Tandem injections in lower eyelid and lateral orbital area result in more pronounced cosmetic result

CARY, N.C. Botulinum toxin type A (Botox; Allergan) has proven to be a powerful tool in facial rejuvenation and is readily used in aesthetic medicine for the treatment of lower eyelid lines and wrinkles. Just how much botulinum A toxin and precisely where the injections should be placed when treating these areas clearly differs from patient to patient, but according to one study, botulinum A toxin for the treatment of infraorbital lines and wrinkles can achieve better cosmetic results when the lower eyelid orbicularis oculi muscle is treated concomitantly with the lateral orbital area, resulting in a more youthful widening of the eye.

Dr. Flynn

"One of the major endpoints of this kind of facial rejuvenation is to try to give the patient a more youthful, wider eye. In my experience, I have seen that this can be best achieved when treating not only the orbicularis oculi muscle, but also the lateral orbital area," he tells Cosmetic Surgery Times.

PEEPER PROTOCOL In the study, each patient received two units of botulinum A toxin in the lower eyelid subdermally in the midpupillary line precisely 3 mm below the ciliary margin. The opposite periocular area received two units of botulinum A toxin in the lower eyelid, and 12 units of botulinum A toxin injected into the lateral orbital area (crow's feet). The lateral orbital area injections were divided into three injections consisting of four units each, and were placed 1.5 cm from the lateral canthus (located 1 cm outside the lower orbital rim), each 1 cm apart.

"Clinically, most patients who seek botulinum A toxin treatment for their fine lines and wrinkles usually have several different areas treated simultaneously, and one common site of treatment is the lateral orbital area or crow's feet area," Dr. Flynn says.

According to Dr. Flynn, the results of this study show that while only a slight improvement of rhytids is achieved when using two units alone in the lower eyelid, when these two units are combined with 12 units of botulinum A toxin in the lateral orbital area, a moderate improvement of the rhytids can be achieved.

"Furthermore, the concomitant treatment of both these areas in one visit proves to be safe and has few if any complications," he adds.

This patient received Botox to the lower eyelid and concomitant treatment of the crow's feet. The treatment effect can best be observed when the patient exhibits a full smile, as she is in both pre- (left) and post-procedure (right) photos. (Photo credit: Timothy C. Flynn, M.D.)

According to Dr. Flynn, an increased palpebral aperture was noted for both two units in the lower eyelid (6 of 15 patients; 40 percent) and also for two units in the lower eyelid plus 12 units in the lateral orbital area. However, a significant increase in the palpebral aperture was seen when both the lower eyelid and the lateral orbital area were concomitantly treated (12 of 15 patients; 86 percent), and this could best be observed when the patients exhibited a full smile.