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In My Practice: Comprehensive Assessment for Facial Rejuvenation

  • Authors: John H. Joseph, MD
  • CME Released: 7/21/2011
  • Valid for credit through: 7/21/2012, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for dermatologists, plastic surgeons, and other physicians who are involved in aesthetic procedures.

The goal of this activity is to review the principles of combination treatment for facial rejuvenation.

Upon completion of this activity, participants will be able to:

  1. Describe the principles of safe and effective aesthetic treatments for facial rejuvenation that combine neurotoxins with other modalities


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  • John H. Joseph, MD

    Assistant Clinical Professor, David Geffen School of Medicine at UCLA, Los Angeles, California; Private practice, Beverly Hills, California


    Disclosure: John H. Joseph, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Medicis Pharmaceutical Corporation; sanofi-aventis; Suneva Medical, Inc.
    Served as a speaker or a member of a speakers bureau for: Medicis Pharmaceutical Corporation; sanofi-aventis; Suneva Medical, Inc.
    Received grants for clinical research from: Medicis Pharmaceutical Corporation; Suneva Medical, Inc.
    Owns stock, stock options, or bonds from: Medicis Pharmaceutical Corporation; Suneva Medical, Inc.

    Dr. Joseph does intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the US Food and Drug Administration (FDA) for use in the United States.

    Dr. Joseph does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.


  • Gina K. Kaeuper

    Freelance medical writer, Knoxville, Tennessee


    Disclosure: Gina K. Kaeuper has disclosed no relevant financial relationships.


  • Kristin M. Richardson

    Senior Scientific Director, Medscape, LLC


    Disclosure: Kristin M. Richardson has disclosed no relevant financial relationships.

CME Reviewer

  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC


    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

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    For Physicians

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    Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

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In My Practice: Comprehensive Assessment for Facial Rejuvenation

Authors: John H. Joseph, MDFaculty and Disclosures

CME Released: 7/21/2011

Valid for credit through: 7/21/2012, 11:59 PM EST



Editor's Note:
Botulinum toxin type A (BoNTA) injections are a mainstay in the contemporary aesthetic treatment algorithm, remaining the most commonly performed aesthetic procedure for more than 10 years.[1] However, no single aesthetic tool can address the myriad presentations of aging and associated pathologies, and experts increasingly use BoNTA as only one part of the overall aesthetic treatment plan. BoNTA injections have been successfully combined with dermal fillers, chemical resurfacing, lasers and energy devices, and surgery in aesthetic treatment plans.[2-7] The efficacy of the combined approach is well accepted; indeed, combination therapy is increasingly considered the foundation of contemporary aesthetic treatment, with combined modalities providing aesthetic effects beyond what could be achieved with each alone.[3,8,9]

The primary impetus toward combination therapy is the evolution of the approach to facial rejuvenation from a 2-dimensional viewpoint of lines and wrinkles to a 3-dimensional or even 4-dimensional perspective on facial aging.[5,10] This shift in focus requires an understanding of the multifactorial etiology of aging, including the many intrinsic and extrinsic factors that combine to create patients' unique presentations. As eloquently stated by Kenneth Beer, "Each patient looks old for their own reasons and in their own way."[10] Taken a step further, patients will require a similarly unique approach to correcting those signs of aging.

A thorough patient assessment lays the foundation for designing a treatment plan that optimizes results. Prior to treatment, clinicians should assess aesthetic patients' lines and wrinkles, muscle anatomy, and movement; the degree and location of volume loss; skin texture and elasticity; the degree of photodamage and dyspigmentation; and any skeletal changes such as bone resorption. The findings will inform the treatment approach. For example, BoNTA injections are widely acknowledged as a superior treatment for softening the lines and wrinkles associated with muscle action, and, in experienced hands, can be used to sculpt and shape certain areas of the face and improve skin texture. They cannot, however, reestablish volume or address skin pigmentation changes. Of course, patients' personal aesthetic goals and commitment to treatment are critical considerations for the final plan, but the therapeutic approach to treatment must be appropriate for the physiology of the demonstrated aging process, asymmetry, or other pathology in order to ensure natural, long-lasting, cost-effective outcomes.

As combination therapy with different aesthetic modalities has become more prevalent, it raises the practical question of the optimal approach to treatment. Specifically, is there a recommended order for the use of each modality? Several expert consensus publications have provided guidance on an effective approach to facial rejuvenation with BoNTA in combination with other therapies[5,6] (Table). Of note, although experts agree that combination therapy must be approached with care to ensure that adverse events are avoided, practical and economic considerations tend to determine the order and timing of multimodal therapy for many patients.[6] As with other facets of aesthetic practice, clinicians should consider individual patient factors in conjunction with professional knowledge and experience to determine the best approach for each situation.

Table. Recommendations for BoNTA in Combination Therapy

Combination Modalities Recommendations
BoNTA + injectable fillers BoNTA and injectable fillers can be administered the same day or separate days. It may be preferable to inject the first agent, wait until effects are clinically evident, and then follow up with second agent as needed.
In the upper face: Typical to inject BoNTA first.
In the mid- and lower face: Typical to inject filler first.
BoNTA + ablative laser resurfacing Inject BoNTA several days prior to the ablative procedure, and wait until BoNTA effects are clinically evident.
BoNTA + nonablative lasers/chemical peels Nonablative procedure first. Inject BoNTA 10-15 minutes following nonablative procedure.
BoNTA + surgery Avoid injecting BoNTA the day of surgery. Follow-up BoNTA injections can continue beginning 3 months following surgery.
Selective presurgical application of BoNTA may aid in the postsurgical healing process.
BoNTA = botulinum toxin type A
Data from Carruthers JD, et al[5]; Kane M, et al.[6]

In the video that follows, John H. Joseph, MD, reviews and demonstrates his patient assessment process and presents practical guidance on the use of BoNTA with other aesthetic treatment modalities. Of note, the only approved indication for the aesthetic use of neurotoxins is temporary improvement in the appearance of moderate-to-severe glabellar lines associated with procerus and corrugator muscle activity in adult patients younger than 65 years of age.

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Supported by an independent educational grant from Medicis Pharmaceutical Corporation.

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