Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers

Focus on the Upper Face

Maurício de Maio, M.D.; Arthur Swift, M.D.; Massimo Signorini, M.D.; Steven Fagien, M.D.


Plast Reconstr Surg. 2017;140(2):265e-276e. 

In This Article


Botulinum toxins continue to be the most important tools for upper face rejuvenation. The use of hyaluronic acid fillers is helpful to provide correction of volume loss and provide structural support. The upper face is considered a basic area for use of botulinum toxin but a challenging area for use of fillers, particularly because serious complications such as blindness and necrosis may occur. For the experienced injector, a combination of using both botulinum toxin and a hyaluronic acid filler may provide benefit in a number of aspects of facial rejuvenation, including more natural appearance, longer duration of effect, injection of lower volumes of filler, and reduced cost.[9,12,18,19] Usually, the dynamic component of the wrinkle is treated in the first session with botulinum toxin, and then the filler is used in the second session. In cases where both products are to be used in the same treatment session, the filler should be injected first with proper massage, and only then should the botulinum toxin be injected.