Both interventions can be used effectively for the treatment of static wrinkles. The depth of the wrinkles, skin type, and recovery time after the procedure may influence the choice of either method. Usually, patients with a fair complexion benefit from laser resurfacing. Patients with a dark complexion specifically in the hands of a less experienced physician may present hyper- and/or hypopigmentation after laser resurfacing. In patients with fair and sun-damaged skin showing a full-face fine wrinkling, laser skin resurfacing may be the treatment of choice to decrease the number of rhytides by increasing the dermal strength. Awaiting the inflammatory phase to subside, in a next step, biodegradable fillers may be injected into deeper wrinkles. The degree of collagen remodeling that occurs following laser treatment varies, depending on laser aggressiveness and levels of enzymes, such as collagenases, which must have stabilized before any biodegradable products are injected. The appropriate time for beginning filler treatment is at the subsiding erythema.

Some patients cannot schedule the required recovery time for a laser resurfacing. Those may prefer fillers to improve the appearance of wrinkles and scars until the time is appropriate for laser resurfacing. The advent of fractional lasers which are characterized by a much faster recovery time allows to use both tools in one session. Therefore, combining both of the methods may be more feasible.

Patients with darker skin are not suitable for aggressive laser resurfacing. For these patients, the combination of a mild exfoliative method or even a fractional laser device and fillers is appropriate. Skin resurfacing should improve skin quality, and fillers should be used to treat deeper defects. Mid-exfoliative methods as well as fractional lasers can be combined with fillers in the same session.

Fillers must be seen as the primary therapy for volume loss of the deep dermis or subcutaneous fat. In contrast, laser resurfacing is the first method to be used for superficial rhytides and elastotic and pigmented skin due to sun damage. For complex scars, both methods should be used. If any resurfacing method reaches the deep dermis or in case of bacterial or viral infections, scar tissue may result. This complication has also been dramatically reduced by the use of fractional lasers. Fillers injected too superficially into rhytides may result in nodule or “sausage” formations and cause irregularities in the skin – specifically when not appropriate fillers are used. When full-face resurfacing is performed, laser resurfacing as well as a deep peel may in some cases decrease the depth of the nasolabial fold, especially a superficial crease, as it tightens the skin from both of the cheeks and upper lips. An aggressive therapy, however, may result in scar tissue formations. Patients with deep nasolabial folds may benefit from a combined therapy with fillers and laser. As a rule, the injection of fillers into the dermis should not be carried out until laser-induced collagen remodeling has ceased. If injection of nonbiodegradable fillers or fat transfer is to be carried out in the subdermal layers (fat or muscle), it may be possible to combine them in the same session. Fillers should be injected immediately before laser resurfacing has begun. Vertical lines of the upper and lower lip benefit from laser resurfacing. Results can be quite impressive. If partial improvement is obtained, fillers can be used to achieve better results after laser resurfacing (Fig. 9.1).

Other lasers may be helpful as well. Vascular lasers such as the KTP laser will reduce telangiectasias and facial erythema. Pigment lasers such as the Rubin laser will decrease lentigines – not only in the face but also in all sun-exposed areas such as the décolleté and the hands.

Chemical peels are also important tools for the removal of superficial wrinkles. Although patients may find the word laser more appealing, depending on the skin type and the time required from recovery, superficial or medium-depth peels are better suited for some patients – and of course more economical. The rules are the same as for laser resurfacing: there are advantages and disadvantages with lasers, chemical peels, and dermabrasion (with the latter being mostly used for acne scar treatment). Combining any of these resurfacing methods may amplify the advantages of each and reduce the disadvantages.

Superficial peels must be used over a course of several sessions to produce a visible result. Since they only exert effects in the epidermis, the recovery time is quite quick, and skin conditioning can be obtained. There is no problem with performing superficial chemical peels and dermal or subdermal fillers in the same session. Fillers must be injected first and the superficial peel applied soon after. Patients must be warned that skin redness may be more prominent at the points of injection. It may be the perfect method for a “lunch-time” visit. Patients can return to their social or professional activities immediately after.

On the contrary, medium-depth peels, such as trichloroacetic acid peels, require at least 1 week away from work and social activities. When the effect of the chemical peel extends down to the dermis, dermal fillers should not be injected in the same session. Injections should only be made when the collagen remodeling has ceased and skin redness fades. In general, dermal filler injection can take place sooner after chemical peels than after deep laser resurfacing.

The use of BoNT-A has changed the way cosmetic procedures are handled. Nonsurgical treatment of wrinkles used to consist of filling (with collagen) or peels, both of which were focused on static rhytides. At the time, dynamic wrinkles could 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. Therefore, the inhibition of muscular activity with BoNT-A might have a beneficial effect on the durability of a filler, especially in the upper third of the face. Furthermore, as the study of the Carruthers et al. (2010) clearly shows the combination of BoNT-A and filler in the same area has a clear advantage over the only BoNT-A therapy of the lower third of the face as with the combination, adverse effects of BoNT-A become less recognizable.

The aging process triggers a change in muscular behavior. Continuous contraction of specific muscles may lead to static rhytides. For such wrinkles, BoNT-A alone might even be the only method required. In severe cases, however, the dermis is so affected by both muscular hyperactivity and sun damage that fillers and even other interventions need to be used. Although the onset of the BoNT-A effect starts after 24–72 h, a period of 15 days is advisable before treatment with fillers in the same area in order to avoid over- or undercorrection. Experienced practitioners, however, may inject both BoNT-A and fillers in one session.

Glabellar lines result from the action of the corrugator and procerus muscles. Surgical section 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 used as complementary treatment (see Fig. 6.​2

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