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Optimizing Facial Aesthetics: Sequential

Application of Botulinum Toxin A and Dermal
Fillers for Enhanced Results
Constance Hall, MSN, RN, FNP-C

outcomes. This article explores the rationale behind this

In recent years, the field of aesthetic medicine has
approach and its potential benefits.
witnessed significant advancements, offering patients a
The human face is characterized by a delicate balance
plethora of options to rejuvenate their appearance. Among
between muscles that elevate and depress facial features.
the most popular techniques are the administration of
Overactivity of depressor muscles, such as the corruga-
botulinum toxin A (BoNT-A) and dermal fillers. This article
tor supercilii and depressor anguli oris, contribute to dy-
delves into the rationale and benefits of preparing the
namic wrinkles and a tired appearance. Although muscles
face with BoNT-A to weaken depressor muscles before
may weaken with age, their relative pull is greater on
proceeding with dermal filler injections. This sequential
less resistant tissues and dermis and this can result in hy-
approach not only enhances patient outcomes but also
perdynamic expressions, creating caricatures that grimace
improves procedural safety and patient satisfaction while
rather than smile (Durand et al., 2016; Schlessinger et al.,
reducing the chances of needing filler. This article reviews
2017; Shetty, 2018). Administering BoNT-A to depressor
the anatomy, scientific evidence, and clinical implications
muscles temporarily weakens their activity and provides
supporting this innovative approach while shedding
a smoother canvas upon which dermal fillers can be
light on the potential for revolutionizing facial aesthetic
strategically placed.
procedures. With advanced applications of BoNT-A, it
Clinical investigations have provided compelling evi-
is possible to slim round faces, reduce jowling, create
dence for the sequential use of BoNT-A and dermal fillers.
hollowing in some patients by obliterating masseters, slim
Scheduled pretreatment with BoNT-A can lead to reduced
the parotid, extend the chin, and more.
muscle contraction and size, thus enhancing the longev-

I
n the practice of facial aesthetics, botulinum toxin A ity and specific distribution of dermal fillers (Schlessinger
(BoNT-A) and dermal fillers are cornerstone treat- et al., 2017).
ments aimed at addressing different signs of aging. Most medical aestheticians have consulted and/or treat-
BoNT-A effectively reduces dynamic wrinkles by inhibit- ed an older woman patient of 60+ years who presents
ing muscle contractions. Dermal fillers restore lost vol- to the practice seeking treatments for the first time and
ume and sculpt facial contours. However, implementing wanting “everything.” Treating this patient requires more
sequential application of both products (i.e., with BoNT-A psychological consideration than most patients because
administered before dermal fillers) can optimize patient as a new aesthetic patient, her knowledge base is likely
quite limited (Lehrer, 2006). Given carte blanche, many
Constance Hall, MSN, RN, FNP-C, is the current owner of The injectors will try to create a masterpiece in a single set-
Secret Boutique, PLLC, Morehead City, NC. Constance is also the ting. However, it is good practice to prepare the patient’s
owner of her own CME course, The Foundations of Aesthetic Medi-
cine offered through the University of Louisville School of Medicine,
face for change by injecting the full face and neck with
Louisville, KY, for which she receives a modest grant from AbbVie, BoNT-A, as needed, and then reevaluating the effects of
North Chicago, IL. the BoNT-A after 2–4 weeks before advancing to dermal
The author reports no conflicts of interest. fillers or taking any other next steps. Many times, under-
This is an open-access article distributed under the terms of the Creative going a full face treatment of BoNT-A will be enough to
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-
NC-ND),where it is permissible to download and share the work provided
satisfy a patient’s subjective need to look and feel better
it is properly cited. The work cannot be changed in any way or used com- (Sundaram et al., 2016).
mercially without permission from the journal. When the patient returns for follow-up, the next treat-
Address correspondence to Constance Hall, MSN, RN, FNP-C, The ment with dermal fillers will be much more satisfying for
Secret Boutique, 108 Camp Morehead Dr, Morehead City, NC 28557
(e-mail: [email protected]).
the injector to place and usually requires much less der-
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc.
mal filler to obtain satisfactory results. This is known as
on behalf of the International Society of Plastic and Aesthetic Nurses. prepping the canvas. The patient also now understands
DOI: 10.1097/PSN.0000000000000546 the benefits of BoNT-A and is less likely to confuse it with

70 www.PANjournal.org Volume 44  Number 1  January–March 2024

dermal fillers or other treatments. Likewise, the patient procedural safety, and increased patient satisfaction. As
is usually more willing to proceed with other treatments the aesthetics field continues to evolve, further research
when the results from BoNT-A are significant (Sundaram and clinical trials are warranted to solidify the scientific
et al., 2016). basis of this approach and refine its techniques.
A sequential approach that begins with BoNT-A and
is followed by dermal fillers offers several advantages. REFERENCES
By weakening depressor muscles, BoNT-A minimizes Durand, P. D., Couto, R. A., Isakov, R., Yoo, D. B., Azizzadeh, B.,
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