Botulinum Toxin and Dermal Fillers

Wrinkles (also called rhytids) usually have both a dynamic and a static component. In many regions of the face, enhanced rhytid reduction can be achieved by addressing both dynamic muscle contraction with botulinum toxin and static lines and volume loss with dermal fillers.^4,5 Botulinum toxin is commonly used in the upper face⁶ and may be combined with dermal filler treatments, particularly in the glabellar frown area (Figure 31-1).^7–9

FIGURE 31-1 Frown lines (A) before and (B) after combination treatment with dermal filler (Juvederm Ultra^®) to areas of volume loss and botulinum toxin (Botox^®) to the glabellar complex muscles.

(Copyright Rebecca Small, MD.)

Botulinum toxin may also be combined with dermal fillers in the lower face, which is a more advanced application for botulinum toxin. Figure 31-2 shows a patient (the author) with radial upper lip lines elicited with active contraction of the orbicularis oris muscle (A) before, (B) 2 weeks after treatment with botulinum toxin, followed by dermal filler treatment 2 weeks later (C). Figure 31-3 shows a patient with volume loss in the oral commissure and marionette line areas, with downturned corners of the mouth, (A) before and (B) after treatment with dermal filler in these areas and botulinum toxin in the depressor anguli oris muscle which were performed in the same visit.

FIGURE 31-2 Dynamic and static radial lip lines (A) before, (B) after treatment with botulinum toxin (Botox) to the orbicularis oris muscle and (C) after dermal filler (Radiesse^®) above the upper lip, during active contraction.

(Copyright Rebecca Small, MD.)

FIGURE 31-3 Oral commissures and marionette lines (A) before and (B) after combination treatment with dermal filler (Juvederm^®) to areas of volume loss and botulinum toxin (Botox) to the depressor anguli oris muscle.

(Copyright Rebecca Small, MD.)

Dermal filler and botulinum toxin combination treatments may be performed on separate days or during the same visit. If performed on separate days, it is recommended that treatment with botulinum toxin be performed first, a few weeks prior to dermal filler treatment, to reduce muscular activity in the treatment area and allow for evaluation of the static appearance of the treatment area. If performed on the same day, the botulinum toxin injection should be performed last, to reduce tissue distortion that may occur from swelling with botulinum toxin injections. If excessive edema is present after dermal filler treatment it is advisable to postpone, botulinum toxin injection and perform treatment 1 week later.²

Figure 31-4 shows a patient (A) before and (B) after treatment with dermal fillers and botulinum toxin to several facial areas. Upper lip radial lip lines were treated using dermal filler and botulinum toxin, and crow’s feet and glabellar complex muscles were treated using botulinum toxin. She demonstrates a typical softened appearance overall after treatment (Figure 31-4B) that is very natural looking and is the desired goal of combination aesthetic treatments.

FIGURE 31-4 Overall facial rejuvenation (A) before and (B) after combination treatment with botulinum toxin (Botox) to the orbicularis oris, orbicularis oculi, and glabellar complex muscles, and dermal filler (Radiesse) above the upper lip.

(Copyright Rebecca Small, MD.)

Botulinum Toxin and Skin Resurfacing

Skin resurfacing is a global, full-face treatment that can address rhytids and irregular texture, as well as dyschromia. Methods of resurfacing range from mild treatments with superficial chemical peels and/or microdermabrasion, to nonablative fractional laser treatments (e.g., 1550 nm) to more aggressive fractional ablative laser resurfacing (e.g., 2940 nm). Botulinum toxin treatments are often performed on the same day, following mild resurfacing treatments,^10,11 and are usually performed at least 1 week prior to laser resurfacing.

The periocular area is a common region for combination therapy with botulinum toxin and laser resurfacing.^12,13 Figure 31-5 shows a patient (A) before and (B) after receiving botulinum toxin to the crow’s feet muscles and ablative laser resurfacing, demonstrating reduction of crow’s feet lines and dyschromia.

FIGURE 31-5 Periocular rhytids and lentigines (A) before and (B) after combination treatment with botulinum toxin (Botox) to the orbicularis oculi muscles and superficial ablative laser resurfacing (Polish Peel with DermaSculpt, HOYA ConBio).

(Copyright Rebecca Small, MD.)

In addition, different methods of superficial skin resurfacing can be combined in the same visit for enhanced results. For example, microdermabrasion, which removes the stratum corneum barrier, may immediately precede chemical peel application in the same visit to allow for more even and deeper acid penetration into the skin.¹⁴

Combining Treatments with Lasers

Nonablative lasers (e.g., IPLs) may be readily combined with other aesthetic procedures, because the skin remains fully intact after treatment. Nonablative lasers for treatment of rhytids (e.g., 1320 and 1064 nm) may be combined with superficial resurfacing procedures. One such technique uses a nonablative laser treatment for rhytids (Q-switched 1064 nm laser) followed by microdermabrasion and then a chemical peel—all in the same visit—to maximize collagen remodeling and reduction of fine rhytids and dyschromia.

Nonablative laser treatments for dyschromia (e.g., IPL and 532 nm lasers) may also be combined with superficial skin resurfacing procedures.¹⁵ Following laser treatment of pigmented lesions, such as lentigines, there is microcrust formation and clinical darkening of the lesions. Resolution of these darkened lesions occurs spontaneously through exfoliation. However, improvements can be achieved more rapidly by combining superficial skin resurfacing using microdermabrasion at least 2 weeks after laser treatments for dyschromia.

Nonablative lasers of different wavelengths may be used in combination during the same visit to treat dyschromia, rhytids, and vascularities. Typically, nonablative lasers for rhytids (e.g., 1320 or 1064 nm) are performed first on the full face, and if the treatment area is not overly warm or erythematous, this may be followed by lasers that target dyschromia and vascularities (e.g., 532 nm or IPL). For example, nonablative full-face laser treatment for rhytids using a Q-switched 1064 nm laser can be immediately followed by IPL or 532 nm localized treatments in dyschromic areas and for vascularities.

When treating dyschromia, it can be useful to combine nonablative lasers that target pigmentation at different depths in the skin. Figure 31-6 shows a patient with dyschromia (A) prior to and (B) after three IPL treatments, which can target deeper pigmented lesions (based on the settings used), followed by treatment with a Q-switched 532 nm laser, which targets very superficial pigment in the skin.

FIGURE 31-6 Dyschromia (A) before and (B) after combination treatment with intense pulsed light (LuxG with Palomar StarLux 500) and a Q-switched 532 nm laser (RevLite, HOYA ConBio).

(Copyright Rebecca Small, MD.)

Advanced facial aging changes include moderate to severe dyschromia and rhytids. These changes can be addressed by combining the more aggressive ablative resurfacing lasers (e.g., erbium and carbon dioxide lasers) for rhytid reduction with nonablative lasers that target pigmentation. Figure 31-7 shows a patient (A) before and (B) after IPL treatment for dyschromia, followed by fractional ablative laser resurfacing for textural improvement in severely photodamaged skin.

FIGURE 31-7 Severely photodamaged skin (A) before and (B) after combination treatment with intense pulsed light (560 nm filter with BBL, Sciton) for dyschromia, and fractional ablative laser treatment (ProFractional-XC, Sciton) for textural improvement.

(Courtesy of Sciton, Palo Alto, CA; and T. Bessinger, MD.)

Conclusion

Combination therapy for rejuvenation of aging skin can be rewarding for both patients and providers by optimizing treatment outcomes in fewer visits, while improving office flow and revenue. A comprehensive aesthetic rejuvenation plan often incorporates regional treatments, such as botulinum toxin and dermal fillers, together with global treatments, such as full-face skin resurfacing or laser treatments. With a foundation in basic aesthetic principles and consultation, together with procedural proficiency using different minimally invasive procedures, providers can successfully combine aesthetic treatments to achieve subtle and natural rejuvenation results.