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Background: Treatment with Onabotulinum toxin A for the improvement of glabellar lines and crow's feet represents one of the most requested and performed procedures in the field of aesthetic medicine. The efficacy of Onabotulinumtoxin A for the treatment of glabellar lines and crow's feet have been widely reported. Although, the assessment of the grade of efficacy is actually based on clinical evaluation scales by an healthcare professional, giving space to a wide interpretative subjectivity which depends on different factors including a personal experience and a subjective aesthetic judgment. Objectives: This study aims to provide a digital evaluation tool in order to assess an objective measure of the degree of improvement for the areas treated with Onabotulinum toxin A, using a digital analysis of the images from the treated areas in order to exclude the subjective component during the evaluation. Methods: A total of 20 women with moderate-to-severe CFL and GL (maximum contraction) were enrolled in the study. Each woman received a total of 44 U of Onabotulinum toxin A (20 U and 24 U for the treatment of glabellar lines and crow's feet, respectively). Images from the treated areas were collected using Antera 3D® device at baseline, 4 weeks and 4 months after treatment, at both rest and maximum muscles contraction. Results: Improvements for both glabellar lines and crow's feet lines were detected with Digital Analysis of the Cutaneous Surface, further confirming the efficacy of Onabotulinum toxin A. Conclusion: The digital evaluation tool proposed in this study is an objective and easy to use method for the assessment of glabellar lines and crow's feet lines improvements after the treatment with Onabotulinum toxin A.

Lateral canthal lines or crow's feet lines (CFL) may be treated with onabotulinumtoxinA. We identified several key concepts important to understanding the use of onabotulinumtoxinA for treatment of moderate-to-severe CFL. To contextualize and integrate data on the recommended dose and injection patterns of onabotulinumtoxinA for treatment of CFL, we summarized data from pivotal clinical studies in the development of onabotulinumtoxinA for treatment of CFL. Data from key studies of onabotulinumtoxinA for CFL are presented. The efficacy and safety of onabotulinumtoxinA treatment of moderate-to-severe CFL were evaluated in 2 randomized, controlled phase 3 studies comprising 1362 patients. The 24U total dose of onabotulinumtoxinA used in these studies was based on a phase 2 dose-ranging trial. Two injection patterns were available to investigators; each involved 3 injection sites per side in the lateral orbicularis oculi muscle. A cross-sectional analysis of photographs from the phase 3 trials provided detailed information on the frequency of 4 distinct CFL patterns. In the primary efficacy analysis for each phase 3 trial, CFL responder rates were significantly greater with onabotulinumtoxinA vs placebo at day 30 ( P < .001). Eyelid edema (1%) was the only adverse event reported in ≥1% of patients receiving onabotulinumtoxinA, occurring more frequently with onabotulinumtoxinA than with placebo. The studies showed that onabotulinumtoxinA is effective and generally well-tolerated for CFL treatment. Additionally, 2 different injection patterns allow physicians to tailor treatment based on a patient's CFL pattern.

Zum ersten Mal wurde in dieser doppelblinden, randomisierten Pilotstudie die Wirksamkeit von BoNT/A (Xeomin®) und BTXCo1 (Dysport®) in einem Dosisverhaltnis von 1:3 bei der Behandlung mimisch bedingter Krahenfuse (FWS 2–3) untersucht. BoNT/A (12 Einheiten) wurde vs. BTXCo1 (36 Einheiten) im intraindividuellen Seitenvergleich bei 22 Patienten uber 4 Monate untersucht. Die Responder zeigten im angespannten Zustand eine Verbesserung auf der Facial-Wrinkle-Skala (FWS) um mindestens 1 Punkt. Der Anteil der Responder lag 1 Monat nach Behandlung deutlich uber 80%. Bei beiden Gruppen lag hier kein statistisch signifikanter Unterschied vor. Der Ruckgang der Krahenfuse (FWS-Punkte) fiel bei den entspannten Patienten starker aus als bei den Patienten im angespannten Zustand. Auch 4 Monate nach der Behandlung zeigte noch mehr als die Halfte der Patienten in beiden Gruppen eine Verbesserung der FWS um 1 Punkt. Beide Botulinumtoxin-Typ-A-Praparate zeigten in dem Dosisverhaltnis von 1:3 eine vergleichbare Wirksamkeit (Responser) bei uberwiegend sehr guter Vertraglichkeit. Der starkere Ruckgang der Krahenfuse im entspannten Zustand zeigt deutlich, wie wichtig die Entspannung der Muskelinsertionen fur den kosmetischen Effekt der Haut in der Periorbitalregion ist.

OBJECTIVE To develop the Crow's Feet Grading Scale for objective quantification of the severity of lateral canthal lines and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify the severity of lateral canthal lines at rest and at maximum contracture of the orbicularis oculi. Nine experts rated photographs of 35 subjects, twice, with regard to the aspect crow's feet in comparison with morphed images. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was significantly high. Furthermore, the test-retest correlation coefficients were high for each expert after an overnight interval, demonstrating low inter- and intraevaluator variability. CONCLUSION The 5-point photonumeric scale generated spans the severity of the type of crow's feet for which patients most commonly seek correction. The scale is well stratified for consistent rating.

A common dissatisfaction after rhytidoplasty are the remaining lateral eyelid wrinkles also known as crow’s feet. This article presents an analysis of the enlarged myectomy of the orbicularis oculi muscle used for the definitive treatment of crow’s feet in 105 patients during face lifting. Myectomy involved all the lateral portion of the orbicularis oculi muscle exposed after the undermining of the face, corresponding to about one third of the whole orbital extension of the muscle. To avoid depression in the area of the excision, a free graft from the superficial musculoaponeurotic system was performed with the blepharoplasty. The reduction of the crow’s feet was significant during the subsequent 5 years of follow-up. The enlarged myectomy allowed the treatment of a larger area in the wrinkled region without increasing the complications and with excellent results.

BACKGROUND Patterns of crow's feet lines (CFLs) vary among individuals. OBJECTIVE To characterize distribution and predictors of CFL patterns. METHODS Patterns of CFLs (full fan, lower fan, central fan, and upper fan) were evaluated at maximum smile and at rest from photographs of subjects with moderate-to-severe CFLs. Relationships between CFL pattern and severity, age, gender, and subject-reported outcomes were explored. RESULTS Evaluations of 2,699 photographs from 1,392 subjects were conducted; 1,389 and 1,310 had evaluable CFL patterns at maximum smile and at rest, respectively. Lower-fan, central-fan, and full-fan patterns were identified in 28.4% to 34.7% at maximum smile and 27.7% to 33.9% at rest; upper fan was found in ∼5%. The pattern distribution of CFLs demonstrated a relationship to baseline CFL severity, age, and gender; full-fan and lower-fan patterns were more common in severe versus moderate CFL at maximum smile; full fan increased with age. Lower fan was more common in males. Subjects with full fan at maximum smile were most dissatisfied with their appearance and perceived themselves to look older versus other patterns. CONCLUSION Baseline CFL severity, age, and gender may predict fan pattern. Patterns may progress with age from central to lower fan or full fan. Pattern heterogeneity of CFLs suggests that tailored treatment may be warranted.

Tatjana Pavicic,1 Welf Prager,2 Markus Klöppel,3 Simon Ravichandran,4 Olivier Galatoire5 1Private Practice, Munich, Germany; 2Dr. Prager & Partner, Derma-Hamburg, Hamburg, Germany; 3Private Practice Clinic of Esthetic Surgery, MediCenter Munich-Solln, Munich, Germany; 4Clinetix Rejuvenation, Glasgow, Scotland, UK; 5Department of Ophthalmology, Adolphe Rothschild Ophthalmological Foundation, Paris, France Purpose: To characterize utilization patterns and treatment satisfaction with incobotulinumtoxinA for aesthetic indications and assess adherence to the Summary of Product Characteristics. Patients and methods: Data were collected retrospectively from physicians in Germany, France, and the UK regarding patients (n=638) treated with incobotulinumtoxinA for aesthetic indications. Data on indication, treatment interval, dose injected, physician and patient satisfaction, and adverse drug reactions were recorded according to routine daily practice. Results: Most patients (76.0%) received incobotulinumtoxinA for glabellar frown lines (GFL) and were given doses of ≤20 U. The majority of treatment intervals were 5 months or longer. Overall, 64.1% of patients were treated for off-label indications, sometimes in combination with treatment for GFL. The most frequently treated off-label indications were horizontal forehead lines (38.6%) and/or crow's feet (CF; 31.7%); for CF, >95% of injected doses were ≤24 U. In Germany, a smaller proportion of patients were given incobotulinumtoxinA treatment for CF (27.6%), compared with France (40.4%) and the UK (33.2%), although country-specific differences were less prominent when treatment cycle data for CF were examined. Treatment satisfaction among physicians and patients (overall, and for GFL specifically) was very high, with excellent tolerability and only one mild adverse drug reaction reported. Conclusion: In daily practice, incobotulinumtoxinA is mainly used for GFL; however, its use for CF and horizontal forehead lines (often in combination with GFL) is relatively common. Treatment satisfaction across aesthetic indications is high, and incobotulinumtoxinA is well tolerated, with time intervals of 5 months or longer between injections in the majority of cases. When considering factors such as dose and treatment interval, adherence to the Summary of Product Characteristics when treating GFL in daily practice is good. These results support previous reports that incobotulinumtoxinA is an effective treatment for GFL, with an excellent safety profile. Furthermore, incobotulinumtoxinA may display efficacy and tolerability in other indications. Keywords: incobotulinumtoxinA, Xeomin®/Xeomeen®/Bocouture®/XEOMIN Cosmetic™, NT 201; free from complexing proteins, retrospective, daily practice, glabellar frown lines, crow's feet

Background Botulinum toxin Type A (BoNT A) for the treatment of facial wrinkles is delivered through local injection. We previously demonstrated that topical surface application of BoNT A has negligible cutaneous bioavailability and is not effective in treating wrinkles. Objective To determine the effect of BoNT A solution applied topically on the skin surface immediately after ablative fractional CO2 laser treatment. Methods We conducted a randomized controlled trial for patients with periorbital wrinkles (crow's feet) (n = 10). Treatment was performed on both sides of the face with fractional ablative CO2 laser followed by the application of topical solutions of BoNT A on one side and normal saline as control on the other side. Pretreatment assessment was performed, and at 1 and 4 weeks after treatment. Results There was a clinically significant greater degree of improvement in wrinkles after treatment with CO2 laser, on the topically applied BoNT A side. Also, the difference between the 2 treatment types (laser followed by topical BoNT A vs laser followed by saline) at 1 week and at 1 month was statistically significant. Conclusion Topically, noninjectable form of BoNT A applied on the surface of the skin after ablative fractional CO2 laser is effective in the treatment of lateral periorbital wrinkles.

Background Although millions of aesthetic procedures are performed annually, few patient-reported outcome (PRO) measures have been used in this setting. Objective To evaluate the impact of onabotulinumtoxinA treatment for crow's feet lines (CFL) on relevant psychological variables and self-perception of age/appearance in subgroup populations. Materials and methods Facial Lines Outcomes (FLO-11) Questionnaire, Self-Perception of Age (SPA), and Subject Global Assessment of Change in CFL (SGA-CFL) were PRO measures administered in 2 Phase 3, double-blind placebo-controlled trials for the treatment of CFL alone or CFL/glabellar lines (GL). Patient-reported outcome measures were analyzed by subgroups (age, gender, and baseline CFL severity). Subject satisfaction with appearance was also analyzed. Results Most subgroups receiving onabotulinumtoxinA demonstrated significant improvements in psychological impact (FLO-11 Items 2, 5, and 8) versus placebo at Day 30 (p ≤ .05). OnabotulinumtoxinA-treated subjects consistently rated themselves as looking younger on SPA versus placebo in all subgroups at Day 30 (p ≤ .05) and showed significant improvements in CFL appearance versus placebo at all time points on SGA-CFL. Overall, subjects were satisfied with their appearance. Conclusion OnabotulinumtoxinA-treated subjects experienced significant improvements in perceived appearance, attractiveness, tiredness, age, and satisfaction versus placebo. Subjects treated for CFL and GL experienced even greater effects.

This was the second study in a Phase 3 program treating crow's feet lines (CFL) with onabotulinumtoxinA.To evaluate the efficacy and safety of onabotulinumtoxinA treatment of CFL alone or with glabellar lines (GL).This multicenter, double-blind, placebo-controlled, repeat treatment, 7-month study randomized subjects with moderate-to-severe CFL and GL (maximum contraction) to onabotulinumtoxinA 44 U (CFL: 24 U, GL: 20 U; n = 305), onabotulinumtoxinA 24 U (CFL: 24 U, GL: placebo; n = 306), or placebo (n = 306). Coprimary end points were investigator-assessed and subject-assessed proportion of subjects achieving a CFL Facial Wrinkle Scale Grade of 0 or 1 (maximum smile; Day 30, Cycle 1). Additional efficacy end points and safety/adverse events (AEs) were evaluated.All primary and secondary end points were achieved; statistically significant differences favored onabotulinumtoxinA (p.001, all comparisons vs placebo). Investigator and subject responder rates were: CFL, 54.9% and 45.8%; CFL + GL, 59.0% and 48.5%; and placebo, 3.3% (both), respectively. Responder rates on other end points also significantly favored onabotulinumtoxinA treatments. Most AEs were mild or moderate. Two subjects discontinued: 1 serious AE unrelated to treatment (myocardial infarction) and 1 treatment-related AE (injection site pain).OnabotulinumtoxinA was effective and well tolerated for treating moderate-to-severe CFL alone or in combination with GL.

Botulinum toxin injection works well and reliably in crow’s feet, glabella, and forehead. With experience, the eyebrows may be repositioned through treatment of the adjacent orbicularis oculi, procerus, corrugator supercilii, and depressor supercilii. Dose is often individualized and may be related to muscle mass.

Crow’s feet injection is one of the simplest and most satisfying applications of botulinum toxin. The radiating dermal crow’s feet lines result from the concentric constriction of the underlying orbital and preseptal orbicularis oculi muscle. Orbicularis oculi injections of botulinum toxin diminishes both active and static crow’s feet rhytids, may prophylactically delay the onset and progression of such wrinkles, and improves final outcome following ablative periocular resurfacing.

Botulinum toxin is currently the most popular aesthetic procedure for men and women. The upper third of the face is frequently treated. The risks and complications of treating three areas above the zygomatic arch are discussed. Combining fillers with toxin in these areas often provides the most successful results. Precautions about treatment and methods to avoid complications are addressed.

Published evidence suggests that botulinum toxin type A (BTX-A) is an effective treatment for crow's feet. However, few dose-ranging studies have been performed.To assess the safety and efficacy of a single treatment with one of four doses of BTX-A (Botox/Vistabel, Allergan Inc) compared with placebo for the improvement of crow's feet.Subjects received a single bilateral treatment of 18, 12, 6, or 3 U of BTX-A or placebo injected into the lateral aspect of the orbicularis oculi muscle (parallel-group, double-blind design). Investigators and subjects rated crow's feet severity at maximum smile on day 7 and at 30-day intervals from days 30 to 180.As observed by both investigators and subjects, all doses of BTX-A resulted in improvements in crow's feet severity when compared with placebo. A dose-dependent treatment effect for efficacy was observed, with higher doses having an increased magnitude and duration of effect. However, a clear differentiation between the 18 U and 12 U doses was not apparent. Few adverse events were reported, with no statistically significant differences between BTX-A and placebo in the incidence of subjects experiencing adverse events.BTX-A is safe and effective in decreasing the severity of crow's feet, with 12 U per side suggested as the most appropriate dose.

The objective of this study was to determine the duration of the effects of a defined dose of BTX-A on crow's feet formation wrinkles.Twenty-five patients each received one injection of 12 units of BTX-A in the orbicularis oculi muscle on both sides of the face. The results were evaluated at 3, 6 and 9 months. Standardized photographs were taken of the wrinkle formations at rest at each step of the 9-month period following the treatment, and the wrinkles were then rated on photographs by blinded observers. Three-dimensional (3D) in vivo profilometry was also used to quantify the degree of improvement.Both the self-assessments by the patients themselves and the objective assessments of the 3D profilometry study provided similar results, but the independent observer assessment results were slightly more optimistic. There was a statistically significant difference observed between baseline and the evaluations at both 3 and 6 months.BTX-A is a safe and effective method for treating crow's feet wrinkles. In both the observer assessment and the 3D skin profilometric assessment, a clear improvement was shown at 6 months.

One of the most common complaints of aging patients is the appearance of crow's feet lines in the lateral canthal region. Many different treatment methods, including chemical peels, surgical procedures, filler material injections, botulinum toxin injections, and laser resurfacing, have been used for effacement of these lines among aging patients and patients with sun damage. Despite the fact that many scientific articles have been written regarding the treatment of crow's feet lines, the actual patterns of these lines have not been adequately studied or classified. Several different patterns of animation in this area have been observed. These different patterns and their frequencies are described. All crow's feet patterns are not the same, and it follows that treatment of different patterns of crow's feet lines should be adapted to the particular patterns.

Crow's feet wrinkles are common complaints in patients looking for facial rejuvenation. This article describes a new technique for a lasting treatment by vertical myectomy of the lateral orbicularis oculi muscle. The author presents 20 cases surgically treated in the past 16 months. The results are very promising.

Hyaluronic acid (HA) has an immediate volumizing effect, due to its strong water-binding potential, and stimulates fibroblasts, causing collagen synthesis, with short- and long-term effects on wrinkle improvement. We investigated the efficacy and safety of HA microneedle patches for crow's feet wrinkles. Using a randomized spilt-face design, we compared microneedle patches with a topical application containing the same active ingredients. We enrolled 34 Korean female subjects with mild to moderate crow's feet wrinkles. The wrinkle on each side of the subject's face was randomly assigned to a HA microneedle patch or HA essence application twice a week for 8 weeks. Efficacy was evaluated at weeks 2, 4, and 8. Skin wrinkles were measured as average roughness using replica and PRIMOS. Skin elasticity was assessed using a cutometer. Two independent blinded dermatologists evaluated the changes after treatment using the global visual wrinkle assessment score. Subjects assessed wrinkles using the subject global assessment score. Skin wrinkles were significantly reduced and skin elasticity significantly increased in both groups, although improvement was greater in the patch group at week 8 after treatment. In the primary and cumulative skin irritation tests, the HA microneedle patch did not induce any skin irritation. The HA microneedle patch is more effective than the HA essence for wrinkle improvement and is a safe and convenient without skin irritation.

This study was part of a Phase 3 program treating crow's feet lines (CFL) with onabotulinumtoxinA.To evaluate the efficacy and safety of onabotulinumtoxinA treatment of CFL.This multicenter, double-blind, placebo-controlled, 5-month study randomized subjects with moderate-to-severe CFL (maximum smile) to onabotulinumtoxinA (24 U; n = 222) or placebo (n = 223). Investigators and subjects assessed CFL severity (maximum smile and rest) using the 4-grade Facial Wrinkle Scale (FWS). Co-primary end points were investigator- and subject-assessed proportion of subjects achieving a CFL FWS grade of 0 (none) or 1 (mild) at maximum smile (Day 30). Additional efficacy end points, patient-reported outcomes, and safety/adverse events (AEs) were evaluated.All primary and secondary end points were achieved; statistically significant differences favored onabotulinumtoxinA (p.001, all comparisons vs placebo). Co-primary responder rates were 66.7% compared with 6.7% for investigator-assessed and 58.1% compared with 5.4% for subject-assessed response (onabotulinumtoxinA group and placebo, respectively; p.001). A significantly greater proportion of the onabotulinumtoxinA group than placebo group achieved a 1 grade or greater improvement on the FWS (maximum smile and rest assessed by both the investigator and subject; all time points; p.001). Most AEs were mild or moderate and did not result in discontinuations.Treatment of moderate-to-severe CFL with onabotulinumtoxinA was effective and well tolerated.

Summary Background Treatments for upper facial lines (UFL), the most visible sign of aging, are of interest to patients and clinicians alike. Patient-reported outcomes (PROs) are valuable in evaluating the impact of such treatments; however, regulatory recommendations have stipulated that the patient perspective be central in developing these assessments. Objectives (1) To evaluate the content validity of the Facial Lines Outcomes Questionnaire, a PRO instrument developed to assess upper facial line impacts, according to the regulatory guidance of the United States Food and Drug Administration and (2) assess whether it adequately measures the psychological impacts associated with crow's feet lines (CFL) (lateral canthal lines) from the patient perspective. Methods Two patient groups participated in face-to-face qualitative interviews. One group included patients with UFL (Group 1, n = 25 interviews), and the other included patients specifically with CFL (Group 2, n = 41 interviews). Each interview consisted of a concept elicitation and cognitive debriefing phase. Results Interviews with both groups elicited all key concepts of the instrument, including “bothered by facial lines”; “looking older”; “looking less attractive”; and looking “tired,” “stressed,” or “angry.” Most Group 2 patients (n = 35, 85%) agreed that the instrument adequately assessed the psychological impacts associated with CFL. During cognitive debriefing, the majority of patients in both groups agreed the instrument was understandable, comprehensive, and easy to complete. Conclusions The Facial Line Outcomes Questionnaire is an appropriate and valid tool to assess the impact of UFL and the psychological impacts associated with CFL.

Careful identification of supraorbital foramen in the medial third of the superior orbital rim is useful to avoid damage to supraorbital nerve and vessel which direct upward to frontal area starting from the foramen.

Summary Botulinum toxins are currently used to reduce facial muscle activity, and hyaluronic acid is used to correct volume loss. This study evaluates the combination of abobotulinumtoxinA (Dysport) and hyaluronic acid 20 mg/mL (Perlane) for rejuvenating specific areas of the upper face. Subjects (n = 20) with mild to moderate temporal volume loss as well as glabellar and/or periorbital rhytids were enrolled in this single-center, open-label, nonrandomized pilot study. Subjects were randomly assigned a number and treated with hyaluronic acid, divided between temporal and glabellar region, and abobotulinumtoxinA in the periorbital and glabellar region. A 1-month touch-up was given if needed. Subjects were evaluated by the investigator, and each subject completed a questionnaire at baseline and at 3, 6, and 9 months after treatment. For glabellar lines and crow's feet, median grades decreased from baseline at 1 month and at 3 months, but returned to baseline values at 6 months. For temporal assessments, the median grade decreased from baseline at 1, 3, and 6 months and returned to baseline at 9 months. Similar trends were observed in subjects’ perceived age, perceived social and professional limitations, and desire to alter their facial appearance. Among subjects previously treated with botulinum toxin alone, 64% rated the combination treatment said “superior.” Adverse effects were mild and transient. The combination of abobotulinumtoxinA and hyaluronic acid appears to rejuvenate the periorbital, temporal, glabellar, and crow's feet areas with minimal adverse effects.

Introduction: Crow's-feet rhytids are a common sign of aging. The deformity is produced by smiling and becomes persistent with dermal collagen shortening and skin laxity during the aging process. It was hypothesized that resection of the lateral orbicularis oculi muscle (OOM) would result in permanent loss of the rhytids lateral to the eyes. Materials and Methods: A retrospective analysis was made of 14 patients who had resection of a beveled crescent of the OOM between September 1993 and September 1996, either as a primary procedure or during a face-lift or brow-lift. Local anesthesia with intravenous sedation was used. Results: Each of the patients had marked improvement or complete resolution of the lateral eye rhytids. The only complication was temporary temporal alopecia following a concurrent forehead–brow lift. Discussion: Medical therapy for crow's-feet rhytids has included injections of collagen, fat, silicone microdrops, and Botulinum Toxin A as well as application of chemical peels, laser, retinoids, and vitamin A. Permanent resolution of the rhytids does not occur with these modalities. Surgical manipulation of the OOM with splitting and suturing techniques have resulted in only minimal success. Beveled crescent resection of the lateral portion of the OOM has eradicated or markedly improved the crow's-feet over a follow-up period of 1 to 51 months.

SummaryBackground Infraorbital skin hyperpigmentation, commonly called dark circles, and crow's feet wrinkles are common cosmetic concerns. Various methods of treatment have been evaluated with variable outcomes. Objective This study was performed to assess the efficacy of platelet-rich plasma (PRP) injection for treating periorbital dark circles and crow's feet. Methods Ten participants with a mean age of 41.2 years were treated in a single session with intradermal injections of 1.5 mL PRP into tear trough area and crow's feet wrinkles on each side. The effects on melanin content, color homogeneity of the treated area, epidermal stratum corneum hydration, and wrinkle volume and visibility index were compared 3 months after treatment with baseline. Physician's global assessment and participants' satisfaction and any potential side effects were also assessed. Results The improvement in infraorbital color homogeneity was statistically significant (P = 0.010), but no statistically significant changes were observed in melanin content, stratum corneum hydration, wrinkle volume, and visibility index. Participant's satisfaction score and physician's global assessment score were 2.2 and 1.7, respectively, on a 0–3 scale. Conclusion Platelet-rich plasma may have the potential to improve infraorbital dark circle in terms of color homogeneity of the region, though this remains to be proven using larger, controlled studies using multiple injections.

Untreated crow's feet often exist as a residual deformity that detracts from an otherwise excellent effort at rejuvenating the aging face. Previous techniques designed to correct this problem were ineffective or time-consuming and have been largely abandoned. The procedure presented here is a simple, safe, and straightforward correction that has proven to produce a predictable and long-lasting improvement.

Background Conservative techniques designed to block or delay the aging process have been utilized in various ways for many years. However, their effects can be relatively minimal and short-term in most cases compared to surgery. The objective of this study was to evaluate the efficacy and safety of gold thread implantation for the treatment of periorbital wrinkles. Methods A total of 78 consecutive patients who showed mild to severe periorbital wrinkles were deemed appropriate candidates, including 69 women and 9 men ranging from 31 to 59 years (mean, 47 years). Six gold threads about 4 cm in length were inserted subdermally in each patient at intervals of about 0.5 cm. Follow-up assessments were performed 1, 4, and 12 weeks after the procedure. The efficacy was rated by the physician using the Wrinkle Severity Rating Scale and patients who made global assessments of changes in periorbital wrinkles using the Visual Analog Scale. Adverse events were monitored throughout the course of the study. Results The patients showed significant improvements after the procedure. There were minor complications such as foreign body sensation in the eye (2.63%) and eye pain (1.32%) that improved spontaneously without any specific treatments. Conclusions Subdermal implantation of gold thread improves the appearance of periorbital wrinkles and does not appear to have serious side effects. Insertion of gold thread may be an effective and safe method for facial rejuvenation.

We have read the article by Radnic et al. “Crow’s feet” as an indication of a vital reaction in a gunshot victim, which considered an occurrence of “crow’s feet” in case of close-range gun-shot victim. This phenomenon was described in the context of fires, explosion, high-voltage, and electric arc accidents. On a sudden exposure to flames or great heat, while alive, victims screw their eyes tightly shut, producing a lateral line of skin at the canthi spared from thermal damage, or soot deposits—“crow’s feet”. Other lines of skin spared from burning also suggest a final contraction of the facial mimic muscles. There is no agreement whether the occurrence of “crow’s feet” is a vital phenomenon in cases of high-voltage accidents, or reaction in the early postmortem phase due to electrical stimulation of the facial mimic muscles. In a case that we examined involving a man who died in a high—voltage accident we found facial burns, predominantly on the forehead.... Language: en

The first sign of the aging process is the appearance of wrinkles around the eyes, known as “Crow’s feet” wrinkles. Standard treatment has been the use of botulinum toxin, which has the disadvantage of a short period of effectiveness. There are surgical treatments to release the orbicular muscle. This muscle can be laterally stretched or even split with its ends tractioned and fixed with sutures. Recurrent “Crows’ feet” is a problem with theses approaches. For an effective and also definitive result, we describe a new technique named vertical lateral orbicularis occuli myectomy. Because of residual depression, in some cases a superficial musculoaponeurotic system (SMAS) fat graft is applied which solves the problem. These techniques are described in this chapter.

The corded crow’s-feet, and the collar square, The change and chance of earthly lot must share. — Class Poem at Harvard College, 1835 1 Harvard University, the oldest and perhaps most celebrated and prestigious university in the United States, has been a fixture of the Boston area for almost four hun dred years. Founded a scant fourteen years after the Pilgrims landed at Plymouth Rock, Harvard has grown from a small colonial school to one of the world’s foremost private research universities. 2 Much has been written about Harvard’s history, but this article explores one small aspect of this vast subject: the history and practice of academic dress at this (by New World standards) ancient institution. Harvard dress as it now stands owes a good deal to academic dress in English universities and therefore to the academic dress of medieval Oxford and Cambridge.

Crow’s feet injection is one of the simplest and most satisfying applications of Botox. The radiating dermal crow’s feet lines result from the concentric constriction of the underlying orbital and preseptal orbicularis oculi muscle. Orbicularis oculi injections of Botox diminshes both active and static crow’s feet rhytids, may prophylactically delay the onset and progression of such wrinkles, and improves fi nal outcome following ablative periocular resurfacing (Figure 106.1). Since the thin periocular skin is prone to visible bruising, injection should be in the subdermal plane while avoiding actual intramuscular injection. The loose periocular subdermal plane in the area of crow’s feet rhytids should visibly balloon up when the injection is delivered at the proper depth. Following injection, the patient may apply pressure for 1–2 minutes over the injection sites to minimize bruising.

Titelblatt, Inhaltsverzeichnis und Anhang Einleitung Material und Methoden Ergebnisse Diskussion Literaturverzeichnis, Verschiedene klinische Skalen finden Anwendung zur Beurteilung der Effektivität der Behandlung mimischer Falten mit Botulinumtoxin A. Bisher wurden jedoch nur sehr wenige dieser Skalen auf ihre Reproduzierbarkeit hin untersucht. Ziel dieser Arbeit war es, die Reproduzierbarkeit zweier Vier- Punkte-Skalen mit den Ausprägungen 0 bis 3 (keine bis starke Faltenbildung) zur Beurteilung periokulärer Lachfalten (Krähenfüße) zum einen bei entspannter und zum anderen bei angespannter Gesichtsmuskulatur zu untersuchen. Dazu wurde im Vorfeld einer klinisch kontrollierten Multicenter-Studie aus standardisierten Fotografien periokulärer Falten verschiedener Schweregrade im Konsensus-Verfahren ein Atlas entwickelt. Anschließend wurden neun Prüfärzte anhand des Atlas in der Anwendung der Vier-Punkte-Skalen geschult. Nach der Schulung wurden denselben neun Prüfärzten (bzw. nur acht Prüfärzten am zweiten Tag) an zwei aufeinander folgenden Tagen 97 Fotografien periokulärer Falten unterschiedlicher Ausprägung in entspanntem (n=49) und in angespanntem (n=48) Zustand in zufälliger Reihenfolge zur Beurteilung vorgelegt. Der Atlas durfte zur Beurteilung benutzt werden. Für die interindividuelle Variabilität ergab sich ein Kappa nach Fleiss von 0,60 für den entspannten und von 0,58 für den angespannten Zustand. Das ungewichtete intraindividuelle Kappa nach Cohen lag zwischen 0,47 und 0,86 für den entspannten Zustand und für den angespannten Zustand zwischen 0,63 und 0,81. Das gewichtete intraindividuelle Kappa nach Cohen erreichte Werte zwischen 0,63 und 0,91 für den entspannten Zustand und zwischen 0,71 und 0,86 für den angespannten Zustand. Die Werte der teilnehmenden Prüfärztinnen lagen tendenziell höher als die der teilnehmenden männlichen Prüfärzte. Im Anschluss an die SMILE-Studie wurden in einer zweiten Reproduzierbarkeitsstudie vier Experten, ebenfalls mit dem Atlas geschult und ihnen an zwei aufeinander folgenden Tagen 97 Fotografien periokulärer Falten unterschiedlicher Ausprägung in entspanntem (n=49) und in angespanntem (n=48) Zustand in zufälliger Reihenfolge zur Beurteilung vorgelegt. Auch sie durften dazu den Atlas benutzen. Dabei ergab sich für die interindividuelle Variabilität ein Kappa nach Fleiss von 0,63 für den entspannten Zustand und 0,50 für den angespannten Zustand. Die intraindividuelle Variabilität erreichte ungewichtete Kappa-Werte nach Cohen zwischen 0,49 und 0,75 für den entspannten Zustand und zwischen 0,35 und 0,62 für den angespannten Zustand. Das gewichtete Kappa nach Cohen lag zwischen 0,64 und 0,83 für den entspannten Zustand und zwischen 0,49 und 0,74 für den angespannten Zustand. Nach Altman sprechen Kappa-Werte zwischen 0,81 und 1,0 für eine sehr gute, Werte zwischen 0,61 und 0,8 für eine gute, Werte zwischen 0,41 und 0,6 für eine mäßige und Werte zwischen 0,21 und 0,40 für eine schlechte Variabilität. Somit wurden für die interindividuelle Variabilität bei beiden Reproduktionsstudien "mäßige" bis "gute" Werte erzielt, sowohl für den entspannten als auch für den angespannten Zustand. Die Werte für die intraindividuelle Variabilität schwankten bei den Prüfärzten zwischen "gut" und "sehr gut" und bei den Experten zwischen "mäßig" und "gut". Auch hier zeigte sich kein wesentlicher Unterschied zwischen dem entspannten und dem angespannten Zustand. Lediglich ein einziger der Prüfärzte erreichte für den entspannten Zustand nur eine "mäßige" und eine einzige der Expertinnen für den angespannten Zustand nur eine "schlechte" intraindividuelle Variabilität. Anhand der ausnahmslos höheren gewichteten Kappa-Werte zeigte sich, dass die Unterschiede in den Beurteilungen nur geringfügig waren. Insgesamt zeigte sich somit für beide Vier-Punkte-Skalen - für den entspannten und für den angespannten Zustand - eine mäßige bis gute interindividuelle und eine gute intraindividuelle Reproduzierbarkeit. Der weitere klinische Gebrauch der beiden Skalen für den entspannten und den angespannten Zustand kann folglich empfohlen werden., Background: Several methods are used to evaluate the efficacy of botulinum toxin A in the treatment of hyperkinetic facial wrinkles. So far nearly very few have been investigated for its reproducibility. Objective: The aim of this study was to investigate the reproducibility of two widely used clinical 0 3 scales (from none to severe) for lateral canthal frown lines (crow's feet). Methods: Based on standardized photographs of the crow's feet area at rest and at maximum frown a consensus atlas depicting different severity grades was developed. Using the photographs of this atlas the investigators and experts of an upcoming clinical trial were trained. In the main study 49 photographs taken at rest and 48 photographs taken at maximum smile were shown on two consecutive days to 9 (first day) respectively 8 (both days) investigators and several months later on two consecutive days to 4 experts. The reproducibility of the scores was investigated by conventional kappa statistics. Results: The overall reproducibility for both scores was moderate to good both for the investigators and the experts. Among the investigators an unweighted kappa according to Fleiss of 0.6 at rest and of 0.58 at maximum smile for the interobserver reproducibility could be measured. For the intraobserver reproducibility the unweighted kappa according to Cohen measured between 0.47 and 0.86 for each observer at rest and between 0.63 and 0.81 for each observer at maximum smile. The weighted kappa with weights used according to Cicchetti and Allison ranged between 0.63 and 0.91 at rest and between 0.71 and 0.86 at maximum smile. Among the experts an unweighted kappa according to Fleiss of 0.63 at rest and of 0.50 at maximum smile for the interobserver reproducibility could be measured. For the intraobserver reproducibility the unweighted kappa according to Cohen measured between 0.53 and 0.75 for each observer at rest and between 0.35 and 0.62 for each observer at maximum smile. The weighted kappa with weights used according to Cicchetti and Allison ranged between 0.64 and 0.83 at rest and between 0.49 and 0.74 at maximum smile. Conclusions: The clinical 0 - 3 scores of crow's feet both at rest and at maximum smile show a moderate to good inter- and intraobserver reproducibility. As it allows a better discrimination than a single score combined for both situations the use of these scores in clinical trials can be recommended.

BACKGROUND Several clinical scoring systems have been used to evaluate the efficacy of botulinum toxin A in the treatment of hyperkinetic wrinkles. So far very few have been investigated for their reproducibility. OBJECTIVE The aim of this study was to investigate the reproducibility of two clinical four-point scales for lateral canthal lines (crow's feet), at rest and at maximum smile. MATERIAL AND METHODS Based on standardized photographs, a consensus atlas depicting the different severity grades [from 0 (none) to 3 (severe)] was developed. After training based on the atlas, 49 photographs at rest and 48 at maximum smile were graded by the same group of investigators on 2 consecutive days (n=9 on Day 1; n=8 on Day 2). The scores were compared for reproducibility using kappa statistics. RESULTS Overall, reproducibility was good for both scales. Interobserver reproducibility showed an agreement of 0.6 at rest and 0.58 at maximum smile (unweighted kappa). Intraobserver reproducibility showed an agreement between 0.47 and 0.86 at rest and between 0.62 and 0.81 at maximum smile (unweighted kappa). Using weighted kappa analysis, the agreement ranged between 0.63 and 0.91 at rest and between 0.71 and 0.85 at maximum smile. CONCLUSION The clinical scales using scores of 0 to 3 for crow's feet, both at rest and at maximum smile, show a good inter- and intraobserver reproducibility. The use of these scores in clinical trials can be recommended.