Introduction

Although botulinum toxin (BoNT) effectively targets hyperfunctional rhytides, deeper folds and wrinkles – along with changes in skin texture, pigmentation, and other signs of photodamage – require additional rejuvenation modalities to obtain optimal results. The very nature of chemodenervation has propelled its use in adjunctive settings, where reduced muscular activity promotes healing and remodeling of the skin. Used in combination with soft tissue augmentation, laser resurfacing, light-based therapies, or surgery, BoNT has been shown to prolong and enhance aesthetic results. Moreover, a greater understanding of volume depletion in the face has led to a shift in the approach to rejuvenation. Over time, loss of fat and bony changes in the face cause the skin to sag and reposition into folds and hollows. A multi-faceted approach and all-encompassing three-dimensional treatment plan target not only muscular movement via BoNT but also volumizing and contouring with soft tissue augmentation to create an aesthetically pleasing outcome.

Soft tissue augmentation

In the last few years, clinicians have gained a greater appreciation for the three-dimensional approach to facial rejuvenation. Treating the surface of the skin – the lines and wrinkles that emerge over time – does not address the volume loss that characterizes the aging process. Volume loss in the glabella and forehead may combine with brow and eyelid ptosis and reduced lateral brow projection (Fig. 22.1). Repetitive movements of facial expression, loss of bone, and thinning of the skin due to photodamage all exacerbate this age-related fat depletion. Loss of support from underlying bony structures and tissue causes skin to sag and reposition over the changing contours of the face.

Figure 22.1 The aging face is characterized by loss of volume, bony changes, thinning skin, and rhytides and folds.

Current approaches to facial rejuvenation combine augmentation and contouring with movement control, using BoNT in combination with HA fillers to achieve results that are longer lasting and more satisfying in resting glabellar rhytides, brow-height adjustment, horizontal forehead lines, nasojugal folds, sculpting the zygomatic and perioral regions, and to improve the appearance of the neck (Table 22.1). Pre-treatment with BoNT serves to reduce the dynamic component of the target rhytide, which may allow more accurate estimation of the volume of filler needed and preventing overcorrection. Moreover, chemodenervation may increase the longevity of the implant by reducing microextrusion caused by repetitive muscular motion.

Table 22.1 BoNT and soft tissue augmentation

A number of studies have shown superior efficacy and patient satisfaction associated with combination therapy compared to fillers alone, particularly in individuals with deep resting rhytides. In 2003, Carruthers and colleagues compared the efficacy of BoNT alone or in combination with hyaluronic acid (HA) in 16 patients with moderate-to-severe resting glabellar rhytides via retrospective analysis. Response to the filling agent plus chemodenervation was compared clinically and photographically to the response to BoNT alone. In 94% of patients receiving combination therapy, severity of rhytides decreased from moderate or severe to mild. By contrast, patients receiving BoNT alone experienced only moderate success. To further examine the relationship between chemodenervation and filling agents, Carruthers and Carruthers conducted a randomized trial of 38 patients with moderate-to-severe glabellar rhytides receiving HA alone or in combination with BoNT; the latter group showed a better response both at rest and on maximum frown (Fig. 22.2). The addition of BoNT also extended the duration of the filling agent, from 18 weeks for HA alone, to 32 weeks for combination therapy. Patel and colleagues found improved clinical effects of longer duration and greater patient satisfaction in 65 subjects who received BoNT and collagen for the treatment of glabellar rhytides compared to patients who received either modality alone. In 2010, Carruthers and colleagues demonstrated similar results in a multicenter, randomized trial of 90 women treated with BoNT, HA, or in combination for rejuvenation of the perioral area and lower face. Combination therapy was superior to either modality used alone (Fig. 22.3).

Figure 22.2 Response to combination of HA with BoNT: (A) pre-treatment, and (B) post-treatment.

Figure 22.3 Perioral rejuvenation with BoNT alone (A, D), Juvéderm (B, E), or in combination (C,F). (A–C): Baseline; (D–F): after 24 weeks.

Although initially considered treatment for only deeper folds and rhytides, combination treatment with toxins and fillers is considered the standard regimen for facial rejuvenation in many cosmetic offices, with a greater emphasis on augmentation. This shift comes, in part, from a greater understanding of the three-dimensional nature of aging, particularly loss of volume from and bone remodeling in the malar and zygomatic regions, brow, and infraorbital hollow. Moreover, clinicians take a more holistic approach, considering not only the treatment of targeted rhytides and folds, but also their interaction with adjacent regions and the influence of augmentation on the appearance of the face as a whole. Volumizing the glabella and medial forehead, for example, can lift the brow, soften forehead lines, elevate the root of the nose, and lessen horizontal procerus rhytides (Fig. 22.4). The authors (JC and AC) use fillers increasingly to layer in a smooth, thin sheet of filler throughout entire regions (i.e. the forehead, upper lip, sides of the chin and anterior cheeks), lessening the need for other modalities.

Figure 22.4 (A, B) Soft tissue augmentation of the glabella and medial forehead enhances aesthetic appearance of the brow without other modalities.

Lasers and light-based therapies

Lasers – including broadband light and radiofrequency devices – have become an indispensable part of the cosmetic surgeon’s armamentarium in combating photoaging (Table 22.2). Concomitant use of BoNT and these devices leads to optimal improvement of dynamic rhytides, superior and longer-lasting outcomes, better healing of newly remodeled skin, and a more permanent eradication of wrinkles.

Table 22.2