Chicago — As physicians increasingly use injectable fillers and botulinum toxin as complementary treatments for facial rejuvenation, success depends on educating patients thoroughly and injecting products cautiously, says Seth L. Matarasso, M.D., clinical professor of dermatology at the University of California, San Francisco, School of Medicine.
"If one objectively evaluates the aging face," he says, "one can resurface, remove, recontour, redrape, replace and relax tissues," with the latter two procedures lending themselves particularly to injectable fillers and botulinum toxin A (Botox Cosmetic, Allergan).
"Often, the patient needs something more invasive than he or she realizes and is asking for," Dr. Matarasso cautions.
And sometimes, he says, one must simply say 'no' to the patient.
"The key is to assess the patient, see what the patient needs, and, if it's beyond the scope and expertise of one's practice, refer the patient to the appropriate physician," Dr. Matarasso says. Intertwined with this recommendation is the need to ensure that patients possess appropriate expectations from esthetic treatments, he adds.
Dr. Matarasso says his practice revolves largely around cosmetic dermatologic surgery, particularly botulinum toxin treatments for the upper face and fillers for the lower face.
"However," he notes, "those treatments are not mutually exclusive. The crux, and the direction we're now going, is combination therapy. We're no longer looking at monotherapy in the form of a particular filler or chemodenervating agent, but combining modalities."
When considering combination therapy, he adds, it's important to give the patient a range of the ultimate financial burden. "After all," Dr. Matarasso says, "how much should a single wrinkle cost a patient? If one is going to be using multiple therapies and multiple injectables, that can become fairly costly to the patient. And cost should become part of the treatment algorithm for the physician."
No less important, he says, is the physician's injection technique.
Dr. Matarasso says, "If one looks at the Food and Drug Administration (FDA) indications for botulinum toxin, there are five injection sites for the mid-glabellar complex. And often, treating these areas leaves residual wrinkles laterally and superiorly. Historically, we are taught not to go past the mid-pupillary line for fear of causing eyelid ptosis. However, one can use botulinum toxin across the mid-pupillary line. The key is to remain superficial, as the muscle fibers are superficial and wispy; to use very small amounts; and to stay well above (1.5 cm to 2 cm) the superior orbital rim."
Following these recommendations helps one avoid creating what's known as the Spock brow of Star Trek fame, he says. Alternatively, Dr. Matarasso says fillers are also effective in treating the residual wrinkles.
The other complication that can occur in the midline glabellar complex is residual lines, he says.
"What frequently happens is that the botulinum toxin works well, but there are residual static or photoaging rhytids in the glabellar area. In this scenario, ideally, one should let the botulinum toxin have its paralyzing effect, and then, subsequently, add superficial filler. That way, one is maximizing muscle relaxation, minimizing the amount of filler needed and optimizing the cosmetic outcome," Dr. Matarasso explains.