Clinical Procedures in Laser Skin Rejuvenation - part 9 pps

the need for a fundamental understanding of this muscular anatomy. 7 It is clear, however, that, due to diffusion effects and the relative safety of Botox, the variability in points of injection and dosages has not significantly reduced the product’s overall satisfactory clinical results. In our opinion, required dosages for a given anatomical area can be reduced by precise localization and direct injection into the targeted muscle or muscle groups. It is imperative that one keep in mind not only the specific muscle locations when providing neuromodula- tor treatment, but also the functional interrelationships of the muscle action. Many of these act as antagonist– protagonists in the position of the brow. The use of Botox in general has evolved with experienced and thoughtful injectors from a simple wrinkle treatment to a means of reshaping, contouring, and softening the facial features associated with aging and the stigmata of the frowning, angry or worried facial form. Botox is frequently used to specifically target different muscular units. In the glabellar region, targeting of the procerus and corrugator muscles is used to eliminate furrowing along the radix and medial eyebrow region.The lateral orbital region, which is commonly referred to as the ‘crow’s feet’, is also a region in which Botox may be of use to target the orbicularis oculi muscle and reshape the upper face.The use of Botox in the forehead must be conservative in order to balance the risk of brow ptosis by targeting the only brow elevator, the frontalis muscle. Perioral lip lines have also been treated with sparing amounts of Botox to suppress the pursing effect of the orbicularis oris muscle. One must be careful not to compromise oral competence as a result of this treatment. Botox injection into the depressor anguli oris muscle can target marionette lines, and its use for contraction of the mentalis muscle can alleviate complaints of a dimpled chin appearance, but one must be careful to avoid the lower lip depres- sors. Platysmal banding in the neck due to overactive platysmal muscle action can be treated using Botox. However, this works best for younger patients with good skin elasticity or postoperative residual bands. 8 This facial characteristic may ultimately only be treated optimally with surgical intervention. The use of botulinum toxin type A and laser resurfacing has been studied recently due to the prolifera- tion of nonsurgical treatments for the aging face and the desire to perform more than one treatment in one visit. It has been demonstrated that the use of Botox in conjunction with laser resurfacing results in improved outcomes in the periorbital region. 9 Other areas of the face have also been studied and have been shown to have less rhytids after Botox and laser than those areas treated with laser alone, and these results were clinically most significant in the crow’s feet region. 10 It has also been shown that the use of Botox as an adjunctive treatment will prolong the beneficial results of laser resurfacing and should therefore be offered as an option to patients wishing to have longer-lasting elimination of rhytids. 11 It is safe to use laser resurfacing after treatment with Botox, as this will have no effect on the efficacy of the Botox injection or other apparent untoward effects. 12 182 Clinical procedures in laser skin rejuvenation Fig.16.1 The glabellar complex as demonstrated before and after injection of botulinum toxin. 16 Carniol-8028.qxd 8/23/2007 10:34 AM Page 182 HISTORICAL PERSPECTIVE The search for an ideal product to be used for soft tissue augmentation has been ongoing with varying degrees of success since the end of the 19th century. Autologous fat was first reported as a soft tissue filler by Neuber in 1893. 13 Paraffin was later used, but with significant drawbacks. 13,14 The ensuing years brought the use of vegetable oils, mineral oil, lanolin, and beeswax; all demonstrating the problems that continue to be associated with fillers in use today, namely chronic inflammation and migration. 15–18 Purified bovine dermal collagen was first developed in an injectable form in 1977 by Knapp et al. 19 In early trials, the most common complications seen were cellulitis, urticaria, and hyperpigmentation of the skin making it superior to its predecessors. 19 Teflon, polytetrafluoroethylene paste, was initially thought to be a useful soft tissue filler. However, its consistency and injectability limit its main commercial use today to vocal cord augmentation procedures. 20 It is reasonable to divide soft tissue fillers into the biologicals and the nonbiologicals.We will first discuss the biologicals, both tissue-derived and synthetic. Finally, we will discuss the nonbiologicals, i.e., fillers not based on animal tissue.Table 16.1 is offered as a reference to help guide clinicians in the selection of a soft tissue filler. BIOLOGICAL MATERIALS USED AS INJECTABLE IMPLANTS The use of biological materials for injection is thought to be advantageous in that the inflammatory response should be less for a substance that is of nonimmuno- genic biological origin. However, cross-reactivity has not been eliminated altogether, and although biological fillers do result in less fibrosis and contraction around the injection site, problems still exist. The most common side-effect seen with the use of soft tissue fillers is the localized reaction to the injection or implantation. Swelling, redness, and pain can all be treated with conservative measures. Allergies and delayed hypersensitivity responses are more serious complications, and indeed preclude the further use of the material. Collagen Collagen was the first material to be approved by the FDA for used as an injectable soft tissue filler, in 1981. 15 Many derivatives are available today, including Zyderm I (35mg/dl), Zyderm II (65 mg/dl), and Zyplast (Collagen Corp., Palo Alto, CA). Cosmoderm and Cosmoplast (Inamed Corp., Santa Barbara, CA) differ from Zyderm and Zyplast only in that they are injectable human collagen products derived from a sin- gle cell line source. Zyderm I was the first nonautologous agent to be approved for use as a soft tissue filler in the USA, in 1981. 21 Zyderm II was soon developed as a more concentrated form.These substances work on the basis of low-grade focal inflammation and are of a for- giving nature.They are easy to inject, and precise injection technique is not very important. Zyderm is derived from bovine dermal collagen, with 95% type I and 5% type III collagen.The processing of Zyderm removes the telopeptide regions of the molecule without dis- rupting the natural helical structure. However, 3–3.5% of the population still demonstrate a hypersensitivity to the substance, and after one negative skin test, 1–5% of patients will still show an allergic reaction when the material is placed in the face. 22 Zyplast is crosslinked by the addition of glutaralde- hyde, which lessens the immune response to it and also serves to increase resistance to bacterial collagenase. Zyderm injections will provide cosmetic results for 2–3 months, at which time repeat injections are needed. Zyplast provides longer results (on average 2–4 months) due to its crosslinking, but eventually The bioscience of the use of botulinum toxins and fillers for non-surgical facial rejuvenation 183 Table 16.1 Soft tissue fillers Synthesized Synthetic Biological filler bioactive non-resorbable materials fillers polymers Bovine collagen Sculptra Artecoll Recombinant Reviderm intra Silicone human collagen Juvederm Radiesse Ultrasoft Hyaluronic acid Softform Dermal matrices Advanta, Dermalive, Dermadeep 16 Carniol-8028.qxd 8/23/2007 10:34 AM Page 183 repeat injections are also necessary. Zyderm and Zyplast have to be injected intradermally. Zyderm is infiltrated into the papillary dermis, whereas Zyplast is preferably placed into the midreticular or deep reticu- lar dermis at the dermal–subcutaneous interface. Zyplast should not be injected into the superficial papillary dermis or in areas of thin skin, because it forms beads on placement. 23 Hyaluronic acid Hyaluronic acid is a biopolymer of glycosaminoglycan chains, which coil on themselves resulting in an elastic and viscous matrix. It is found naturally in the dermis and has a high affinity for water, thereby serving to hydrate and plump the skin. 24 The loss of hyaluronic acid with age leads to dermal dehydration and the formation of rhytids. 25 Crosslinking can lengthen the half-life of hyaluronic acid, but cannot eliminate its degradation. Products clinically available include Hyalform, Hyalform Plus and Hyalform Fine Line (Biomatrix, Inc., Ridgefield, NJ), Restylane (Q-Med, Uppsala, Sweden), and Captique (Genzyme, Ridgefield, NJ), and other forms, such as Juvederm (Allergan, Irvine, CA), are under clinical trail in the USA. Q-Med is also responsi- ble for Restylane Fine Line and Perlane. Perlane is designed for subcutaneous injection and is primarily used for volume replacement. It is a larger particle than that found in Restylane, and therefore has a longer duration. While Juvederm is a pure hyaluronic acid form that is rapidly absorbed, Hyalform is a crosslinked xenogenic variety derived from rooster combs, which was submit- ted for FDA approval as an equivalent product to Restylane.The latter is only partially crosslinked and is processed from a streptococcal fermentation. 24 Neither material requires skin testing. Restylane, not being derived from an animal source, has a lower risk of immune reaction. Both forms are reabsorbed, albeit at a slower rated than the collagen products. It has been reported that effects last up to 6 months. 26 Hylaform is less viscous, and this may decrease the duration of its effect to 2–4 months, although no side-by-side trials have been published. Hylaform is a modified form of hyaluronan, a naturally occurring substance found in human skin and throughout the body. Since Hylaform is based on natural hyaluronan, the human body accepts it as its own. Hylaform also mimics the hydrating and lifting effect of hyaluronan, which keeps the skin hydrated and elastic. In side-by-side comparison with Restylane, Hyalform showed a higher incidence of skin reaction. 26 Hyalform also behaves as a stronger hydrogel than Restylane and contains a lower amount of crosslinked hyaluronic acid. Restylane can contain up to four times as much protein, from bacterial fermentation, as Hyalform for the same volume. Finally, hyaluronan derived from rooster combs has been in use longer than that derived from streptococci, and has demonstrated its reliability and safety. A randomized study of 138 patients comparing Restylane and Zyplast for the correction of nasolabial folds demonstrated that a more durable aesthetic improvement was found with Restylane. 27 Less injection volume was required with Restylane, which was also superior to Zyplast in retaining its shape. A comparison of Restylane with and without the addition of Botox demonstrated that glabellar rhytides responded better to the combination of Restylane and Botox. 28 Those patients who present with deep vertical glabellar lines at rest may not be able to eliminate those lines with the use of Botox alone. Restylane can serve to fill the resting lines, and the addition of Botox prevents the deforma- tion of the filler residing in the dermis, thereby performing a protective function. Restylane is also useful as a soft tissue filler for microchelia (Fig. 16.2). Captique is a filler that utilizes a recombinant form of hyaluronic acid that lowers the probability of immunological reactions.The profiles of this filler are much the same as those of Hyalform, with a duration of 2–4 months and a similar injection and viscosity profile. Materials that are resorbable by the body are less likely to provoke a longstanding immunological response, because of their transient nature. However, substances that are derived from nonautologous sources have the potential to evoke cross-reactivity. Restylane and Hylaform are newer materials that are beginning to undergo long-term studies, which are beginning to show side-effects.A study of 709 patients over 4 years showed positive skin tests in those who developed delayed skin reactions to these materials. The manufacturer does not recommend skin testing for these materials – but these reports may suggest 184 Clinical procedures in laser skin rejuvenation 16 Carniol-8028.qxd 8/23/2007 10:34 AM Page 184 otherwise. 29 Case reports have also shown the potential for granuloma formation with the use of hyaluronic acid derivatives. 30 Positive skin tests have demonstrated chronic inflammatory reactions at up to 11 months and serum immunoglobulin G (IgG) and IgE antibodies to hyaluronic acid. 32 Of course, these aesthetic complications must be fully addressed with the patient before any procedure is performed. Dermal matrices The search for soft tissue fillers free of antigenicity has led to the development of Alloderm and Cymetra (LifeCell Corp.,Branchburg,NJ).Alloderm is processed from cadaveric skin, preserving the basement mem- brane and dermal collagen matrix. After the fibroblasts have been extracted, the material is cryoprotected, which enables it to be freeze-dried in a two-step procedure.Alloderm is screened and monitored for bacterial contamination before it is shipped to the physician. It is supplied in sheets of differing sizes and thicknesses, which must be rehydrated by the physician before use. The sizing of this material makes it ideal for repairing large tissue defects. Skin testing is not necessary, because it is an acellular graft. It is also less likely to develop secondary infection. However, if infection does occur, it is not necessary to remove the implant, only to treat the infection. 22 Alloderm does not appear to last as long or be as consistent as originally described, which, along with its high cost, has decreased its use and popu- larity.The requirement for a surgical procedure has also limited its use.Zyplast was studied in direct comparison with Alloderm with follow-up at 1 year, by Sclafani et al. 32 Superior results were seen with Alloderm which stabilized in resorption at 6 months, while Zyplast was progressively absorbed. Cymetra is a micronized injection of Alloderm tissue. It is created by homogenizing an Alloderm sheet cut into strips. In a study of 44 patients involving the use of Cymetra and Zyplast to fill upper lip lines, there was a statistically significant improvement at 1 year in lip appearance among those randomized to receive Cymetra. Some reports suggest that Cymetra does not reabsorb as Zyplast is observed to do, and therefore repeated treatments provide an additive effect and are more effective. 33 Cymetra carries an increased incidence of inflammatory reactions and has not been shown to last longer than Zyplast. It also requires mixing into a thick paste, usually with 1% or 2% lidocaine. This thick mixture can be difficult to inject. Due to the lack of The bioscience of the use of botulinum toxins and fillers for non-surgical facial rejuvenation 185 Fig.16.2 Restylane used as a soft tissue filler for lip augmentation. 16 Carniol-8028.qxd 8/23/2007 10:34 AM Page 185 long-term results and the increased cost, Cymetra is not used as frequently as other soft tissue fillers. Small-intestinal submucosa, marketed as Oasis, Surgisis, or Stratasis, is a sterile acellular graft material extracted from the small intestine of pigs. Its main uses continue to be for nasal reconstructive surgery, but increasing experience may broaden its applications. Isolagen (Isolagen Tech., Metuchen, NJ) is currently under FDA investigation. It consists of injectable fibroblasts derived from an autologous source and cultured for 4–6 weeks. Skin is harvested from the preauricular region in a 3 mm punch biopsy. 34 Repeat injections, most commonly three, are required, spaced 2 weeks apart. A 6-month study by Watson et al 35 showed increased thickness and density of the postau- ricular dermal collagen and no inflammatory reaction. Due to the viability of the fibroblasts, Isolagen must be shipped, processed, and injected within 24 hours. However, it theoretically has the advantage of low immunoreactivity, as with the other human derivatives. A significant drawback is that patients must also be willing to wait up to 18 months to see results,as the fibroblasts must first produce new collagen. SYNTHESIZED BIOACTIVE FILLERS The search for the ideal soft tissue fillers has led to the development of materials that do not mimic collagen but rather serve to increase volume for a longer period of time due to their preformed microsphere shapes. Sculptra (Biotech Industry, SA, Luxembourg) is a powder of poly- L-lactic acid microspheres ranging from 2 to 50µm. Studies comparing the various soft tissue fillers have shown the microspheres of Sculptra to be histologically degraded at 9 months. Sculptra has only been FDA-approved for the treatment of HIV lipodystrophy, and provokes an intense inflammatory reaction leading to a fibroblastic response resulting in increased appearance of the tissue.The complications reported include draining granulomas, and (like other fillers) it must be injected subcutaneously. Reviderm intra (Medical International, Netherlands), available in Europe, is a suspension of 2.5% dextran microspheres of 40µm in 2.0% hyaluronic acid. Radiesse (formerly Radiance FN) (Bioform Inc., Franksville, WI) is a suspension of 30% calcium hydroxyapatite (similar to the composition of bone) microspheres ranging in size from 25 to 40µm in a carboxymethylcellulose gel. The microspheres of Reviderm produced the greatest amount of granula- tion tissue, but were also disintegrated at 9 months. Radiesse microspheres were gone at 9 months, but they stimulated almost no foreign body reaction. 36 Few macrophages were visualized surrounding the microspheres of Radiesse, suggesting that they are degraded by enzymatic processes rather than cellular one. Radiesse is not recommended for use in lip augmentation, as the microspheres will be compressed into strands during the act of mastication. Radiesse is a thick paste,which can be difficult to inject and must be injected only in deep dermis. It is used in the nasolabial folds, but we caution use in the lips, which is also the policy of the manufacturer. It has an increased incidence of nodule formation, which can only be dealt with by surgical excision. SYNTHETIC NONRESORBABLE POLYMERS Materials that are foreign to the human body have also been used in the development of soft tissue fillers in both injectable and implantable forms. Injectable Artecoll (Artes Medical Inc., San Diego, CA) is a suspension of 20% microspheres 40µm in diameter made of polymethylmethacrylate (PMMA) in 3.5% bovine collagen solution.Artecoll works by microgranu- loma formation, which may not be controllable.This product produces immediate correction with collagen and also permanent replacement with new collagen produced as part of the inflammatory response. 22 Artecoll, unlike the other microspheres, does not become reabsorbed, and histologically new collagen deposits are visible at 1 month. 36 A minimal immunogenic response has been observed due to the fact that the telopeptides are removed from the collagen.As with other xenogenic injectables, skin testing is required before use. The smooth surface of the microsphere prevents a foreign body reaction, and the size prevents migration 186 Clinical procedures in laser skin rejuvenation 16 Carniol-8028.qxd 8/23/2007 10:34 AM Page 186 and phagocytosis. 37 It should not be used in areas of fine skin, as the implants may be more visible, and should be avoided in those patients prone to keloids, as any foreign material may serve to increase the incidence of keloids. However, Artecoll demonstrates a much lower incidence of immunological response, 0.06%, as compared with Zyderm, which has an incidence of 3%. 36 Migration has only been observed when the material is injected into the dermis in trials with guinea pigs, and has not been observed with correct placement of the material. 38 Artes Medical may reformulate the product in a US version with hyaluronic acid to meet FDA requirements. All injectable filler materials may lead to overexpression of the host’s foreign body-type immunological reaction.This may, in rare cases, lead to the formation of a granuloma. The combination of materials is foreshadowed in the development of Dermalive and Dermadeep (Dermatech, Paris, France). In Europe, 30 or more synthetic polymers are available for use in general, although this may vary somewhat by country. Examples of such polymers include Dermalive, and Dermadeep, which are combinations of pure hyaluronic acid (40% and 60%, respectively) and an acrylic hydrogel.The hyaluronic acid is used as a carrier for the acrylic polymer.They have been developed in response to the need for repeat injections when using such materials as pure hyaluronic acid and collagen. The tolerance of Dermalive is excellent and it has been supplemented with injections of Juvederm or Restylane for fine line and superficial defects. 39 A 3-year study of this combination therapy in 455 patients demonstrates an 88% patient satisfaction rate with minimal side effects. 39 Silicone, much maligned due to its history in breast augmentation, is another synthetic injectable. Its use has been associated with the development of connective tissue ingrowth and granulomas from macrophages and foreign body cells (Fig.16.3). 40 This is more commonly seen in patients with very lax skin, which facilitates the migration of the silicone, and with the substitution of cheaper, non-medical- grade silicone fluids used by nonprofessionals. 36 When used as silicone fluid, the material is injected via the microdroplet technique. In the rare case of siliconoma development, the use of corticosteroids has proven helpful, but this is rarely a completely satisfactory treatment. 41 Late-term granulomas are not uncommon. As a result, we do not recommend this material. Implantable Implantable expanded polytetrafluoroethylene (e- PTFE) (WL Gore and Assoc., Flagstaff, AZ) has been used in the field of vascular surgery for over 30 years, demonstrating its safety and reliability. 42 Tissue ingrowth is marginal into the material, but when it is shaped into a tube, longitudinal growth occurs.This serves to strengthen the filler and secure it to the site of implantation. 43 Ultrasoft is a thinner, softer form of the tubular form of implantable expanded polytetrafluoroethylene (Fig. 16.4). The tubular form was originally marketed under the name SoftForm (Collagen Corp., Palo Alto, CA), and was used as soft tissue filler for lip augmentation. There still exists a risk of extrusion or exposure of the ends of the material at the entrance wound where the implant is delivered. Softform showed wall stiffening due to the abundance of ePTFE creating an accordion effect.The risk of extrusion at the insertion sites cre- ates a potential source of infection. If complications do arise, the implant is always removable. Due to the higher content of ePTFE, Softform shortens and hard- ens with time.This can create an ‘accordion effect’. Ultrasoft, with its thinner walls, has addressed this issue, with early success being reported. The bioscience of the use of botulinum toxins and fillers for non-surgical facial rejuvenation 187 Fig.16.3 Granuloma and foreign body reaction after injection of silicone. 16 Carniol-8028.qxd 8/23/2007 10:34 AM Page 187 Advanta (Atrium Medical Corp., Hudson, NH) is a dual-porosity implant developed to provide softer palpability, less migration, and reduced shrinkage.The outer core measures 40µm and the inner 100µm, with the inner core being exposed to the surrounding tissue. A study comparing Softform with Advanta demonstrated neovascularization and cellular integra- tion into the interstices of the Advanta implant, while the Softform implant demonstrated a cellular capsule, more inflammatory cells, and fewer vascular elements within the devices. 44 Advanta is designed for use in the nasolabial folds and for lip augmentation. TECHNIQUES When considering injectables, there are basically three techniques used to deliver material to the deep dermis or subcutaneous level: linear threading, serial puncture, and droplet. Linear threading is a technique by which an agent is delivered in a uniform fashion while the needle is slowly withdrawn from the tissue. It is particularly effective when performing lip augmentation along the mucocutaneous border.The serial puncture technique is used to deliver small aliquots of filler at multiple spots to achieve even distribution over a two-dimensional area. Finally, the droplet technique is used in a manner similar to that in linear threading. However, instead of an even distribution of filler as the needle is withdrawn, microdroplets of filler are delivered into the tissue by gentle pumping on the syringe as the needle is withdrawn.The droplet technique has been advocated for use when injecting silicone. The depth of injection, however, is dependent on the injectable material being used. Most clinicians prefer the serial injection technique for use in fine lines and the lips.The other options include the microdroplet technique or surgical implantation in the subcutaneous plane. CONCLUSIONS Many patients who present to their physicians with complaints of an aging face or cosmetic deformities are eager to avoid surgical intervention. As such, they are willing to use newly introduced minimally invasive options for their desired corrections.Today, there is a myriad of injectable and implantable soft tissue augmentation options at the experienced clinician’s disposal. A concern with the use of permanent filler is the potential for migration to other areas outside of the injection site, which can lead to potential deformities.The choice of 188 Clinical procedures in laser skin rejuvenation Fig.16.4 Ultrasoft used for lip augmentation. 16 Carniol-8028.qxd 8/23/2007 10:34 AM Page 188 which product to use can be based on a number of factors, including the desires of the patient, the cost to the patient, and the experience of the clinician. Caution must be exercised, however, when considering the use of soft tissue fillers that have been newly introduced to the market and have not yet undergone long-term observation and study.With more knowledge and experience, one will be better able to tailor the use of specific materials to the particular desires of each patient. REFERENCES 1. Scott AB, Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery. J Pediatr Ophthalmol Strabismus 1990;17:21–5. 2. Schantz EJ, Johnson EA. 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Consensus recommendations on the use of botulinum toxin type A in facial aesthetics. Plast Reconstr Surg 2004;114 (6 suppl): 1–22. 9. Yamauchi PS, Lask G, Lowe NJ. Botulinum toxin type A gives adjunctive benefit to periorbital laser resurfacing. J Cosmet Laser Ther 2004;6:145–8. 10. Zimbler MS, Holds JB, Kokoska MS, et al. Effect of botulinum toxin pretreatment on laser resurfacing results: a prospective, randomized, blinded trial. Arch Facial Plast Surg 2001;3:165–9. 11. West TB, Alster TS. Effect of botulinum toxin type A on movement-associated rhytids following CO 2 laser resurfacing. Dermatol Surg 1999;25:259–61. 12. Semchyshyn NL, Kilmer SL. Does laser inactivate botulinum toxin? Dermatol Surg 2005;31:399–404. 13. Neuber F. Fat grafting. Cuir Kongr Verh Otsum Ges Chir 1893;20:66. 14. Ersek RA, Beisang AA 3rd. Bioplastique: a new biphasic polymer for minimally invasive injection implantation. Aesthetic Plast Surg 1992;16:59–65. 15. Bailin PL, Bailin MD. Collagen implantation: clinical applications and lesion selection. Dermatol Surg Oncol 1988;14 (suppl 1):49. 16. Castrow FF 2nd, Krull EA. Injectable collagen implant – update. J Am Acad Dermatol 1983;9:889–93. 17. Maas CS, Papel ID, Greene D, Stoker DA. Complications of injectable synthetic polymers in facial augmentation. Dermatol Surg 1997;23:871–7. 18. Newcomer VD, Graham JH, Schaffert RR, Kaplan L. Sclerosing lipogranuloma resulting from exogenous lipids.AMA Arch Dermatol 1956;73:361–72. 19. Knapp TR, Kaplan EN, Daniels JR. Injectable collagen for soft tissue augmentation. Plast Reconstr Surg 1977; 60:398–405. 20. Landman MD, Strahan RW,Ward PH. Chin augmentation with polytef paste injection.Arch Otolaryngol 1972;95: 72–5. 21. Cooperman LS, Mackinnon V, Bechler G, Pharriss BB. Injectable collagen: a six-year clinical investigation. Aesthetic Plast Surg 1985;9:145–51. 22. Ashinoff R. Overview: soft tissue augmentation. Clin Plast Surg 2000;27:479–487. 23. Skouge JW DR. Soft tissue augmentation with injectable collagen. In: Papel ID, ed. Facial Plastic and Reconstructive Surgery,2nd edn. St Louis, MO: Mosby, 1992:208. 24. Krauss MC. Recent advances in soft tissue augmentation. Semin Cutan Med Surg 1999;18:119–28. 25. Duranti F, Salti G, Bovani B, Calandra M, Rosati ML. Injectable hyaluronic acid gel for soft tissue augmentation. A clinical and histological study. Dermatol Surg 1998; 24:1317–25. 26. Lowe NJ, Maxwell CA, Lowe P, Duick MG, Shah K. Hyaluronic acid skin fillers: adverse reactions and skin testing. J Am Acad Dermatol 2001;45:930–3. 27. Narins RS, Brandt F, Leyden J, et al. A randomized, double-blind, multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds. Dermatol Surg 2003; 29:588–95. 28. Carruthers J, Carruthers A. A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with the derivative and BTX-A. Dermatol Surg 2003;29:802–9. The bioscience of the use of botulinum toxins and fillers for non-surgical facial rejuvenation 189 16 Carniol-8028.qxd 8/23/2007 10:34 AM Page 189 29. Lemperle G, Morhenn V, Charrier U. Human histology and persistence of various injectable filler substances for soft tissue augmentation. Aesthetic Plast Surg 2003;27: 354–66; discussion 367. 30. Fernandez-Acenero MJ, Zamora E, Borbujo J. Granulomatous foreign body reaction against hyaluronic acid: report of a case after lip augmentation. Dermatol Surg 2003;29:1225–6. 31. Micheels P. Human anti-hyaluronic acid antibodies: Is it possible? Dermatol Surg 2001;27:185–91. 32. Sclafani AP, Romo T 3rd, Jacono AA. Rejuvenation of the aging lip with an injectable acellular dermal graft (Cymetra).Arch Facial Plast Surg 2002;4:252–7. 33. Sclafani AP, Romo T 3rd, Parker A, et al. Homologous collagen dispersion (dermalogen) as a dermal filler: persistence and histology compared with bovine collagen.Ann Plast Surg 2002;49:181–8. 34. West TB, Alster TS. Autologous human collagen and dermal fibroblasts for soft tissue augmentation. Dermatol Surg 1998;24:510–12. 35. Watson D, Keller GS, Lacombe V, et al. Autologous fibroblasts for treatment of facial rhytids and dermal depressions.A pilot study. Arch Facial Plast Surg 1999;1: 165–70. 36. Lemperle G, Kind P. Biocompatibility of Artecoll. Plast Reconstr Surg 1999;103:338–40. 37. Lemperle G, Hazan-Gauthier N, Lemperle M. PMMA microspheres (Artecoll) for skin and soft-tissue augmentation.Part II: Clinical investigations. Plast Reconstr Surg 1995;96:627–34. 38. McClelland M, Egbert B, HankoV, Berg RA, DeLustro F. Evaluation of artecoll polymethylmethacrylate implant for soft-tissue augmentation: biocompatibility and chemical characterization. Plast Reconstr Surg 1997;100:1466–1474. 39. Bergeret-Galley C, Latouche X, Illouz YG.The value of a new filler material in corrective and cosmetic surgery: DermaLive and DermaDeep. Aesthetic Plast Surg 2001; 25:249–55. 40. Rapaport MJ, Vinnik C, Zarem H. Injectable silicone: cause of facial nodules, cellulitis, ulceration, and migration.Aesthetic Plast Surg 1996;20:267–76. 41. Bigata X, Ribera M, Bielsa I, Ferrandiz C. Adverse granulomatous reaction after cosmetic dermal silicone injection. Dermatol Surg 2001;27:198–200. 42. Costantino PD. Synthetic biomaterials for soft-tissue augmentation and replacement in the head and neck. Otolaryngol Clin North Am 1994;27:223–62. 43. Ahn MS MN, Maas CS. Soft tissue augmentation. Facial Plast Surg Clin North Am 1999;7:35–41. 44. Truswell WH. Dual-porosity expanded polytetrafluoroethylene soft tissue implant: a new implant for facial soft tissue augmentation. Arch Facial Plast Surg 2002;4:92–7. 190 Clinical procedures in laser skin rejuvenation 16 Carniol-8028.qxd 8/23/2007 10:34 AM Page 190 INTRODUCTION Constantly evolving technology has given cosmetic physicians and surgeons an ever-increasing armamen- tarium with which to deliver more effective treatments with minimal or no downtime. Combining a variety of therapeutic options can yield an enhanced effect that is more than the sum of its individual parts. Understanding the balance of facial musculature is essential for facial rejuvenation and facial reshaping utilizing botulinum toxin. The concept of facial muscle relaxation and balance is the foundation on which further rejuvenation with fillers can be built.The expanding menu of fillers gives us an enlarging palate of materials for facial filling, volumizing, and rhytid ablation (Fig. 17.1). BOTULINUM TOXIN TYPE A DILUTION AND INJECTION TECHNIQUE Botulinum toxin type A (Botox and Botox Cosmetic) binds to the nerve endplate and blocks the release of acetylcholine, decreasing the strength of muscle contraction and reducing dynamic rhytidosis. 1,2 This bond is permanent, and acetylcholine release begins again when the nerve sprouts a new endplate. One hundred units of Botox is packaged as a powder.This purified protein is reconstituted in sterile saline, typically in 1, 2, or 4 ml to give the desired dose in 0.1ml aliquots. 3 Different vials can be mixed for different strengths for different muscles (Figure 17.1). During the actual mixing of Botox,the vacuum seal must be broken with two needle punctures before instilling the saline to avoid an overex- uberant mixing and frothing of the Botox, which can affect potency.The saline should be added slowly, angled against the side of the vial, avoiding frothing of the mixture. Although it is claimed that the use of preserved saline diminishes discomfort during injection (there is less of a burning sensation) and that it lengthens the time that reconstituted refrigerated Botox can last, we continue to use non-preserved saline for reconstituting Botox.We feel that it may retain its potency for a longer period of time. 4 When storing reconstituted Botox, it should be refrigerated and not frozen.Adequate dosage for each muscle group is key.While an insufficient dose will yield an insufficient result, overtreating is also not a desired cosmetic result. Because the patient may not begin to notice the clinical effect for at least 3–5 days, and the full effect may not be evident for 7–10 days, we request a revisit for a dose adjustment in 1–2 weeks following the initial treatment session. After cleansing the injection sites with alcohol (there is some discussion about alcohol reducing the effect of botulinum toxin), we prefer to apply a topical lidocaine/tetracaine anesthetic cream, Photocaine (Universal Pharmacy, Salt Lake City, Utah), for 15–20 minutes. Further vasoconstriction is encouraged by 17. Adjunctive techniques II: clinical aspects of the combined use of botulinum toxins and fillers for non-surgical facial rejuvenation Stephen Bosniak, Marian Cantisano-Zilkha, Baljeet K Purewal, and Ioannis P Glavas 17 Carniol-8028.qxd 8/23/2007 3:33 PM Page 191 [...]... move during injection The needle enters the skin to the desired depth, a small aliquot of filler is deposited, and the needle is withdrawn .9 The linear threading technique consists of holding the needle parallel to the length of the wrinkle or fold to be treated, piercing the skin, and advancing the needle and injecting in either a retrograde or anterograde fashion, making sure to stop injecting prior... ptosis, and again we injected Radiesse trancutaneously in the canine fossa to fill her nasolabial folds and to give her some midface-lifting effect (b) She has achieved a significant mid-face lifting and filling of her nasolabial folds 199 17 Carniol-8028.qxd 200 8/23/2007 3:33 PM Page 200 Clinical procedures in laser skin rejuvenation a b Fig 17 .9 (a, b) Restylane and Perlane were used to correct these... Augmentation Philadelphia: Elsevier,2005:1 9 8 Rzany B, Zielke H Overview of injectable fillers In: de Maio M, Rzany B, eds Injectable Fillers in Aesthetic Medicine Berlin: Springer-Verlag, 2006:1 9 17 Carniol-8028.qxd 8/23/2007 3:33 PM Page 203 Clinical aspects of the combined use of botulinum toxins and fillers 9 Bowman PH, Narins RS Hylans and soft tissue augmentation In: Carruthers J, Carruthers A, eds... Carniol-8028.qxd 192 8/23/2007 3:33 PM Page 192 Clinical procedures in laser skin rejuvenation a b Fig 17.1 Facial asymmetries can be corrected with an intimate knowledge of the balance of facial musculature Botulinum toxin can be used to weaken the overactive muscles, allowing opposing musculature to function normally, thereby creating a balance (a) This patient had a hemifacial spasm following Bell’s... Pretreating the entire midface with volumetric RF dermal heating (Thermage) and reinforcing with submalar and preauricular vectors will elevate the malar eminences Further malar augmentation can be accomplished with longer-lasting more-viscous 17 Carniol-8028.qxd 8/23/2007 3:33 PM Page 197 Clinical aspects of the combined use of botulinum toxins and fillers a b c 197 d Fig 17.3 CO2 Cellulair insufflation... neither of which is available in the USA) works well following pretreatment of the platysma with botulinum toxin We routinely inject botulinum toxin into the platysmal bands using 2.5 units per injection site along the length of the band before treating the skin of the neck and submental area with volumetric RF deep dermal heating (Thermage) Stacked pulses of Thermage in the submental area will enhance... botulinum A exotoxin injection Invest Ophthalmol Vis Sci 199 0;31:178–81 2 Coffield JA, Considine RV, Simpson LL The site and mechanism of action of botulinum neurotoxin In: Jankoric J, Hallet M, eds.Therapy with Botulinum Toxin, 4th edn New York: Marcel Dekker, 199 4:3–13 3 Carruthers J, Fagien S, Matarasso SL Botox Consensus Group: consensus recommendations on the use of botulinum toxin type A in facial aesthetics... folds needs larger volumes of deeper, longer-lasting filling material In our experience, Sculptra and autogenous fat work best for this purpose Supporting the malar and cheek areas, we fill out the face, support the midface, and redrape the nasolabial folds (Fig 17.6) 17 Carniol-8028.qxd 198 a 8/23/2007 3:33 PM Page 198 Clinical procedures in laser skin rejuvenation c b Fig 17.5 (a–c) Two aliquots... in the cheeks and chin), correcting deep folds, and for lip augmentation Not yet in the USA 9 12 months 27-gauge Fine Lines (Touch) Bacterial fermentation NASHA technology Not yet FDA-approved Designed for correcting thin superficial lines, forehead lines, and perioral rhytids Not yet in the USA 4–6 months 32-gauge Restylane SubQ Bacterial fermentation NASHA technology Not yet FDA-approved Designed... midface-lifting effect (b) She has achieved a reasonable midface lifting and filling of her nasolabial folds; in addition, her multicontoured melomental folds were filled with Sculptra Midface lifting can also be enhanced with implantation of a more-viscous, longer-lasting material injected into the canine fossa.We have found Radiesse to be effective for this purpose, supporting the midface and softening . on movement-associated rhytids following CO 2 laser resurfacing. Dermatol Surg 199 9;25:2 59 61. 12. Semchyshyn NL, Kilmer SL. Does laser inactivate botulinum toxin? Dermatol Surg 2005;31: 399 –404. 13 Arch Facial Plast Surg 2002;4 :92 –7. 190 Clinical procedures in laser skin rejuvenation 16 Carniol-8028.qxd 8/23/2007 10:34 AM Page 190 INTRODUCTION Constantly evolving technology has given cosmetic physicians. Carniol-8028.qxd 8/23/2007 3:33 PM Page 193 194 Clinical procedures in laser skin rejuvenation Table 17.2 Hyaluronic acid products Approved indication FDA Injection Product Source a in USA approval

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