Although they may not often state it, most cosmetically oriented dermatologists believe that combination therapy produces the best results. The likely reason it isn’t presented at meetings is because it is mainly anecdotal, difficult to study and thus often thought of as unworthy of scholarly presentation. However, it is what we all do in our offices every day to give our patients the best possible outcomes.
The Beauty of a Combination Approach
This is because no single technology, filler or neuromodulator can achieve all the results desired in treating the aging face. For example, using energy-based devices with highly specific targets, it is difficult to target multiple anatomical areas such as epidermis and dermis, or superficial dermis and deep dermis. Likewise, the different fillers and neurotoxins have different capabilities best suited to different applications and sites. “Synergy” is a term that is often bandied about to describe the additive effects of this difficult-to-prove but highly desirable phenomenon.
Combination therapy for acne, however, is widely discussed and accepted. Nowadays, few dermatologists use monotherapy to treat acne. One reason for this is the multiple factors involved, including comedones, pustules, and different etiologic mechanisms that could be attacked such as inflammatory, hormonal, bacterial and follicular plugging.
Similarly, there are multiple factors to address with our cosmetic patients. We want to be able to target the superficial dermis for superficial wrinkles and small telangiectasias, the deeper dermis for deep rhytides and tissue tightening, muscles for dynamic rhytides, the epidermis for lentigines and superficial texture, the mid-deep dermis for large pores, and subcutaneous layers for fat remodeling.
Typical Combinations, Rationales
One basic aesthetic combination is botulinum toxin and fillers. It is often said that the upper third of the face is the domain of botulinum toxin, whereas the lower two-thirds of the face is reserved mainly for fillers, partly due to the fact that we require function preservation of the muscles in the lower two-thirds of the face and partly because volume correction is of paramount importance here. Even layering one filler over another or combining different fillers is a form of combination treatment.
One study showed that IPL plus botulinum toxin was more effective than IPL alone for muscle response, lentigines, pore size and facial texture.1
Another commonly utilized combination is botulinum toxin prior to tissue tightening or resurfacing procedures of the periorbital and forehead regions. The rationale here is that the relaxation of the tissues that botulinum toxin affords will decrease the “resistance” of the skin to being firmed or resurfaced and yield a better result.
Some Approaches to Try
Here are a few combination treatments that are either based on published studies or anecdotal case reports. They may stimulate your own ideas on creative combinations.
Fillers Plus Tissue Tightening
The aging face often has a combination of laxity and loss of volume. Tissue tightening is a procedure designed to firm the skin via a combination of collagen conformational change and gradual collagen synthesis. Although this often does result in flattened nasolabial folds, the main results consist of firming and elevation of the cheeks, better definition of the mandibular/neck junction with ensuing reduction of a jowly appearance, and a return of a more heart-shaped face.
However, there is usually a loss of volume in the perioral region that cannot be corrected by tissue tightening alone. This area may be enhanced by adding fillers.
In patients shown in Figures 1 and 2, we combined tissue tightening with hyaluronic acid and/or botulinum toxin to achieve the overall aesthetic result we sought.
Due to the almost universal presence of laxity and loss of volume in the aging face, this is a classic combination utilized on a daily basis in cosmetic practices all over the world.
Fractional Resurfacing Plus Tissue Tightening
Tissue tightening often results in deeper dermal effects and isn’t usually utilized for superficial rhytides or epidermal changes. Likewise, fractional resurfacing isn’t noted for tightening effects — although this may change with the advent of carbon dioxide fractional resurfacing. It makes sense to combine tissue tightening for deep dermal remodeling via a non-ablative mechanism with an ablative wounding process, which might make for a complementary effect on tightening and textural improvement.
Usually fractional resurfacing is a multi-procedure therapy. However, we were interested in determining whether we could make this combination therapy into a procedure that could be done in 1 day.
In the 53-year-old patient shown in Figure 3 (below) we performed tissue tightening first and then applied 30% lidocaine for 60 minutes after which we performed fractional resurfacing. She is shown here 3 months after a single full-face tissue tightening and fractional resurfacing, plus 1 cc of hyaluronic acid injected into the lips.
These are early results, but it seemed that the effects on the superficial rhytides and overall facial contouring were more than what we would have expected from either of these treatments separately. Obviously, a clinical trial would need to be undertaken to establish a definitive effect.
Tissue Tightening Plus Cellulite Remodeling
Cellulite reduction with shape contouring and diameter reduction is a new goal of aesthetic high technology. No definitive cause of cellulite has been advanced, with hypotheses ranging from genetically determined anatomy specific to females, altered connective tissue septae, vascular changes, and inflammatory factors.2
The VelaSmooth is a device that is a combination therapy in itself, consisting of bipolar radiofrequency, suction and pulsed infrared light designed to reduce cellulite by mechanical manipulation, heat and radiofrequency energy.3 The idea of adding a second procedure consisting of bipolar radiofrequency and diode laser used mainly for tissue tightening (ReFirme ST) was based on the hope that there would be an even more marked effect on the distorted fibrous bands that restrain the fat. Making them stronger and more uniform, we theorized, might reduce the herniation of fat through its interstices more than with the VelaSmooth alone. This procedure is being utilized on thighs, buttocks, abdomen and upper arms to reduce circumference and improve the contour and cellulite of these body areas.
Figure 4 (above) depicts a patient whose abdomen has undergone a series of four treatments with the combination of the ReFirme and the VelaSmooth devices. In addition, there are reports of combinations of phosphatidylcholine-based cream and LED light.4 This is a burgeoning area, which also suggests the need for combination therapy when disease states are multi-etiologic, requiring varied interventions to achieve optimal effects.
Bipolar Radiofrequency/Diode Laser Plus Bipolar Radiofrequency Plus Pulsed Light
In one recent study,5 the three energy sources that make up most non-ablative rejuvenation procedures — pulsed light, lasers and radiofrequency — were combined into one treatment to target laxity, rhytides and photoaging. The technology called ELOS (electro-optical synergy) was devised as a combination strategy combining radiofrequency with various forms of light or laser. This combination was conceived to both reduce the energy needed from light or laser to achieve the goal of selective photothermolysis (hence theoretically to reduce the development of complications) as well as to yield tightening and pore reduction along with targeting specific chromophores to achieve superior results. (See Figure 5.)
In Dr. Armenakas-Alexiades’ study,5 she combined two different ELOS technologies (Aurora=PL + RF with Polaris WR/=diode laser + Polaris WR) to try to get superior overall results. She found a mean of 26% overall improvement, with a patient satisfaction rating of 71% and concluded that combining non-ablative technologies may maximize clinical results as well as patient detection of improvement.
Photodynamic Therapy Plus Electrocautery Plus Chemical Peels
Some cases just require individual combination therapy to achieve a desired result. The 47-year-old Asian female shown in Figure 6 (below) desired pore reduction, smoothing of the skin and reduction of both pigmented and non-pigmented lesions. We treated her with a combination of blue light and aminolevulinic acid (ALA) for one treatment as well as PDT with ALA and ELOS (Aurora SR=bipolar RF and pulsed light 580 nm to 980 nm), 20% salicylic acid peels and electrocautery of her sebaceous gland hyperplasia. Nearly 1.5 years later, she has maintained her improvement with topical therapy alone.
Short-Pulse Duration 1064 nm Laser with Intense Pulsed Light and Topical Therapy
A combination of short-pulse duration 1064 nm laser (Genesis, Cutera, Inc)6 and pulsed light 600 nm to 850 nm. (Xeo OPS) and also including long-pulsed infrared broadband light (Titan) has been dubbed 3-D rejuvenation. The idea is to target multiple areas of the dermis as well as utilizing different target chromophores to achieve an overall effect that would be better than any of these modalities alone.
The Goal of Aesthetic Remodeling
The “holy grail” of aesthetic facial remodeling has been to improve both tightening and wrinkles in the same treatment. It was believed that carbon dioxide laser resurfacing achieved this, but the complication rates were unacceptably high. The carbon dioxide fractional resurfacing device that is now emerging is being touted as the next biggest thing in this arena.
Without minimizing the magnitude of that possible achievement, we would still be left with volume loss, muscle over-activity and atrophy at least. There will still be patients who want absolutely no downtime and minimal risk who will not want to be resurfaced.
Despite the current richness of technology, most of it is fairly specific, so it makes sense to combine them to give us our best aesthetic results. Although a drawback of combination procedures is that we rely much more on anecdote than scientific clinical trials to create and refine treatment protocols, it also is a way to innovate as well as differentiate ourselves from other aesthetic providers. Perhaps when certain combinations are perceived as more established, clinical trials will be performed to validate their usage together.