Combination treatment

22 Combination treatment







Soft tissue augmentation


In the last few years, clinicians have gained a greater appreciation for the three-dimensional approach to facial rejuvenation. Treating the surface of the skin – the lines and wrinkles that emerge over time – does not address the volume loss that characterizes the aging process. Volume loss in the glabella and forehead may combine with brow and eyelid ptosis and reduced lateral brow projection (Fig. 22.1). Repetitive movements of facial expression, loss of bone, and thinning of the skin due to photodamage all exacerbate this age-related fat depletion. Loss of support from underlying bony structures and tissue causes skin to sag and reposition over the changing contours of the face.



Current approaches to facial rejuvenation combine augmentation and contouring with movement control, using BoNT in combination with HA fillers to achieve results that are longer lasting and more satisfying in resting glabellar rhytides, brow-height adjustment, horizontal forehead lines, nasojugal folds, sculpting the zygomatic and perioral regions, and to improve the appearance of the neck (Table 22.1). Pre-treatment with BoNT serves to reduce the dynamic component of the target rhytide, which may allow more accurate estimation of the volume of filler needed and preventing overcorrection. Moreover, chemodenervation may increase the longevity of the implant by reducing microextrusion caused by repetitive muscular motion.


Table 22.1 BoNT and soft tissue augmentation

























Filling agents Indications for combination therapy Outcomes
Hyaluronic acid


Calcium hydroxylapatite
–Radiesse®
Collagen
–Evolence®
Poly-l-lactic acid
–Sculptra®

A number of studies have shown superior efficacy and patient satisfaction associated with combination therapy compared to fillers alone, particularly in individuals with deep resting rhytides. In 2003, Carruthers and colleagues compared the efficacy of BoNT alone or in combination with hyaluronic acid (HA) in 16 patients with moderate-to-severe resting glabellar rhytides via retrospective analysis. Response to the filling agent plus chemodenervation was compared clinically and photographically to the response to BoNT alone. In 94% of patients receiving combination therapy, severity of rhytides decreased from moderate or severe to mild. By contrast, patients receiving BoNT alone experienced only moderate success. To further examine the relationship between chemodenervation and filling agents, Carruthers and Carruthers conducted a randomized trial of 38 patients with moderate-to-severe glabellar rhytides receiving HA alone or in combination with BoNT; the latter group showed a better response both at rest and on maximum frown (Fig. 22.2). The addition of BoNT also extended the duration of the filling agent, from 18 weeks for HA alone, to 32 weeks for combination therapy. Patel and colleagues found improved clinical effects of longer duration and greater patient satisfaction in 65 subjects who received BoNT and collagen for the treatment of glabellar rhytides compared to patients who received either modality alone. In 2010, Carruthers and colleagues demonstrated similar results in a multicenter, randomized trial of 90 women treated with BoNT, HA, or in combination for rejuvenation of the perioral area and lower face. Combination therapy was superior to either modality used alone (Fig. 22.3).




Although initially considered treatment for only deeper folds and rhytides, combination treatment with toxins and fillers is considered the standard regimen for facial rejuvenation in many cosmetic offices, with a greater emphasis on augmentation. This shift comes, in part, from a greater understanding of the three-dimensional nature of aging, particularly loss of volume from and bone remodeling in the malar and zygomatic regions, brow, and infraorbital hollow. Moreover, clinicians take a more holistic approach, considering not only the treatment of targeted rhytides and folds, but also their interaction with adjacent regions and the influence of augmentation on the appearance of the face as a whole. Volumizing the glabella and medial forehead, for example, can lift the brow, soften forehead lines, elevate the root of the nose, and lessen horizontal procerus rhytides (Fig. 22.4). The authors (JC and AC) use fillers increasingly to layer in a smooth, thin sheet of filler throughout entire regions (i.e. the forehead, upper lip, sides of the chin and anterior cheeks), lessening the need for other modalities.







Mar 12, 2016 | Posted by in General Surgery | Comments Off on Combination treatment

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