Combination Therapy SOP — Dermal Filler - Newcastle Cosmetic Doctor

1. Purpose & Scope

Define evidence‑based protocols for combining dermal fillers (HA/CaHA) with botulinum toxin, lasers, radiofrequency (including RF microneedling), MFU‑V/HIFU, threads, PRP/PRF, and skin‑quality HA, in compliance with Australian regulation and governance.¹ ² ³ ⁴

2. Clinical Rationale for Combination Therapy

Multimodal plans address muscle tone, structure, collagen stimulation, and skin quality. Coordinated sequencing improves durability and natural outcomes; incorrect timing (especially thermal devices over fresh HA) risks swelling and accelerated hyaluronan breakdown.⁵ ⁶ ⁷ ⁸

3. Treatment Sequencing Protocol (safe default)

Botulinum toxin first; allow 7–14 days to settle dynamic vectors before filler.
Structural fillers (HA/CaHA) at deep planes (bone/deep fat), then contour blending.
Threads (if used) before superficial filler refinements; let vectors integrate 2–4 weeks.
Energy-based devices (EBD): MFU-V/HIFU before filler or ≥2 weeks after; non-ablative lasers/IPL before filler or ≥1–2 weeks after; fractional RF/RF-MN before filler or ≥2–4 weeks after; ablative fractional lasers before filler or ≥2–4 weeks after.
Skin-quality HA boosters after EBDs (1–2 weeks) or in separate planes; avoid immediate heat over recent injections.
PRP/PRF in separate planes same day or ≥1–2 weeks apart; space if uncertain.

Key sources: ⁶ ⁷ ⁸ ⁹ ¹⁰ ¹¹

4. Combination Treatment Timing Matrix

Pairing	Same day?	Safer sequence & minimum gap	Rationale / sources
BoNT‑A ↔ HA/CaHA	Yes (prefer staged)	BoNT‑A → 7–14 d → filler	See ⁶
MFU‑V/HIFU ↔ HA	Avoid over fresh HA	MFU‑V/HIFU before or ≥2 w after filler	See ⁶
Non‑ablative laser/IPL ↔ HA	Laser first if same day	Laser → same day filler or filler → wait ≥1–2 w	See ⁷ ⁸
Fractional RF / RF‑MN ↔ HA	No (over fresh HA)	RF before or wait ≥2–4 w post‑filler	See ⁷ ⁹
Ablative fractional laser ↔ HA	No	Laser before or wait ≥2–4 w	See ⁷
Threads ↔ HA	Not in same plane	Threads → wait 2–4 w → filler	See ¹² ¹⁵
PRP/PRF ↔ HA	Yes (sep. planes)	Separate planes same day or ≥1–2 w	See ⁹
Skin‑quality HA ↔ EBDs	Yes (spaced)	EBD first → 1–2 w → booster	See ¹⁰ ¹¹

5. Contraindications & Risk Mitigation

Do not run thermal devices (RF/ablative lasers) over fresh filler in the same session.
Do not mix injectables in the same syringe; maintain sterile technique; change needles/cannulas between products/planes.
Use ultrasound to confirm planes in high‑risk zones and post‑device sequencing; save screenshots to the record.
Defer treatment in areas of active inflammation/infection; address dental/ENT issues first.
Record product batch/expiry/ARTG (and UDI where available) and the exact treatment sequence in the note.

Key sources: ⁷ ⁸ ¹ ² ¹⁴

6. Management of Complications

Vascular compromise: stop; massage; warm compress; flood hyaluronidase across the ischaemic field (repeat to reperfusion); escalate per occlusion SOP.
Visual symptoms: follow RANZCO pre‑hospital pathway immediately (call 000; urgent ophthalmology).¹⁸
Post‑device inflammatory swelling with filler: ultrasound to localise HA; consider low‑dose US‑guided hyaluronidase (5–30 IU foci); staged review.⁷ ¹⁰
Report significant device/product adverse events via TGA MDIR/IRIS; log under NSW Health PD2020_047.² ¹⁴

7. Clinical Governance (Australia 2025)

Ahpra: non‑surgical cosmetic procedure + higher‑risk advertising rules now in force.
TGA: no public advertising of S4 injectables; ensure ARTG inclusion and capture UDI where applicable.²
RACGP + ACSQHC/NSQHS: apply IPC and safety/quality standards to injectables & device workflows.³ ⁴
NSW Health: record incidents and corrective actions (PD2020_047).¹³

8. Documentation & Audit

Consent per modality; treatment map with planes/entry points; device parameters (fluence, pass count, stack, depth); product details (brand/line, batch, expiry, ARTG, UDI if applicable); sequence and intervals; pre/post photos; ultrasound images if used.
Quarterly audit: case mix, sequences used, complications, corrective actions; check advertising compliance.⁴

Sources

Ahpra (2025) Performing non‑surgical cosmetic procedures — Guidelines hub., viewed 04 November 2025, https://www.ahpra.gov.au/Resources/Cosmetic-surgery-hub/Cosmetic-procedure-guidelines.aspx ↩
TGA (2025) Advertising health services & cosmetic injections — FAQs (incl. 2024 PDF)., viewed 04 November 2025, https://www.tga.gov.au/products/regulations-all-products/advertising/specialised-advertising-issues-and-topics/advertising-health-services-and-cosmetic-injections-frequently-asked-questions-and-answers ↩
RACGP (2024) Infection prevention & control guidelines (office‑based)., viewed 04 November 2025, https://www.racgp.org.au/running-a-practice/practice-standards/racgp-infection-prevention-and-control-guidelines ↩
ACSQHC/NSQHS (2nd ed., upd. 2021) National Safety and Quality Health Service Standards., viewed 04 November 2025, https://www.safetyandquality.gov.au/sites/default/files/2021-05/national_safety_and_quality_health_service_nsqhs_standards_second_edition_-_updated_may_2021.pdf ↩
Cartier H. et al. (2020) Combined BoNT‑A + HA + skin‑quality HA: outcomes vs monotherapy. Dermatol Surg. (OA summary), viewed 04 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC7147415/ ↩
Carruthers J. et al. (2016) Consensus on integrated aesthetic treatments (BoNT‑A, HA/CaHA, MFU‑V). Dermatol Surg., viewed 04 November 2025, https://pubmed.ncbi.nlm.nih.gov/27100962/ ↩
Hsu SH. et al. (2019) Histology of fractional lasers/RF over HA fillers; timing implications. Lasers Surg Med., viewed 04 November 2025, https://europepmc.org/article/med/30570514 ↩
Urdiales‑Gálvez F. et al. (2019) Combining lasers and HA fillers: literature review. (OA), viewed 04 November 2025, https://europepmc.org/article/pmc/pmc6742610 ↩
Yi KH. (2024) Thermal degradation of HA; RF temperature ranges & safety windows. Aesthetic Plast Surg (OAEPublish)., viewed 04 November 2025, https://www.oaepublish.com/articles/2347-9264.2024.119 ↩
Humphrey S. et al. (2025) Integrating VYC‑12L with EBDs for skin quality — consensus. ASJ Open Forum (OA)., viewed 04 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC12287879/ ↩
Rosso P. et al. (2025) Sequential low‑crosslink HA for skin quality (RHA1/R1). Aesthetic Surgery Journal., viewed 04 November 2025, https://academic.oup.com/asj/article/45/10/1051/8161339 ↩
Moon H. (2021) Combined fillers, threads, BoNT‑A — review & recommendations. J Cutan Aesthet Surg., viewed 04 November 2025, https://journals.lww.com/jcas/fulltext/2021/14020/a_review_on_the_combined_use_of_soft_tissue.2.aspx ↩
NSW Health (2020) Incident Management Policy PD2020_047., viewed 04 November 2025, https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2020_047.pdf ↩
TGA (2025) Medical device adverse event reporting (IRIS/MDIR) and UDI hub (AusUDID)., viewed 04 November 2025, https://www.tga.gov.au/how-we-regulate/manufacturing/manufacture-medical-device/unique-device-identification-udi-hub ↩
Wan J. (2025) HA filler with PDO threads — 1–2 y series. J Cosmet Dermatol (OA/PMC)., viewed 04 November 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC11845956/ ↩
RANZCO (2024) Filler Blindness Guidelines — Pre‑hospital Pathway., viewed 04 November 2025, https://ranzco.edu/wp-content/uploads/2024/06/RANZCO-Filler-Blindness-Guidelines_2024.pdf ↩

Disclaimer for Newcastle Cosmetic Doctor Policies & Procedures

The policies and procedures contained within this document are the exclusive property of Newcastle Cosmetic Doctor and are provided for internal clinical governance and educational purposes only. These materials represent the internal operational framework, safety standards, and evidence-based protocols developed and implemented by Dr. Bart John Scanlon and the Newcastle Cosmetic Doctor team. They are designed specifically for use within Newcastle Cosmetic Doctor and reflect our clinic’s own professional standards, risk assessments, and compliance obligations under Australian law and regulatory authorities. External individuals, practitioners, or organisations must not copy, reproduce, distribute, or rely upon these materials, in whole or in part, for their own clinical, commercial, or educational use without prior written consent from Newcastle Cosmetic Doctor. These materials do not constitute medical, legal, or professional advice and are not intended to be adopted as official protocols or procedures by any other entity. Any external use or adaptation must be independently reviewed and modified to meet the relevant laws, guidelines, and standards applicable to the user’s own jurisdiction, scope of practice, and facility operations. Newcastle Cosmetic Doctor and Dr. Bart Scanlon accept no liability for any loss, injury, or damage arising from the unauthorised use, reliance upon, or misinterpretation of this material.

Combination Therapy SOP — Dermal Filler