Newer injectables, energies prove to suit darker skin types

Key Points

In particular, combining newer neuromodulators and fillers with the latest radiofrequency (RF) and ultrasound-based treatments can provide results that are greater than the sum of their individual parts, says Dr. Sundaram, a Washington dermatologist and cosmetic surgeon in private practice.

"The idea is to look at each patient individually. What combination of procedures is going to give the patient what he or she is looking for - or hopefully results above and beyond what they're looking for?" she says, adding that this requires an understanding of the patterns of aging, which are unique in skin of color, and how newer technologies can help address these changes.

Injecting synergy

Among injectable fillers, "Belotero Balance (Merz/BioForm) is a different type of hyaluronic acid (HA) filler," Dr. Sundaram says. Because it's a cohesive polydensified matrix HA, "When you inject it, it distributes very smoothly and homogeneously through the skin, so there are no lumps or particles. That means you can inject it very superficially."

The product contains no particles to scatter back shortwave blue light, she adds, so injectors need not worry about the Tyndall effect. These characteristics make Belotero Balance especially well suited to fine lines, Dr. Sundaram says. "Although we as clinicians often think in terms of volumizing the face, patients are still very concerned about fine lines such as smokers' lines in the perioral region. This is an ideal filler for that." Belotero Balance also allows very precise definition of the lip borders and restoration of the white roll at the vermilion border, she says. "You can inject it all along the border, and superficially, and it will give a very nice restoration."

On a broader scale, she says this product fits well within the multiplane rejuvenation technique. Dr. Sundaram uses high-viscosity, high G prime fillers such as Radiesse (calcium hydroxylapatite, Merz) or Perlane (HA, Medicis) for deep lifting volumization. "The high G prime confers a lot of lift; the high viscosity confers contour stability. I inject above the bones in the supraperiosteal plane, or subcutaneously," she says.

Dr. Sundaram then uses Belotero Balance superficially to get what she calls superficial tension volumization. "I run it through the dermis as a sheet. For all patients, including patients of color, injecting into the dermis creates a phenomenal restoration of radiance to the skin. It's a very lustrous appearance, because you're re-volumizing superficially," she says.

Additionally, physicians can use Belotero Balance for fine lines that remain after treatment with Botox (onabotulinumtoxinA, Allergan), Dysport (abobotulinumtoxinA, Medicis) or Xeomin (incobotulinumtoxin, Merz) in areas such as the forehead. "You can't completely freeze the forehead or overinject neuromodulators there because that may look unnatural or drop the eyebrows," she says.

Presently, "I tend to work with lower doses of neuromodulators, in conjunction with fillers," Dr. Sundaram says. "For instance, for the forehead or glabella, I might be using 20 to 22 units of Xeomin or Botox. The equivalent for Dysport would be about 50 to 55 units."

Among new neuromodulators, "Xeomin behaves exactly the same as Botox terms of dosing, effects, onset of effects and longevity. But it's a purified toxin that doesn't have accessory proteins," as Botox does, she says. Xeomin's lack of accessory proteins is considered an advantage in some respects, Dr. Sundaram says, because it may decrease the risk of resistance.

"It makes for a very predictable neuromodulator," she says. "We now have some evidence from basic science literature that the accessory proteins influence behavior of the toxin, even though they are supposed to dissociate from the toxin within a minute or two after injection (Cheng LW, Onisko B, Reader JR, et al. Toxicology. 2008;249(2-3):123-129. Epub 2008 May 2)."

Conversely, she says Dysport has a broader field of effect, which physicians can leverage to patients' advantage. In the lower face, for example, "Because of the beneficial spread, I can target a little bit of the depressor anguli oris along with the platysma to accomplish neck lifting and target a little bit of the masseter to achieve lower-face slimming. You can target multiple treatment areas from just a few injection points."

A split-face controlled study on which Dr. Sundaram served as a principal investigator in collaboration with San Diego dermatologist Mitchel Goldman, M.D., has shown that for crows' feet in various skin types, Dysport via one injection site performs comparably to the same dose of Dysport delivered via three injection sites (American Society for Dermatologic Surgery Annual Meeting. Nov. 3-6, 2011. Washington). "You inject the same dose as you would with three injection points, but using one injection point may be beneficial because it reduces the risk of bruising and increases patient comfort," she says.