Abstract
The facial aesthetic market is predicted to grow by as much as 14% annually through 2026, 1 and this trend should continue well into the future as individuals become more educated about the available treatments that now exist to improve one’s appearance. This improvement is not simply “cosmetic” as studies have shown the significant psychosocial benefits these interventions provide.2,3 Furthermore, with improved technologies, the results can be sustained and at times dramatic.
The skin’s anatomy and its changes over time due to both intrinsic and extrinsic factors have been studied and this knowledge allows us to direct therapy to specific targets in the skin and below. The intent is to improve skin hydration, collagen and elastin production, and volume deficits, while at the same time to reduce actinic damage, pigment dyschromia, vascular ectasia, and hyperdynamic muscle activity.
Traditionally, one would approach a patient on a transactional basis, responding to a person’s main concern. However, we now acknowledge and understand that a more integrated approach that addresses all of an individual’s concerns is to be preferred and yields the best outcomes for the patient.
Lasers, other energy-based devices, botulinum toxin, and injectable fillers have been available for over 30 years, and during this time, the technology has evolved considerably. As knowledge and experience with these devices and drugs has grown, so too has our understanding of where they fit together to the benefit of our patients.
As such, multimodality therapy is appearing as the standard of care for physicians dealing with the aesthetic patient—whether this be for skin rejuvenation or the reduction in acne scarring. These treatments may be administered synchronously (same day) or asynchronously depending on the procedure and areas to be addressed.
This comprehensive approach always incorporates proper skin care to include sunscreens, and when appropriate, other agents like topical retinoids, alpha hydroxy acid peels, or skin lightening formulations. 4
Recently a novel approach to dermal hydration and improved skin quality has been developed. 5 These hyaluronic acid (HA) products have low cohesivity that allows these gels to be readily dispersed into the skin at the dermal level. Clinically, patients have expressed that the injection of these HA products increases the luminosity, hydration, and texture of their skin. This is substantiated by histologic studies that have shown a stimulation of both collagen and elastin subsequent to the injection of these agents. 6 Furthermore, there is anecdotal evidence that certain conditions such as rosacea may also be improved after treatment with these products. The question then appears: Can combination therapy provide an added benefit to monotherapy, whether the added therapies include laser, intense pulsed light, or other injectable neuromodulators or devices like HA, calcium hydroxylapatite, and poly L-lactic acid?
In the author’s clinic, a retrospective chart review of 100 consecutive patients who were treated with a low G prime product, VYC-12 (Skinvive; Allergan), either alone or in combination with other treatments was examined. Women (91% Caucasian, 9% Asian) with a mean age of 59 years formed 98% of the group. The majority of patients underwent multiple treatments either on the same or other days most often with neuromodulators, other dermal fillers [ie, products of higher viscosity and elasticity (G prime) and placed into the subcutaneous or supraperiosteal space], or energy-based devices. Patient satisfaction was high as shown by repeat treatments over time and the recommendation to their acquaintances for similar treatments.
Ogilvie et al 7 showed, in a prospective study, VYC-12 alone could improve subject satisfaction (in terms of perceived fine lines and skin quality) by 90% from baseline at 1 month posttreatment and remained at 76% 8 months later. However, others have reported added benefits of the use of VYC-12 in combination with other treatments—either on the same or alternative days. Bertossi et al examined the combination therapy of a fractionated laser in combination with botulinumtoxinA and a low G prime HA filler (VYC-12) in 45 patients. Treatments were performed sequentially at different sessions (first laser, then microbotox, then VYC-12) and patients were assessed by questionnaire at 12 months. They concluded that the combination of all 3 treatments yielded a better outcome than individual treatments in isolation. 8 In a retrospective chart review of 736 patients who received VYC-12, almost every individual (98%) received same-day or asynchronous therapy, with neuromodulators and fillers being utilized most often. 9 The authors concluded that VYC-12 is safe for improving skin quality and hydration as part of a comprehensive management strategy.
In sum, the approach to the aesthetic patient should include a treatment plan that addresses all layers of the skin and underlying structures. When minimally invasive procedures are employed, a combination treatment plan will enhance the patient’s aesthetic journey, and the sum effect will be greater than the individual parts.