31 Combination Cosmetic Treatments
Facial aging is a complex process of static and dynamic wrinkling, loss of soft tissue volume with formation of folds and contour defects, and vascular and dyschromic changes. Addressing these different issues often requires the use of multiple aesthetic procedures. Many of the minimally invasive aesthetic procedures in use today are complementary, and may be combined to achieve optimal treatment outcomes and high patient satisfaction.1,2
Treatments typically combined with one another include botulinum toxin, dermal fillers, lasers and intense pulsed light (collectively referred to as lasers* in this chapter), microdermabrasion, chemical peels, and skin care products.3 These procedures can be incorporated into treatment plans over several visits, or some may be combined on the same day in multimodality visits. This chapter demonstrates common treatment combinations of procedures discussed in the aesthetic section of this book.
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
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.
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.
