Hung Jury

Problem Area: Crow's Feet

I think the jury is out on this problem area.  I have patient's that are religious about their skincare treatments, diligently conditioning their skin to reduce the appearance of fine lines and wrinkles...yet they say "I don't mind having expression lines around my eyes."  I have other patients that only treat the crow's feet area, and it becomes their nemesis.  I don't have an opinion either way...I say treat what bothers you, not what bothers others.  The expression of winking or squinting at the sun condenses the eye area in a sphincter like pattern.  It also pulls the tail of the eyebrow down in some more than others.  We will talk about the anatomy of the orbicularis oculi muscle in a bit, this is the muscle that we are injecting when treating the crow's feet.

 

The Fix: Neurotoxin

To treat this we would use a neurotoxin to temporarily weaken the muscle contraction.  Botox or Dysport are good choices for this treatment area.  An average dose for females for the orbicularis oculi muscle is 12-30 units of Botox or 30-75 units of Dysport.  In the U.S., I would say it's more common for the left crow's feet to have more lines and activity, possibly due to more UV exposure when in the driver seat of the car.  With this being said, I find that I may need more product on the left eye's crow's feet compared to the right.  Dosing above is total treatment for both eyes and is an average of what I use for my patients.

The result is not seen immediately.  It takes 2-3 days for the neurotoxin to uptake into the muscle.  The product is completely active at 2 weeks out.  On average, the result lasts for 3-4 months.  I tell my patients to budget for their treatment 3-4 times a year, if they want to keep the results up.  Some patients are able to stretch their appointments out and others have to come in sooner.  Metabolism, skin quality and condition, under-dosing, and overall desired result can have an impact on how often you will have a treatment.

Anatomy Lesson: Orbicularis Oculi

Your orbicularis oculi muscles are sphincter muscles that wrap around each eye.  The lateral aspects of these muscles are most active, hence why we tend to see lineage in the "crow's feet" area.  When squinting or winking the eye, the skin of the upper and lower eye lids scrunch together and close off the eye opening.  The tail of your eyebrow also pulls down.  This treatment area is great for someone who has an issue with upper eyelid heaviness.  Unfortunately, upper eyelid issues tend to be a bit genetic, so I find that my patients young or seasoned can benefit from this treatment.  Sometimes my patients will comment on a new found creepiness of the medial portion or inner corner of the eye after we treat the crow's feet.  This is because your body is really smart and the untreated portion of the muscle tries to compensate for the lack of activity it has post neurotoxin.  This happens with the nasalis muscle too post glabella treatment.  We are going to cover the nasalis in my next post.  Keep in mind that not all lines around the eyes can be fixed from treating the orbicularis oculi.  Some lines in the lower lateral quadrant are caused from your smile activity.  I will not inject your zygomatic major or minor to keep you from smiling so don't ask...  : )

 

Treatment Pattern: Four to Ten Pokes

Expect four to ten pokes from the injection needle for a crow's feet treatment.  The treatment dose and pattern is identified during animation of the muscle.  If you have a hooded upper eyelid, and you're looking to get some lift from the tail of the brow by treating the orbicularis oculi, you can just treat the upper lateral quadrant of the muscle.  Many times I will treat the glabella and additionally put two units on either side at the tail of the brow superficially to capture the downward pull of the orbicularis oculi.  Your biggest struggle as a treatment provider is helping your patient understand the difference between crow's feet activity and cheek movement.  Have your patient look in the mirror with you...have them wink/squint at the sun...point out the lines that this creates on their skin...then have them squint at the sun and smile at the same time...highlight to them the increased wrinkling of the lower lateral quadrant.  It is still beneficial to treat this area, but remind your patient that you won't be able to calm down all of the activity due to the fact that they will continue to smile and this will form some lines around the eyes.  Orbicularis oculi muscle is thin and the skin around the eyes is thin too, so the injections should be placed superficially to the point where you see a little wheel, bleb, mosquito bite raised surface.  Caution your patients that this is a common area where patients bruise after a neurotoxin treatment.  Even the most skilled injectors are not immune to bruising their patients.  When patients ask me if they will bruise...I simply reply...I am poking you with a needle, so yes it is possible.  I like to think that I have a good track record, but it is always possible to bruise someone, especially in a vascular rich area such as around the eyes.