Facial rejuvenation offered to eye-care patients

May 1, 2008

Facial rejuvenation procedures can be worthwhile adjuncts to an ophthalmology practice. Surgeons, however, require detailed knowledge of products and anatomy, must make patient education a priority, and should obtain specific training. Patients undergoing cosmetic procedures often have very high expectations, and it is important to have an in-depth understanding of aesthetic facial anatomy and features.

Key Points

Baltimore-Facial rejuvenation procedures performed with injectables such as botulinum toxin type A (Botox, Allergan) and nonanimal stabilized hyaluronic acid (NASHA) gel (Restylane, Medicis Aesthetics) are worth incorporating into the ophthalmology practice as adjunctive procedures, said Michael P. Grant, MD, PhD, FACS, during a presentation at the Current Concepts in Ophthalmology meeting here. Success with facial aesthetics depends on the ophthalmologist's knowledge of the products, the limitations and complications of those products, a detailed knowledge of the anatomy of the region being treated, and well-informed and educated patients, he said.

During his presentation, Dr. Grant, who is an assistant professor of ophthalmology and plastic surgery, oculoplastics division, Wilmer Eye Institute, Johns Hopkins University, Baltimore, described currently available products for noninvasive facial rejuvenation.

Botulinum toxin

Injections with botulinum toxin are the most common cosmetic procedures performed, accounting for 20% of the total and more than 2 million procedures each year. In the ophthalmic arena, botulinum toxin is FDA-approved for treatment of blepharospasm and strabismus. A recent indication that seems promising includes injection into the temporalis muscle to treat migraine headaches, Dr. Grant said. The mechanism of action is blockage of neurotransmitter release at the neuromuscular junction.

Despite several medical applications, botulinum toxin is best known for its cosmetic application, which is what most likely will attract patients, Dr. Grant said. "The goal of using [botulinum toxin] is not just to inject wrinkles. What you really want to do is think about redistributing tissue by selective chemodenervation."

Knowledge of anatomy is important to perform selective paralysis of the antagonist muscles, Dr. Grant added. For example, the frontalis muscle is the primary elevator in brow lifts, whereas the lateral orbicularis and corrugators are the depressors. The procerus muscle and medial head of the orbicularis oculi muscle are subcutaneous, whereas the depressor supercilii and corrugator supercilii muscles are deep.

"Just by knowledge of the anatomy of this area, you can produce a very striking effect on the patient," he said.

After injection, botulinum toxin treatment takes effect in 3 to 5 days, and it will last, on average, 3 to 4 months. Complications with treatment usually are associated with either the technique or the compound. Anaphylaxis, a compound-related complication, is extremely rare, Dr. Grant said. Only about seven cases have been reported in the literature. Problems associated with technique include asymmetry, eyelid or brow ptosis, and excess lateral brow elevation, whereas the injection may cause bruising and headaches.

Dermal fillers

Although popular, botulinum toxin now shares the spotlight with dermal fillers, Dr. Grant said. Use of those fillers has grown tremendously, he said, and they may displace surgery as a facial rejuvenation modality over the next 10 years. Those compounds fill in lines, restore lost volume, and soften facial folds.

NASHA gel was the first filler to receive FDA approval (2003) and clearly showed superiority to collagen, Dr. Grant said. The newer hyaluronic acid compound (Juvéderm, Allergan), approved in 2006, is more similar to NASHA gel than the other available fillers, and Dr. Grant said he finds the two interchangeable.

NASHA gel is indicated for mid-to-deep dermal injection for correction of moderate-to-severe wrinkles. The performance and potential complications of this and other fillers depend on particle size, composition, and depth of injection.

Potential complications related to all of the hyaluronic acid injectables include allergic or inflammatory responses to the product. Such complications are rare, however, he said. Lumps and contour deformities may occur as a result of problems with technique, such as overly superficial injections. Bruising, erythema, vascular occlusion, and tissue necrosis also have been reported.

Dr. Grant also discussed calcium hydroxylapatite, a next-generation dermal filler made of calcium-based microspheres suspended in a water-based gel. It is indicated for vocal fold augmentation and facial fat loss in people with human immunodeficiency virus. Calcium hydroxylapatite produces both an immediate correction by adding volume and a longer-term correction resulting from the development of scaffolding for the growth of new tissue. This produces a longer-lasting fill than other products and may last 2 to 4 years, Dr. Grant said.

An infrequent complication associated with calcium hydroxylapatite is the appearance of nodules that may require steroid treatment or surgical intervention, he said.

The meeting was held at Johns Hopkins University and was co-sponsored by Ophthalmology Times.