Overview

Today, neurotoxins and temporary facial fillers are the top cosmetic procedures purchased by the public, replacing more invasive procedures such as face lifts and facial peels. According to a 12‐year retrospective analysis conducted by the American Society of Plastic Surgeons, major facial cosmetic procedures declined by 27% in one 3‐year period (2006–2009) (Remington 2008), while minimally invasive procedures (MIP) increased during the 12‐year study period. Neurotoxin use increased by 680% and soft tissue fillers increased by 205% during the same period (Sandoval et al. 2014). Facial fillers have been available for decades but only in the last dozen years has there been the development of fillers that are technically easy to use, non‐allergenic, give predictable results, are easily manipulated and sculpted by the injector, and have minimal risk of complications. Neurotoxins have also been available for years. They were first isolated and potential medical uses described in 1822. The source of the toxin, however, was not isolated until 80 years later (Foster 2014). Neurotoxins for cosmetic use were first approved by the US Food and Drink Administration (FDA) in 2002. Since then they have become the most commonly used cosmetic procedure by far, with soft tissue facial fillers the second most common cosmetic procedure performed.

The clinician that provides his or her patients with cosmetic neurotoxins and soft tissue fillers must have a detailed understanding of facial anatomy and the mechanics of the muscles of facial expression. A thorough appreciation of the aging process, including the physiologic changes that occur to skin, subcutaneous tissues, and muscles of the face, is critical to successfully treating cosmetic patients. This knowledge must be combined with an in‐depth understanding of the pharmacology and working properties of the products to be used to restore facial volume. The clinician must also have an appreciation for the artistic qualities of the human facial form to be successful in creating an aesthetically pleasing result for the patient.

Patient Selection and Assessment

Patient motivation for seeking MIPs varies tremendously but can be divided into three primary sectors. Young patients, generally 18–35, are usually motivated by the desire to augment an area of their face they feel is deficient or not normal. Those in the 35–55 age group are usually seeking rejuvenation and the 55+ are usually looking for restoration. All are looking for MIPs with minimal downtime, providing minimal risks and rapid results.

MIPs are generally procedures with minimal risks and complications when performed correctly and on the right patients. Fortunately, there are few medical contraindications for the use of neurotoxins or facial fillers today. Success in providing MIPs is the result of a careful evaluation of the patient’s motivation in seeking treatment as well as a complete facial assessment. Cosmetic patients may have unrealistic expectations of what can be accomplished with MIPs and the clinician must be able to educate the patient about realistic outcomes.

The evaluation begins with the patient describing what they are unhappy with about their face. This provides a starting point for the examination. It provides the clinician with an initial focal point to understand a patient’s motivation. For example, a patient may tell the clinician that family and friends tell them they always look angry or tired. A patient may say that their cheeks look flat or hollow. Some patients describe the loss of lip exposure. Each of these complaints provides a starting point for the clinical evaluation. Once the patient’s primary concern/complaint and treatment goal is ascertained the clinician can perform a comprehensive facial evaluation and develop treatment recommendations to achieve the patient’s goal.

No evaluation is complete without a review of the patient’s past medical history, medications, and social history, including sun exposure, smoking, and history of any prior facial cosmetic procedures. The examination should include an assessment of the skin condition using the Glogau Classification of photo aging and wrinkles (Table 13.1).

The physical evaluation should follow the three facial esthetic zones as first described by Leonardo da Vinci. These three zones divide the face horizontally into thirds. The top extends from the top of the forehead to the inferior orbital rim. The midface extends from the inferior orbital rim to the base of the nose. The lower third extends from the nasal base to the chin.

It is useful in this evaluation to have a frontal facial diagram on which the clinician can indicate the location of static and dynamic wrinkles, areas of volume loss, redundant or sagging skin, and deep folds. Consent should be obtained and pretreatment photos and or videos obtained to demonstrate the areas of concern. Videos are particularly useful in demonstrating dynamic vs. static rhytids. Preexisting facial asymmetries should also be noted. This is very important to document so that the patient is made aware of their existence prior to any treatment administration. Once the evaluation is complete, the clinical findings should be reviewed with the patient and treatment recommendations discussed in detail, including the rationale, expected result, and potential risks and complications. If different products are available to treat the same problem, the benefits and risks of each should be reviewed.

Neurotoxins

Currently there are three neurotoxin products available for cosmetic uses: Botox Cosmetic^®, Dysport^®, Xeomin^®, and Jeuveau^®. All of these are derivatives of BoNT A. Use of botulinum toxin type A (BoNT A) derivatives is FDA approved to treat glabellar frown lines. Botox Cosmetic^® has been approved for crow’s feet treatment. Each derivative has its own specific unit concentration but the results are similar (Rubin 2013).

Common adverse effects at the injection site include pain, bruising, erythema, and edema. The most common general adverse effects are headaches, upper respiratory tract infections, nausea, pain, and flu‐like symptoms.

Temporary and Semipermanent Fillers

The first cosmetic filler used was paraffin in 1899 (Kontis and Rivkin 2009). Its popularity was short lived as the complications associated with its use quickly exceeded the benefits. Today, there are many types of temporary and semipermanent facial fillers available on the market. The most commonly utilized are the hyaluronic acid (HA) fillers. These fillers (Restylane^® family, Juvaderm^® family, and Belotero^®) are composed of micro particles of hyaluronic acid, a naturally occurring substance in our body with the highest concentrations found in the connective tissue and fluid around our eyes and also in some cartilage and joint fluid. HA fillers are synthetically derived and are more concentrated than those naturally found in our bodies. The injected gel provides a volume greater than the volume injected because it is hydrophilic (draws water into the area of injection). It is important not to over‐inject because of this delayed phenomenon. The material is slowly degraded over time. The microspheres vary in size by product and the indications for the use of each are based on the desired effect. The small particle sizes are used for wrinkle ablation and the larger sizes for volume replacement.

Another commonly utilized product is hydroxyapatite filler (Radiesse^®). This product is composed of microspheres of hydroxyapatite crystal (a component of bone) suspended in a gel matrix. The mechanism of action is immediate volume enhancement (what you see is what you get). Over time the degradation of the hydroxyapatite stimulates collagenesis. Although this new collagen is not permanent it does prolong the benefit of the treatment.

Neither hyaluronic acid nor hydroxyapatite produces an allergic response or requires allergy testing. Most HA products provide 12–18 months of benefit. Hydroxyapatite gel will usually provide 18–24 months of volume enhancement. Both product types are relatively risk free with minimal complications such as bruising (Table 13.2). An important distinction between the two is the reversibility of HA by injecting the treated area with hyaluronidase.

Treatment Sequencing