written by Dr MICHAEL MIROSHNIK FRACS

PLASTIC & COSMETIC SURGEON

www.drmiroshnik.com.au

There has been tremendous progress in the field of non-surgical facial rejuvenation and reshaping over the last 10 years and there is no doubt that the demand for the use of both Botulinum toxin and NASHA gel fillers continues to skyrocket. And why not? With the promise of minimal side effects, virtually no downtime, quick minimally uncomfortable procedural times and reasonable costs, it’s little wonder why a steadily growing proportion of the population are considering the procedures. 

Since the advent of collagen injections, filler treatments have been associated with filling in lines and folds throughout the aging face. Today, however their utility has been expanded to the use of volume enhancement. In this way, developmentally or age deficient regions of the face such as the cheeks, chin and nose can be enhanced with the addition of larger than the usual quantities of product that are required to simply fill out a wrinkle.

Indeed, for most traditional volumising and lifting plastic surgical procedures such as cheek & chin implants, brow lifts, midface lifts, facelifts, and blepharoplasties – there are now effective non-surgical equivalents. Although these treatments of course lack the longevity of the surgical approach, their wash-and-wear nature and minimal downtime have made them the mainstays of today’s bustling cosmetic enhancement industry.

In concert with the advances in fillers, botulinum toxin Type A (BTTA), which is now the most commonly practiced cosmetic procedure in the world, is just as important an adjunct to not only remove dynamic lines and wrinkles but to manipulate the balance between muscular elevators and depressors so that specific portions of the aging face can be elevated. This is especially true in the region around the eyes and mouth.

Now, when combining BTTA with fillers to accomplish a certain aesthetic goal- there is often a greater than additive effect on rejuvenation and reshaping and this important principle is used on a day-to-day basis in any modern aesthetic practice.

For instance, in the upper third of the face- the corrugator & depressor supercilii, orbicularis oculi, and procerus muscles are the major brow depressors, while the frontalis muscle alone is the major brow elevator (see fig). By selectively paralysing the brow depressor groups and leaving the frontalis muscle unopposed- the brow elevates. To enhance this BTTA effect even further though, non-animal stabilised hyaluronic acid (NASHA) filler can be injected directly under the brow area, particularly laterally, to create brow elevations of sometimes 3-4mm. This is quite significant considering that there has been no surgical intervention.  

Similarly, in the lower third of the face, selectively blocking the depressor anguli oris helps support a downturned corner of the mouth (oral commissure), a strong sign of aging. This effect of BBTA is increased by the addition of NASHA filler, underneath the same region.

The following case studies illustrate some common scenarios that can effectively be treated with the combined use of BTTA and NASHA-gel fillers.

Fig 1. Facial muscles around the eyes

CASE1: Facial Reshaping – Jaw & Cheeks

Mid 20s, excessive width lower facial third and lack of cheek projection gives a squarish and heavy appearance to the face, here it was caused by overly developed masseter (jaw clenching) muscles. A combination of BTTA to the masseters and cheek NASHA filler has created a more appealing oval shape to the face. In essence the BTTA has been used to decrease the lower facial volume, while the NASHA fillers have been used to increase the midfacial volume. Not only is it more pleasing to the observer but it is also more youthful as our eye is programmed to associate increased mid facial volume with youth.

CASE 2: Facial Reshaping – Cheeks & Chin

Mid 20s, lack of chin and cheek projection gives a sunken and tired look to the face. Here a combination of long-lasting NASHA fillers to both cheeks and chin have enhanced these deficient areas and hence led to a more balanced and healthier looking appearance.

CASE 3- Facial Reshaping – Nose

Mid 20s, concerned about the dorsal ‘hump’ on the profile view of the nose. Whereas this area is traditionally treated by means of a surgical rhinoplasty, a quick alternative or so called ‘non-surgical nose job’ is to treat the area with long lasting filler. Concomitant BTTA injections to the nasalis muscle take care of any nasal ‘bunny-lines’ that may also bother the patient.

CASE 4- Facial Rejuvenation

70s, a combination of NASHA-filler and BTTA can restore volume where it is needed and remove tiresome wrinkles for a fresher overall look. Here they have been used throughout the entire face.

CASE 5- Rejuvenation around the eyes

Late 30s, brow height and sunken look to the eyes has been restored with again a combination approach of NASHA-fillers & BTTA to the brow area, upper and lower lids.