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    Benefits abound when incorporating fillers with botulinum toxins

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    Understanding the dynamics of the aging face and knowing in which order to use fillers and botulinum toxin for combination facial rejuvenation therapy are key to maximizing aesthetic outcomes, according to a German physician.

    "Cosmetic physicians need to understand the dynamics of the aging face, the vectors pulling on the face as the skin ages, and how to effectively address these in order to optimize results that are longer-lasting," says Sabine Zenker, M.D., a dermatologist in private practice in Munich.

    Rejuvenating the aging face is a constant work in progress, Dr. Zenker says. Aging is in part due to loss of collagen and elasticity over time, as well the effects of gravity. The human face does not age uniformly, however, and there are both fixed and mobile areas that can be identified, she says.

    According to Dr. Zenker, fixed areas include the mid- and lateral face, where ligamental substructures remain static and do not slide downwards as the skin ages. The skin and fat compartments between these fixed points, however, will be affected by the years of gravitational pull, and this mechanical pull (coupled with tissue loss and bone resorption) will result in the typical facies of the aging face over time. It is here where fillers can be strategically placed to rejuvenate and lift the patient's aging skin, she says.

    BETTER TOGETHER "The glabella region represents one of the most common areas for cosmetic concern in my patients," says Stein Tveten, M.D., a facial plastic surgeon, Bad Honnef and Kempten, Germany. "However, in my experience, this area has the highest success rate in terms of patient satisfaction, especially when combining filler treatments with botulinum toxin. These are commonly performed in the same treatment session, but the trick is knowing which product to use where and when."

    The aging lines typically seen in the glabella, forehead and nasolabial fold regions can go very deep, and here, Dr. Tveten says he always uses fillers before botulinum toxin treatments. Though many botulinum toxin manufacturers suggest the use of toxins before fillers, Dr. Tveten says "fillers first" is the logical path to take.

    "It makes much more sense to first use the fillers when addressing facial lines and facial rejuvenation on a whole," Dr. Tveten says. "Though you can achieve good aesthetic outcomes when using botulinum toxin before the filler, you will never have the same opportunity to fill the lines optimally. In my experience, it is always better to perform a proper filling of the lines first using fillers and then use the toxin."

    After injecting filler into the "valley," or the deeper lines in the face, Dr. Tveten then injects botulinum toxin into the muscle where its thickness is greatest. He does this to smooth out the remaining wrinkles in the surrounding area, where appropriate, he says.

    "I often use this combination treatment approach in different areas of the face, including the glabella, forehead, lips and even periorbital lines, depending on the cosmetic work that needs to be done," he says. "It is very important to keep treatments simple, and when following this treatment philosophy and approach, I can optimize the rejuvenation potential of botulinum toxin and filler."

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