Transcript Vieillissement cutané du visage Techniques combinées

The upper face
From BTX A to combined
techniques
Dr LE PILLOUER-PROST A.
Dermatologist, Clairval PH, Marseille
[email protected]
Conflict of interests
Expert and fees (boards,teaching,studies,talks…)
- DEKA, Candela, Aesclepion, Deleo
- Merz, Q-med, Galderma
- Urgo
- Avène, La Roche Posay
Absolutely no conflict of interest for this talk
Totally independant work
Aesthetic patient « EDUCATION »
- Goals have changed
• 2-D to 3-D restoration of volumes and contours
• Improvement of « bad » or « negative » expressions BUT NO
« overcorrection-blockage-mask appearance » : 4-D restoration
for an harmonious and « natural look »
- Global approach (not to treat a wrinkle) :
• Areas interdependancy, for example:
Malar enhancement should improve the appearance of the nasolabial and
nasojugal folds
Temple enhancement and eyebrow reshaping should improve the « look »
- Combined techniques : Cumulative
and synergistic effect
• More natural restoration (avoiding overcorection from each technique)
• More persistent effect
• Cost? Cheeper in the long term
Aesthetic patient « EDUCATION »
- INFORMATION
•
•
Possibility of downtime
Risks / benefits balance : adequation/motivation… consenting patient
- ADAPTATION (« taylor » to each patient)
•
•
Male/Female, age, aging scores, race….
Preexisting asymetries : photos
Literature…
1. Carruthers JDA, Glogau RG, Blitzer A, and the facial aesthetics consensus group faculty
Advances in facial rejuvenation : Botulinum toxin type A, hyaluronic acid dermal fillers, and combination
therapies –consensus recommendations
Plastic Reconstructive Surgery, supplt may 2008, vol 121:5S-30S
2. Carruthers J, Carruthers A.
A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal
sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane)
alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides
with a hyaluronic acid derivative compared with the derivative and BTX-A.
Dermatol Surg. 2003 Aug;29(8):802-9
3. Braccini F, Dohan Ehrenfest DM.
Advantages of combined therapies in cosmetic medicine for the treatment of face aging: botulinum
toxin, fillers and mesotherapy.
Rev Laryngol Otol Rhinol (Bord). 2010;131(2):89-95
4. Dubina M, Tung R, Bolotin D and coll
Treatment of the forehead/glabellar rhytidecomplex with combination BTX A and HA versus BTX A
injection alone: a spilt face, rater-blinded, randomized control trial
J Cosmet Dermatol 2013Dec;12 (4):261-6
“Lines can be effectively and safely reduced with BTX A alone as well as BTX A in
combination with fillers. Combination treatment may provide a slightly better
cumulative benefit and also increase the persistence of effect”
Glabellar rhytides
Literature:
– BTXxA +++ (alone 90% of the experts in the
PRS consensus may 2008)
– In case of HA (only 25% of the experts in the
PRS consensus may 2008)
• In case of persistent rhytids after BTxA or alone
• Intradermal: mid dermis (needle visibility and
skin blanching)
• Low quantity: no more than 0.5 ml
• « medium » filler in the range : Restylane,
Emervel classic, Belotero balance, Juvederm Ultra 2,
Stylage S, Teosyal global action
• Vascular supratrochlear compression by a
controlateral finger
• Always retrograde injection –aspiration if needle in
the depth
High risk area for vascular (arterial) complications and
necrosis …
Crow’s feet, eyebrows and temples
• Crow’s feet
– BTX A +++
Often alone
Superior and medium points (supero ext part of the
orbicularis oculi)
Additional lateral points
Mephisto prevention (if needed- sometimes only at
3 weeks)
–
Fillers
(near 90 % of the experts combine
fillers)
• TEMPLES « volume »
• EYEBROW « reshaping »
– Lasers and EBD +++
mode)
traditional or fractional
Fractional CO2 (SmartXide DOT² - DEKA)
Before treatment
Just after
1 month after
Combined technique in 2 sessions
• Session 1 : BTxA
• Session 2 (3 weeks later) : Filler
• Case 1
Temple injection : Needle
Combined technique in 2 sessions
• Session 1 : BTxA
• Session 2 (3 weeks later) : Filler
• Case 2
Glabellar area: Needle
Temple injection : Canula
Combined technique in 2 sessions – other fillers
Day 15
3 Deep bolus technique: Voluma (Allergan)
Right temple : 2 cc (0.4, 0.6, 1)
Left Temple : 1 cc (0.3, 0.3, 0.4)
Ca HA Radiesse (Merz Aesthetic)
25 G blunt cannula
Superficial Fanning technique
1.5 ml / side
Mid-face restoration
(for global upper face or « look » rejuvenation)
Mid-face restoration
Thick HA (Perlane – Q-med)
Fanning technique
1 cc per side
Mid-face restoration
BTxA
+ Sub-Q (Q-med) : 2 cc per side
Ctl : Day 15
Forehead
BTxA
• Alone : Low dosage +++, upper points
• Or (rarely): plus thin or medium HA, ID, multipuncture or retrograde…
Laxity – pre-ptosis (> 50 years old) : challenging
– Medium HA : ID…
–Ablative or non ablative resurfacing with
lasers (traditional or fractional)
Forehead :
– Traditional or fractional resurfacing
Traditional mode
Traditional mode
Fractional mode