Why “Hybrid is Better”

• NAHYCO® TECHNOLOGY
• Based on stabilized hybrid cooperative complexes of
high and low molecular weight Hyaluronic Acid (HA):
 Low (80-100 kDa): L-HA
 High (1100-1400 kDa): H-HA
• Concentration:
32 mg L-HA + 32 mg H-HA in 2 ml pre-filled syringe
• Total of 64 mg HA
 Why Hybrid is Better
1. Slow long-lasting release of high and low MW HA
2. High concentration of HA
3. High stability
4. High flowability
5. An improved biological profile:

Profhilo supports keratinocyte and fibroblast

viability leading to a remodeling of the
extracellular matrix in terms of elasticity and
support
 High flowability

Adapted with permission from: Sundaram H, Cassuto C, Gavard Molliard S (publication in preparation)
 Remodeling of the
extracellular matrix in
terms of elasticity and
support
PROMOTING AND MAINTAINING
THE VIABILITY OF:
• KERATINOCYTES (epidermis)
• FIBROBLASTS (dermis)
• ADIPOCYTES
(subcutaneous/superficial
fat)

Salti G . et al. 2015. Facial Rejuvenation with Fillers: The Dual Plane Technique. 2015, J Cutan Aesthet Surg 8:127-
133.
 The BAP Technique
The BAP (Bio Aesthetic Points)
technique, developed for the
lower third of the face due to its
predisposition to dermal atrophy
caused by the aging phenomena;
• reduces the number of
injection sites (5 injection
points, 0.2 ml per bolus in the
deep dermis/subcutis)
• reduces the number of
treatment sessions (2
treatments with an interval of 4
weeks)
 The BAP Technique
Why does it work?
• 4 different fat compartments involved
• Lifting + filling effect The technique
• Safety: far from large vessels and nerves

• High HA concentration and high flowability

The product
• Remodeling of the extracellular matrix in terms of
elasticity and support thank to the multi layer
action
The BAP Technique

The technique

+
The product

The perfect hybrid

 Treated area
Malar & submalar areas – BAP Technique

Baseline 1 month after • 29G 13mm

2nd treatment needle
• 1 ml per side
• 2 treatments
Courtesy of Dr. Emma Ravichandran, Glasgow - Scotland • 4 week interval
 Treated area
Neck
 Bolus technique +
 Cannula

Baseline 1 month after • 25G 50mm cannula

2nd treatment • 29G 13mm needle
• 2 ml per side
• 2 treatments
Courtesy of Dr. Patrizia Piersini, Turin - Italy • 4 week interval
 Treated area
Inner arm
 7 points technique

Baseline 1 month after • 29G 13mm

2nd treatment needle
• 2 ml per side
• 0.2-0.3 ml
Courtesy of Dr. Bruno Bovani, Perugia - Italy bolus
• 2 treatments
 Treated area
Hands
 Cannula, fanning

• 25G 50mm cannula

Baseline 1 month
• 2 ml per side
after
• 2 treatments
2nd
Courtesy of Dr. Giovanni Salti, Florencetreatment
- Italy • 4 week interval
 Redefinition of mandibular contour and neck
remodeling Mandibular contour
• Aliaxin EV
• Fanning technique
• 22G 60mm cannula
• 1 ml per side
• Touch-up after 4
weeks if necessary
Neck
• Profhilo
• Fanning technique
• 25G 50mm cannula
• 1 ml per side
Baseline 1 month • 2 treatments
after • 4 week interval
2nd
Courtesy of Prof. Daniel Cassuto, Milan - Italy
and Dr. Irfan Mian, London - UK
treatment
Facial remodeling and cheeckbone enhancement
Zygomatic area
volume/contour
• Aliaxin GP
• Bolus deep on
periosteum
• 27G 19mm needle
• 1 ml per side
• Touch-up after 4 weeks
if necessary
Malar/submalar
remodeling
• Profhilo
Baseline 1 month after • BAP technique
2nd treatment • 29G 13mm
needle(inside)
Courtesy of Dr. Sharon Davidson, Tel Aviv - Israel
• 1 ml per side
 Profhilo for
subcutaneous
tissue
restoration
before
treatment with
Aliaxin
Baseline 1 month
after
2nd
treatment
Courtesy of Dr. Daniel Cassuto, Milan - Italy
NECK APPROACH
 To rejuvenate the
neck a multi-modal
approach should be
considered to provide
the optimal results
Patient

• Characteristics
Before • Requests/Needs
Photo
• Considerations
 PARAMETER USED TO EVALUATE THE NECK
PARAMETER TO BE CONSIDERED

Necklace lines Platysmal bands Skin laxity

horizontal crease lines the platysma

etched into the contracts with aGe appear as fine lines
skin. They tend to which causes bluntinG that run
deepen and look more of the sharp Jawline
parallel to each other
noticeable and
with aGe and appear as as aGeinG proGresses.
vertical neck bands in
the first siGn of aGeinG. the area.

NECK APPROACH
 EVALUATION OF NECK
GROUP 1 GROUP 2 GROUP 3
ANAMNESI – NECK CLASSIFICATION

textural changes (increased textural changes (increased textural changes (increased

laxity) of the skin laxity) of the skin laxity) of the skin
with or without necklace with or without necklace with or without necklace
lines lines lines
platysmal bands and or loss
platysmal bands and or loss of jawline contour
of jawline contour

advanced skin
laxity/sagging.

MILD SEVERE
SKIN LAXITY SEVERITY

NECK APPROACH
 NECK APPROACH
GROUP 1 GROUP 2 GROUP 3
NECK CLASSIFICATION
APPROACH

PROFHILO BAP NECK PROFHILO (CANNULA)

PROFHILO – BAP NECK + +
BOTULIN TOXIN TYPE A BOTULIN TOXIN TYPE A

MILD
SEVERE
SKIN LAXITY SEVERITY

NECK APPROACH
PROTOCOL
PROTOCOL
 FACE London 2018 -10 minutes after live injection

Face
• Profhilo
• BAP technique
• 29G Needle
• 1 ml side

Neck
• Profhilo
• BAP technique
• 29G Needle
• 1 ml side

Courtesy of Dr. Gabriel Siquier-Dameto

 NECK APPROACH
- GROUP 2: BAP NECK + BOTULIN TOXIN -

1. Botulinum
Toxin Type A,
PROTOCOL

2. Profhilo BAP
(DAY 15)
3. Profhilo BAP
(DAY 45)
 NECK APPROACH
- GROUP 2: BAP NECK + BOTULIN TOXIN -

1. Botulinum
Toxin Type A,
PROTOCOL

2. Profhilo BAP
(DAY 15)
3. Profhilo BAP
(DAY 45)
 NECK APPROACH
- GROUP 3: PROFILO CANNULA + BOTULINUM -

1. Botulinum Toxin
Type A,
PROTOCOL

2. ProfHilo Cannula
(DAY 15)
3. ProfHilo Cannula
(DAY 45)

Pictures courtesy of Dr. Gabriel Siquier-Dameto

 NECK APPROACH
- GROUP 3: PROFILO CANNULA + BOTULINUM -
Courtesy A. Tateo

NECK APPROACH
Methods
 RESULTS
All participants tolerated the procedure well, without bruising, asymmetry, ptosis, surface
nodules, or other complications. The combined product that was massaged locally
immediately after injection blended smoothly into the treatment areas (Figures 6 and 8).
Botulinum toxin, when given in combination with filler in this small population, appeared to
take hold as rapidly (3–5 days) and robustly as historical rates of product onset when given
alone, without evidence of “drift” into undesired areas (Figures 7 and 9). Study
participants were all pleased with their results both immediately post-treatment and
throughout the 2-month observation period.
COMMENT
The application of safe and effective nonsurgical cosmetic treatments, particularly with
injectable shaping agents such as HA and BNT, has increased substantially over the last
decade. With more collective experience and as more is learned about the anatomy of the
aging face, more sophisticated and innovative methods for delivering these products have
developed, resulting in less downtime and improved outcome. Hyaluronic acid and BNT
are now routinely injected into similar locations of the face to optimally address the
needs of the aging face.In addition to the complementary actions of these products, data
are emerging to suggest that the combination of HA and BNT may actually result in
synergism of effects, with both products lasting longer than when compared to individual
administration, an issue of considerable importance to patients.
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Mesobotox
BY DR SARAH TONKS / 01 AUG 2014

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Dr Sarah Tonks explores the alternative use of botulinum toxin to achieve

whole-face rejuvenation

Botulinum toxin has been widely used for facial rejuvenation. Today it is
common for practitioners to treat the whole face with the toxin, rather than
confining it to individual areas. The traditional discord seen when the upper face
is successfully treated and the hyperkinetic lower is left untreated is now

https://aestheticsjournal.com/feature/mesobotox Tel: 0203 096 1228 Fax: 01268 754429

Email: [email protected]
 Mesobotox and HA in the same syringe?
New published Technique.
Dr Sarah Tonks explores the alternative use of botulinum toxin to achieve
whole-face rejuvenation.
Botulinum toxin has been widely used for facial rejuvenation. Today it is
common for practitioners to treat the whole face with the toxin, rather than
confining it to individual areas. The traditional discord seen when the upper face
is successfully treated and the hyperkinetic lower is left untreated is now
increasingly recognized as a failure of aesthetic result — the disharmony of the
face is a certain giveaway of cosmetic intervention. It is our job to educate
patients about the use of toxins and other rejuvenation procedures in the mid-
face, lower-face, neck and décolletage, as this is something not often covered in
the media and patients may be unaware of the options. In order to achieve this
whole-face, global change we can use a technique of dilute botulinum toxin,
judiciously placed in specific areas.
“Mesobotox” is a term coined for the application of botulinum toxin by papule
needle injection into the dermis of the skin.
Often these toxins are more dilute than those traditionally used for treating areas such as
the glabellar, and in some cases mesotherapy products such as hyaluronic acid, are added
to the mixture.
It is theinjection not of specific muscles, but the treatment of large areas of dermis with
dilute botulinum toxin.
Mesobotox has four advantages and can be used successfully in people of all skin types.
1. Botulinum toxin has been shown to decrease sebum production and improve acne, so
can be used in oily and sebaceous skins.
2. Botulinum toxin can be used to improve older skins with fine lines and wrinkles by
diminishing the pull of the facial depressors, resulting in an improvement of the facial
contour.
3. Botulinum toxin blocks production of eccrine sweat glands which can give a
smoother appearance of the skin.
4. The addition of mesotherapy products can produce an additional benefit to the health
of the skin.
The facial muscles are classified into levators (frontalis, zygomaticus major and
minor, levator labii superioris, alequai nasa, anguli oris) and depressors (procures,
corrugator supercilii, orbicularis oculi, platysma, depressor anguli oris, depressor
labii inferioris).
Levators and depressors are balanced in younger people but with ageing, this balance
shifts towards the depressors. By injecting into the dermis, rather than a muscle, we
can reduce the strength of the depressors.

This works because the facial muscles insert onto the skin rather than onto bone, so
when toxin is injected into the dermis it blocks the superficial fibres of the muscle
inserted into the skin. Intradermal injection is suitable for flat, sheet like muscles rather
than muscle bundles. It can be used where the skin is lax with poor tone. A flat, thin
muscle, like platysma, has a medium motor endplate concentration whilst a short, thick
muscle, such as corrugator, has a high concentration of motor endplates near the point
of injection, influencing the choice of concentration used for the injections.6

In a study of 275 patients selected for cheek droop and mid-cheek groove, 24.9%
attained high improvement with the cheeklift, softening of the nasolabial folds and
redefining of the facial contour.
 Technique

Injection pattern and reconstitution vary according to the issue needing treatment
and a practitioner’s clinical judgement. To prepare the skin, it is first cleaned with
chlorhexidine while anatomical landmarks and injection points are marked up, if
lifting the mid-face. For oily skin I use Azzalure, reconstituted with 130 Speywood
units bacteriostatic saline, mixed with 1ml non crosslinked HA, applied via a bevel
up superficial nappage technique to the dermis using a 32g, 6mm (TSK) needle,
causing a blanching effect in the skin.
Points are placed approximately 5mm apart and areas with excessive oiliness, such as
the T-zone, are targeted.
For drier areas of skin on the oily face, the remaining 2ml mesotherapy product is
used plain, without the addition of toxin unless facial sculpting is indicated. Areas
such as the cheeks, neck, hands and décolletage can be targeted. The patient is
reviewed at two weeks and the treatment can be repeated if indicated. If not, the
patient undergoes a further four mesotherapy treatments using the non
crosslinkedHA alone, in order to derive the maximum benefits from mesotherapy.
For the platysma the first row starts from the TMJ down the mandibular joint at 1cm
intervals. The second row is placed 1cm superiorly to this with the injection points between
the ones beneath.
The lateral orbicularis oculi injections are made across the lateral border of the
muscle in the temporal area, as seen in figure 1. Each injection placed in the
superficial dermis should cause blanching of approximately 3-4mm diameter.

Figure 1

Figure 1. Reproduced from ‘Midface lifting with botulinum toxin: intradermal

technique’, Journal of Cosmetic Dermatology 2009;8:312-6. C Petchnagaovilai.
 Figure 4

Figure 4. Reproduced from ‘The wrinkles soothing effect on the middle and lower
face by intradermal injection of botulinum toxin type A’, International Journal of
Dermatology 2008; 47:1287- 1294. SH Chang, HH Tsai, WY Chen, WR Lee, PL Chen.