Tiêm Botulinum Toxin Trong Trẻ Hóa Khuôn Mặt (Ấn Bản Thứ 2)

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BOTULINUM TOXIN IN FACIAL REJUVENATION
Many fillers are currently available on the market. Fat transplantation (the Sydney Coleman
technique) offers a permanent solution, but is a semi-surgical procedure requiring time off work,
and often more than one treatment session. At least 30% of the fat is absorbed, hence the need
for a ‘top up’, but new microcentrifuged solutions of autologous fat (nanofat) are ideal for many
oculo facial procedures, such as safe volume restoration at the superior and inferior orbital rims.
A further benefit of autologous centrifuged fat is the accompanying platelet rich serum and its
nutrients (the core part of a popular skin enhancing ‘vampire facial’).
In the past, routine cosmetic blepharoplasties included removal of all the orbital fat pads. The
resulting gaunt look has long disappeared from fashion and volume is recognised as an essential
part of youthful healthy skin. The author may sculpt fat in the lower lids, for example, but fre­
quently transplants fat into the lacrimal fossae to restore rather than remove volume and mini­
mise the dark circles under the eyes (Fig. 11.4A and B).
Hyaluronic acid is available in several ranges. The author continues to favour Perlane, Restylane
and Restylane vital skin boosters by QMed. Skin boosters are popular for rejuvenation of face, neck,
décolletage and hands, increasing hydration and elasticity for up to six months. Juvederm products
appear to have a similar effect and the Belotero range of finer particled hyaluronic acid (Merz) is
equally effective. Perlane, Restylane and Restylane fine line last for 9 months, but the author has
evidence of Restylane fine line remaining in tear troughs for more than 24 months (Fig. 11.5).
The author’s personal choice of product, based on experience, is currently as follows:
n Perlane appears to be the most viscous, most enduring and the best for deep rhytids.
n Restylane is of moderate viscosity, long lasting, good for deeper and superficial injections
and the most versatile (d eep, superficial and lips).
Image of Fig. 11.4
Image of Fig. 11.4
Fig. 11.4  Before (A) and after (B) autologous fat transplant to the tear trough.Image of Fig. 11.3
Fig. 11.3  Structural framework of Restylane and Perlane molecules. Initial volume is maintained throughout
the degradation phase.

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n Restylane fine line and Belotero Soft come with a 32-gauge needle and smoothly fill fine
superficial rhytids, for example crow’s feet.
n Restylane skin boosters and Belotero Soft are ideal for nourishing skin.
n Sculptra (polylactic acid) is the synthetic filler of choice (if not using autologous fat) as
a foundation in emaciated faces or faces with excessive lipoatrophy, for example after
chemotherapy.
Indications
The choice of product depends on the area to be filled and on the volume required. Patients may
also be restricted financially in their choice of treatment, which can be adapted to give the best
value for their money. For example, Perlane may be best for deeper rhytids, but if a patient has
both superficial and deep rhytids (e.g. a glabellar crease and nasolabial folds) and can only afford
one syringe, 0.7 mL of Restylane may be used to treat both. Patients can be advised to plan for a
full Perlane syringe in the future, and they should be made aware that the deepest rhytids com­
press the gel most quickly and require a top-up sooner. If there are no budgetary constraints, open
as many syringes as are necessary to achieve the desired result (Fig. 11.6A and B). Failure to do
so always leads to a dissatisfied patient.
It is important to analyse the facial features and then tell patients exactly what volume is re­
quired for an optimal result, for example 23 Perlane 0.7 for deep nasolabial folds; 13 Restylane
classic 0.75 mL for lips; 13 Restylane fine line for cheeks. They will then appreciate that subop­
timal results will be achieved with less and will not telephone the next day to say ‘the lines are
still there’ if they buy only one syringe.
Image of Fig. 11.6
Image of Fig. 11.6
Fig. 11.6  Before (A) and after (B) filler to the nasolabial folds and perioral lines.
Fig. 11.5  Restylane filler remains in tear trough after 24 months.

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Patient Preparation
Injections of hyaluronic acid without local anaesthesia are sore—the pain being a sensation of
pressure rather than the possible ‘sting’ of botulinum toxin. Injections are usually superficial and
so can be effectively anaesthetised topically with proprietary lidocaine/prilocaine cream (EMLA)
or lidocaine 4% cream (LMX). Deeper injections, for example to the lips, can be very painful. It
is recommended to choose either a filler containing local anaesthetic or to infiltrate local anaes­
thetic submucosally first.
Patients should be warned that preparation takes at least 30 minutes. They should arrive early,
in order that the nurse can apply EMLA and cover (with Opsite or Clingfilm) the area to be
treated. They can then relax before treatment. For the lips, tetracaine gel is applied to the gums
after these have been dried with a swab. A dental syringe with a short 30-gauge needle is used to
infiltrate Citanest (or lidocaine [lignocaine]) submucosally in the fornix. This works in 10 to
20 minutes. Sterex antiseptic cream is applied after the treatment and the patient is allowed
to apply make-up.
Nasolabial Folds
Some deep nasolabial folds are associated with a short upper lip and respond well to botulinum
toxin treatment to the apex. Most deep folds, however, are best treated with volume replacement
to the superolateral support structures of the face, replacing lost ‘suspension’ of the midface and
therefore ‘lifting’ the nasolabial folds. Some patients require a surgical facelift, although it is not
uncommon for a deepening of the nasal end of the fold to persist after an effective operation.
Most patients presenting for botulinum toxin are not ready to consider major surgery at the time
of their initial consultation and are thrilled to have a short-term ‘cheat’ with Perlane. Some will
benefit from thread lifting, albeit for about 18 months before the threads dissolve.
Superficial filling can be very effective (Fig. 11.7A and B) and achieved either with Perlane
or Restylane. Deep filling may take more than one session (Fig. 11.8A and B). Perlane may be
placed in the superficial dermis of the nasolabial skin, deep to the epithelium. Deeper placement
often fails to ‘lift’ the skin and may be ‘lost’ towards the sinuses. Warn the patient that this layer
will become slightly compressed by facial movements and recommend a top-up over the same
layer after 6 weeks. This compensates for the compression of the initial layer and achieves a long-
lasting effect.
Image of Fig. 11.7
Image of Fig. 11.7
Fig. 11.7  Before (A) and after (B) treatment of fine nasolabial line with 0.4 mL Restylane.

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Marionette Lines
These can be improved greatly by lower facelift surgery. Some patients tend to slide their lower
jaw back, emphasising the downturn of the corners of the mouth. Discuss the need for a dental
opinion with such patients and refer them back to their own dentist if appropriate. The treatment
of marionette lines with a filler is rewarding. As with the resolution of a frown, the elimination
of these descending lines can alter a patient’s countenance and create the illusion of lifting the
whole face.
USER TIP
Do not overfill an area of skin with hyaluronic acid as this can cause local necrosis and
bruising. It is better to bring the patient back after 6 weeks for further treatment to the same
area. This allows for some compression of the initial gel and achieves a greater ‘lift’.
Glabellar Crease
The treatment of a glabellar crease with botulinum toxin is discussed in detail in Chapter 9.
Hyaluronic acid offers an instant ‘fix’ if a patient is waiting for procerus and corrugator muscle bulk
to diminish. It is also ideal for those who are unsuited to full-blown botulinum treatment because
of brow ptosis. The author favours Restylane for this area but has often placed some Perlane in the
deeper dermis, or Belotero Soft or Restylane vital (skin boosters) more superficially. Usually less
than 0.2 mL of hyaluronic acid is needed to treat this area. A small syringe (e.g. 0.4 mL) can be
opened and sometimes the remains can usefully be placed periorally or nasolabially.
The Upper Lip
Patients complain of upper lip rhytids (especially smokers), or of a thinning of the upper lip, or both.
The nose-lip distance elongates with age and some plastic surgeons shorten this surgically with an
elliptical excision of skin from under the nose. Most patients are unaware of this elongation.
Overfilling of this fashionable area is not recommended as it increases the length of the upper
lip, an ageing as opposed to a rejuvenating result. Deep CO2 resurfacing of the upper lid not only
erases rhytids, but also tightens and shortens the lip and is the author’s treatment of first choice.
Look carefully before the anaesthetic is applied or injected. Ask the patient to pout and ob­
serve the gaps between the fibres of the orbicularis oris. Examine the distance from lip to nose.
Image of Fig. 11.8
Image of Fig. 11.8
Fig. 11.8  Before (A) and after (B) treatment of deep nasolabial folds with Perlane 0.7 mL.

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BOTULINUM TOXIN IN FACIAL REJUVENATION
Fig. 11.10  Cupid’s bow/philtrum.
Fig. 11.9  Wrinkled upper lip emphasised by pouting.
Fig. 11.11  Fine line injection.
Look for rhytids at rest and deeper rhytids in motion. Examine the symmetry of the lips and
discuss this with the patient.
Care must be taken with ‘wrinkles in motion only’: inject Restylane into the gap that is seen
with pouting (Fig. 11.9). Inject the superficial dermis and take care not to leave a bleb above the
surface of the skin at rest. If a ‘lump’ forms, massage the area between two fingers and disperse
the gel. Instruct the patient to do the same over the following few days.
‘Wrinkles at rest’ are always best treated with a combination of laser resurfacing and Re­
stylane. Many patients will go ahead with fillers while waiting for the right time for resurfacing.
Restoring the convexity of the upper lip with injections between the orbicularis oris fibres
shortens the lip nicely and improves its appearance. The philtrum can be reconstructed, again
rejuvenating the lip instantly (Fig. 11.10), and often place a small amount at the Cupid’s bow too.
Deep ‘rhytids at rest’ can be kept at bay with Restylane injected very superficially into the
epithelium (Fig. 11.11).
Lip enhancement depends largely on taste. The author prefers not to enhance an upper lip
that will protrude noticeably above the lower one, even if the upper lip is much thinner. It is
not always possible to guarantee vertical volume, and in particular, with certain types of dentition,
the gel can expand the lip anteriorly (Fig. 11.12A and B). Restylane is excellent for providing
symmetry to lips. It is also useful for patients with cleft lip deformities, and when layered with
Perlane, a nice anterior displacement of the upper lip can be achieved.

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Image of Fig. 11.12
Image of Fig. 11.12
Fig. 11.12  Before (A) and after (B) Restylane to the vermillion border of the upper lip.
Image of Fig. 11.13
Image of Fig. 11.13
Fig. 11.13  Before (A) and after (B) Perlane to facial scar, repeated treatments over 12 months.
Scars
Hyaluronic acid is useful for the volume expansion of scars (Fig. 11.13A and B). Treatment with
botulinum toxin is dealt with in detail in Chapter 10.
Crow’s Feet
Botulinum toxin will erase some crow’s feet and laser resurfacing will erase the rest (Fig. 11.14A and B).
It is important, however, to identify ‘hooding’ before treatment. Patients with a fold of skin at the
outer corner of their eyes will be disappointed with botulinum toxin if it is not demonstrated to them
that their fold is due not to contraction of the orbicularis oculi, but to sagging of their lateral brows
and temporal areas. In this case, the correct ‘hidden-scar’ treatment is by an endoscopic brow lift
(Fig. 9.16A and B). Nanofat autologous transplant to the forehead reverses apparent volume loss
with subtle restoration of brow positioning. Temporary correction of hooding may be possible by
upper blepharoplasty. Some patients do not mind a lateral extension of their upper blepharoplasty
incision, simulating a ‘wrinkle’, with extension of the scar along the crease, or sometimes with inter­
nal brow fixation (Fig. 11.15A and B). Patients are always advised that their hooding is obscuring
their lateral vision and that surgery will rejuvenate, but also restore their lateral visual field.
Patients with hooding can sometimes cheat with Restylane fine line or Belotero Soft injected
to the deep crease. The 32-gauge needle is inserted just below the epithelium, and gel is injected

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BOTULINUM TOXIN IN FACIAL REJUVENATION
Image of Fig. 11.15
Image of Fig. 11.15
Fig. 11.15  (A) Pre- and (B) 1 week post-upper lid blepharoplasty with repositioning of the anterior levator
muscle and extension of upper lid scar laterally to compensate for hooding.
Image of Fig. 11.14
Image of Fig. 11.14
Fig. 11.14  Before (A) and after (B) eye zone CO2 laser blepharoplasty (no surgery).
along the rhytid. Another method is to place a series of gel micro-blebs. The result is an instant
improvement, although some patients experience temporary oedema at the injection site. Fine
line gel is also good for infraorbital rhytids, although laser resurfacing may be preferred rather
than risk irregularities in the fine periocular skin.
The Chin
The use of botulinum toxin is an effective way of reducing ‘pebbly chin’ (Fig. 10.8). Perlane
or Restylane may be recommended for irregularities in this area, particularly over dimples.

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Cheeks
Botulinum toxin is not indicated for sagging cheeks: the treatment of choice is a mid-facelift or
full facelift. Laser resurfacing will also tighten the cheeks significantly, but lost volume must be
replenished with volume. An emaciated face, with or without lipoatrophy, will often benefit from
a foundation of Sculptra. Autologous fat is a very good permanent foundation if the patient
is suitable, with hyaluronic acid to the more superficial areas. The author has had considerable
success with Restylane fine line to the fine rhytids of the cheeks, particularly those lying lateral
to the orbicularis oris.
The tear trough may be carefully filled with Belotero soft, aiming to layer it deep to the orbi­
cularis muscle to minimise the Tyndall effect. Fat injections work very well here, although they
are less predictable (Fig. 11.5).
USER TIP
Avoid placing hyaluronic acid in the epithelium of a nasolabial rhytid, tear trough or the
cheeks if the skin is fine and translucent. Translucent skin will show a blue grey mark
of gel at the injection site (Tyndall effect).
Laser Resurfacing
Botulinum toxin is excellent for ‘crow’s feet in motion’ and may diminish some ‘rhytids at rest’
with time. However, the complete removal of crow’s feet is best achieved with laser resurfacing.
Laser resurfacing is the treatment of choice for perioral rhytids, with or without fillers.
All of the results shown in this book were achieved with the Feathertouch (Sharplan) and
Active FX (Lumenis) lasers.
Patient selection is discussed in detail in Chapter 5, but make sure that the patient is informed
about static wrinkles and laser resurfacing before giving botulinum toxin. Failure to do so will lead
to unrealistic expectations and disappointment.
USER TIP
Botulinum toxin is essential for the long-term results of the laser resurfacing of crow’s feet.
Counsel patients carefully about the natural return of rhytids after the laser resurfacing of crow’s
feet without paralysis of the orbicularis oculi (Fig. 11.16A–C). Suggest botulinum toxin injections
are given a week before, and 3 months after treatment, as part of the resurfacing procedure.
Most patients who require botulinum toxin for crow’s feet are happy to have the injections once
they understand that their ‘wrinkles at rest’ may diminish and that the ‘wrinkles in motion’ will
improve greatly. Most do not want the downtime of deep laser resurfacing, but can easily choose
5 days down time for superficial eye zone lines. It is important at the initial consultation to offer
resurfacing as a long-term solution. If your practice is not involved in resurfacing, it is important
to provide the following information—and a referral, if requested, to a laser practice.
Basic facts about laser resurfacing for wrinkles
n A laser vaporises the superficial layer of the skin, carrying the wrinkled layer with it.
n Treatment is under local anaesthetic for the eye zone and full conscious sedation for the face
and neck. Eye zone CO2 takes 15 minutes for crow’s feet.
n The skin will heal in 5 to 10 days, depending on depth treated.

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n The skin will have ointment on it.
n Following treatment, the skin will be red, brown or even paler than the before.
n Freckles will be obliterated, providing a contrast with unfreckled skin. Intense pulsed light
(IPL) may help blend.
n Treatment itself is painless, but simple analgesics may be needed over the first 24 hours.
n The patient must rest in an elevated position and apply cold packs for the first 24 hours to
minimise oedema.
n The patient must be available for post-treatment examinations by the practice nurse—daily
if necessary (rare)—for 5 to 10 days.
n The patient should take 1 week off work and socialising, although some can return to work
with camouflage make-up after 5 days.
n The initial results will be greatly improved after 3 months when new collagen has been
formed in the skin.
n Botulinum toxin is essential to keep the skin flat until this happens.
n The patient must avoid sunburning the new skin while it is healing.
n The patient must appreciate that sun exposure at 6 weeks will darken the treated area
(postinflammatory hyperpigmentation). The use of a sun block is very important even
though the pigmentation is reversible.
n Complete eradication of rhytids is not uncommon, but the patient should be warned to
expect 20% to 50% improvement of the deeper ones.
Image of Fig. 11.16
Image of Fig. 11.16
Image of Fig. 11.16
Fig. 11.16  (A) Before CO2 skin resurfacing; (B) 6 weeks after CO2 resurfacing: note return of crow’s
feet, before Botox; and (C) 6 weeks after Botox and 12 weeks after initial resurfacing: note wrinkles have
disappeared.

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n The older patient will still benefit from fat and/or hyaluronic acid injections for volume
replacement as the ‘new collagen’ is often not enough.
n Non-lasered skin can be blended with the treated area by using IPL, Retin A, alphahy­
droxyacids, Dermaroller, chemical peels and sun block.
Upper Lid Blepharoplasty
Ageing patients who have an excess of skin over their upper lids (dermatochalasis) will often
elevate their brows subconsciously using the frontalis muscle. This lifts the skin off their lids,
restores the deep crease and takes ‘the weight off their lids’. This excessive brow elevation will
cause deep horizontal frown lines to develop. Such patients often ask for these wrinkles to be
removed with botulinum toxin (as discussed in detail in Chapter 9). However, treatment of the
frontalis with botulinum toxin will drop their brows to their lower natural resting position and
accentuate the dermatochalasis. It is important to explain to these patients that they will look
tired and older if their frown is paralysed. They must choose between frown lines and an upper
blepharoplasty. Some patients may also need brow repositioning if their brows have sagged.
Some patients complain that using botulinum toxin for their forehead made their ‘lids swell’. This
is because a loss of brow elevation may also allow normal orbital fat to protrude. Figs 11.17A and B,
11.18A and B illustrate pre- and post-laser blepharoplasty patients. Making transcutaneous incisions
and vaporising excess fat using a CO2 laser reduces haemorrhage, oedema and recovery time.
If your practice does not perform oculoplastic surgery, then the following information may be
given to patients, along with an appropriate referral.
Basic facts about upper lid blepharoplasty.
n Blepharoplasty means the excision of skin and/or fat from the upper eyelids.
n An incision will be made in the lid crease.
n The surgery takes place under local anaesthesia and lasts for between 30 and 60 minutes.
n Stitches will be removed between 4 and 7 days after the operation.
n The scar will usually be hidden in the crease.
n The patient must rest in an elevated position for the first 24 hours.
n Rest is important for the first 4 days to prevent late complications such as haemorrhage.
Image of Fig. 11.17
Image of Fig. 11.17
Fig. 11.17  Before (A) and after (B) endoscopic brow lift with transconjunctival fat sculpture and eye zone
CO2 resurfacing.

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n One week off work usually suffices.
n The most common complication is bruising (reduced with laser incision).
n Rare complications include infection, prolonged swelling and haematoma formation.
n Results last until ageing causes further sagging of the skin, that is forever in some patients
and at least 10 years in most.
Lower Lid Blepharoplasty
Ageing causes the skin under the eyes to sag. Laxity of the orbital septum behind the skin and
muscle also allows the lower orbital fat pads to protrude, emphasising the ‘bags’, which are often
held in the orbit by the tone of the orbicularis oculi muscle. It is very important not to inject
botulinum toxin into the lower lid orbicularis muscle if it seems to be restraining fat in this way.
Such patients must be told that they can only have their lateral rhytids (crow’s feet) treated if they
have lower lid blepharoplasties.
Traditional lower lid blepharoplasty is transcutaneous, through an incision underneath the
eyelashes (subciliary). A skin/muscle flap is raised, the fat is excised, and the flap is trimmed and
sutured (Fig. 11.19). Limitations to this procedure are a visible scar and increased problems with
Fig. 11.19  Six days after infraciliary transcutaneous blepharoplasty (note blue continuous suture ready for
removal), upper-medial fat pad vaporisation and eye zone CO2 laser resurfacing (note ointment on post-
lasered skin).
Image of Fig. 11.18
Image of Fig. 11.18
Fig. 11.18  Before (A) and after (B) upper blepharoplasty.

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haemorrhage and bruising. It must be augmented with lateral canthal tendon reinforcement in
patients with a strong negative vector, as with Graves ophthalmopathy, to avoid unattractive
‘rounding’ of the outer corner of the eye (Fig. 11.20A and B). Patients often combine transcuta­
neous surgery, if they have muscle sagging and require a trim, with CO2 laser skin rejuvenation
and transconjunctival fat vaporisation. (The fat may also be sculpted through the transcutaneous
incision, but the author often favours retention of an intact orbital septum, particularly for
patients with a strong negative vector who benefit from the extra support for their orbital fat.)
This procedure may be restricted to those who are not suitable for laser resurfacing, for ex­
ample sun bathers with sun-damaged skin on their faces and no desire to blend old skin with new;
patients with excessive orbicularis folds who require muscle shortening; and the many men who
would find it embarrassing to wear make-up to hide the erythema that follows CO2 laser resur­
facing, which the author favours instead of excising excess skin (Fig. 11.21A and B).
USER TIP
Do not inject botulinum toxin into the lower eyelid if there is excess lower lid skin and fat. This
causes the prolapse of fat, with protrusion of ‘bags’, until the orbicularis muscle tone returns.
The author prefers to perform transconjunctival fat removal. An incision is made through the con­
junctiva in the lower lid fornix. Fat is then vaporised. This may be done without skin resurfacing
(Fig. 11.22A and B), but most patients want their skin tightened too, and two passes with the CO2
laser can achieve this. The type of skin can determine the choice of treatment. For example,
Image of Fig. 11.20
Image of Fig. 11.20
Fig. 11.20  Thyroid eye disease with protruding fat pad in patient with minimal infraorbital rim support and
upper lid ptosis. Before (A) and after (B) upper lid ptosis correction and transconjunctival fat removal only to
lower lids.
Image of Fig. 11.21
Image of Fig. 11.21
Fig. 11.21  Before (A) and after (B) traditional transcutaneous blepharoplasty with subciliary incision.

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Image of Fig. 11.23
Image of Fig. 11.23
Fig. 11.23  Before (A) and 3 weeks after (B) deep CO2 laser blepharoplasty with lower lid transconjunctival
blepharoplasty and eye zone CO2 laser resurfacing and botulinum toxin. Note pink discolouration that usually
fades quickly.
Image of Fig. 11.22
Image of Fig. 11.22
Fig. 11.22  Before (A) and after (B) transconjunctival fat removal with no CO2 resurfacing.
Fig. 11.23B reveals persistent erythema, 3 weeks after CO2 tightening of type 1 skin (extremely
fair). This is easily camouflaged with make-up, but deep CO2 laser tightening is contraindicated for
someone who won’t wear concealer. Such patients are advised to choose transcutaneous surgery
instead of CO2 laser. On the other hand, the patient in Fig. 11.24 had a more shallow CO2
treatment (70 microns depth) with only 6 days of postoperative erythema and no long-term
sequelae, as seen 15 years later in Fig. 11.24C. Fig. 11.25A and B demonstrates four-lid CO2 eye
zone blepharoplasty with resurfacing, pre– and post–6 weeks with no make-up/concealer on skin.
Basic facts about lower lid blepharoplasty.
n This is the removal of lower lid fat bags with tightening of the skin.
n Skin can be tightened by excision with a cut under the eyelashes, or without a scar with a laser.
n If the skin is cut, the sutures will be removed between 4 and 6 days. There will be a fine scar,
which can easily be concealed with an eyeliner pencil. Most people should take 1 week off work.
n If the skin is lasered, there will be no scar, but the resurfaced skin will take 6 to 10 days to heal.
Postoperatively, the resurfaced skin may be red, brown and then pale (as above). Make-up can be
applied as camouflage as soon as the skin has healed. Most people should take 2 weeks off work.
n The eye may be bloodshot after the surgery—due to bruising.
n The patient may require lateral canthal tendon plications (tightening of the outer corner
of the lids through fine incisions in the upper and lower corners) to prevent ‘rounding’
of the eye contour.

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Combination Treatments
Some patients need botulinum toxin in combination with a filler, blepharoplasty and laser
resurfacing to achieve the best result.
USER TIP
Do not give botulinum toxin injections at the same time as surgery. The effect may be altered
by a local or general anaesthetic and in the author’s experience has been unpredictable. In
contrast, fillers, especially autologous fat, can be injected during surgery with good effect.
Image of Fig. 11.25
Image of Fig. 11.25
Fig. 11.25  Before (A) and 6 weeks after (B) four-lid blepharoplasty, CO2 resurfacing and botulinum toxin in
skin type 11, no concealer.
Image of Fig. 11.24
Image of Fig. 11.24
Image of Fig. 11.24
Fig. 11.24  Before (A), 1 week after (B), and 13 years after (C) upper and lower CO2 blepharoplasties with
superficial CO2 skin resurfacing and botulinum toxin.

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Lips
Fig. 11.26A shows a patient who underwent laser resurfacing of her upper lip. Fig. 11.26B is the
same patient postoperatively, with residual clefts between her orbicularis oris rhytids. Botulinum
toxin had little effect on reducing the depth of these. Fig. 11.26C demonstrates the lip immedi­
ately after an injection of Restylane.
Frown
Botulinum toxin will reduce the size of hypertrophic frown muscles—the ‘mountains’ on either
side of the valley of the frown. The skin will, however, remain wrinkled at the point of chronic
compression. Fig. 11.27A and B shows a patient who had Azzalure to her glabellar muscles, laser
resurfacing of the sun-damaged rhytid and Restylane to the base of the rhytid.
Fig. 11.28A and B shows a patient before, and 3 months after, laser resurfacing and Botox to
her glabella.
Face
Fig. 11.29A and B shows a patient before and after full-face CO2 resurfacing including the upper
lids, with Botox to crow’s feet and frown and Restylane to upper lip and perioral rhytids.
Image of Fig. 11.26
Image of Fig. 11.26
Image of Fig. 11.26
Fig. 11.26  Before (A) after (B) CO2 laser resurfacing to upper lip and (C) after Restylane to vertical rhytids.

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Image of Fig. 11.29
Image of Fig. 11.29
Fig. 11.29  Before (A) and after (B) full-face CO2 resurfacing, Botox and filler.
Image of Fig. 11.28
Image of Fig. 11.28
Fig. 11.28  Before (A) and after (B) CO2 resurfacing and Botox to glabella.
Image of Fig. 11.27
Image of Fig. 11.27
Fig. 11.27  Before (A) and after (B) CO2 resurfacing, Azzalure and Restylane to glabella.

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Rejuvenation of the Skin
It is important when considering the management of crow’s feet or frown lines to address the
underlying causes. Inform patients that smokers have damaged 50% of the collagen in their skin
at the age of 50 compared to non-smokers. Demonstrate their sun damage by comparing the skin
on the inside of the upper arm with that on their face. Tell them that laser resurfacing might
achieve the translucency of skin undamaged by the sun, but that this must then be blended in
with the skin on their neck and the rest of their face.
An aesthetic nurse spends much time at the initial consultation explaining the effects of
UVA and UVB on the skin, discussing different types of sun block and giving suitable samples.
Interested patients can be provided with an anti-ageing regime that includes vitamins C and E
and alpha-hydroxy acids. Paraben-free tretinoin 0.05% can be prescribed when appropriate. Such
a regime, in combination with botulinum toxin alone, can provide dramatic results.
Patients who have booked laser resurfacing of their crow’s feet with botulinum toxin are
strongly recommended to have a course of IPL to the rest of their face.
Nonablative Collagen Stimulation
Patients are informed about nonablative collagen stimulation, for example, with Dermaroller,
with IPL and with Viora radiofrequency to combat future effects of the ageing process. The
author has developed pain-free solutions for all these treatments, allowing the patients to achieve
superior results with little downtime and no pain.

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