Hyaluronic Acid Fillers Plus Botulinum Toxin Provide Good Cosmetic Results to Perioral Region of Face

Nancy A. Melville

October 07, 2009

October 7, 2009 (Phoenix, Arizona) — Despite having very different mechanisms of action, botulinum toxin and hyaluronic acid fillers, when used in combination in the lower face and perioral region, provide better and durable cosmetic results than either modality used on its own, according to a study presented here at the American Society for Dermatologic Surgery 2009 Annual Meeting.

Before physicians started getting creative with the products, botulinum toxin was primarily used in the upper face to treat the glabella and periorbital wrinkles, whereas the lower face and perioral region were primarily treated with fillers, according to Gary D. Monheit, MD, lead author of the study and associate clinical professor in the Departments of Dermatology and Ophthalmology at the University of Alabama in Birmingham.

"The paradigm we used to follow was that neurotoxins were good in the upper face and fillers were for the lower face, but now that we are starting to combine things, we use both products in the upper and lower face. The combination produces both reflation and relaxation," Dr. Monheit told Medscape Dermatology.

Previous studies have indicated that a combination with botulinum toxin helps extend the longevity of hyaluronic acid filler in the upper face, but with a decidedly different and complex musculature in the lips and perioral region. Dr. Monheit's study was designed to evaluate the combination in the lower face.

For the study, 90 patients were randomized into 3 groups: 30 patients received injections of botulinum toxin type A (Botox, Allergan); 30 received injections of hyaluronic acid (Juvéderm Ultra or Ultra Plus, Allergan); and 30 received a combination of both products.

Each group received an initial treatment, and 1 touch-up was provided for those receiving filler; botulinum toxin touch-ups were given at 4 months.

The subjects were evaluated by a blinded investigator and the principle investigator for 4 visits over 6 months. Patients also kept diaries to assess adverse events and safety.

The evaluations included ratings on scales for lip fullness, oral commissures, resting contraction, perioral lines, and cosmetic improvement based on patient and investigator assessments.

The results showed that on all scales, the patients receiving combination therapy received the highest scores, and longevity and durability of the filler was improved when combined with botulinum toxin.

"If you combine [botulinum toxin] with [hyaluronic acid], there is longer viability of the filler, and it makes sense because the less movement there is, the longer the filler will survive," Dr. Monheit said.

Among the 3 groups, there were no significant differences in adverse effects, which included injection-related bruising and redness; however, patients in the combination group said they did not experience some of the adverse effects that can occur when botulinum toxin alone is used around the lips, he added.

"The side effects you tend to see with [botulinum toxin] around the lips — the potential slurring of words, drooling, or some asymmetry — seemed to be present in the [botulinum toxin] alone group, but the patients in the combination group never complained about them at all."

With so many physicians combining neurotoxins and hyaluronic acid fillers, the findings offer some important evidence to back up the common practice, Dr. Monheit concluded.

"It's always good to confirm objectively what we do intuitively," he said.

Arash Kimyai-Asadi, MD, comoderator of the session and a dermatologic surgeon based in Houston, Texas, who was not involved in the study, agreed that the findings offer important evidence of the safety and efficacy of combination treatments.

"Traditional teaching has been to use botulinum toxin in the upper face, including the forehead, glabella, and crow's feet, and fillers in the lower face, including the lips and nasolabial folds," he said. "What Dr. Monheit's study showed was that the combination of the 2 appears to offer some advantages without increasing risk."

"In the old days, there was a lot of concern that the use of [botulinum toxin] in the lower face would cause distortion or functional deficits, but its proper use along with fillers appears to be safe."

This study received financial support from Allergan. Dr. Monheit reports that he is a consultant and clinical investigator for Allergan. Dr. Kimyai-Asadi has disclosed no relevant financial relationships.

American Society for Dermatologic Surgery (ASDS) 2009 Annual Meeting: Abstract GD161. Presented October 1, 2009.

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