CASE STUDY – INJECTABLES
PRIME Journal Vol. 8 Issue 2 – 2018
The combination of hyaluronic acid and botulinum toxin can be an effective treatment protocol to smooth and improve contractility in wrinkles. Free hyaluronic acids, at low density (200 kilodaltons), transport the botulinum toxin as well as hydrates the skin surface, making it tauter. More severely affected patients underwent a longer and differentiated treatment with hyalu-botox and a mixture of chemical stimulation using amino acid replacement therapy (AART). Patients were treated solely with hylau-botox every 2 months for a period of one year. Once patients had been supervised carefully, a personalised therapeutic plan could be put in place.
HYALU-BOTOX IS A BLEND OF FREE HYALURONIC ACID AND BOTULINUM TOXIN
A few units of botulinum toxin is applied over the muscle surface, not intra-muscularly, and works well to reduce superficial contractility. In addition, it achieves a relaxation and distension of wrinkles such as crow’s feet and vertical wrinkles such as the ‘bar code effect’.
For years now, botulinum toxin has been a cornerstone of aesthetic medicine thanks mainly to its manageability and its natural outcomes. Similarly, hyaluronic acid has established itself as the other widely used instrument in basic aesthetic medicine, thanks to its characteristics as a perfect filler and its hydrating action on connective tissue.
I have recently begun experimenting with a mix of botulinum toxin and non-crosslinked hyaluronic acid (hyalu-botox), for distribution in micro-spots over the face. This mix enables a reduction in fine wrinkles thanks to its action on both the muscular component (botulinum toxin) and dermis hydration (hyaluronic acid).
In my experience, injections of this combination have guaranteed patients a smoothing of thin wrinkles and an improvement of skin texture: decreased pore visibility and increased brightness and smoothness. The action of hyalu-botox is also optimal for oily skin types, as it regulates sebaceous gland secretion by suppressing parasympathetic activity.
My first approach from periorbital region, included the lower and upper eyelid and the external area formed by the zygomatic and frontal bone structures. This region is frequently affected by early signs of ageing and often requires intervention in order to improve wrinkles, abnormal pigmentation, skin relaxation, and brow ptosis, albeit, without altering the facial expression.
In order to determine the best treatment, it is necessary to define a global approach to the affected area since most aesthetic defects tend to be associated.
There are two approaches; on one hand, the surgical route (lower blepharoplasty, upper blepharoplasty, eyebrow lifting and canthopexy, cheekbone lift and lipofilling). Alternatively, there is the medical-aesthetic solution, which represents the mostly used and standardised options. These include botulinum or hyaluronic acid injections, peeling treatments and the use of dermarollers. These two approaches are often integrated with each other in order to obtain comprehensive results in the subcutaneous muscular structure, as well as in the skin itself.
Following my experience in an area as delicate as the periorbital region, I applied this procedure to the peribuccal area, with the sole aim of correcting vertical wrinkling, the so-called ‘bar-code deformities’.
In accordance with our clinical experience, patients were assigned to two groups, depending on the severity of wrinkling. The first group was composed of relatively young patients (30-50 years), with fine dynamic lines and with relatively good skin elasticity. The second group consisted mostly older patients (over 50 years of age) with considerable static wrinkling and a ‘bar-code’ appearance at rest. In order to ensure objectivity of group assignment and homogeneity within the groups, a wrinkle scale was used. Patients belonging to the first group had perioral wrinkles graded as 0-2 on the Lemperle scale; patients in the second group had a wrinkle severity of 3-5.
Taking this division into account, we analysed and standardised a treatment protocol below.
Group 1 (23 patients in our series)
Patients were treated with hyla-botox only, every 2 months for a period of 1 year. We prepared hyalu-botox using a mixture of botulinum toxin A (8 IU) and 1 ml of amino acid or non-crosslinked hyaluronic acid.
Group 2 (39 patients in our series)
Patients underwent a longer and differentiated treatment. Firstly, hyalu-botox, with the same formulation described above, was injected in all patients. Then, after 2 weeks, having evaluated the wrinkle response, patients were treated using a combination of mechanical and chemical stimulation using amino acid replacement therapy (AART). It has been shown that the active ingredients in ARRT drugs bring about fibroblast chemotaxis migrations into the injected area stimulate neo-collagenesis, thereby improving skin quality, accelerating wound healing and reducing the recovery period after invasive procedures. Intradermal injection increases skin thickness, improves its elasticity, and smooths out surface features.
We usually applied peeling during a needling session. This protocol was repeated three times over a 6-month period.
Following on from our findings from using this treatment on the expression line over the orbicularis muscles (both periorbital and peribuccal), we transferred our experience to the treatment of neck deformities. Venus rings and platysmal bands. It worked very effectively to ameliorate these deformities.
1) Hyalu-botox is a blend of free hyaluronic acid and botulinium.
2) This mix enables a reduction in find wrinkles thanks to its action on both the muscular component (botulinum toxin) and dermis hydration (hyaluronic acid).
3) Amino acid replacement therapy (AART) stimulate neo-collagenesis, thereby improving skin quality, accelerating wound healing, and reducing the recovery period after invasive procedures.
Figure 1. (A) before and (B) 2 months after treatment with hyalu-botox
Treatment was conducted on an out-patient basis, using small infiltrations, without any need for local anaesthetic. Repeated sessions may have been required to obtain the desired effect.
Following infiltration, it is important to massage the treated area to promote uniform distribution of the injected solution. We can conclude that:
- this is a simple and safe procedure,
- it has no negative impact on the patient’s personal or working life,
- it can be executed under out-patent conditions,
- the results are highly satisfactory, even after a single application,
- the effected lasts for 2 months,
- the procedure can be repeated,
- it is relatively inexpensive.