Luca Piovano unveils his novel approach to improve wrinkles on the face and neck using a combination of hyaluronic acid and botulinum toxin
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’ effect1.
For years now, botulinum toxin has been a cornerstone of aesthetic medicine, thanks mainly to its manageability and its natural outcomes2. 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 the 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 expression3.
There are two approaches; on the one hand, the surgical route (lower blepharoplasty, upper blepharoplasty, eyebrow lifting, and canthopexy, cheekbone lift and lipofilling)4-6. Alternatively, there is the medical-aesthetic solution, which represents the most used and standardised options. These include botulinum or hyaluronic-acid injections, peeling treatments and the use of dermarollers7. 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 of 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 used8. 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 hyalu-botox only, every 2 months, for a period of 1 year. We prepared hyalu-botox using a mixture of botulinum toxin A (8 I.U.) and 1 ml of amino acid or non-cross-linked 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 AART drugs bring about fibroblast chemotaxis migrations into the injected area and 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.
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-patient conditions
- The results are highly satisfactory, even after a single application
- The effect lasts for 2 months
- The procedure can be repeated
- It is relatively inexpensive.
Declaration of interest Dr Piovano has consulted for Bioform Medical, Merz Aesthetics, AQTIS Medical, IBSA Academy, Sinclair Pharma, Professional Derma SA, and General Topics
Figure 1 © Dr Piovano
- Lieu S. Discussion: Microbotox of the Lower Face and Neck: Evolution of a Personal Technique and Its Clinical Effects. Plastic Reconstruct Surg 2015; 136: 102S
- Wu WTL. Microbotox of the lower face and neck: evolution of a personal technique and its clinical effects. Plast Reconstr Surg 2015; 136: 92S–100S
- Mohindra NK, Bulman JS. The effect of increasing vertical dimension of occlusion on facial aesthetics. Br Dent J. 2002 Feb 9;192(3):164-8
- Gonzalez-Ulloa M, Simonin F, Flores E Anatomy of the ageing face: Transactions of the Fifth International Congress of Plastic and Reconstructive Surgery 1st Ed London: Butterworth and Co Ltd 1981
- Gilchrist BA. Age associated changes in the skin. J Am Geriatr Soc 1982; 30: 139–143
- Wollina U. Perioral rejuvenation: restoration of attractiveness in aging females by minimally invasive procedures. Clin Interv Aging. 2013;8:1149-55
- Leveque JL, Goubanova E. Influence of age on the lips and perioral skin. Dermatology. 2004;208(4):307–313.
- Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent 1978; 39: 502–504