EADV 2024: Botulinum Toxine And Hyaluronic Acid - When, Where And How To Inject Both - An Advanced Guide

Speaker- Christopher Rowland Payne

Botulinum and hyaluronic acid could be injected on the same day without any contraindications for their simultaneous use. The initial query regarding timing was deemed acceptable, while the subsequent inquiry concerning the methodology was not favored. It was advised against using the same syringe for both substances, as the approach compromised the accuracy of botulinum administration. However, performing injections on the same day, as well as the anatomical locations chosen for injection, posed no issues. 

Advanced techniques for applying hyaluronic acid (HA) and botulinum were detailed in a specific guide, which began with the concept of a heart-shaped face and concluded with the depiction of a lantern. To correct facial descent, the guide suggested administering 0.5 ml of filler to each side of the face. To execute an eyebrow lift, practitioners were instructed to support the eyebrow mound.the cross sectional anatomy shows connecting fibers of the frontalis muscle to the overlying skin at the ligamentous terminations of the muscle. The eyebrow mound, composed of connective tissue and fat, was identified as a critical structure. If the eyebrow mound were lost, the eyebrow would descend, resulting in a sagging forehead and the upper eyelid developing a concertina-like appearance. Restoring volume behind the eyebrow, restores anterior projections and helps lift the eyebrow.

The injection depth could be subdermal or pre-periosteal, with subdermal injections yielding more more effects. When using a small amount of the filler use a cannula in retrograde in threading injections. Lifting the eyebrow by 1mm improves the look of the patient The cannula was maneuvered to scrape along the back of the dermis, allowing for subdermal injection in the middle and lateral halves of the eyebrow. The technique resulted in a noticeable improvement in the appearance of the eyelids. Subdermal injections of 0.1 ml HA were administered to each eyebrow. The method was recognized as straightforward and effective, successfully restoring volume and anterior projection while lifting the lateral and middle sections of the eyebrow by one to two mm. Additionally, it contributed to an elevation of the lid crease. The technique delayed blepharoplasty by approximately one year, effectively opening the orbital area and brightening the overall facial appearance. Patients appeared less exhausted and refreshed, with many returning for additional eyebrow procedures after a six-month interval. Botulinum injections were scheduled every five and a half months, with the effects of each HA injection lasting a similar duration. If botulinum was administered at four months, it could be safely repeated at the same four-month interval, even if the botulinum was injected into the eyebrows.

The retro-ala nasi mid-face lift, 0.1 ml each side was considered the ultimate single injection technique for the face, recognized for its volume efficiency compared to other facial filler injections. The nose functioned as the tent pole of the face, supporting the anterior middle region of the face. In individuals who underwent rhinoplasty to achieve a ski-jump nose in their twenties or thirties, subsequent aging typically resulted in increased facial descent. The hump of the nose plays a significant role in addressing nasal tip ptosis. As individuals age, bone and fat involution leads to volume loss, contributing to the condition. The resultant volume loss caused the nasal tip to tilt downward. Compression of the fat that lies posterior to the ala nasi, if you smile more that creates a darker shadow in the ala nasi fossa and nasojugal creases. Culturally, smiling was prevalent in Western societies, with Americans often captured in photographs displaying smiles. In contrast, individuals from Eastern cultures tended to exhibit fewer creases due to a less frequent smiling expression. Additionally, gravity, sleep position, and fat involution further exacerbated nasal tip ptosis. To mitigate this, individuals were recommended to sleep without a pillow lift, avoiding direct contact with the pillow to maintain nasal position. The causes of nasal tip ptosis included muscular factors, gravity, sleep habits, and fat involution.

The retro-ala nasi lift was designed to restore volume and enhance anterior projection, effectively lifting the midface. Recommended to use HA 0.05/0.1 ml  It was performed by placing a cannula in Ristow's deep pyriform space, located posterior to the relevant anatomical structures. Given the proximity of the angular artery to the area, using a cannula was deemed essential to minimize the risk of vascular injury. The procedure involved palpating the area and injecting the cannula through a ligamentous restraint. If you did not experience the characteristic "pop" sensation, the cannula would not successfully enter the compartment. Aspiration and injection were conducted with a cannula rather than a needle, facilitating better light reflection for the patient and reducing the appearance of shadows on the face. The procedure effectively restored the volume, the anterior projection of the nasal tip, effaced the ala nasi fossae, and diminished the appearance of nasolabial sulci. It also modestly impacted the jawline and dark circles under the eyes. Patients observed immediate improvements in their appearance when looking in the mirror. By restoring volume, the procedure enhanced the anterior projection of the nasal tip, addressed the ala nasi fossae and nasolabial sulci, and improved the anterior projection of the medial cheeks, thereby lifting the midface. Additionally, it improved the appearance of the tear troughs and jowls.

The Mona Lisa smile procedure aimed to enhance the angles of the mouth, specifically focusing on the upper and lateral lips. The medial part of the upper lip was suspended from the columella, while the orbicularis oris muscle exerted a downward pull. Laterally, the cheek provided the only support, which gradually descended due to gravitational forces and the involution of cheek fat. Gravity, sleep positions, and continued fat involution exacerbated the lack of support for the lateral mouth. To execute the enhancement, the angle of the mouth was identified, and a point of three mm superimmedial was selected to the angle of the mouth. The needle was inserted along the white line space, advanced until reaching the hub, and filler was implanted using a retrograde threading technique back to the entry point. The needle was then advanced medially and anteriorly into the superficial vermilion, close to the surface. A small bolster of filler was placed in the area to define the new mouth angle. In the desired outcome of an upturned mouth, the upper lip appeared shorter than the lower lip. The effect was achieved by replacing the existing angle with a new, superior angle. Consequently, the upper lip was shortened while the lower lip received additional tissue volume. The technique involved marking the existing angle with a small amount of filler, injecting a thread retrograde, maneuvering the needle into the vermilion, and placing a small bolster. The total syringe output was less than 0.1 ml for each side, with approximately half of 0.1 ml administered per side. At the mouth angles, 2 mm were effectively "stolen" from the upper lip on each side and transferred to the lower lip, resulting in a shorter upper lip and a lengthened lower lip. The technique could be performed during the same visit, regardless of previous Botox treatments around the mouth, in the depressor anguli oris (DAO) or the depressor labii inferioris (DLI) regions. The procedure's outcome was visually evident, showcasing an elevation of one to two mm, an upturned mouth angle, and a widened appearance, contributing to a more youthful and contented look. 

In conclusion, a one-ml facelift was designed to restore volume, enhance anterior projection, elevate the mid-face, and improve the angles of the mouth, effectively restores the patient's own look and not a filler face The cost-effective procedure could be performed up to two-three times a year and was compatible with simultaneous Botox treatment in all facial areas. 

33, European Academy of Dermatology And Venereology Congress, 25-28 September 2024, Amsterdam