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).
When working with such products, Dr. Matarasso explains that the first step is assessing patients' requirements. He offers the example of a cost-conscious 86-year-old woman who came in for filler treatments but actually needed surgery to achieve her desired goals.
"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 aesthetic 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 (Figure 1). 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 fine. 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.
Conversely, he says that even when one has appropriately paralyzed the midline procerus and bilateral corrugator muscles, "Often patients will recruit the adjacent nasalis muscle, which creates 'bunny lines' that traverse the nasal root. Therefore, it's incumbent upon the physician to relax the nasalis as well."
To do this, he advises injecting three to five units, in equal aliquots, across the nasalis muscle.
Dr. Matarasso adds, "Caveats to be aware of in treating bunny lines are twofold. The first is that the skin in this area is very thin, and there's a great deal of potential for bruising. The second is that if one comes too far down on the nasal side wall, one can inactivate the levator labii superioris alaeque nasi muscle. Weakening that muscle creates lip ptosis (Figure 2, p. 26)."
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Lateral ocular lines, known as crow's feet, also are "very amenable to treatment with botulinum toxin," he says. "The protocol is three to four aliquots of three to five units each, injected approximately 1 cm lateral from the lateral bony orbital rim. The primary concern in this area is that the inferior wrinkles will not be adequately effaced with botulinum toxin. One must educate the patient that the inferior dynamic wrinkles are due to the zygomaticus major muscle. And if one weakens this muscle, the patient will have hemi-facial paralysis and appear as if they've suffered from Bell's palsy or a cerebrovascular accident."
The 'triple punch'
To treat the entire periocular area and inferior wrinkles, Dr. Matarasso uses what he calls "triple-punch therapy."
He explains, "For treating mimetic rhytids around the eye, I inject about 12 units of botulinum toxin into the hyperactive musculature. I use a fine filler such as Zyderm 1 or CosmoDerm 1 (both collagen, Inamed) into the static lines. And as a third modality, I will place Restylane (hyaluronic acid, Q-Med Laboratories) into the orbital sulcus. I call it triple-punch therapy because not only does it involve three different injectables, but also because the skin in this area is very thin, and it tends to bruise easily."
Treating the large frontalis muscle of the forehead can be fraught with difficulties, according to Dr. Matarasso. Too much toxin imparts a frozen face or brow ptosis; too little can result in residual rhytids. When treating the frontalis muscle, he says, "It's always a good idea to relax the glabella first. Not only does that neutralize the consequent brow descent, but the natural propensity for the toxin to diffuse allows better visualization of the remaining intact frontalis muscle fibers, and hence less toxin is used.
"The primary problem everyone--physicians and patients alike--always talks about is the non-emotive face.... The best technique here is to use very small amounts, and to leave some muscle fibers intact so there are still some very fine lines in the forehead."
The concept of combining botulinum toxin and fillers furthermore extends to the lower face, Dr. Matarasso says.
"With botulinum toxin," he says, "it is advisable to initiate one's patients with injections in the upper half of the face. Don't start a neophyte or new patient with botulinum toxin injections below the zygomatic arch, because it can be an overwhelming, daunting experience. Especially if a complication occurs, patients tend to be less forgiving, and they do not appreciate the temporary nature of the procedure. Furthermore, for the lower half of the face, one must use much smaller amounts of toxin, to cause paresis as opposed to frank paralysis, and generally augment the effects of the toxin with a filler (Figure 3, p. 26)."
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Disclosure: Dr. Matarasso has served as a consultant to Inamed, Medicis and Allergan, although he received no financial compensation.
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