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Combination therapy with botulinum toxin and fillers has another benefit: it produces much longer lasting results than either fillers or toxin used alone when used to treat folds and furrows of the glabella.
"Aging is caused by photodamage, hyperactive muscles and volume loss. By combining botulinum (toxin) and fillers, you attack the problem on two of the three fronts. Botox eliminates the muscular hyperactivity that causes wrinkles or enervation and fillers restore the volume loss," Dr. Flynn says.
He cites a recent study by Drs. Jean and Alastair Carruthers, et. al. published in Dermatologic Surgery concluding that combination therapy with botulinum toxin and fillers has another benefit: it produces much longer lasting results than either fillers or toxin used alone when used to treat folds and furrows of the glabella.
"Botulinum (toxin) has some improvement when used alone in the lip area but offers much better effects when used in combination with fillers," he notes.
Dr. Flynn, clinical professor of dermatology at the University of North Carolina in Chapel Hill and medical director at the Cary Skin Center in Cary, N.C., notes that the Center is independently conducting studies to investigate the use of combination therapy for treatment of the perioral area.
"We fill the corners of the mouth and also concomitantly use botulinum toxin in perioral muscles. Particularly helpful is the injection of botulinum (toxin) into the depressor anguli oris with its origin in the mandible and its insertion point at the corner of the mouth. Botox used as a sole agent results in the corners of the mouth being elevated. The combination of fillers plus botulinum toxin periorally has been done now for several years, and patients are now coming back and routinely requesting the combination procedure. It produces a wonderful effect," he says.
Dr. Flynn emphasizes that cosmetic practitioners need to use all the therapeutic tools on hand. Sometimes that means botulinum toxin in combination with two or more fillers, in order to restore the face to a more youthful condition.
This addresses another problem dermatologists sometimes run into when using hyaluronic acid derivatives superficially. They can produce small subcutaneous nodules and imbue the skin with a blue color. Topping with collagen, which is whiter and softer, makes the presence of fillers more difficult to detect.
Dr. Flynn says, "You can use this combination of fillers and botulinum (toxin) cautiously for the glabella. Treatment of the glabella must be done carefully because of reports of problems such as cutaneous necrosis. It's not a technique for beginners."
Getting good results To get good results with botulinum toxin, dermatologists have to pay attention to a patient's individualized anatomy and devise a case-by-case injection strategy, rather than going by the textbook. Also, patients who come in with an altered anatomy due to a browlift or blepharoplasty require extra attention because muscles may not be positioned in the usual locations.
Occasionally Dr. Flynn is referred a patient who is described as "resistant" or a "non-responder." The solution is often using more botulinum toxin.
He notes, "There is a frequent problem of men being under-dosed. Dermatologists need to use more product when treating big, beefy guys who have a lot of muscle mass. Research again by the Carruthers has proven that, in the male glabella, you can use significantly more botulinum toxin - 60 to 80 units."
Some patients may warrant a trial of type B toxin. Some patients prefer type B for their routine upkeep. Other patients wish to try using A and B, ultimately deciding on a preferred agent.
Disclosure: Dr. Flynn has done consulting and research with Elan Biopharmaceuticals, Inamed and Allergan, in which he owns common stock.