts: palpebral and orbital. 10

The zygomaticus major and minor muscles are also impor- tant since they can be involved in the interesting muscular com- plex of the periocular region. They arise in the malar bone (the zygomaticus major laterally and the zygomaticus minor medial- ly,) and insert into the orbicular muscle of the mouth (the orbicularis oris muscle). 11 If incorrectly relaxed by an injection of BT in the palpebral region, these muscles can cause undesir- able asymmetries in the perioral region. Therefore, both muscles must identified correctly.

Based on observations of the anatomical details and muscle dynamics in these patients, and considering the specific charac- teristics of individual patients, the authors developed the follow- ing classification system for the wrinkles of the periorbital region (Figure 2):

Type I – Wrinkles lateral to the external canthus of the eye, extending from the brow to the zygomatic arch

Type II – Wrinkles lateral to the external canthus of the eye, extending from the line of the external canthus of the eye to the zygomatic arch (absence of wrinkles in the superior lateral region)

Type III – Presence of wrinkles in the line of the external canthus only

These three types of wrinkle can occur together with:

A – Absence of lower eyelid wrinkles

B – Presence of lower eyelid wrinkles, according to the following sub-classification:

B1 – Lateral wrinkles

B2 – Medial wrinkles

B3 – Wrinkles in the internal canthus

Patients included in the study were observed and classified according to this system and possible combinations thereof. Patients were asked to move their facial mimicry by forcing a smile, to allow the identification of the exact position of the orbicularis oculi muscle. Additionally, the lateral border of the orbicular bone was palpated. After classification of the wrinkles was carried out, standardized photographs were taken of all patients, both when the orbicularis oculi muscle was at rest and when it was contracting. One hundred units of BoNTA (Botox®; Allergan, Inc., Irvine, CA, USA) were diluted in 2 ml of saline solution and 30G × 1/2" needles were used to inject the toxin.

The initial application was made in three points for Type I patients, in two points for Type II patients and in a single point for Type III patients, with 2–3 units of BoNTA being injected into each point.

When a fourth point, below the three classic points, was needed to achieve the desired effect, the exact insertion point of the zygomatic muscles was measured and BoNTA was applied superficially (2 mm deep) to avoid asymmetries in the perioral region.

At the second follow-up visit, 1 month after initial appli- cation, when wrinkles in the lower eyelid were identified, doses of 0.5–1.0 unit of BT were applied in additional points, accord- ing to the location of the wrinkles (Figure 3):

Type B1: This was observed in the lateral region of the lower eyelid and, after palpation of the orbicularis oculi muscle on the zygomatic arch, was treated with an intradermal injec- tion of BoNTA into the point located 1 cm medially and infe- riorly in relation to the most caudal point of Types I or II.

Type B2: This was observed in the medial region of the lower eyelid and treated with an intradermal injection into the point located between the ciliary border and the orbital border, in the mid-pupillary line.

Type B3: This was observed in the medial and inferior region in relation to the internal canthus of the eye, becoming noticeable when the pars palpebralis of the orbicularis oculi muscle exerts a more evident contraction than that of the pars orbitalis; it was treated with intradermal injection into a point located 5 mm below the internal canthus of the eye, in the cen- ter of the contraction area.

In some cases, a few wrinkles persisted in the external can- thus of the eye, within the orbital border . In those cases, 0.5 unit of BoNTA was injected into the dermis, between the external angle of the eye and the external margin of the orbital border.

All patients were clinically assessed and analyzed using standardized photographs taken before treatment and 30 days after each treatment session.

RESULTS

The ages of the 530 patients ranged from 27 to 55 years (average: 49 years), with 280 patients older than 45 and 250 younger than 45 (Figure 4). Ten percent were of Asian origin, 0.1% were of Afro-Brazilian origin, 89% were white, and 90% were women.

Eighty percent of patients younger than 45 (200) and 30% of patients over the age of 45 (84) presented total improvement of the wrinkles after the first session (Graph 1). The remaining patients needed treatment in the additional points of the lower eyelid, with the number of units and points varying according to the individual patient (Graph 2).

Patients with no palpable subcutaneous tissue mainly pre- sented Type I-B1, Type I-B2 or Type I-B3 wrinkles. Individuals with palpable subcutaneous tissue mainly presented Type II, infrequently combined with B1 or B2. The anatomical differ- ence between the presence and absence of palpable subcuta- neous tissue was more important than age. The most frequent complications were local pain (5%), edema (4%), ecchymosis (1%), and pseudo-herniation of fat (0.1%).

DISCUSSION

The classic points of BoNTA injection, as described by Carruthers in 1998, are located in the lateral portion of the orbic- ularis oculi muscle. 8 Despite being very useful in the treatment of wrinkles, they occasionally are not enough to achieve a success- ful outcome, therefore leading to the search for improved results.

In 2000, Talarico described cases of patients in which the external canthus of the eye and the superior line of implanta- tion of the ear were unusually distant from each other and required a second line of points intercalated with the three clas- sic points. 12

Different classification systems for dynamic wrinkles in dif- ferent facial regions have been published, leading to an impor- tant advance in obtaining better results with BoNTA applica- tion. 4-6

Additionally, in-depth study of facial anatomy ensures that safety is maintained when injecting BoNTA, which causes tem- porary chemical denervation of the neuromuscular junction fibers.

In addition to a detailed understanding of the different parts of the orbicularis oculi muscle, further important anatom- ical regions must also be detected and considered when treating this region, namely the orbital rim (which must always be located by means of palpation), the infrapalpebral skin, and the insertion points of the zygomaticus major and minor muscles.

Based on anatomical studies of the palpebral region, on the perception of how the muscular system of each individual patient is structured and works, and on the data from patients who needed additional injection points (in addition to the clas- sic points), the authors developed a classification system mainly aimed at the treatment of the wrinkles in the lower eyelid.

In 2003, Kane published a classification of periorbital wrinkles, which, however, did not comprise the lower eye- lid.13Flynn described a point located 3 mm below the cilia of the lower eyelid, in the medial region of the lower eyelid, , in the region of the pre-septal orbicularis oculi muscle, taking the midpupillary line as reference, , with a view to increasing the ocular opening. The result of the BoNTA injection into this point is very good. However, if the patient presents a flaccid periocular musculature and excess or ptosis of the inferior peri- orbicular fat tissue, those features can become even more evi- dent. 14 The point developed to treat B2 wrinkles is also located in the midpupillary line, but in a more inferior location.

In order to avoid the undesirable effects of BoNTA appli- cation in the palpebral region, careful clinical examination and critical analysis of the medical history of the patient, which focuses on several important features – such as the existence of visible adipose tissue in the infraorbital region, the presence of sagging in the muscle or at the edge of the eyelid, the patient complaining about ocular edemas – are fundamental.

If any of these important features apply, the authors do not recommended that BoNTA is applied to the lower eyelids, since this could lead to a worsening of the condition.

Additionally, the precautions that must be taken when treating the palpebral region by injecting BoNTA are very important. With regard to the classic points, the substance should be applied laterally to the orbital rim; in the infrapalpe- bral points the injection must be made into the superficial der- mis to avoid paralysis of the oculomotor muscle and, in turn, the needle must always be directed against the ocular conjunctiva, to avoid undesired traumas.

Other observations that ensure the safety of this procedure are: the number of points and units, according to individual variations, and small doses and volumes.

In the present study, we demonstrated that the classification of wrinkles and the use of the classic points, together with new, additional ones, in the lower eyelid brought considerable bene- fits to patients. The results improved as the skills acquired with practical experience minimized any side effects.

As well as needing additional sites for the application of BoNTA, it was also observed that the presence of subcutaneous cellular tissue in the region and the patient''''''''s age are important factors that should be taken into account.

Finally, physicians should inform the patient that, in spite of the application of BoNTA in several points, its isolated use frequently does not eliminate all periorbicular wrinkles, and that the combination of additional procedures to obtain the best possible results is often necessary.

Patients do not always identify or complain about wrinkles in the region where the additional points are located, however, the application of BT in those sites can lead to surprisingly good aesthetic results.

Finally, the clinical pearl is that most wrinkles can be easi- ly treated. Nevertheless, the anatomical dynamics and intrinsic facial mimicry, as well as the presence of subcutaneous fat and the quality of skin and muscle tone may require additional points so that the best results can be achieved.

CONCLUSIONS

The classification of wrinkles allows for a better treatment outcome. In spite of the great benefit brought about by the identification of the classic points, the authors verified the need for treating additional points with BoNTA. The age of the patient and the presence of subcutaneous cellular tissue must also be taken into account.

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