J Cosmetic & Laser Ther 2003; 5: 210–212

# J Cosmetic & Laser Ther. All rights reserved ISSN 1476-4172

DOI: 10.1080/14764170310021896 210

Pearls from meetings

Botulinum toxin in association with

other rejuvenation methods
Maurı́cio de Maio
Botulinum toxin is an import agent in paper briefly reviews the use of botu-
Author: facial rejuvenation, and the use of linum toxin in associate with dermal
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Maurı́cio de Maio botulinum toxin in combination with fillers, laser resurfacing and other
Plastic Surgeon, Brazil other methods helps preserve and surgical rejuvenation modalities. J
maintain a long-term result. This Cosmetic & Laser Ther 2003; 5: 210–212

Keywords:
botulinum toxin – filler – laser
resurfacing – rhytides – facial
rejuvenation
For personal use only.

Introduction
Botulinum toxin is an import agent in facial rejuvenation.
It is also an adjunctive procedure to surgical treatments.1 It
can be injected before, after or even associated with fillers,
lasers, chemical peels and facial surgery. Its aim is to reduce
the dynamic muscular activity.2 The association of
botulinum toxin with other methods helps preserve and
maintain a long-term result.
Facial rhytides differ in origin and can be defined as
static, dynamic, gravitational, pressure and associated
wrinkles. The use of a single method to treat an associated
wrinkle may achieve only partial results. Wrinkles can also
be defined by their morphological structure and their
depth, which can be superficial, intermediate or deep. Mid
peels are suitable for superficial wrinkles, whereas fillers
and deep peels are suitable for intermediate and deep
wrinkles. Associated wrinkles present static and dynamic
components. It is usually better to treat the dynamic
component of the associated wrinkle first, and its static
component afterwards. Sometimes, the single use of
botulinum toxin can provide a satisfactory result and
there is no need for further treatments, at least for a certain
period of time.

Figure 1
Combined treatment of dermal fillers and botulinum toxin in the nasolabial fold. The static analysis shows improvement of this area (B).
However, the dynamic analysis shows asymmetry, which should be corrected after 7 days (C).
 Botulinum toxin in association
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Figure 2
Before (A) and after (B) combined treatment with laser resurfacing and botulinum toxin. Even after the laser, there is still formation of glabella
lines when frowning. After the injection of botulinum toxin, the glabella lines disappear completely.
Although it might be possible to seek the most
‘academically correct’ way of treating our patients, some-
times patients request less invasive procedures than laser
resurfacing and rhytidectomy. The academic approach
would be to start with peelings, followed by muscular
For personal use only.
inhibition with botulinum toxin and finally dermal fillers.
However, fast recovery demands only botulinum toxin and
dermal fillers, and some patients would prefer to postpone
laser resurfacing, deep chemical peels and surgery.
Botulinum toxin and dermal fillers
The concomitant use of botulinum toxin and dermal fillers
is well suited for associated wrinkles. This combined
approach appears to promote longer-lasting results than
their isolated use. Biodegradable fillers are influenced by
the movement of the muscles that act in the area into
which they are injected. Mechanical forces resulting from
mimetic action might break the polymers of fillers, leading
to quicker absorption.
Botulinum toxin, as a paralyzing agent, reduces the
muscular traction and avoids the problem that biodegrad-
able fillers be withdrawn soon. It can be considered to
enhance the performance of the filler. Fillers can also
improve the result of botulinum toxin. Because fillers are
considered tissue micro-expanders, the dermis becomes
thicker and fewer wrinkles are produced with mimetic
movements. So, the chemical denervation would have the
following purposes: first, it eliminates or reduces the
dynamic/muscular component of rhytides formation;
second, theoretically it may increase the longevity of
dermal fillers by reducing the supposed mechanical
inflammatory influence on atrophy on the implant and
third, it may simply reduce the immediate micro-extrusion
at the injection sites by repetitive muscular action.3
The preferred sequence would be to treat first the
dynamic component of the wrinkle with botulinum toxin
and, after its total effect, analyze the necessity of the dermal
211
Pearls from meetings
filler. This decision can be delayed for up to 15 days.
However, some patients may prefer to have both
treatments in the same session. With experience, the
surgeon may conclude that the botulinum toxin alone
would be insufficient to produce the desired result. In these
cases, both can be injected in the same session. It is
preferable to inject the botulinum toxin first into the
muscle and then the dermal filler.
These treatments can be used for the glabellar crease,
forehead lines, crow’s feet, the nasolabial fold, upper lip
rhytides, the oral comissure, the malar area, the chin and
the neck. Special attention should always be given to
treatments into the lips.
Botulinum toxin and laser resurfacing
Laser resurfacing has proven effective in counteracting the
photoaging through epidermal ablation, collagen shrinkage,
stimulation of neocollagenesis, dermal reorganization,
regeneration of cellular organelles and intercellular attach-
ments.4 The improvement of the skin and the wrinkles is
impressive. However, there are some wrinkles associated
with movement that usually recur within 6 to 12 months.5
It is specifically for those cases that botulinum toxin can be
used after laser resurfacing. The appropriate time to start
with botulinum toxin depends on the clinical signs when
dynamic rhytides appear after laser resurfacing, which can
range from one to three months. The first recurrent
rhytides are those located in the periorbital and perioral
regions. If botulinum toxin is used prior to laser
resurfacing, the ideal interval would be around 15 days.
Pretreatment with botulinum toxin may improve the
smoothing effect of the new remodeled skin long enough
to effect more permanent eradication of wrinkles.6
Laser procedures are generally done once in a lifetime
and skin conditioning, superficial peels and botulinum
toxin should provide maintenance of the result. Enhanced
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Pearls from meetings
and more prolonged correction of the treated areas can be
observed with a combined approach.7
Botulinum toxin and facial surgery
Patients who undergo surgical procedures may benefit form
the use of botulinum toxin before or after the procedure.
The upper third of the face is usually treated with
botulinum toxin rather than surgery. The chemical
denervation provided by botulinum toxin produces a low
risk and effective treatment for wrinkles in the forehead,
glabella and the crow’s feet regions. Sagging of the
musculocutaneous and fatty tissue can only be treated by
lifting. Botulinum toxin can be used as a maintenance
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treatment and be useful to treat asymmetries and transitory
surgical palsies following surgery. When injected into the
upper third of the face before surgery, it produces a
substantial reduction in operative time and risks, such as
alopecia, pathological scarring and pain.
However, botulinum toxin does not need to be used
For personal use only.
References
1. Carruthers J, Carruthers A. The adjunctive usage of
botulinum toxin. Dermatol Surg 1998; 24: 1244–1247.
2. Carruthers J, Carruthers A. Combining botulinum toxin
injection and laser resurfacing for facial rhytides. In:
Coleman W III, Lowrence N, eds. Skin Resurfacing.
Baltimore: Williams & Wilkins, 1998: 235–243.
3. Fagien S. Facial Soft Tissue augmentation with
Autologous and Homologous Injectable Collagen
(Autologen and Dermalogen). In A. Klein (Ed.),
Tissue Augmentation in Clinical Practice: Procedures
and techniques. New York: Marcel Dekker, Inc., 1998:
87–124.
4. Alster TS, Garg S. Treatment of facial rhytides with a
M de Maio
instead of a surgical procedure but as an adjunctive agent.
For brow lifting surgical procedures, botulinum toxin may
enhance results by weakening the inferior vector force of
the antagonist of the frontalis, the lateral orbital orbicularis
muscle and provide maintenance of the elevated eyebrow
position. Reinforcement during lateral canthal suspension
procedures such as the tarsal strip or the lateral retinacular
suspension can de aided by botulinum toxin not only by
reducing canthal rhytides but also by reducing local
orbicularis oculi function that, in part, may compromise
the position and security of the lateral canthus with
repeated muscular contraction.8
Conclusion
Botulinum toxin has shown to be useful when used alone
and in conjunction with a variety of treatments for facial
rejuvenation. The old appearance of the face results from
different etiologies and a single method should not be
relied upon to treat the complexity of the aging process.
high-energy pulsed carbon dioxide laser. Plast Reconstr
Surg 1996; 98: 791–4.
5. Nanni CA, Alster TS. Cutaneous carbon dioxide laser
resurfacing: long-term follow up of 300 hundred patients.
Lasers Surg Med 1997; 39 (Suppl 9).
6. Fagien S. Extended use of botlinum toxin A in facial
aesthetic surgery. Aesthetic Surg J 1998; 18: 215.
7. West T, Alster T. Effect of botulinum toxin type A on
movement-associated rhytides following CO2 laser resur-
facing. Dermatol Surg 1999; 25: 259–261.
8. Fagien S. Botox for the treatment of dynamic and hyper-
kinetic facial lines and furrows: adjunctive use in facial
aesthetic surgery. Plast Reconstr Surg 1999; 103: 701–713.