Combination Therapies

Lisa A. Zdinak, MD · Stephen Bosniak, MD FACS · Marian Cantisano-Zilkha, MD · Ioannis P. Glavas, MD

Introduction

New insights into the facial aging process and the introduction of safer, longer-lasting materials for adding volume to facial structures has added a new dimension to noninvasive facial rejuvenation. Since the introduction of injectable bovine collagen for improving or eliminating facial wrinkles, many new agents have been introduced with safer and more effective properties. These newer injectable fillers used in combination with other minimally invasive therapies for the skin, such as microdermabrasion, chemical peels, and radiofrequency-based and light-based treatments, has increased the degree of esthetic results and the level of satisfaction for patients and physicians. The selective application of neuromodulation (Botox, botulinum toxin type A, Allergan) prior to their use further enhances and prolongs the esthetic result.

Anatomy of the Aging Face

The progression of facial aging is determined by three factors: genetics, sun exposure, and smoking. These factors can hasten the replacement of elastic fibers in the dermis and the muscles of facial animation [superficial musculoapneurotic system (SMAS)] by fibrous connective tissue. Aging produces characteristic alterations in facial anatomy.

In the upper face the frontalis, corrugator, and procerus muscles are responsible for upper facial and forehead expression and the resultant creases. The thin, flat frontalis muscle extends from the galea aponeurotica to the root of the nose and eyebrows. Contraction of the frontalis creases the forehead and raises the eyebrows. The bilateral procerus muscles extend from the superomedial orbital margin superiorly and laterally to the medial eyebrow. Their contraction lowers the eyebrow, pulls it nasally, and creates horizontal creases at the root of the nose ("bunny lines"). The vertically oriented corrugator supercilli muscles are contiguous with the frontalis muscle in the midline, extending from the root of the nasal bones to the medial eyebrow. Their contraction causes vertical glabellar lines ("frown lines"). The soft tissues overlying the superior orbital rim compose the eyebrow. Temporally, the eyebrow is attached to a bony ridge above the superior orbital rim. This support, weakened by aging, may result in a temporal brow ptosis.¹ The most conspicuous landmarks of the upper lid are the lid crease, lid fold, and superior sulcus. The superior sulcus of the upper eyelid is tucked under the superior orbital rim. In young patients the superior sulcus is a flat or concave surface. Elderly patients with orbital fat atrophy have hollow, deep superior sulci. The deep superior sulcus may be accentuated by levator aponeurotic disinsertions with lid crease retraction. The orbital septum, contiguous with the arcus marginalis, travels inferiorly and fuses with the levator aponeurosis 10 mm to 12 mm above the superior tarsal border. Septal dehiscences may cause eyelid bulges that may be clinically undifferentiated from eyelid bulges secondary to orbital fat hypertrophy with anterior displacement of an intact septum.²

In the midface the levator muscles and SMAS insert along the nasolabial crease that extends from the nasal alar cheek junction to a point lateral to the oral commissure. Gravity and years of contraction loosen the attachment of the subcutaneous malar fat pad to the SMAS. The fat pad then slides down and forward with the infraorbital skin to create the prominent nasolabial fold accentuating the nasolabial crease. Facial soft tissue is supported by a series of supporting ligaments (zygomatic, mandibular, masseteric cutaneous). With advancing age and stretching of the facial supporting ligaments, the lower cheek continues to droop, developing into the jowl at the mid mandibular border.³

The lips and perioral region also undergo characteristic changes with aging. The lips lose volume and pigment. The perioral bony support structures lose volume and shrink. The skin of the upper lip develops rhytids, and the depressor anguli oris muscles become un-opposed and overactive, forming prominent oral commisures (marionette lines).⁴

Age-related changes in the neck begin in the submental region with laxity of the skin and platysma. In thin necks, cords or platysma bands may occur with aging. These are single paired or multiple vertical folds of skin and platysma muscle resulting from years of cervicofacial contraction of the platysma.³

The typical changes associated with aging skin can be primarily attributed to chronic sun exposure. Photoaged skin is characterized by rhytids, laxity, uneven pigmentation, lentigines, sallow color, telangiectasias, increased pore size, and a leathery appearance. Dermal damage induced by ultraviolet radiation is principally manifested histologically as the disorganization of collagen fibrils and the accumulation of elastin containing material (solar elastoses). It appears that the collagen fibers in the upper dermis are destroyed over time and gradually replaced by an amorphous material that is associated with an increase in reticulin fibers. The amount of elastoic material and associated fiber breakdown is probably responsible for the fine rhytid formation associated with sun-damaged skin.⁵

Overview of Injectable Fillers

Prior to advent of modern soft tissue fillers, the anatomical changes of the aging face were primarily addressed surgically (e.g., rhytidectomy, brow lift, midface lift) or by the use of ablative (carbon dioxide [CO₂]) lasers. These more invasive techniques are associated with an increased morbidity (e.g., infection, bleeding, increased downtime) but are still valuable tools in the cosmetic surgeon's armamentarium for advanced facial aging.

Combination therapies using soft tissue fillers, chemodenervation, and non-ablative laser and light sources provide a more appealing option to patients and surgeons and can address many of the mild to moderate signs of aging. Injectable fillers can be categorized based on their source as follows:

Autogeneic: fat, autologous plasma, autologous collagen
Allogenieic: cadaveric collagen, human fibroblast cell culture
Xenogeneic: collagen, mostly from bovine or porcine sources, and hyaluronic acid products from rooster combs or bacterial fermentation
Synthetic: silicone products, polymethylmethacrylate (PMMA), hydroxyapatite, polylactic acid, polyacrylamide

Fillers with a temporary effect include hyaluronic acid, collagen, polylactic acid, and autologous plasma. Fillers with a permanent effect include silicone, PMMA, hydroxyapatite, and autogenous fat.⁶

Permanent filling agents
Liquid injectable silicone
Liquid injectable silicone has been used since the 1940s as a soft tissue filler. However, its misuse by injecting excessive volumes, or using adulterated product, has led to controversial complications. Two U.S. Food and Drug Administration (FDA)-approved medical-grade liquid injectable silicones are available today. Adatosil (Escalon Medical Corp, Chicago, Ill) and Silikon (Alcon Laboratories, Fort Worth, Tex) are approved for the tamponade of retinal detachments and their off-label use for soft tissue augmentation is permitted by the FDA's Modernization Act. Following microdroplet liquid silicone injection, there is a transient, mild inflammatory response lasting approximately 2 weeks, followed by a fibroblastic response and collagen deposition. One year post-injection intense fibrosis occurs and may cause some hardening of the tissues injected. Therefore, silicone is best used to augment areas of denser, less mobile tissue.⁷

Temporary filling agents
Collagen
For the past 2 decades, the most widely available and widely used substance for filling in facial rhytids has been bovine collagen. Approximately 25% of the protein in the human body and 75% in the skin is collagen. Injectable bovine collagen has been used for facial rejuvenation since the 1980s. It requires skin testing before it can be used as a filler. The second generation, derived from human fibroblast cell culture, does not require prior skin testing. The average longevity of correction with these products is approximately 3 months. Because the products are mixed with anesthetic, they may be less painful for the patient, but over- and undercorrections must be gauged. Collagen fillers produced from bovine sources have a risk of inducing allergic reactions. Sensitivity skin tests prior to treatment are recommended for bovine-derived collagen but not for human-derived fibroblast collagen products.⁷

Zyderm 1 and Zyderm 2
Zyderm 1 (INAMED Corporation, Santa Barbara, Calif) is a highly purified bovine dermal collagen (35 mg/mL) dispersed in buffered saline solution. Zyderm 2 (INAMED) contains bovine dermal collagen of higher concentration (65 mg/ML). Both Zyderm 1 and Zyderm 2 contain 0.3% lidocaine to provide local anesthesia at the time of injection. The FDA approved Zyderm 1 in 1981, and Zyderm 2 was approved in 1983. They are provided in sterile disposable ready-for-use syringes that should be kept refrigerated. Because they are produced from animal sources, a skin sensitivity test should be conducted at 8 and 4 weeks prior to treatment to identify sensitive patients. Zyderm 1 is recommended for fine lines and wrinkles. Because Zyderm 2 has twice the viscosity of Zyderm 1, it is recommended for deeper lines and furrows.⁷

Zyplast
Zyplast (INAMED) contains purified bovine dermal gluteraldehyde cross-linked collagen with concentration of 35 mg/mL similar to Zyderm 1. Its cross linkage with gluteraldehyde makes the collagen fibers stronger. It is indicated for the correction of deeper skin wrinkles and deformities. The FDA approved it in 1985. Skin sensitivity tests should be performed at 8 and 4 weeks prior to treatment to identify patients with sensitivity to the bovine collagen.⁷

CosmoDerm 1 and CosmoDerm 2
CosmoDerm 1 (INAMED) and CosmoDerm 2 (INAMED) are the second generation of injectable collagen fillers and are derived from human fibroblast cell culture. They do not require a pretreatment skin test, however their use is not recommended in persons with known sensitivities to bovine or collagen products. CosmoDerm comes in a sterile syringe with 0.3% lidocaine as local anesthetic. As injectable fillers placed in the papillary dermis, CosmoDerm 1 and CosmoDerm 2 have the same indications as their predecessors, Zyderm 1 and Zyderm 2.⁷

CosmoPlast
CosmoPlast (INAMED) is also derived from human fibroblast cell culture and cross linked with glutaraldehyde and contains 0.3% lidocaine as local anesthetic. It is recommended for the same indications as Zyplast; that is, correction of deeper dermal folds such as nasolabial folds and marionette lines.⁷

Autologous and allogenic collagen products
Dermalogen (Collagenesis, Beverly, Mass) is an injectable human dermal implant material made from a suspension of pooled human cadaver collagen. Autologen (Collagenesis) is an injectable autologous human tissue matrix containing intact collagen fibrils isolated from a patient's skin harvested during rhytidectomy or blepharoplasty and processed. Isolagen (Isolagen Technologies, Paramus, NJ) has been temporarily taken off the market pending FDA approval. It is composed of injectable autologous fibroblasts cultured for 4 to 6 weeks from a 3-mm punch biopsy taken from the postauricular skin.⁷

Hyaluronic acid
Hyaluronic acid is a polysaccharide found in the extracellular matrix of all tissues of all vertebrates and comprises 56% of the extracellular matrix of human skin. It is composed of hydrophilic disaccharide units containing glucuronic acid and N-acetylglucosamine. Hyaluronic acid derived from rooster combs (Biomatrix, San Tropez) has been used for almost 3 decades by ophthalmic surgeons during intraocular procedures. Non-Animal Stabilized Hyaluronic Acid (NASHA) is patented and produced by Q-Med AB, Uppsala, Sweden. The following products produce longer-lasting results and fewer hypersensitivity reactions than collagen products. No pretreatment skin testing is required. These agents are not mixed with anesthetic and therefore pretreatment of the areas to be injected with topical anesthetic creams is required.

Restylane (Medicis, Scottsdale, Ariz), FDA approved December 12, 2002, has 20 mg/mL of hyaluronic acid with a gel bead size of 250 µm and 100,000 units per mL.

Perlane (Q-Med, Uppsala, Sweden), not approved in the United States, has 20 mg/mL of hyaluronic acid with a gel bead size of 1000 µm and 10,000 units per mL.

Restylane Fine Lines (Q-Med), not approved in the United States, has 20 mg/mL of hyaluronic acid with a gel bead size of 100 µm and 250,000 units per mL.

Restylane, Perlane, and Restylane Fine Lines are NASHA products, biosynthesized from a nonanimal source. The residence time of NASHA is dependent on the size of the gel particle and the concentration. NASHA gels will stay approximately the same size and shape as injected.⁷

Restylane is used for the filling of fine lines and moderate rhytids and furrows. It is supplied as a sterile glass syringe with 0.7 mL of Restylane loaded onto a 30-gauge needle. It does not require refrigeration. Restylane is injected into the mid dermis and lasts an average of 9 months.⁷

Perlane is used for the filling of deeper furrows and contour irregularities. Because it is thicker, it can allow for more effective filling and lasts longer than Restylane. Restylane can be layered over Perlane for correction of residual superficial irregularities. Perlane is also supplied in a sterile glass syringe containing 0.7 mL of Perlane loaded onto a 27-gauge needle. It does not require refrigeration. Perlane is injected into the deep dermis or into the subcutaneous tissue.⁷

Restylane Fine Lines (not available in the United States) is used for the correction of delicate upper lip rhytids. Because it is used in smaller quantities, its residence time is shorter, averaging 3 to 4 months.⁷

Other temporary products
Sculptra (polylactic acid)
Sculptra (Dermik Laboratories, Berwyn, Pa) is synthetic polylactic acid powder (0.15 g per bottle) that has to be mixed and put into suspension in 4 mL to 5 mL of diluents (half sterile water and half lidocaine) immediately prior to injection to avoid clogging of the 26 gauge needle (supplied with product). This product works well to fill in broad irregular areas. It must be injected subdermally. Because the amount of correction improves with time, a gradual filling in the contour defect is recommended. Rather than aiming for complete correction in one session, partial correction is augmented in 3- to 4-month intervals.⁷

Artefill (PMMA)
Artefill (Artes Medical, San Diego, Calif) is composed of uniform PMMA beads (30 µm-42 µm in diameter) suspended in collagen. It is not U.S. FDA-approved. The collagen acts as a temporary filler, and the microspheres create an inflammatory response with secondary collagen production and a longer lasting effect. Because it contains bovine collagen, it requires skin testing before use.⁷

Matridex (Hypromellose, dextanomer DEAE)
Matridex (BioPolymer GmbH, Germany) is hypromellose, dextranomer DEAE suspended in hyaluronic acid and cross-linked hyaluronic acid. The hyaluronic acid provides temporary filling without the need for pretreatment skin testing and the hypromellose and dextanomer DEAE (positively charged microparticles) promote fibroblast formation and collagen neogenesis, inducing a longer lasting effect. It is not approved in the United States.⁷

Alloderm (Acellular Cadaveric Dermis) Alloderm (Lifecell Corporation, Branchburg, NJ) is a solid acellular biological implant that is useful in eyelid and lip reconstruction and for repairing large facial contour deformities. Human dermal tissue is harvested from cadavers. The cells, which are targets for the immune response, are removed without altering the collagen and extracellular matrix of the dermis. This immunologically inert tissue then serves as a framework to support revascularization and cellular repopulation. Cymetra (Lifecell Corporation) is its micronized, injectable form. It is supplied as a cryofractured, dried, acellular, particulate dermal matrix. When refrigerated, it has a shelf life of 2 years. We have found that when it is injected for lip augmentation considerable swelling and rapid resorption are the rule.⁷

Patient Preparation and Injection Techniques

Regardless of the product to be used, each patient is prepped with alcohol and treated while sitting in an upright position. The patient is given three sublingual Arnica Montana C5 pellets (Boiron, Newton Square, Pa) and asked to continue taking them four times daily for 3 days. We use the topical anesthetic Photocaine (University Pharmacy, Salt Lake City, Utah) on every patient and rarely use regional blocks.⁷

Silicone products
Microdroplet liquid injectable silicone (LIS) using a serial puncture technique is the safest and most efficacious use of LIS. For silicone of 350 centistokes viscosity, a 4 mm 30-gauge needle on a 1 mL syringe will allow small volumes (.0005 mL-0.02 mL) to be injected in a uniform fashion. The desired plane of injections is either the deep dermis or the superficial subcutaneous tissue. The angle of the needle determines the depth of the injection. The goal is to undercorrect initially, using small-volume injections and at each subsequent treatment session, in 1- to 3-month intervals, to augment until the final result is obtained. More viscous (1000 centistokes) silicone is injected with a 27-gauge needle.⁷

Collagen products
Collagen products contain lidocaine. The area to be injected is cleaned with alcohol. Zyderm and CosmoDerm are used to ablate fine lines and augment lip borders utilizing linear threading and serial puncture techniques into the superficial or mid-dermis. Zyplast and CosmoPlast are injected into the deep dermis utilizing linear threading, serial puncture, fanning, and cross-hatching techniques to fill in deep contour irregularities and folds. Because 20% of the injected volume is anesthetic agent, at least 20% overcorrection is the desired endpoint of the treatment.⁷

Hyaluronic acid products
Restylane and Perlane do not contain any anesthetic agent. The area must be cleansed with alcohol and anesthetized with topical agents left in place for approximately 20 minutes. After removing the anesthetic agent and cleansing the skin again with alcohol, Restylane is used to treat fine and moderately deep lines and lip borders utilizing linear threading and serial puncture techniques. Restylane is applied to the superficial and mid-dermis with a 30-gauge needle. Applications that are too superficial will appear gray through the translucent skin (we warn our patients of this possibility; however, our experience has shown that female patients in particular prefer to have the contour irregularities eliminated and to cover the mild discoloration with cosmetics - still we offer them the option between choices). Perlane is injected with a 27-gauge needle into the deep dermis or subcutaneously to fill in broader and deeper irregularities, utilizing linear threading, serial puncture, fanning, and cross-hatching techniques. No overcorrection is necessary. Repeat injections may be performed at 1-week intervals until the final correction is achieved.⁷

Polylactic acid
Utilizing a 26-gauge needle, polylactic acid injections are given subdermally, using a linear threading, fanning, or cross-hatching technique after application of a topical anesthetic. Small amounts (1 mL-2 mL) are injected over a 6-month period and are repeated until a satisfactory correction is achieved.⁷

Anticipated Results and Complication Management

Each of the temporary products used has its own inherent breakdown time or longevity. In addition, the greater the volume used and the less mobile the tissue into which it is implanted, the longer it will last. Concomitant therapies such as neuromodulation increase the persistence of the desired filling effect. Generalizing our experience, collagen products last an average of 2 to 3 months. Hyaluronic acid products last an average of 6 months (the nasolabial furrows lasting slightly longer whereas the melolabial depressions and lips slightly less). Products with suspended microspheres and polylactic acid may last for several years. Filling glabellar furrows with hyaluronic acid products with concomitant chemoneuromodulation of the procerus and corrugator muscles can last for 9 to 12 months.⁷

Silicone
Microdroplet usage of ultrapurified silicone may avoid the extreme and often unrepairable complications secondary to its abuse. Large volumes that have been injected will migrate over time. Because of the adjacent inflammatory reaction, these masses of silicone may be difficult or impossible to resect satisfactorily.⁷

Collagen
Bovine collagen requires two skin tests before use because the first skin test may function as a sensitization. Even patients with two negative skin tests may eventually exhibit an inflammatory response following implantation, requiring corticosteroid injections. Many patients who have long histories of implantation develop subcutaneous cicatrization. There has also been some controversy regarding sequential collagen implantation and the development or exacerbation of autoimmune and collagen-vascular disesase.⁷

Hyaluronic acid
Local areas of induration and gel aggregation can often be palpated for several days at the injection sites. Although they are rarely visible, a patient should be told that this is not unusual and will become less apparent over time. After lip augmentation, secondary edema can be avoided if patients are instructed not to continue rubbing the areas with their tongue. Localized edema following implantation is usually not problematic and may even accentuate the correction. We instruct our patients that if the correction is less evident in 5 to 7 days, this is not because the gel has dissipated but, rather, because they need more volume implanted. We ask the patients to return in 7 to 10 days for a possible touch-up. In areas where there has been an overfilling, patients may not want to wait for the naturally occurring breakdown of product. These areas can be injected with hyaluronidase.⁷

Polylactic acid
This product has to be reconstituted and mixed well before use. If it is not mixed thoroughly enough or not sufficiently diluted, there may be an increased incidence of granuloma formation. If it is not used immediately upon mixing, it will clog the needle and require frequent needle changes.⁷

Microspheres
Products containing PMMA microspheres should not be used in the periorbital area because there is the possibility of a retrograde venous injection and central retinal vein occlusion with secondary blindness. Furthermore, many patients injected with products containing microspheres are prone to granuloma formation at the injection sites. We have seen several patients referred from Europe who have developed skin ulcerations.⁷

Combined Techniques in Oculofacial Rejuvenation

Noninvasive therapies

A multidimensional approach using a combination of modalities provides improvement of facial skin texture, pigmentation, tone, and rhytidosis, as well as an improvement in facial contour. Botox, injectable filling agents, chemical peeling agents, intense pulsed light devices (IPL), nonablative lasers, and radiofrequency instrumentation are applicable to different facial areas.

Alpha-hydroxyl acid peels
Alpha-hydroxyl acid peels are useful in the management of mild rhytidosis and dyspigmentation. They are available in varying strengths. We usually begin with a 70% buffered solution applied for a maximum of 10 minutes. A 50% buffered solution is much more potent. The strength of the peel is increased during subsequent sessions.⁸

Trichloracetic acid peels
Trichloracetic acid peels are useful in the management of mild-to-moderate rhytidosis and dyspigmentation. Trichloracetic acid (TCA) can be used as a superficial (20% or 25%) or medium depth (30% or 35%) peel depending on the concentration used and the number of layers applied.⁸

Botox
One hundred units of botulinum toxin type B is packaged as a powder. The purified protein is reconstituted in sterile saline in 1 mL, 2 mL, or 4 mL to give the desired concentration in 0.1-mL aliquots. Botulinum toxin functions by blocking the release of acetylcholine from the nerve end plate, decreasing the strength of muscle contraction and reducing dynamic rhytidosis.⁹

Injectable fillers
Restylane, Perlane, and Sculptra are the injectable fillers that we find most useful in our practice. Their properties and injection techniques were described above. Their uses in oculofacial rejuvenation will be described in the upcoming section of this tutorial.

Intense pulsed light
Intense pulsed light is administered by a flash lamp device emitting light of multiple wavelengths. Cut-off filters are used to enhance the preferential absorption by blood vessels or pigment.¹⁰

Nonablative lasers
Nonablative lasers include the 1064-nm neodymium:yttrium-aluminum garnet (Nd:YAG), which is useful for vessel ablation and hair removal (Cool Glide), and the 1320-nm Nd:Yag (Cool Touch) which is used for collagen stimulation.¹¹

Thermage
Thermage uses radiofrequency energy to provide volumetric tissue heating of the deep dermis and subcutaneous tissues. It is primarily a lifting and tightening procedure and protects the epidermis.¹¹

Recommended Techniques by Facial Area

The following discussion serves as an overview of the various combination therapies that we find useful in rejuvenating various regions of the aging face. Please refer to the references at the end of this session for publications that outline our specific protocols for using each of these modalities.

Forehead and eyebrows
Radiofrequency-mediated volumetric heating of the dermis and subdermal tissues (Thermage) stimulates collagen contraction over a 3- to 6-month period. We have found that treating the brow depressors with Botox 2 weeks prior to Thermage treatment enhances and extends the longevity of the result. In theory, diminishing the downward pull of the brow depressors allows for unopposed collagen remodeling.

Twenty to 40 units of Botox are used to treat the glabella, procerus, and depressor supercili muscle insertions. Five to 10 units are used to treat the lateral orbicularis muscle fibers at the tail of the brow. Four to five 0.1-mL injections (5 units per each 0.1 mL) are given in the glabellar area. Two to four 0.1 mL injections are given at the tail of the eyebrow (2.5 units per each 0.1 mL). For brow elevation, a specific Thermage protocol is followed.¹¹

An improvement in forehead skin tone, texture, pigment, rhytidosis, and actinic changes can be accomplished with peels and IPL. For mild actinic changes, a series of alpha-hydroxyl acid peels are performed at weekly intervals. For more marked changes, TCA peels are effective. In skin types I to III, monthly treatments with IPL can improve dyspigmentation and telangiectasias without downtime.¹¹

Glabella
The paired corrugator muscles create frown furrows. If the "number 11" remains when a patient is relaxed, then combination therapy filling the vertical depressions after relaxing the muscles with Botox will be necessary. The patient is asked to frown. The corrugator and procerus muscle insertions are observed and injected with 25 units of Botox (5 units per injection site). Residual depressions are filled using serial puncture or linear threading techniques. The preferred fillers in this area are Restylane and Perlane.¹¹

Upper eyelids
For management of upper lid retraction, 2 to 4 units of Botox can be administered subcutaneously in the central lid crease. For temporary correction of mild blepharoptosis, 1 to 2 units of Botox is injected subcutaneously in the extreme nasal or lateral pretarsal areas.¹¹

Preseptal cutaneous 20% TCA peels or one pass of the erbium:YAG laser will reduce mild upper lid rhytidosis. The current development of smaller Thermage tips holds potential for skin tightening and upper lid fatty recontouring.

Micropigmentation is a technique of rapidly increasing popularity. The existing brow is shaped and contoured, and then a background color is selected. Individual hair strokes can be added, one shade darker.

Lateral canthi
Injection of 7.5 to 15 units of Botox per side can effectively reduce crow's feet rhytidosis. Three to four aliquots of 0.1ml (2.5 units per 0.1 mL) are injected subcutaneously over this area. If there is lower lid margin or lateral canthal laxity or lower lid retraction, then the injections are kept lateral to the lateral orbital rim. Pretreatment of this area with Botox enhances the results of chemical peels and IPL treatments, as well as allowing for greater temporal lifting with Thermage.¹¹

Lower eyelids
Lower lid rhytidosis and dyspigmentation are amenable to several noninvasive modalities. If there is laxity or lower lid retraction, then lateral canthal tendon plication must be performed first to avoid any accentuation of the lower lid margin malposition.

A roll of hypertrophic pretarsal orbicularis muscle can be relaxed and flattened with 1 to 2 units of Botox. In patients requiring improvement of the lower lid skin texture in addition to orbicularis flattening and rhytid ablation, pretreatment of the lower lid and lateral canthus can be performed prior to 20% TCA peel or erbium:YAG laser therapies.¹¹

Malar eminences
With age-related loss and ptosis of subcutaneous fatty tissue, the malar fat pockets descend, and the facial contour is altered. Concomitant cutaneous therapies for improving skin texture and pigmentation following radiofrequency-mediated lifting and tightening can be used for rejuvenation of this area. Skin texture and pigmentation are treated with IPL, chemical peels, or nonablative lasers. Thermage is a separate entity used specifically for lifting and tightening and is not primarily a rhytid ablating therapy. Residual depressions can be filled with Restylane, Perlane, or Silikon 1000.¹¹

Nasolabial folds
These facial depressions are conveniently managed with filling agents. Perlane can be injected into the deep dermis or subcutaneously for deep creases. Restylane is injected more superficially for shallower creases. These filling techniques are effective if there is no marked laxity of the fold. The laxity can be improved with Thermage treatment of the cheek. Markedly redundant folds can be filled with the injection of a subcutaneous long-lasting filler such as polylactic acid (Sculptra).¹¹

Melomental folds
Marionette lines can be softened not only by filling the melomental groove but also by supporting the corners of the mouth and the lateral aspect of the upper and lower lips. Relaxing the depressor anguli oris muscles with 2.5 units of Botox on each side will enhance the filling effect and the duration of the result. In more pronounced cases, larger volumes of polylactic acid (Sculptra) can be used to fill diffusely lax tissue. Thermage for lifting the folds will improve the quality of the result. In extreme cases, CO₂ laser resurfacing will be required.¹¹

Lower facial contours
Skin laxity at the jawline and jowl formation are amenable to correction with Thermage therapy. Pretreatment of the platysma and depressor anguli oris muscles with Botox (2.5 units to each depressor muscle and 20 to 40 units to the platysma muscle) will enhance the Thermage effect.¹¹

Lips
Effective rejuvenation of the peri-oral region requires a multi-dimensional approach: filling, neuro-modulation, neocollagenesis, and repigmentation. Micropigmentation of the lip border can be used to create the illusion of fullness. After defining the lips with micropigmentation, Restylane is used to define the lip contour, and Perlane adds volume to the body of the lip. Further lip eversion can be accomplished with Botox (1-2 units) to the orbicularis oris muscle midway between the nose and the upper lip margin.⁴

Summary

Noninvasive approaches for improving facial skin texture and contours are enjoying increasing popularity. Treating physicians and patients must understand that one treatment modality alone is not the answer. Our patients have experienced significant improvement with combined approaches to rejuvenation. Noninvasive facial rejuvenation is an effective modality with few complications and little recovery time. When multiple therapies are used in combination, the results can exceed the expectations. The final result can be more than the sum of the individual components.

References

Bosniak S, Cantisano-Zilkha M. Eyebrows: Anatomy and surgical techniques. In: Cosmetic Blepharoplasty and Facial Rejuvenation. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins. 1999.
Bosniak S, Cantisano-Zilkha M. Upper lids: Anatomy and surgical techniques. In: Cosmetic Blepharoplasty and Facial Rejuvenation. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins. 1999.
Holk DE. The development of the modern facelift. Presented at: the American Society of Ophthalmic Plastic and Reconstructive Surgery scientific meeting; November, 2003; Anaheim, Calif.
Cantisano-Zilkha M, Bosniak S, Rinaldi P, et al. Lip and peri-oral rejuvenation: A multi-disciplinary approach. Operative Techniques in Oculoplastic, Orbital and Reconstructive Surgery. 2001; 4:104-108.
Cantisano-Zilkha M. Patient home care regimens. Ophthalmol Clin N Am. In press.
Glavas IP. Filling agents. Ophthalmol Clin N Am. In press.
Bosniak S, Cantisano-Zilkha M, Glavas IP. Injectable fillers. In: Minimally Invasive Techniques of Oculofacial Rejuvenation. In press.
Cantisano-Zilkha M. An ophthalmologist's guide to chemical peels. Ophthalmol Clin N Am. In press.
Bosniak S. Combination therapies: A nonsurgical approach to oculofacial rejuvenation. Ophthalmol Clin N Am. In press.
Zdinak L, Summerfield M. Nonablative skin therapies. Ophthalmol Clin N Am. In press.
Bosniak S. Introduction to alternative techniques of oculofacial rejuvenation. In: Minimally Invasive Techniques of Oculofacial Rejuvenation. In press.