Combination noninvasive facial aesthetic treatments with botulinum toxin type A

Anatomy related to multiple therapeutic modalities

Facial aging is the result of changes in all anatomic layers of the face, including bone, fat, connective tissues, retaining ligaments, and skin. Computed tomography of facial bones over time shows predictable skeletal alterations: frontal bone moves anteriorly and inferiorly; maxilla shifts posteriorly and superiorly; bony angles of the pyriform aperture, maxilla, and mandible sharpen; anterior orbital aperture becomes wider; and mandibular length and height significantly decrease. As unfair as it is, these bony changes begin around age 25 in women and 45 in men. Moreover, the loculated and distinct fat pads in the cheeks, jaw, and chin age independently via atrophy and descent of soft tissues. Facial retaining ligaments loosen and elongate.

Bony remodeling, fat atrophy, and weakened retaining ligaments contribute to the descent of the brows and hollowing of the forehead contour, deepening of the infraorbital hollows, loss of midface volume and the ogee contour, and deepening of the nasolabial folds. In the lower face, there is a downturn of the lateral oral commissures (“mouth frown”), thinning and flattening of the vermilion lip, and the development of vertical/radial lip lines. While the bony mandible loses projection, the skin overlying the mentalis develops a pebbled appearance from repetitive muscular activity and volume loss. Alterations in retaining ligaments allow jowls to emerge. Simultaneously, exposure to ultraviolet (UV) and infrared (IR) radiation from the sun as well as other environmental exposures reduces the skin’s integrity, loosening its contours and giving rise to wrinkling, areas of hyperpigmentation, and precancerous lesions. Hence, combination therapies provide an opportunity to address the many layers of change, working synergistically to create meaningful outcomes.

Combination therapy in the upper face

In the upper face, the eyes and brows convey important emotional and gender cues. However, this facial area is one of the first to demonstrate alterations due to constant expressive movement, sun exposure, and intrinsic aging. To be successful with upper face rejuvenation, multiple factors need to be addressed in the therapeutic plan.

It is important to listen carefully to each patient’s concerns and target therapy appropriately. Should it be glabellar frown lines, injection of botulinum toxin type A (BoNT-A) is the preferred first step, with follow-up at 2 weeks to ensure optimal results and determine if other facial features are now bothersome. A single good experience will instill confidence and allow for discussions about additional treatment options.

Use of fillers in the upper face has become extremely popular, since deep resting glabellar furrows can be further softened, forehead concavities can be supported, temple hollows can be improved, and tails of brows can be lifted. We prefer to use hyaluronic acid (HA) fillers in the upper face because of their reversibility in the rare but serious situation of vascular occlusion or other adverse events. Note, the glabella and forehead are two of the highest risk regions for vessel compromise with or without vision impairment, hence a firm grasp of vascular anatomy is paramount when performing filler treatments especially in these areas. Combination of HA fillers and BoNT-A leads to high patient satisfaction with greater aesthetic improvement and patient retention rates. And repeated combination treatments of BoNT-A, HA filler, and skin-boosting HA yield greater changes in overall facial appearance versus monotherapy. A global expert consensus group recommended a patient-tailored and culturally sensitive combination of BoNT-A and HA filler in the upper face in diverse patient populations. Customized treatment is necessary as dosing, placement, and ideal product may vary.

Additionally, noninvasive facial surface treatments, such as intense pulsed-light (IPL) and vascular or pigment lasers, are remarkably effective in removing telangiectasias, lentigines, and venous malformations; they also brighten the skin. Resurfacing lasers or microneedling stimulate neocollagenesis, which can augment the effects on frontalis, glabellar and periocular fine lines.

Patients often ask if having energy-based device treatments will alter the effects of previous BoNT-A or filler treatments. Helpfully, HA filler in the nasolabial folds is known to be unaffected by nonablative laser, monopolar radiofrequency (RF), and IPL treatment. Furthermore, a recent single-center retrospective study showed minimal risk of spread of glabella and periorbital BoNT-A in the setting of concomitant full-face nonablative fractionated laser. However, postponing treatment in the setting of edema that obscures assessment may be reasonable (see below).