Facial Aesthetics Using Botulinum Toxin and Dermal Fillers

Part 2 - Treatment of lips, forehead and eyes

Instructors:

Bob Khanna, DDS

Bob Khanna, DDS

Professor Bob Khanna is a Cosmetic and Reconstructive Dental Surgeon. He runs successful clinics in Ascot and Reading and carries out a full spectrum of treatments from Aesthetic Dentistry, Surgical Implantology and bone regeneration procedures to full mouth rehabilitation.

Dr. Khanna demonstrates the use of dermal fillers around the lips for treatment of oral rhytids and botulinum toxin for use in a non-surgical forehead lift.

We have Bobbi with us today and chief complaints for Bobbi are that she's not happy with her lips. She feels that they're starting to lose that luster which of course most ladies would like to retain for as long as possible. She feels that they're starting to develop these little lines. We often refer to this incorrectly as smoker's lines because of course Bobbi doesn't smoke. But she has the little lines. These little creases essentially in her upper lip and lower lip. In addition to treading the lips, Bobbi has asked me to treat her upper forehead region which is a commonly asked for area. In Bobbi's case, you'll see this asymmetry of the brows. So in Bobbi's case which is very typical, we can see the appearance of the furrows even at rest. And we can see that of course this essentially gives rise to negativity or negative expression to other human beings in nonverbal communication. And so it's very typical for us to have to treat this area and it's very much in demand. Also what we'd like to do is reduce and soften some of the lineage in her forehead region, the horizontal creases. And so what I'm going to do is actually administer botulin toxin in all those areas to address them. I'll also work around the eyes because of course whilst we like to see laughter lines we don't like to see them at rest. So I'm going to just soften them, maybe blunt them a little bit so that we can retain some of Bobbi's wonderful character but at the same time rejuvenate her. As you can see these little creases that give the appearance of an aged appearance to the lips and of course we want to rejuvenate and hydrate this area. What I'm going to do is mark up a number of areas. I always like to mark the top of the cupid bow. This is very important to be able to align yourself during treatment. So it's a nice little trick just to be always constantly remind us to where the central line is. Cause invariably you'll be treating from the side. Once having achieved this, I think we're ready to roll. Okay. So with my bevel facing the creases as you can see here, I'm going to gently just place my needle at approximately 10 degree, nice and shallow into the crease. So I'm in the line of the vermillion border. And you can see here just work very slowly in order not to cause too much discomfort to our patients. Bobbi is telling me that she's not really feeling too much discomfort. Good. Wonderful. You're beautiful. So I'm just working on the vermillion border itself cause that's where the base of these creases are. So I need to make sure that I augment this region nicely, rejuvenate this region. So you want to be just supramuscular. So just above the orbicularis oculi, just above the orbicularis oris even. So I'm just placing my needle just at a 10 degree angle in the vermillion border, very carefully and delivering small amounts of the hyaluronic acid to shape the area as you can see. So I'm just going to work the philtrum. Let me have a look here. And the trick here is to make sure you angle your needle on the exit so that you get a nice sweeping cupid bow and philtrum complex like so. And finally I'm going to treat the oral commissure. And this is very useful when you want to just pick up the corners of the mouth and bring up a nice upturn to the corners and I'll do the same here. Relax for me. And this layer is just sub-dermal or very deep dermal and this is a very nice way of supporting the tissue and bringing about an upturn as I'd said. And finally we're going to just massage the area. Making sure there's no nodule. Making sure the whole area is homogenous or homogenous as you American will say. So now we're going to move on to the upper forehead region around the eyes. We're going to initiate a lifting process of the brows and we're going to essentially alleviate the underlying asymmetry that exists in the brows. So over to Bobbi now. So I'm going to mark up two sites in the posteriors. I'm going to mark up a site in the medial corrugator or the lower aspect of corrugator. Frown for me. Relax. We're also going to mark up some central sites in the forehead region and the frontalis muscle. Smile for me. Big smile. Big smile. Big smile. Big smile. This is dermatochalasis a nice fold of skin that exist and often occurs as we all aged. So these are the markings I'm going to take into account in Bobbi's case. I'm going to just check them. That's wonderful. Good. So I'm going to place 10 units here with an angulation of 90 degrees. I'm going to place another 10 units just here. This is Dysport. Deeper angle in to corrugators and a very shallow angle into frontalis. Frontalis is just beneath the skin or rather layer of fat which then sits above the periosteum. So we need to make sure that we engaged the frontalis itself as opposed to the underlying fat or in fact the periosteum. In this way, we can ensure predictable treatment and then we're going to place some very superficial injections in the orbicularis oculi. So in this way, you can see we've treated the entire glabellar region and the central aspect of both lobes of the frontalis and leaving behind the lateral segments deliberately so that we can engage a nice lifting effect of the lateral flanks of brows which is of course very needed in Bobbi's case to help stretch the skin that exist above the eyelid which is typical in many patients. As we all aged, we inherent this skin excess which of course is very unaesthetic. So by stretching this skin will bring about a nice esthetically pleasing appearance to the eyes.