Anatomy Flashcards
Where do facial wrinkles typically form?
- In areas of muscle contraction perpendicular to long axis of muscle.
- Example is frontalis muscle when eyebrows raise - horizontal lines and vertical contraction.
Glabellar Muscle Group
- Procerus
-Corrugator supercilii
- Depressor supervilii: (Controversial Muscle. Many anatomic authorities consider it to be part of orbicularis oculi muscle.)
Procerus location
midline of the nasal bone and nasal cartilage
Procerus insertion
The skin of the lower to mid forehead between the eyebrows, merging with the fibers of the frontalis muscle
Procerus action
- Helps draw down the skin between the eyebrows and assists in flaring nostrils.
- Contributes to expression of anger or intensity
Depressor supervilii location
Laterals of the nasal bridge
Depressor supervilii insertion
Flares out across the intercantal region, frontalis muscle, and under the skin about level with eyebrows
Depressor supervilii action
- Draws down the eyebrows along with the procerus
- The horizontal wrinkle at the bridge of the nose
Corrugator supercilii location
Medial superciliary arch
Corrugator supercilii insertion
Forehead skin near the eyebrows
Corrugator supercilii action
Pulls the eyebrows downward and toward the midline of the nose
Eyelid Ptosis Mechanism
- Occurs from diffusion through orbital septum
- Weakening upper eyelid elevators (levator palpebrae superioris)
Eyelid Ptosis Prevention
Lateral corrugator injections medial to mid-pupillary line and 1-2 mm deep
Eyelid Ptosis TX
Alpha-adrenergic eye drops: apraclonidine 0.5% 1-2 TID
Eyebrow Ptosis Mechanism
Occurs from overly weakening frontalis muscle.
Eyebrow Ptosis Prevention
- Dosing conservatively.
- Frontalis is only brow elevator.
Eyebrow Ptosis Management
- Review images.
- Document asymmetries
Spok Brow Mechanism
Occurs from not injecting frontalis laterally enough
Spok Brow TX
Inject medial and lateral frontalis fibers.
Upper eyelid raiser muscles
- Levator palpebrae superioris
- Superior tarsal muscles
Oribicularis oculi origin
- Frontal
- Lacrimal
- Maxilla bone
- Medial palpebral ligament
Oribicularis oculi insertion
Lateral palpebral raphe
Oribicularis oculi action
Closes eyes & cheek raiser
Supraorbital and supratrochlear artery
- Arises from the superior border of the bony orbit and courses superficially to supply blood to the forehead and scalp musculature and the overlying skin.
- Superaorbital foramen is within 1 mm of medial iris and 1-1.5 cm medial to superior temporal line.
Superficial temporal artery
- A branch of the external carotid that supplies the lateral portion of the face of the faces and gives rise to the transverse facial artery.
- It runs subdermal at the anterioinferior to the tragus and continues anteriomedially deep to the facial muscles to anastomose with branches of the supraorbital and supratrochlear vessels.
Superficial temporal pulse
Palpated anterior to the auricle as the artery crosses the zygomatic arch.
Deep temporal artery (anterior and posterior) location
Ascend between the temporalis and the pericranium.
Dorsal nasal artery
- Arises from the ophthalmic artery and is the terminal branch of the ophthalmic artery.
- It emerges from the orbit above the medical palperbral ligament, supplies blood to the lacrimal sac, and then divides into two branches.
Inner brow raiser
Fronatalis (medial part)
Outer brow raiser
Frontalis (lateral part)
Brow lowerer
- Procerus
- Depressor supercilii
- Corrugator supercilii
Upper eyelid raiser
- Levator palpebrae superioris
- Superior tarsal muscle
Cheek raiser
Orbicularis oculi (orbital part)
Glabella Tx points Skeletal Anatomy
- Palpate the orbital rim (typically just below the eyebrows, but not always).
- Injections are always 1 cm above. Identify the supraorbital notch
- Aligns with medial corrugators.
Glabella Tx points Muscular Anatomy
- Palpate Procerus and Corrugators.
- Observe muscles during forceful contraction.
Glabella Tx points Triangulation Points
- Procerus commonly aligns with medical end of eyebrows.
- Lateral Corrugator: Medial to the mid-pupillary line
Frontalis TX points Skeletal Anatomy
- Palpate the temporal fusion line
- Guides lower treatment row lateral points.
- Palpate orbital rim - lower treatment row is 2 cm above orbital rim
Frontalis TX points Muscular Anatomy
Palpate frontalis muscle, focus on upper border.
Frontalis TX points Triangulation Points
- Lateral lower treatment points are in the same plane as lateral tip of eyebrow.
- Lower treatment row generally 2 finger breadths from eyebrow.
Lateral Canthal TX points Skeletal Anatomy
- Palpate orbital rim
– Treatment points are just lateral to orbital rim.
Lateral Canthal TX points Muscular Anatomy
Palpate and identify each patient’s unique fan-shaped pattern.
Lateral Canthal TX points Triangulation Points
Treatment points are 1 cm from the lateral canthus of eye
Lateral Corrugator Injection Location
- 1cm above supraorbital ridge (superior orbital rim)
- Injection should be more superficial (injection depth 1-2mm) as muscles goes deep to superficial
- Inject just medial to mid pupillary line
Medial Corrugator Injection Location
1cm above orbital rim
Procerus Injection Location
1cm above orbital rim
Frontalis injection TX goal
Soften, not eliminate forehead lines
Frontalis injection sites for upper TX row
- Left upper frontalis
- Right upper frontalis
Frontalis injection sites for lower TX row
- Middle frontalis
- Left lower frontalis
- Right lower frontalis
Lateral Canthal Lines 1st injection
1.5 - 2cm from lateral canthus (finger width) and just temporal to lateral orbital rim
Lateral Canthal Line 2nd injection
1-1.5 cm above first injection site and at an approx 30 degree angle medially
Lateral Canthal Line 3rd injection
1-1.5 cm below 1st injection site and at an approx 30 degree angle medially
Elevation Eyebrow lift injection sites
- Medial and Central: Same Tx points as the glabella - just dose slightly higher and be slightly more conservative on the frontalis
- Lateral elevation: Just under tail of eyebrow
Glabellar injection areas to avoid
- injections placed 1 cm above supraorbital ridge (typically 1 cm above central eyebrow)
- lateral corrugator injections medial to mid-pupillary line
- Inadvertently injecting the lateral corrugator too deep can lead to eyelid ptosis
Frontalis injection areas to avoid
- Distance between eyebrow and lower treatment row >2 cm
- Dose conservatively: too much paralysis causes eyebrow ptosis
- If too much lateral activity remaining, results in spock eyebrow
- Lateral injection site 1.5-2 cm from lateral temporal fusion line
Lateral canthal injection areas to avoid
Always inject temporal to the orbital rim (to avoid diffusion to the palpebral orbicularis oculi or levator palpebrae muscle)
“U” Pattern injection
Classical five-injection-site model at the standard doses
“V” Pattern injection
- Require higher toxin doses into a greater number of injection sites, with the seven-site model being the best approach.
- The higher doses are concentrated at the procerus and corru- gators
“Converging Arrows” Pattern Injection
- The injection technique should be more horizontal, targeting the muscles involved.
- There is no need for injecting the procerus and frontalis muscles, or they may be injected at minimal doses
“Omega” Pattern injection
- Inject the toxin into the corrugators and orbicularis oculi pars palpebralis and into the medial portion of the frontalis muscle, with higher doses into the corrugators and orbicularis and lower doses into the frontalis sites.
- The procerus would be spared from treatment or would receive only a minimal dose
“Inverted Omega” Pattern Injection
- Higher doses injected into the procerus and depressors supercilii and additional sites at the internal portion of the orbicularis oculi pars palpebralis and nasalis muscles.
- A minimal dose may or may not be injected into the corrugators
Dermatochalasis (Eyelid Hooding)
Naturally occurs as part of aging process - many people develop redundancy in eyelid tissue
Dermatochalasis (Eyelid Hooding) Management
- Identify and discuss with patient during consultation, demarcate with orange dot.
- Always dose the frontalis conservatively - can exacerbate subtle baseline hooding
Frontalis Shelving
Naturally occurs in many patients and is visible during frontalis activation
Frontalis Shelving Management
- Identify and discuss with patient during consultation
- For Botox-naive, recommend deferring shelving and readdressing in 2-week dose adjustment.
