Derm Topics

Evaluating and Treating Patients with Soft Tissue Fillers and Neuromodulators

Is beauty really in the phi of the beholder? Are the faces that conform to the phi mask, that perfectly display the golden ratio of 1.618, really the most beautiful faces among us? Should we be seeking to help our patients approach a mathematical definition of beauty, or should we be seeking to preserve, enhance, and celebrate that which is unique and distinctive in their features, and forget the golden ratio? I would hope that many of us would argue the latter; I certainly would.

There is a reason why Lil’Bub, Grumpy Cat, Marnie the Dog, Smush, and so many other furry comrades who have risen to the highest peaks of social media stardom—there is beauty in that each is different and unconventional!

At the 2020 ODAC Dermatology, Aesthetic and Surgical Conference, Dr. Kavita Mariwalla, founder of Mariwalla Dermatology and a nationally recognized leader in dermatology and dermatologic surgery, gave an extremely comprehensive yet immaculately detailed lecture on some of the fundamental concepts that must be kept in mind when evaluating and treating patients with soft tissue fillers and neuromodulators. Her lecture served as a reminder of the impressive results that can be obtained with filler and neurotoxin alone, as well as the need for aesthetic providers to celebrate diversity by helping patients look like the best versions of themselves, not of the Phi mask.

This post will provide an overview of the following aspects of facial sculpting with neurotoxins and soft tissue fillers:

    • Anatomical changes associated with aging
    • Administering botulinum toxin
    • Choosing a filler
    • And a heap of PEARLS sprinkled throughout!

But first, let me share a few of my “A-ha” moments from Dr. Mariwalla’s talk, in the hope that they will entice you to read on…

    • Have a patient who isn’t pleased with the outcome of their botulinum toxin treatment? Dr. Mariwalla has some amazing tips on how to hasten the clearance of the toxin, and make your patient happy. It can be done! Keep reading to find out how!
    • Everyone’s muscular facial anatomy is slightly different, but there are some techniques that you can use to locate the procerus and corrugators every time. Read on to learn about this!
    • Lip injections can HURT and bruise. But Dr. Mariwalla was involved in a recent study that found a way to potentially minimize these adverse effects. Find out more at the end of this post!

Anatomical changes associated with aging

Providing your patients with optimal improvements in their appearance through the use of botulinum toxin and soft tissue fillers is contingent upon a fundamental understanding of the anatomical changes that take place as we age. While there are certain changes in skin color and texture that patients will seek your expertise in correcting, there are also skeletal changes that bear upon the placement of fat pads and ultimately, how the skin drapes the face. These changes include, among others, a reduction in facial height, resorption of the maxilla and mandible, and a diagonal increase in orbital diameter.  There are also differences among how these musculoskeletal changes manifest across different races, as well as among men vs women. For example, men tend to exhibit brow descent, muscle reduction, and elongation of their ears, whereas women are more likely to develop sagging cheeks, eyelid ptosis, and crow’s feet. Other changes that are likely to be observed as a consequence of aging are the formation of infraorbital hollows, concavity at the temples, more pronounced nasolabial folds, and the appearance of jowls.

The bottom line is that if you are going to try to reverse these changes with a combination of neurotoxin and filler, you need to understand their underpinnings, as well as what you are endeavoring to re-volumize, in order to accomplish that you seek to do.

Botulinum toxin

When using neurotoxins you must possess a firm understanding of facial anatomy, technique, appropriate dosing, and what the unique patient in front of you needs (this last one is imperative, because oftentimes patients will come to you with a certain idea of what they want, which will not conform to what they actually need). When assessing a patient, it is crucial to observe the patient not only when they are maximally contracting to create the wrinkles, but also as they animate when speaking and performing routine facial expressions. Also, know that most patients do not desire to have their faces completely frozen—they want their wrinkles softened while retaining the ability to move their facial musculature. If you estimate neurotoxin dose based on their maximal facial contraction, there is a risk of administering too much and making the patient unhappy. It is therefore better to err on the side of underdosing toxin since more can always be added later.


If a patient is unhappy with their outcome, offer them a peel! The advantages to this are numerous—it is a low-cost remedy for you, the patient will like the way their skin looks, and they will be introduced to a new treatment that will hopefully keep them coming back for more!

If you administer too much toxin, or toxin in the wrong place, you can hasten the return of normal muscle function by applying the back of an electric toothbrush to the area a couple of times daily. The vibration will help the toxin dissipate in a matter of weeks rather than months.

Counseling a patient on appropriate expectations is crucially important before you administer any type of aesthetic treatment. For example, patients sometimes need help understanding that one session of botulinum toxin will not instantly melt away deep wrinkles that took decades to create. It is crucially important that you explain this before you treat a patient—if you don’t, they are going to think that your treatment failed and lose all confidence in you as a result.

botulinum toxin

A couple of strategies that can help patients wrap their minds around what they can expect botulinum toxin to accomplish for their static wrinkles are the following:

        • Use your fingers to try to make the wrinkle disappear. Explain to the patient that if the pressure applied by your fingers is not able to press the wrinkle out, then botulinum toxin certainly won’t.
        • Use the analogy of a dress that has been folded tightly in a drawer for several years—when the dress is taken out it will hang straight but the wrinkles will still be present.

Glabellar complex and forehead

The muscles of the glabellar complex are responsible for frown lines and include the procerus, corrugator supercilii, depressor supercilii, orbicularis oculi para frontalis, and to a certain extent in some individuals, nasalis. The frontalis muscle is mainly responsible for horizontal forehead lines. There are a number of different approaches when it comes to treating this area with neuromodulators, but before you embark upon this, it is very important to first discern how the patient desires their eyebrows to be positioned, as well as what their unique muscular contraction pattern is. Understand that injection schemes should vary depending on which of the 5 different glabellar contraction patterns—U, V, converging arrows, omega, or inverted omega—the patient displays when they frown. And also know that differences in muscle structure across ethnicities, as well as how those muscles respond to botulinum toxin, should also be taken into account when determining which doses to use.

botulinum toxin

Everyone’s anatomy is slightly different! Here are tips to help you locate the procerus and corrugators:

          • Procerus: Make an “X” from the head of one eyebrow to the opposite medial canthus bilaterally. The center of the “X” is where you’ll want to inject procerus.
          • Belly and the tail of the corrugators: Medial canthus straight up, and midpupillary line straight up, respectively, is where you will find these injection points.

Considerations when choosing and using a filler

Hyaluronic acid (HA) fillers are hydroscopic and cross-linked for longevity. The number and type of cross-links present help to impart different HA fillers with their unique characteristics, which include viscosity (ease of injection), elasticity (firmness), cohesivity (extent to which the filler can withstand compression), and others.

Infraorbital hollows

There is no one size fits all approach to treating this area, as there are a number of different anatomic factors that contribute to the appearance of infraorbital hollows—ligamentous architecture, soft tissue volume, vasculature, and dermal thickness. It is crucial to first determine whether the patient’s concerns relate more to the color of the skin in this area or to true hollowing.  It has been calculated that a woman will spend up to $15,000 during her lifetime in an attempt to improve the appearance of infraorbital hollows, so it definitely behooves you to become adept at understanding various techniques to improve the appearance of this area, such as filler placement, chemical peels, and skin-lightening cosmeceuticals.

Lips Pearl #5

One final pearl to close. Although we may be more accustomed to doing retrograde injections when filling the lips, a recently published study that Dr. Mariwalla was involved in found that an anterograde injection technique may cause less pain and bruising.

So what are your thoughts on helping patients attain the golden ratio vs celebrating and maintaining their unique features? What are some tips that you can share on managing the expectations of the aesthetic patient? Do you have any special techniques that help you minimize pain and bruising while treating patients with injectables?

Please tell us all about it in the comments at the end of this post, and on Instagram @nextstepsinderm!

This information was presented by Dr. Kavita Mariwalla at the 17th Annual ODAC Dermatology, Aesthetic and Surgical Conference held January 17–20, 2020 in Orlando, FL. The above highlights from his lecture were written and compiled by Dr. Kimberly Huerth, Chief Dermatology Resident at Howard University, and one of the 7 residents selected to participate in the Sun Young Dermatology Leader Mentorship Program (a program supported by an educational grant from Sun Pharmaceutical Industries,

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