A Novel, Multistep, Combination Facial Rejuvenation Procedure for Treatment of the Whole Face With IncobotulinumtoxinA, and Two Dermal Fillers- Calcium Hydroxylapatite and a Monophasic, Polydensified Hyaluronic Acid

September 2013 | Volume 12 | Issue 9 | Original Article | 978 | Copyright © September 2013

Tatjana Pavicic MD,a Julius W. Few MD,b and Jürgen Huber-Vorländer MDc

aKlinik und Poliklinik für Dermatologie und Allergologie, Munich, Germany
bThe Few Institute LLC, Chicago, IL
cFort Malakoff Klinik, Mainz, Germany

Facial aging is a three-dimensional process, and facial rejuvenation procedures intended to reverse the effects of aging need to address this by combining products that relax hyperkinetic musculature, volumize/fill, and recontour/lift the whole face. In line with the desire of patients to achieve an overall youthful facial appearance, we report for the first time three cases where patients have been successfully treated across the whole face with a novel, three-step approach, layering incobotulinumtoxinA and two dermal fillers (calcium hydroxylapatite and a monophasic hyaluronic acid filler with CPM Technology) injected at three separate treatment visits. The results suggest that this layering approach based on an understanding of the underlying causes of facial aging, where different products are used in combination to treat the entire face, can enable patients to achieve the desired outcome of a return to the characteristics of a more youthful face.

J Drugs Dermatol. 2013;12(9):978-984.


There is an increasing demand for non-invasive cosmetic procedures that reverse the signs of facial aging as people want to look younger and more beautiful for longer. Visual signs of facial aging include forehead wrinkles, brow ptosis, glabellar frown lines, lateral periorbital wrinkles, loss of cheek and lip fullness, nasolabial folds, the appearance of jowls, and a sagging neck line.1, 2 These are caused by age-related changes such as loss of collagen, soft tissues and skin elasticity, bone demineralization, redistribution of fat, and hyperkinetic facial muscles.1, 3
An improved understanding of the aging process and the underlying causes has led to better methods to treat these conditions.4, 5 For example, subcutaneous fat in the face is compartmentalized, and facial aging is influenced by how these compartments change over time.6 Some facial areas are characterized by fat atrophy, others by fat accumulation due to fat pad sagging.1, 7 Accordingly, some areas need to be filled while others need lifting. This suggests that the face may not age as a single confluent mass; abrupt contour changes and shearing between adjacent compartments indicate that facial aging is a three-dimensional (3-D) process.6, 8 Therefore, to return to the characteristics of a youthful face without wrinkles and folds but with large eyes, well-defined cheeks and neck line, and a small, well-defined chin,2, 9 a 3-D approach to facial rejuvenation, involving muscle relaxation, volumizing/filling, and recontouring/lifting of the whole face, is expected to prove most effective.
Facial rejuvenation methods are becoming more sophisticated, with the increasingly refined use of dermal fillers and botulinum toxins alone and in combination.10 As there are different underlying causes of wrinkles such as volume loss or hyperkinetic muscle activity, layering of different products is needed to address all contributing factors. The rationale behind this is similar to that of building a house. Inhibition of muscle contraction first provides a stable basis (the foundation) for the second stage using a highly viscous filler to improve structure (brickwork). Finally, the finishing touches are applied with a low-viscosity filler (the render). This approach also helps to satisfy the patient’s expectation that aesthetic treatment should not only improve wrinkles but also enhance their whole facial appearance. Indeed, a recent survey of nearly 3,000 women across Europe revealed their desire for a gentle, whole-face, holistic approach to managing facial aging.11