Global Aesthetics Consensus: Hyaluronic Acid Fillers and Botulinum Toxin Type A-Recommendations for Combined Treatment and Optimizing Outcomes in Diverse Patient Populations

Abstract

Background: Combination of fillers and botulinum toxin for aesthetic applications is increasingly popular. Patient demographics continue to diversify, and include an expanding population receiving maintenance treatments over decades.

Methods: A multinational panel of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated guidelines with a worldwide perspective for hyaluronic acid fillers and botulinum toxin. This publication considers strategies for combined treatments, and how patient diversity influences treatment planning and outcomes.

Results: Global Aesthetics Consensus Group recommendations reflect increased use of combined treatments in the lower and upper face, and some midface regions. A fully patient-tailored approach considers physiologic and chronologic age, ethnically associated facial morphotypes, and aesthetic ideals based on sex and culture. Lower toxin dosing, to modulate rather than paralyze muscles, is indicated where volume deficits influence muscular activity. Combination of toxin with fillers is appropriate for several indications addressed previously with toxin alone. New scientific data regarding hyaluronic acid fillers foster an evidence-based approach to selection of products and injection techniques. Focus on aesthetic units, rather than isolated rhytides, optimizes results from toxin and fillers. It also informs longitudinal treatment planning, and analysis of toxin nonresponders.

Conclusions: The emerging objective of injectable treatment is facial harmonization rather than rejuvenation. Combined treatment is now a standard of care. Its use will increase further as we refine the concept that aspects of aging are intimately related, and that successful treatment entails identifying and addressing the primary causes of each.

Clinical question/level of evidence: Therapeutic, V.

Fig. 1.

Age-related bony changes are mainly in the periorbital and midcheek zones, including the superomedial and inferolateral aspects of the orbit, the medial suborbital and piriform areas of the maxilla, and the prejowl area of the mandible. Arrows indicate the areas of the facial skeleton susceptible to resorption with aging. The size of the arrow correlates with the amount of resorption. (From Mendelson B, Wong CH. Changes in the facial skeleton with aging: Implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2012;36:753–760. Reprinted with permission from Springer International Publishing AG. © EFE.)

Fig. 2.

Efficacy of nasolabial fold correction with crosslinked hyaluronic acid filler in patients with Fitzpatrick skin phototype VI. Nasolabial folds are shown before injection and 2 and 24 weeks after injection with Hylacross hyaluronic acid filler. (Above) Before and after injection of Juvéderm Ultra. (Below) Before and after injection of Juvéderm Ultra Plus. (From Grimes PE, Thomas JA, Murphy DK. Safety and effectiveness of hyaluronic acid fillers in skin of color. J Cosmet Dermatol. 2009;8:162–168. Reprinted with permission from John Wiley & Sons.)

Video.

Supplemental Digital Content 1 demonstrates transarterial degradation of Vycross and Hylacross fillers, by injection of exogenous hyaluronidase into the surrounding soft tissues, in a fresh, frozen cadaver model in real time. Courtesy of Dr. Mark Magnusson, Dr. Tim Papadopoulos, and the Australasian Society of Aesthetic Plastic Surgery. This content was developed for the Society’s Anatomical and Live Injecting Workshop, in association with the Australasian Society of Aesthetic Plastic Surgery Annual Non-Surgical Symposium. © 2014 Australasian Society of Aesthetic Plastic Surgery, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at, http://links.lww.com/PRS/B683.

Fig. 3.

Consensus panel’s practice patterns in the (left) upper face, (center) midface, and (right) lower face, based on premeeting surveys. Percentage use of botulinum toxin alone, filler alone, and botulinum toxin plus filler are shown for each facial zone. Because percentages are rounded to the nearest whole number, they may not add up to 100 percent. PO, perioral; OC, oral commissure; ML, marionette lines.