INTRODUCTION
Perioral aging occurs secondary to both extrinsic and intrinsic factors including photodamage, cigarette smoking, loss of subcutaneous fat and elasticity, changes in bony structures of the mouth, and the repetitive action of the perioral muscles. These processes result in the appearance of rhytids, dyschromia, and uneven skin texture. An optimal approach to rejuvenation should ideally target these different factors. Laser resurfacing, botulinum toxin, and fillers are all popular noninvasive cosmetic procedures used in facial rejuvenation. Though previous studies and case reports have demonstrated improved outcomes when combining botulinum toxin with resurfacing techniques1-4 or with fillers,5 there have not been published reports of the sequential use of these three modalities. Here we present a sequential combination approach to perioral rejuvenation using botulinum toxin type A (BoNTA), hyaluronic acid (HA) gel filler, and ablative laser resurfacing.
Case Report
A 60-year-old non-smoker Caucasian female was seen in 2013 with concerns regarding wrinkling, loss of volume, and photodamage to the mid and lower face—especially the perioral area. She emphasized that she wanted gradual and very natural-appearing overall improvement. To address her concerns, a multistep combination treatment plan was developed. At baseline she underwent injection of cross-linked HA gel filler into her nasolabial folds (2.0 cc per side), marionette lines, and oral commissures (0.25 cc per side). Six months later, additional HA filler was added to her cheeks (1.0 cc total) and marionette lines (1.0 cc total). Also at six months, she had six units of BoNTA injected the orbicularis oris muscle (four units upper lip, two units lower lip). Due to constraints with downtime, she underwent full field perioral erbium: YAG resurfacing five weeks (and not the planned 2 weeks) after her peri-oral muscle column BoNTA treatment. Marked reduction in dynamic and static rhytids, reduction in perioral folds and volume loss, as well as overall improvement in texture and pigmentation was then noted 4 months after laser resurfacing compared to baseline (See Figure 1A and 1B).
DISCUSSION
With respect to lower facial rejuvenation, the ultimate goal of treatment is to decrease perioral fines lines and wrinkles, add volume, and create a more even skin tone. More recently there has been a paradigm shift with the use of combinations of noninvasive rejuvenating modalities to achieve more desirable, longer lasting results. In a published Consensus Recommendation from 2008, experts agreed that combination treatment with filler and botulinum toxin was standard for lower facial rejuvenation.6 A multicenter, randomized study of BoNTA and HA fillers alone or in combination for lower facial rejuvenation demonstrated superior, longer lasting effects with combination therapy compared to either treatment alone.5 Combination therapy likely results in superior outcomes because botulinum toxin decreases perioral muscle contraction, thus decreasing perioral movement and increasing the durability and longevity of filler.5,7
Previous studies have also shown a greater reduction in upper facial rhytids when BoNTA was used prior to ablative laser resurfacing,1,4 and others have found a prolonged decrease in dynamic rhytids when BoNTA was used following laser resurfacing.3 Pretreatment of the orbicularis oris muscle with BoNTA has also been shown to improve both the short and long term results of perioral chemabrasion.2 The mechanism by which botulinum toxin is thought to improve resurfacing outcomes is by reducing tension across the wound, allowing for reepithelialization and collagen remodeling in a relatively adynamic environment.1,8
