While mono-therapy is effective for both facial and non-facial rejuvenation procedures, combination therapy with non-invasive modalities achieves the best results.
That’s according to Vic A. Narurkar, M.D., and was the focus of his presentation, “Advanced Injection Techniques: Optimizing Outcomes,” at the inaugural Aesthetic + Medical Dermatology Symposia, held in Coeur d’Alene, Idaho, in May.
Dr. Narurkar, director and founder of the Bay Area Laser Institute and chair of dermatology at California Pacific Medical Center, San Francisco, not only discussed combining neuromodulators and fillers for facial contouring, but also energy-based devices and skin care.
“The advanced injection techniques involve how we use fillers and neuromodulators, as the palette of injectables now available has increased and will continue to,” he says. “Botulinum toxin is used panfacially and on the neck to not only relax hyperdynamic rhytids but also for facial shaping, such as with the use in the masseter, as well as for more subtle changes in the depressor anguli oris and perioral area. There is now clinical evidence of increased pliability and elasticity of the skin with Botox.”
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His Injectable Approach
“The Food and Drug Administration’s approval of Voluma really changed how we use volumizing fillers, starting laterally deep along the periosteum to give the initial lift and then to restore subtle changes in the anteromedial cheek and submalar region,” he says.
Dr. Narurkar says he treats marionette lines with a variety of hyaluronic acid (HA) fillers, such as Juvéderm and Restylane, or calcium hydoroxyapatite fillers such as Radiesse. He treats the jawline with Voluma or Radiesse off-label, and then fine lines with the newly approved filler Restylane Silk.
“We have also shifted from overfilling lips and rather soft augmentation, with softer fillers such as Restylane Silk and the use of Juvéderm Ultra for a more robust body of the lip,” he says, adding that fillers are best administered in stages, as opposed to all at once, to provide a more natural, gradual improvement.
“We recently completed a Phase 4 FDA trial using a variety of HA fillers for facial contouring and Botox cosmetic for frown lines and crow’s feet, which shows the evidence of utilizing these in combination,” Dr. Narurkar says.
His Skincare, Energy Approach
The effectiveness of injectables aside, “we still need to address photodamage, telangiectasias, dyschromias — essentially the facial and neck canvas,” says Dr. Narurkar, who suggests starting with a good skin-care regimen — “My favorite includes anti-oxidants, growth factors, retinols and sunscreen” — to prime the skin and enhance peel and laser therapy.
“The facial canvas is then treated with the appropriate energy-based device — vascular and pigmented-lesion lasers or intense pulsed light lasers for milder photodamage, and non-ablative and ablative fractional lasers for moderate to severe photodamage,” he says. “Facial laxity is then addressed with monopolar radio frequency or focused ultrasound devices.”
Dr. Narurkar stresses the importance of timing in these combination treatments.
“We do not recommend using energy-based devices that create a lot of edema on the same day of treatment with injectables, as there can be diffusion of botulinum toxin as well as infection creating biofilm for fillers,” he says. “It is best to stage energy-based devices and injectables on different days.”
As for what’s new in injectables and what’s on the horizon, Dr. Narurkar said he’s excited about the newly FDA-approved Kybella (deoxycholic acid, Kythera Biopharmaceuticals), an injectable for treating submental fat.
“I am excited to use this in conjunction with skin-tightening devices such as Thermage, treating the submental fat first, waiting, addressing laxity with Thermage and finally relaxing the platysmal bands with Botox — a perfect example of combination therapy,” he says. “In the pipeline are more dermal fillers, a topical botulinum toxin for needle-phobic patients and better cosmeceuticals to be used in conjunction with fractional lasers.”