Botox and Fillers injection in modern aesthetics
Facial aging is associated with a gradual thinning of the skin and loss of elasticity over time, accompanied by the diminishment of dermal collagen, hyaluronic acid (HA), and elastin. This intrinsic aging process is accelerated and compounded by sun damage and other extrinsic factors such as smoking, resulting in facial lines and wrinkles (also called rhytids or rhytides). Habitual muscle contraction with facial expression also contributes to the formation of wrinkles, particularly in the upper one-third of the face. These dynamic wrinkles are typically treated with botulinum toxin injections. Volume loss and laxity are more evident in the lower two-thirds of the face, and dermal fillers are most commonly used in this region. This area’s lines and wrinkles are typically visible when the face is at rest, which is referred to as static lines. Facial volume loss, also referred to as biometric reduction, results from resorption of facial bones, degradation of subcutaneous tissue, and descent of the fat pads. With age, facial contours change from high cheeks and a small chin to a bottom-heavy appearance with flattened cheeks and prominent jowls.
Approached skin rejuvenation and skincare showed a significant improvement in the last decade. That includes both topical care and aesthetic procedures. This post aims to focus on injectables and fillers as one of the most desired cosmetic minimally invasive aesthetic procedures. The injectables such as Botox, fillers, and plasma is currently the cornerstone of non-invasive facial rejuvenation and skincare. Botox, for example, showed an almost 100% increase over the last decade! Botox function as a muscle relaxant; it inhibits the pre-synaptic release of acetylcholine at the neuromuscular junction. This results in partial or total muscle paralysis. The initial FDA approval of Botox injection was to treat the 11 lines (Glabellar rhytids) in patients under 65. The approval for crow feet (Lateral Canthal line) was granted in 2013.
Contrary to the widespread myth, research showed that frequent injection of Botox will not prolong the effect span, which is about three to four months. The main side effect of Botox injection is the “Mephisto” brow. This happens when the lateral part of the eyebrow is positioned higher than the medial one. Brow ptosis is another frequent cosmetic side effect; this mainly happens due to Botox injection within the danger zone, 2 cm above the eyebrows. If a patient is concerned about wrinkles within the danger area, it is recommended to do filler injection instead.
Similarly, dermal fillers injection showed a significant increase over the last decade. Both Botox and fillers injection is used complementary to each other to achieve the best cosmetic results. There are numerous options for fillers; our preferred ones at Albany Cosmetic and Laser center is the Vycross line of Juvederm, which is hyaluronic acid cross-linked to various degrees. The ideal choice of fillers depends on the anatomical location of the targeted wrinkles, the skin type of the patients, and medical professional preference. The main disadvantage of fillers injection is the need for multiple injections. This can be avoided by using the microcannula for fillers injection. I prefer using the microcannula for mid-face augmentations (check lift, nasolabial fold removal) rather than using it for lips filler injection.
The beauty of the cannula blunt cannula is that you need only one entry point (one needle poke); once you are past the epidermis, you can move the blunt cannula the way you like. The cannula has a good balance between rigidity and flexibility that allows you to move in and out without bruising or the risk of damaging the tissue. However, the injector will have a hard time placing the fillers precisely. That is ok with the deep filler deposition but would be problematic with superficial ones such as lip injections.
Basic and Advanced Procedures The treatment area, type of product (temporary, semipermanent, permanent, etc.), and injection techniques used determine the level of complexity for dermal filler procedures. When getting started with dermal filler injection, it is advisable to start with the basic dermal filler procedures described below, acquire proficiency, and then proceed to the advanced procedures.
Basic Procedures Recommended dermal filler products for basic procedures include Prevelle Silk®, Juvederm®, and Restylane®, all of which are hyaluronic acids (HAs). These dermal fillers are generally easier to handle, with good flow characteristics during injection in tissue, requiring gentle plunger pressure. Once injected, they feel supple and are easily molded and compressed, which reduces the risk of undesired product collections and contour irregularities. In addition, HA products can be degraded using injectable hyaluronidase for correction if necessary. Dermal filler treatments in these facial areas yield predictable results, have the greatest efficacy, fewest side effects, and are preferred for providers to start dermal filler procedures. Injection techniques for basic procedures include linear threading, fanning, and cross-hatching.
Advanced Procedures Recommended dermal filler products for advanced procedures include the products used for basic procedures as well as Perlane® and Radiesse®. Perlane and Radiesse tend to have increased longevity compared to the basic dermal fillers. They also offer advantages of significant structural support in tissue and are useful for facial contouring, in addition to soft tissue filling. Greater plunger pressure during treatment and more practiced injection skills are typically necessary with advanced dermal fillers. Dermal filler treatments in these areas often require the precise placement of small volumes and can be associated with greater risks and longer-lasting complications. Injection techniques for advanced procedures include those used for basic procedures and depot and layering techniques. It is advisable to obtain injection proficiency and confidence with basic dermal filler procedures before proceeding to more advanced procedures.
Dermal Filler Indications
The U.S. Food and Drug Administration (FDA) approved the injection of HA and calcium hydroxylapatite (CaHA) dermal fillers into the mid- or deep dermis for correction of moderate to severe facial wrinkles and folds, such as nasolabial folds and marionette lines.
Radiesse, a CaHA dermal filler, has also been FDA approved to treat HIV-associated facial lipoatrophy.
Dermal filler treatment of lips and other cosmetic areas is considered off-label.
Patient Selection Dermal filler procedures are most commonly performed as corrective measures for patients with skin aging to smooth static lines and wrinkles, particularly in the lower two-thirds of the face, such as nasolabial folds and marionette lines. They are also performed for augmentation and facial contouring, such as lip and malar enhancement. It is important to set the expectation that dermal fillers will soften lines and wrinkles instead of erasing them and that subtle improvement in contours can be achieved, but fillers do not offer surgery-like results. Patients with excessive skin laxity and folds usually require surgical intervention for significant improvements. Patients with unrealistic expectations or body dysmorphic disorder are not candidates for aesthetic treatments.
HA is a naturally occurring glycosaminoglycan in the dermal extracellular matrix that provides structural support and nutrients and, through its hydrophilic capacity, adds volume and fullness to the skin. Commercially available HAs vary in the formulation, concentration, and degree of cross-linkage, which affects their duration of action and postprocedure risks of swelling. For example, Juvederm Ultra has 24 mg/mL of HA and typically has mild to moderate postprocedure swelling, compared with Hydrilla, which has 28 mg/mL of HA and can be associated with more significant postprocedure swelling. HA formulation also affects tissue filling effects. Some HA products have softer tissue filling effects, such as Juvederm Ultra XC, whereas others have firmer tissue filling effects, such as Juvederm Ultra Plus XC and Restylane-L. HA products are clear, colorless gels (Fig. 5). Some HAs are formulated with lidocaine (referred to as HA-lidocaine in this book) to increase patient comfort during injection and reduce the need for anesthesia. Maximum treatment doses of HA dermal filler vary by manufacturer and are reported in the product package insert. For example, the maximum dose for Juvederm is 20 mL per year and for Restylane is 6.0 mL per patient per treatment. Radiesse, the currently available CaHA filler, consists of CaHA microspheres (30%) suspended in a carboxymethylcellulose gel (70%). After CaHA injection, the gel is absorbed at approximately 3 months, at which time the patient’s native fibroblasts are stimulated to synthesize new collagen. CaHA offers significant structural support to tissues into which it is injected. CaHA is an opaque white product. CaHA has also been FDA-approved to be mixed with small amounts of lidocaine, reducing product viscosity and providing some anesthesia.
Do not hesitate to contact us for a free consultation. Albany cosmetic and laser center in Edmonton’s most advanced aesthetic clinic. Our quality laser and microneedling machines, along with experienced medical aestheticians, is the best choice for all skin tightening, wrinkle removal, laser hair removal, pigmentation removal, melisma treatment, body shaping, fat reduction, fat removal, body slimming, body contouring, skincare, skin resurfacing, skin rejuvenation.