Botulinum Toxin and Fillers

The use of BoNT-A has changed the way cosmetic procedures are handled. Nonsurgical treatment of wrinkles used to consist of filling or resurfacing methods, both of which were focused on static rhytides. Dynamic wrinkles could at that time only be treated by a surgical approach and only in a few areas, such as the forehead and glabella. Muscle action may affect the duration of biodegradable fillers so that the presence of wrinkles in areas of direct muscular action produces only partial results in treatments with fillers and skin resurfacing. Inhibition of muscular activity with BoNT-A has been the solution to this problem in various areas, especially in the upper third of the face.

The aging process produces a change in muscular behavior. Continuous contraction of specific muscles may lead to dermal alteration and produces static rhytides. For such wrinkles, BoNT-A is injected before the fillers; indeed in some cases it may even be the only method required. In some cases, however, the dermis is so affected by both muscular hyperactivity and sun damage that fillers should also be used. Although the onset of the BoNT-A effect starts after 24-72 h, a period of 15 days must be respected before treatment with fillers is commenced. Experienced practitioners may inject both BoNT-A and fillers in the same session.

Glabellar lines result from the action of the cor-rugator and procerus muscles. Surgical section

Depressor Nasi Resection
Fig. 7.3 a Patient before treatment to reshape the nose. b This patient submitted to nasal reshaping with fillers and botulinum toxin to block the depressor of the septum. There is a change in the smile line and elevation of the tip of the nose

of both muscles often produces imperfect results and may cause a distorted frown line. BoNT-A is the optimal solution to treat this area, and fillers may be needed as complementary treatment (see Fig. 5.2 and 5.4; see Chap. 5). This is the case when the wrinkle is very deep; some wrinkles are so deep that they seem to be scars, and thus unsolvable. In these cases, direct excision or sub-cision should be considered. Horizontal lines in the forehead are due to excessive movement of the frontalis. BoNT-A is usually the single method needed in this area. Depending on the skin thickness and dermal injury, however, fillers may also be needed. After the effects of BoNT-A are complete, fillers can be injected into the remain ing wrinkles. The use of combination treatment with BoNT-A and fillers is also interesting in the oral commissure. BoNT-A inhibits the hyper-activity of the depressor anguli oris muscle and fillers promote structural support (Fig. 7.2; see Fig 5.43 Chap. 5).

Platysmal bands reduce or disappear with BoNT-A. However, some of the horizontal lines in the neck need complementary treatment with fillers. Fillers may be injected in the same session or after the BoNT-A has completely worked.

Other areas where both methods can be combined are in the nose and nasolabial folds. As mentioned earlier (Chap. 5), nose reshaping may be conducted with fillers. Here fillers can be nicely combined with BoNT-A, which will block the action of the depressor of the septum and thus lift the tip of the nose (Fig. 7.3).

Treating the nasolabial fold is feasible with BoNT-A, but it must be conducted only in very few cases where muscular action plays an important role. In this situation, the opposite happens: fillers should be injected first into the nasolabial fold and BoNT-A may be injected subsequently to decrease the muscular puffiness next to the nasal flare. Care should be taken because asymmetry is not an uncommon occurrence in this situation. BoNT-A should be injected to flatten this area. The gummy smile may also be treated with fillers and BoNT-A. The former is used to make the lips thicker and the latter to inhibit hyperactivity of the alaeque nasi labii superioris levator and the labii supe-rioris muscles.

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