Combining Toxin, Soft Tissue Filler & Threads: Achieving the Best Result for Facial Rejuvenation
Facial aging is a complex process that involves multiple factors. As individuals age, they experience changes in various aspects of their facial anatomy, including the skin, fat distribution, muscle tone, ligament laxity, and bone structure. Skin changes involve a decrease in collagen and elastin production, leading to wrinkles, fine lines, and a loss of elasticity. Fat loss in the face can result in hollowed areas and a less youthful appearance. Changes in muscle tone and ligaments can contribute to sagging and the formation of jowls. Lastly, alterations in bone structure can affect the overall shape and contours of the face.
Furthermore, clinicians have to acknowledge that patients from diverse ethnic backgrounds may have distinct facial features and aging patterns. For example, Asian and Caucasian individuals often have different facial shapes and proportions. As the effect of these differences, the treatment approach may need to be customized to suit the patient's ethnicity. Generally, individuals of Asian descent tend to exhibit facial characteristics that include a rounder face, notably demonstrated by wider measurements in bitemporal, bizygomatic, and bigonial dimensions. Additionally, they commonly feature a forehead that appears somewhat recessed, as well as specific distinctions in orbital rims and medial maxillary/pyriform areas. Furthermore, Asians often display a lower nasal bridge and a distinct mandibular contour.
In contrast, individuals of Caucasian ethnicity typically present with facial features that are narrower and longer. Their faces tend to exhibit more pronounced anterior projection of the orbital rims, deeper-set eyes, a higher nasal bridge, and a relatively more prominent maxilla and mandible. Consequently, these fundamental anatomical disparities between ethnic groups result in variations in the types of aesthetic procedures they may request. Understanding these ethnic variations is essential for practitioners to provide treatments that appear natural and harmonious with the patient's unique facial characteristics.
Recognizing the complex factors of aging, doctors have found that no single treatment modality can address all aspects of facial aging effectively. Different areas of the face may require specific approaches to achieve the best results. Common areas of focus include the upper, mid, and lower facial thirds, each of which may benefit from different combinations of treatments to address specific concerns. For example, the forehead may need botulinum toxin to address lines and wrinkles, while the cheeks may benefit from dermal fillers to restore volume. Combining treatments allows practitioners to tailor their approach to the patient's unique needs and achieve a more comprehensive rejuvenation.
In this blog, we will explain several alternatives of facial rejuvenation and the combination therapies of each alternative, the procedure, and management of adverse events to achieve the best result for patients
Facial Rejuvenation Alternatives
1. Botulinum Toxin
While botulinum toxin is often considered the primary treatment for wrinkle correction, it is not suitable for all types of wrinkles. Wrinkles, also known as rhytids, are typically classified into two categories: dynamic and static. Static wrinkles encompass both superficial fine lines and deeper furrows. Most static wrinkles develop as a natural consequence of the aging process. On the other hand, dynamic wrinkles result from the overuse of facial expression muscles and are commonly observed in areas like the glabellar region, lateral canthal areas, or periorbital regions. Examples of furrows include nasolabial folds and glabellar lines.
Botulinum toxin is specifically effective for addressing dynamic wrinkles such as forehead lines, glabellar lines, periorbital lines (canthal), wrinkles on the dorsum of the nose, and fine lines around the lips. However, when dealing with furrows like deep nasolabial folds and marionette lines, fillers are the preferred choice to enhance their appearance. Botulinum toxin is also not recommended for certain dynamic wrinkles, such as transverse infraorbital wrinkles and zygomatic wrinkles, due to the potential risk of worsening the aesthetic appearance of the area.
Anatomical differences play a crucial role in determining the suitability of botulinum toxin treatment. Asians typically possess a thicker dermis and increased facial adiposity both above and below the superficial muscular aponeurotic system (SMAS). They also have denser fat and fibrous connections between the SMAS and deep fascia of the parotid gland and the masseter. Moreover, Asians tend to have facial muscles with less mass, shorter length, narrower width, and lower hyperactivity compared to Caucasians, particularly in muscles like the corrugators. Conversely, most Caucasians have less developed masseter muscles than Asians. These variations necessitate the application of varying amounts of toxin on different facial regions to achieve optimal results.
2. Soft Tissue Fillers
The deeper subcutaneous layers in the midface can be visualized as containing localized fat compartments separated by septal tissue. These compartments can be categorized as either superficial or deep. The superficial fat compartments are situated between the skin and the layer known as the superficial muscular aponeurotic system (SMAS). The SMAS represents a continuous and organized fibrous network that connects the facial muscles, other fascia (such as the parotid fascia), and the periosteum to the dermis. This network comprises a complex three-dimensional structure consisting of collagen fibers, elastic fibers, fat cells, and muscle fibers.
Within this fibrotic network of the SMAS, we can find the fat tissue of the superficial compartments. In contrast, the deep fat compartments are positioned beneath the SMAS layer and lie below the mimetic muscles. These deep compartments are effectively addressed using soft tissue fillers to correct deep furrows in areas such as the glabella, periocular lines, inferior orbital rim/tear trough, cheeks/zygomatic region, nasolabial folds, and perioral regions. Additionally, these fillers can be used for enhancing the lips, defining the jawline, and addressing the chin crease.
In terms of ethnic variations, Asians commonly seek correction in the chin, Marionette or prejowl sulcus, and jawline, while Caucasians often opt for volume correction in the zygoma, lateral maxillary areas, and lips.
3. Combination of Botulinum Toxin and Soft Tissue Fillers
For a more profound and longer-lasting effect, particularly in mature patients, addressing static lines may necessitate a combination of botulinum toxin and low-density HA fillers. The primary purpose of HA fillers is to correct age-related volume loss, but these products have recently found application in lifting and supporting sagging tissue, as well as contouring the face and rejuvenating the skin. While restoring tissue volume loss is commonly performed in the midface area (including the malar regions, periorbital and perioral regions), HA fillers are also used to correct structural deficiencies in the jawline and for reshaping the chin and nose. The choice of suitable soft tissue fillers is guided by their physical properties, such as rheology. For example, a novel HA range with proprietary eXcellent Three-dimensional Reticulation (XTR™) Technology offers three different levels of rheological characteristics (touch, restore, core) to cater to various clinical needs in volumizing and reshaping.
Clinical studies extensively support the positive effects of combining botulinum toxin and fillers. This combination provides cumulative benefits, particularly in treating the forehead/glabellar rhytide complex and is often preferred by patients over toxin treatment alone. Patients previously treated solely with toxin for correction of periorbital, temporal, glabellar lines, and crow's feet have rated the combination as "superior," with only mild and transient reactions. In a large prospective multicenter study known as HARMONY, a global approach to facial rejuvenation involving botulinum toxins, subcutaneous fillers, and bimatoprost (for eyelash hypotrichosis) led to significant improvements in patient satisfaction and perceived younger facial appearance.
4. Bioabsorbable Threads
Bioabsorbable threads serve multiple purposes, including lifting, mobilizing, and contouring facial tissue. These effects result from the physical traction they exert on the surrounding tissue and their ability to stimulate biostimulation. Consequently, threads not only address the mild to moderate sagging of tissues typically observed in the midface and lower face but also encourage the formation of a supportive collagen matrix in the soft tissue. Early, albeit small and nonblinded studies suggested that when combined with other aesthetic techniques, threads can provide temporary improvements in facial rejuvenation. However, more recent iterations of bioabsorbable threads, such as anchoring/lifting and stimulating threads, have been developed to overcome the limitations of earlier thread technologies, and these have demonstrated high levels of patient satisfaction. Further research on the effects of these innovative threads in combination with conventional aesthetic approaches to address midface and lower face aesthetic concerns is anticipated in the near future.
When it comes to the use of bioabsorbable suspension threads, Caucasians typically undergo treatment to address ptosis of hypertrophic fat compartments, which are often repositioned upward and laterally. Conversely, in the case of Asians, techniques that reposition soft tissues laterally are less favored since they could potentially widen the face. Instead, there is a preference for a more vertical repositioning of soft tissue using vertical vector techniques. This involves reducing volume along the jawline and redistributing it in the midface region.
5. Combination of Botulinum Toxin, Soft Tissue Fillers, and Bioabsorbable Threads
When applied altogether, there is a documented synergistic effect that occurs between botulinum toxin, HA filler, and bioabsorbable threads. Given that these modalities can produce overlapping effects, the combination or pairing of these approaches has the potential to yield enhanced aesthetic results. Moreover, the utilization of multiple modalities serves the additional purpose of minimizing the need for excessive product usage. However, it should be noted that every patient must be considered as an individual with unique needs. The fundamental step for each aesthetic procedure is a thorough anatomical–aesthetic–clinical assessment followed by an open discussion with the patient regarding possible outcomes of the procedure.
Combination Therapy Procedure
1. Before the Procedure
Patients often come to us with specific aesthetic goals in mind, but it is our responsibility to educate them about addressing underlying anatomical concerns rather than focusing solely on individual issues to achieve the desired outcome. For instance, clients might present pictures of celebrities and request corrections without being aware of the appropriate procedures. Therefore, it's essential to educate the patient about the expected outcomes of the recommended procedures and make them aware of the associated risks and benefits.
Using pretreatment photographs can be a valuable tool to illustrate potential improvements to patients. Ensure that you have adequate lighting and high-quality cameras available in your clinic.
It's crucial to be aware of contemporary standards of attractiveness to ensure that patient expectations align with ethnicity-specific enhancements. For example, it's no longer a universal desire for Asians to achieve a Western appearance.
Proper product selection should be based on the patient's specific needs. Physicians may consider preliminary skin resurfacing procedures, such as chemical peels, one to two weeks before other treatments to prepare the skin. To address sagging skin, such as marionette lines and jowls, micro-focused ultrasound (MFUS) and radiofrequency treatments may be employed. These resurfacing and rejuvenation procedures are typically performed first to minimize unnecessary manipulation of the face when using products like fillers or threads (incorrect sequencing could lead to bruising or displacement of injected materials).
Mapping the injection sites using dermal pencils can be particularly helpful for more invasive procedures, such as thread treatments. Strict adherence to aseptic technique is essential. For deeper procedures, local anesthesia and/or icing may be used as the preferred pain management techniques to ensure the patient's comfort during the visit.
2. During the Procedure
When injecting botulinum toxin into the face and neck, a fine needle should be used, and the dosage should be adjusted according to the patient's muscle mass and degree of muscle hyperactivity (Asians typically require lower toxin doses). As a general practice, botulinum toxin should be administered during the initial treatment session. This targets dynamic wrinkles associated with facial expressions, allowing the treatment effects to be more effectively assessed before other procedures.
HA fillers or threads can be administered approximately two weeks later. While some practitioners opt for combination injections in a single session, it's not recommended to perform filler injections and thread procedures on the same day to avoid overcorrection and the potential complications of multiple procedures.
For HA filler injections, it is advisable to gradually apply them over several visits, starting from deeper planes and moving outward. This approach helps prevent sudden and noticeable facial changes, as well as minimizing bruising and swelling.
3. After the Procedure
Following filler injections and/or thread placement, patients should be advised to refrain from massaging the treated areas for about 6 hours and avoid exposure to extreme temperature changes to minimize the risk of bruising. Strenuous physical activity should also be avoided during this period to prevent elevated blood pressure due to the vasomotor effects of epinephrine and/or lidocaine.
Sleeping with the head elevated for one night may be necessary to reduce short-term post-traumatic edema, and over-the-counter pain medications can be used if needed. The use of skincare products can typically be resumed the day after the procedure to minimize the risk of bruising. Additionally, another skin resurfacing procedure, such as a chemical peel, may be considered during follow-up (2–4 weeks after) to further optimize the aesthetic treatment outcome. Touch-up procedures may also be performed during the same visit.
A Review on the Combined Use of Soft Tissue Filler, Suspension Threads, and Botulinum Toxin for Facial Rejuvenation (2021)
Biostimulatory effects of polydioxanone, poly‐d, l lactic acid, and polycaprolactone fillers in mouse model (2019)
Long‐term results following polydioxanone sling fixation technique in unstable lateral clavicle fracture (2016)
Preterm premature rupture of membrane after polypectomy using an Endoloop polydioxanone suture II (2016)
Investigation on the cutaneous change induced by face‐lifting monodirectional barbed polydioxanone thread (2017)
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