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Fig. 8.3a,b. Patient presenting with acne scars and deep dynamic wrinkles in the forehead and glabella area. Also, a slight asymmetry in his upper lip on the right side can be noticed. Before and after treatment with a combination of injectable fillers and BNT-A. The result is very natural and there is no evidence of any cosmetic procedure done in this male patient

Very superficial and superficial skin wrinkling is best treated with ablative methods, such as lasers or chemical peels. However, medium or deep wrinkles and folds are ideally treated with fillers. Depending on the depth of a wrinkle or fold, the appropriate filler should be chosen. Why combine BNT-A and fillers? If we analyze the negative cosmetic landmarks of the face, we may notice that some of the most evident wrinkling occurs on the area where mimic activity is the greatest. The kinetics of mimetic muscles and skin atrophy determine how BNT-A and/or fillers are used. Muscles do produce more intense skin wrinkling when the skin is thin or atrophic. The single use of fillers to increase the dermal thickeness may be enough to decrease the mimetic action on the skin. Hyperkinetic or hypertonic patients, however, will continue to move the dermis even when it is thick. In these patients the durability of a biodegradable injectable filler might be shorter. By blocking the muscular activity or even hyperactivity, BNT-A will directly reduce the degradation of the biodegradable filler and so prolong the duration of the effect.

Depending on the area of treatment, the decision regarding the timing of injection of BNT-A or use of fillers may differ. Usually, the dynamic component should be treated before the static component of the wrinkle, mainly because the use of BNT-A may be enough for resolving the hyperkinetic line. However, in selected cases, dermal atrophy or deep static lines do not disappear after BNT-A injection. These patients usually get disappointed with BNT-A alone and the experienced injector should recommend the concomitant use of fillers in those patients. In more complicated areas, such as in perioral wrinkling or the nasolabial fold, fillers are best scheduled to be injected first. If, after the filler injection, many wrinkles are still evident during animation, the subsequent injection of BNT-A should be considered.

Experienced practitioners may know firsthand that combined use of fillers and BNT-A will be necessary and can do both in the same session. One procedure does not interfere with the other because both are injected into different layers. Usually, BNT-A will be injected first and fillers soon after (Table 8.1).

Table 8.1. Combination of BNT-A with injectable fillers

Area

BNT-A

Fillers

Observation

Forehead lines

First

After if needed

BNT-A is usually enough

Glabella

First

After if needed

Fillers at this level are very beneficial for glabella reshaping. The duration of both procedures will be longer

Periorbital

First

After if needed

Fillers are barely needed at this area

Nasolabial fold

After if needed

First

The use of BNT-A should be done with caution to avoid asymmetries

Nose

To be used into the depressor septi nasi to block the drooping effect of muscle contraction

To be used into the nasal dorsum, at the fronto-nasal and nasolabial angle.

Their use may be concomitant with non-surgical reshape of the nose

Perioral

After if needed*

First

Usually fillers are enough in this area. The use of BNT-A is used to improve performance of result

Cheek

After if needed*

First

BNT-A injection in this area should be carried out with caution

Oral comissure

First if the main component results from muscle depression

First if the main component is tissue atrophy

The synergist use of both procedures is ideal in moderate to severe cases

Chin

First

After if chin enlargement is targeted

Skin wrinkling is more common than chin reshape with fillers

Neck

Ideal for platysma bands Ideal for moderate to deep (vertical) horizontal lines

Both procedures can be undertaken in the same session

* Some colleagues may start with BNT-A first if there is a strong muscular component

* Some colleagues may start with BNT-A first if there is a strong muscular component

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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