Combination techniques: Facial rejuvenation could benefit from multiple fillers plus Botox

September 1, 2009

Correction of facial lines and folds may benefit from a combination approach that targets different aspects of the defects.

Key Points

Los Angeles - For patients seeking rejuvenation of facial lines and folds, a combination approach incorporating different types of injectable fillers or using fillers together with onabotulinumtoxinA injection (Botox Cosmetic, Allergan) may offer a better cosmetic outcome than onabotulinumtoxinA or a single filler, says Derek Jones, M.D., clinical assistant professor of dermatology, University of California Los Angeles.

Injection of onabotulinumtoxinA has well-established efficacy for improving the appearance of glabellar lines that arise as a result of muscle hyperactivity. However, for patients who have deep-etched lines present at rest, onabotulinumtoxinA alone usually will not provide sufficient benefit, Dr. Jones says.

"It is incumbent upon the cosmetic surgeon to caution such patients that botulinum injection may improve their appearance, but they should not expect complete correction," he says.

Only a small volume of filler - usually about 0.4 cc of hyaluronic acid - is needed to achieve optimal results. However, Dr. Jones cautions that the glabellar region is a danger zone because of the presence of abundant vasculature.

"The hyaluronans, Restylane (Medicis) or Juvéderm (Allergan), are a good option, and CosmoDerm (human collagen, Allergan) also works well. However, the injection must be delivered very superficially, into the dermis and not into the subdermal plane where the supratrochlear vessels reside.

"More robust fillers, including Zyplast (bovine collagen, Allergan), CosmoPlast (human collagen, Allergan) and calcium hydroxylapatite (Radiesse, BioForm Medical) should be avoided, as their injection can easily compromise the vasculature," Dr. Jones says.

Restoring lips

Combining onabotulinumtoxinA with a filler is also useful for volumizing, smoothing and restoring definition of the lips. For this indication, Juvéderm is Dr. Jones' filler of choice, used with a low dose of onabotulinumtoxinA injected into the superior orbicularis oris muscle, about four units (one unit per quadrant), to decrease dynamic motion that contributes to vertical lip rhytids.

Choosing a low dose of onabotulinumtoxinA is important to avoid inducing problems with phonation. Nevertheless, patients should be cautioned that they may have some difficulty pursing the lips for one to two weeks after the procedure. Another important caveat is to avoid over-volumizing the lips with the filler.

"A lot of women will insist that they do not want their lips injected, because they are afraid of a sausage-like result. The goal should be to create a natural appearance with enhanced crispness to the vermilion border, and achieve a restored, but not overcorrected, volume to the mucosal aspect or pink of the lip," Dr. Jones says.

For treating the vermilion border, Dr. Jones still favors the human collagen product CosmoPlast, injecting about 1 cc into the potential space, although he noted that surgeons outside of the United States who have access to Evolence Breeze (OrthoNeutrogena) report good results using this version of porcine collagen. Smoothing out fine etched perioral vertical rhytids is achieved using CosmoDerm or hyaluronic acid in very small quantities, Dr. Jones says.

Disclosure: Dr. Jones has received honoraria, consulting fees, or undertaken clinical studies for Allergan, BioForm, Dermik, Merz and Medicis.