Pain associated with injection of botulinum A exotoxin reconstituted using isotonic sodium chloride with and without preservative: a double-blind, randomized controlled trial

Selection and preference for botulinum toxins in the management of photoaging and facial lines: patient and physician considerations

Various noninvasive to minimally invasive techniques can be used for the improvement of cutaneous changes seen with photoaging. These include dermabrasion, chemical peels, ablative and nonablative lasers, and filler agents such as hyaluronic acid. However, the most common nonsurgical cosmetic procedure performed in the treatment of rhytides is injection with botulinum toxin. Its extensive safety history and relative ease of use by the practitioner has led to high satisfaction in millions of patients. Nonetheless, proper training of the fundamentals in injection technique, the choice of the appropriate candidate, and knowledge of potential adverse events are imperative to ensure a satisfactory and safe outcome.

Botulinum toxin type A for the management of glabellar rhytids

There is an increasing demand for minimally-invasive cosmetic procedures to arrest the aging process. Botulinum toxin type A injections are the most commonly used nonsurgical cosmetic procedures in the United States. There has been research spanning over two decades dedicated to safety, efficacy, dosing, and complications of botulinum toxin type A. There are now two Food and Drug Administration (FDA) approved botulinum toxin type A options in the United States: Botox(®) and Dysport(™), with new advances being made in the field.

Botulinum toxin type A injection without isopropyl alcohol antisepsis

PURPOSE

To evaluate the infection rate after botulinum toxin type A injection without the use of isopropyl alcohol antisepsis. Isopropyl alcohol 70% solution has been used for routine skin preparation prior to botulinum toxin injection for decades; however, alcohol antisepsis does not routinely sterilize the skin, and it may not reduce the injection site infection rate.

METHODS

The authors performed a retrospective analysis of patients undergoing botulinum toxin type A injection without the use of isopropyl alcohol antisepsis from one surgeon from October 1999 through December 2004. Charts were reviewed for patient age, gender, indication, total number of visits, total number of needles, total number of injections, and complications attributable to infection.

RESULTS

One hundred forty-two patients underwent botulinum toxin type A injection without isopropyl alcohol antisepsis during the study period. Patients underwent a total of 11,627 injections during the study period. Average number of visits was 6 (range, 1-25 visits). Average follow-up was 707 days (range, 7-2,165 days). No patient receiving botulinum toxin type A injection without isopropyl alcohol antisepsis sustained a local complication consistent with infection.

CONCLUSIONS

Injection of botulinum toxin type A reconstituted with preserved saline results in an extremely low rate of infection.

The five D's of botulinum toxin: doses, dilution, diffusion, duration and dogma

The purpose of this review is to update cosmetic dermatologists and surgeons on the latest information about botulinum toxin injections for the treatment of the face and neck and to provide a practical guide to effective and safe technique. We review indications, recommended doses and dilutions, storage recommendations and injection techniques.

Botulinum toxin: description of injection techniques and examination of controversies surrounding toxin diffusion

The benefits derived from botulinum toxin (BTX) injections may be negated by unintentional weakness of adjacent uninjected muscles. Such weakness may be the result of inaccurate targeting, or diffusion of BTX to surrounding muscles. Several techniques, using electromyographic, endoscopic or imaging guidance are purported to increase the accuracy of targeting. Diffusion of BTX is thought to be influenced by factors such as dose, concentration, injectate volume, number of injections, site and rate of injection, needle gauge, muscle size, muscular fascia, distance of needle tip from the neuromuscular junction, and protein content of the BTX formulation. This article describes techniques that aim to increase the accuracy of BTX injections and examines the controversies surrounding diffusion of BTX following injection.

Botulinum neurotoxins: fundamentals for the facial plastic surgeon

The most commonly performed nonsurgical cosmetic procedure in the facial plastic surgery armamentarium involves the various commercial preparations of botulinum neurotoxins. These drugs have undergone a transformation from public health scourge to near ubiquitous therapeutic modality across the entire medical spectrum. Herein, the history of botulinum neurotoxins is reviewed, including an exploration of their pharmacology, neuromuscular junction physiology, a description of the commercially available preparations, and the recent research concerning the practicalities of their clinical use.

Efficacy of skin cooling and EMLA cream application for pain relief of periocular botulinum toxin injection

PURPOSE

To investigate the efficacy of EMLA cream and local dry cold application for pain relief before periocular botulinum toxin injection, and to compare these two methods.

METHODS

In this prospective study, 40 patients underwent bilateral periocular botulinum injections for blepharospasm treatment or wrinkle reduction. Patients were divided into three treatment groups. In the first group (n = 12), cold was applied to the periocular area on one side before injection; the other side served as the control. In the second group (n = 12), topical anesthetic cream (EMLA) was applied to one side and the other side served as the control. In the third group (n = 16), cold was applied to one side and EMLA was applied to the other side. A visual analog scale was used for pain intensity, and patients in the third group were asked which treatment they preferred.

RESULTS

In the first group, the average pain score on the side where cold was applied was 3.00 +/- 1.70, whereas it was 5.83 +/- 1.40 on the control side (p < 0.001). In the second group, the average pain score on the side receiving EMLA was 3.25 +/- 1.86, and on the control side was 5.83 +/- 1.89 (p < 0.001). In the third group, the average pain score was 3.18 +/- 1.68 for the EMLA side and 3.12 +/- 1.31 for the cooled side (p > 0.05); nine of the 16 patients (56.2%) preferred EMLA.

CONCLUSIONS

Skin cooling and EMLA applications significantly decrease the pain associated with periocular botulinum toxin injections. Clinically or statistically significant difference in pain scores between the two methods was not noted. Patients had a slight preference for EMLA cream over skin cooling.

A Pilot Study on the Effect of Epinephrine on Botulinum Toxin Treatment for Periorbital Rhytides

BACKGROUND

Relaxation of hyperactive facial muscles by injection of botulinum toxin type A (BOTOX, Allergan Inc., Irvine, CA) represents the most common cosmetic procedure performed in the United States.

OBJECTIVE

The objective of this split-face randomized double-blind study was to determine the effect of epinephrine (EPI) on the efficacy of BOTOX treatment of muscle hyperactivity in the upper face.

MATERIALS AND METHODS

Fourteen subjects (ages 39-57 years) with moderate to severe periorbital rhytides were enrolled. Study patients were blinded to the two treatment arms, BOTOX and BOTOX plus EPI 1:100,000. Subjective and objective evaluations were performed at 0 and 4 days and 1, 3, and 6 months, and clinical improvement was assessed using a nominal scale from 0 to 4, corresponding to 0, 1% to 25%, 26% to 50%, 51% to 75%, and 76% to 100% improvement, respectively. The incidence of adverse events was also recorded. RESULTS Fourteen subjects with moderate to severe periorbital rhytides were treated with BOTOX or BOTOX plus EPI. One subject was discontinued from the study after receiving asymmetric doses of BOTOX. At 4, 30, and 90 days after treatment, subjective and objective improvement scores revealed that EPI enhanced the efficacy of BOTOX when compared to BOTOX alone. By 3 months, the effect of BOTOX and BOTOX plus EPI had peaked and continued to fall through 6 months. One of 14 patients did not appear to respond to BOTOX treatment. Both treatments were well tolerated with no serious adverse events.

CONCLUSION

To our knowledge, we are the first to test under randomized double-blind conditions the effect of EPI on efficacy of BOTOX. Our data suggest that addition of EPI may accelerate the rate of onset as well as the short-term efficacy of BOTOX for treatment of periorbital rhytides.

Complications With the Use of Botulinum Toxin Type A for Cosmetic Applications and Hyperhidrosis

In dermatology, botulinum toxin is now most often used to reduce dynamic facial creases and treat primary focal hyperhidrosis. The exemplary safety record of this medication is such that after nearly 2 decades, it is not known to have any long-term adverse events. Transient adverse events, such as mild injection pain, are typically minor and spontaneously remitting. Headache, nausea and flu-like symptoms, lid and brow ptosis after upper face injection, lower face asymmetry after perioral injection, and fine motor impairment after palmar injection are uncommon to rare. Understanding of anatomic landmarks and site-specific precautions can further mitigate the incidence of unwanted effects. Patients who do experience uncommon, transient effects can be reassured that these are not dangerous and will resolve completely without intervention.

Efficacy of Botulinum Toxin Type A After Topical Anesthesia

PURPOSE

To determine whether the use of topical anesthesia has an impact on botulinum toxin type A (BTX-A) efficacy.

METHODS

Forty patients (20 receiving BTX-A for facial cosmetic rhytid reduction and 20 for benign essential blepharospasm) were evaluated in a double-blind, randomized, triple-crossover study at 2.5- to 4.5-month intervals. The discomfort and efficacy of BTX-A injections after betacaine application to half the face (random assignment) were compared against the discomfort and efficacy of a placebo ointment on the other half of the face. This was followed by cryoanalgesia to the entire face.

RESULTS

Patients ranged from 27 to 81 years of age (mean, 53 years), and 34 were female. Of the 120 total injection comparisons, a better BTX-A effect on one side of the face was reliably identified by 80% and 77% of blepharospasm and cosmetic patients, respectively, with the placebo-treated side providing better BTX-A effect approximately 90% of the time (p < 0.001). Patients reported a more painful side during injection in just 18 of the 120 trials, and only 1 of 40 patients believed the administration of analgesia was worth the trouble.

CONCLUSIONS

Pretreatment with topical betacaine followed by skin cooling seems to have a deleterious impact on BTX-A effect without a significantly beneficial patient-perceived reduction in injection discomfort.

Sterility assessment of multiple use botulinum A exotoxin vials: A prospective simulation

BACKGROUND

A preponderance of evidence now indicates that storage of reconstituted botulinum toxin solution for longer than the 4 hours recommended by the manufacturer does not result in loss of effectiveness.

OBJECTIVE

Then purpose of this study was to assess whether serial re-extraction of reconstituted botulinum toxin solution from vials undergoing prolonged storage is associated with increased risk of microbial contamination.

METHODS

Consecutive 100-U vials of botulinun A exotoxin were reconstituted with 2.5 mL each of normal saline with preservative (benzyl alcohol). Within 1 week after reconstitution, each vial was used to treat 1 to 3 patients, for a total of 60 to 80 U used. Thereafter, each vial was stored in a plastic kidney basin in an unlocked, multiuse medication refrigerator. Two weeks later, a randomly assigned nurse removed the vial from the refrigerator and withdrew and discarded 0.1 mL (5 U) using the same technique used for therapeutic extractions. Iterations of this withdrawal and discarding procedure were continued until a 0.1-mL aliquot could not be withdrawn without prying off the metal cover. Once this threshold was reached, the vial was sent to the microbiology laboratory for sterility testing using a thioglycolate broth.

RESULTS

In all, 127 vials were handled per protocol. On average (mean), vials underwent 4.5 access procedures, including 1.6 therapeutic extractions for a total of 76 U removed during a period of 7 weeks. Sterility analysis with thioglycolate broth indicated no evidence of contamination.

LIMITATIONS

Preservative-containing saline was used for reconstitution.

CONCLUSION

Routine refrigerator storage of medication vials containing reconstituted botulinum toxin does not result in microbial contamination of the contents even after serial re-extraction of solution from these vials, and after handling of such vials by multiple personnel. Storage and subsequent reuse of botulinum toxin appears safe for at least 7 weeks after reconstitution.

Pain Sensation during Intradermal Injections of Three Different Botulinum Toxin Preparations in Different Doses and Dilutions

BACKGROUND

Pain sensation associated with injections of botulinum neurotoxin (BoNT) is commonly reported. To date differences in pain sensation between the commercially available products containing BoNT have not been quantified.

OBJECTIVES

The pain sensations during injection of Dysport, Botox, Neurobloc, and pure saline (control) were compared. In addition, the nociceptive effect of different volumes used for the dilution of the same BoNT dose was investigated.

METHODS

In a prospective, double-blind, controlled trial, 10 healthy subjects were injected intradermally with Dysport (12 U), Botox (3 and 4 U), Neurobloc (150 and 300 U) reconstituted in 0.9% saline, and pure saline. Pain sensation was quantified during injections.

RESULTS

Neurobloc injections caused significantly more injection pain than Botox, Dysport, and saline. No significant differences between Dysport, Botox, and saline were found, although there was a trend toward less pain with pure saline injections. Higher pain levels with higher volumes could not be demonstrated significantly.

CONCLUSION

Our data demonstrate that BoNT type B injections are associated with substantial pain. There is a considerable difference between the commercially available BoNT type B compared to the two BoNT type A preparations. Therefore, considering mitigation of injection pain seems necessary when using BoNT type B.

Does Laser Inactivate Botulinum Toxin?

BACKGROUND

Botulinum toxin is a popular and effective treatment for dynamic rhytids. It is a neurotoxic protein complex that exerts its effect by inhibiting acetylcholine release at the presynaptic neuromuscular junction. Nonablative resurfacing treatments have also become well liked by patients and physicians owing to the minimal downtime associated with treatment. Currently, same-day nonablative laser treatments are performed prior to botulinum toxin injection owing to the concern that the laser may inactivate it. On occasion, it may be desirable to perform nonablative laser after the botulinum toxin has been injected (ie, patient afterthought, scheduling concern).

OBJECTIVE

To determine whether the use of nonablative rejuvenation laser or intense pulsed light (IPL) immediately following botulinum toxin injections has any effect on the efficacy of the botulinum toxin treatment.

METHODS

Nineteen subjects received botulinum toxin injections to either the glabellar or crow's-feet areas. One side of the treated glabellar or periorbital area was treated with either VBeam laser (Candela, Wayland, MA, USA), SmoothBeam laser (Candela), CoolGlide laser (Cutera, Brisbane, CA, USA), or an IPL or radiofrequency (RF) device within 10 minutes of botulinum toxin injection. Pretreatment and 2-week post-treatment photographs were compared.

RESULTS

No decrease in the efficacy of botulinum toxin denervation was observed when glabellar or perioral areas were treated with VBeam laser, SmoothBeam laser, CoolGlide laser, or an IPL or RF device within 10 minutes of botulinum toxin injection.

CONCLUSION

Patients may be treated with several nonablative lasers and IPL or RF devices immediately after botulinum toxin injection without loss of efficacy or other apparent untoward effect.

Power and Sample Size of Therapeutic Trials in Procedural Dermatology: How Many Patients Are Enough?

BACKGROUND

Many new devices and therapeutic interventions are continually introduced in cutaneous surgery. The efficacy of these new techniques must be compared with that of preexisting standards so that patients can be appropriately counseled.

OBJECTIVES

The purpose of this article is to (1) review methods for estimating sample size and power, (2) estimate the range of sample sizes sufficient to ensure that true differences are not missed in clinical trials of new procedural dermatologic therapies, and (3) consider the reasons why the sample size may be too small in procedural dermatology trials and how this problem can be addressed.

METHODS

(1) Selective review of textbooks and other relevant literature, presentation of a brief tutorial describing sample size and power determination for therapeutic clinical trials comparing two groups with continuous outcomes variables; (2) implementation of standard formulae and assumptions to estimate sample size in cutaneous surgery therapeutic trials.

RESULTS

Assuming that one group receives a standard surgical intervention and another group undergoes a new technique, to identify a moderate difference in efficacy between groups, at least 50 to 200 subjects will need to be enrolled if conventional strategies are used to reduce the likelihood of finding a difference that does not really exist (Type I error), as well as the likelihood of missing a true difference (Type II error).

CONCLUSION

By face validity, it is apparent that most efficacy comparisons in procedural dermatology have low sample size and a concomitant risk of failing to detect actual differences between therapeutic arms. Owing to the limitations that restrict surgeons from frequently performing large randomized controlled trials in procedural dermatology, meta-analyses may be needed to pool the results of smaller studies. When it is critically important that differences between groups be accurately identified, dermatologic surgeons may consider eschewing smaller trials in favor of collaborating on larger trials with an adequate sample size.

Botulinum toxin in blepharospasm and oromandibular dystonia: comparing different botulinum toxin preparations

Amongst all regions of the body, the craniocervical region is the one most frequently affected by dystonia. Whilst blepharospasm--involuntary bilateral eye closure--is produced by spasmodic contractions of the orbicularis oculi muscles, oromandibular dystonia may cause jaw closure with trismus and bruxism, or involuntary jaw opening or deviation, interfering with speaking and chewing. Both forms of dystonia can be effectively treated with botulinum toxin injection. This article summarizes injection techniques in both forms of dystonia and compares doses, potency and efficacy of different commercially available toxins, including Botox, Dysport, Xeomin and Myobloc/NeuroBloc.

Reduced potency after refrigerated storage of botulitum toxin A: Human extensor digitorum brevis muscle study

To determine whether the potency of botulinum toxin A (BTA) decreases after being reconstituted with normal saline and stored in refrigerator, we injected one side of the extensor digitorum brevis muscle with 2.5 units of botulinum toxin A that had been immediately reconstituted with saline, and the contralateral side with identical material that had been reconstituted and stored in a refrigerator for preselected periods (1, 2, and 4 weeks) in 32 healthy volunteers. Mean compound muscle action potential amplitudes expressed as a percentage of the baseline amplitude were more reduced in sides injected with immediately reconstituted BTA than in sides injected with BTA stored for 1 week or more (P < 0.05). No bacterial growth was observed in any stored BTA samples. Storage of reconstituted BTA at low temperatures may affect the potency of the toxin. Therefore, the use of BTA after refrigerated storage is not recommended.

Interaction of botulinum toxin type A with local anesthetic agents: an experimental study with rabbits

Injection of botulinum toxin is a painful procedure, limiting the number of patients treated. This study was designed to establish whether infiltration of local anesthetics plays a role in the effectiveness of botulinum toxin. For the study, 24 New Zealand white rabbits were divided into three groups. In all three groups, local anesthetics (prilocaine, lidocaine, lidocaine, and epinephrine) were injected into the right anterior auricular muscle before a 2.5-U injection of botox A. The contralateral anterior auricular muscle of all the rabbits was injected with the same dose of the toxin to serve as a control. Photographic documentation was recorded; electromyographic study was performed; and results were statistically analyzed. The results show that local anesthetics do not play a role in the efficacy of botulinum toxin. Thus, the use of infiltrative local anesthetics before botulinum toxin injection is a safe method for achieving a less painful procedure for the patient.

Adverse event reporting for botulinum toxin type A

A recent article published in the Journal of the American Academy of Dermatology reviewed adverse events regarding botulinum toxin type A (BTX-A) reported to the Food and Drug Administration between 1989 and 2003. Although postmarketing surveillance is a vital mechanism to ensure drug safety, the events reported in this paper must be considered in context to be appropriately interpreted. The majority of data was related to therapeutic rather than cosmetic use. The proportion of serious adverse events was 33-fold higher for therapeutic use and no deaths were reported after cosmetic use. The data were derived from a spontaneous reporting system and do not include assessments of causality between the BTX-A and purported adverse events. The report notes that over a third of these events were related to off-label use of BTX-A, a common practice in dermatology, yet no significant differences were reported in rates of adverse events between on-label and off-label use. The report reflects a favorable safety profile for cosmetic use of BTX-A, and if misinterpreted, could lead to unreasonable conclusions regarding a product considered to be highly safe and effective.

Managing adverse events associated with botulinum toxin type A: a focus on cosmetic procedures

Botulinum toxin A (BTXA) has become a widely used drug in cosmetic dermatology, not only to treat focal hyperhidrosis but also hyperkinetic facial lines, platysma bands, décolleté bands, and other skin features. The spectrum of possible adverse effects of BTXA is broad but fortunately those that have been observed with cosmetic use of this product are generally mild and transient. The major tools for preventing adverse effects from BTXA are knowledge and skill. Use of correct injection techniques is mandatory since most unwanted effects are caused by incorrect technique. Knowledge of the target structures, e.g. the facial and extrafacial muscles, allows physicians to select the optimal dose, time and technique. The most common adverse effects are pain and hematoma. In the periocular region, lid and brow ptosis are important adverse effects. Adverse effects such as pain, hematoma, ecchymosis, and bruising may also occur in the upper and lower face and at extrafacial sites. Other possible adverse effects seen in other indications that the user of BTXA in cosmetic dermatology should be wary of include induction headaches and possible interaction with concomitant medications. Induction of neutralizing antibodies due to cosmetic BTXA treatment has not been observed. This article also outlines recommendations regarding use of BTXA. Of these, the most important for avoiding most unwanted adverse effects are the proper techniques of dilution, storage, and injection, as well as the careful exclusion of patients with any contraindications. Pain, hematoma, ecchymosis, and bruising can be prevented by cooling the skin before and after BTXA injection. Upper lid ptosis may be partly corrected using apraclonidine or phenylephrine eyedrops. If simple rules relating to the indications for and application of BTXA are followed, this is a safe and effective drug in cosmetic dermatology.

Evaluating effects of preservative-containing saline solution on pain perception during botulinum toxin type-a injections at different locations: a prospective, single-blinded, randomized controlled trial

Pain is a side effect of botulinum toxin type-A (BTX-A) injections. The efficiency of the preservative-containing saline solution used as the "dilution solution" for controlling the pain felt during multiple injections in different areas has been investigated by a prospective, randomized, single-blinded, controlled study. A total of 93 patients were divided into three groups for the study. All the patients were given BTX-A. Of these 93 patients, 60 received injections in the upper face, 15 in the neck, and 18 in the axillary regions. The visual analog scale (VAS), a single-dimension pain intensity rating scale, was used to evaluate pain perception. The average VAS values for pain sensation experienced by the groups were 1.2 of 10 points for the upper face area in the experimental group (n = 60) and 4.5 point for the control group. In the neck region (n = 15), the respective scores were 0.6 in the experimental group and 3.9 in the control group. Finally, in the axillary region (n = 18), the respective values were 0.9 and 5.1. The authors conclude that the preservative-containing saline solution significantly decreased pain perception during BTX-A injections (p = 0.000).

Complications of botulinum toxin A use in facial rejuvenation

The esthetic application of botulinum toxin type A (Botox) is a safe treatment modality; nevertheless complications can occur as a result of patient-and physician-related factors. Fortunately, adverse effects and undesirable sequelae after Botox injections are temporary. Complications may be more serious in patients who have more severe rhytids (which require more Botox), previous facial plastic surgery (altered anatomy), and those who have pre-existing neuromuscular disease. The physician can reduce complications by using proper injection techniques, appropriate regional Botox dosing, and by being conservative in the overall approach to Botox-mediated facial rejuvenation.

Evaluating the Effects of Ice Application on the Pain Felt During Botulinum Toxin Type-A Injections

The pain felt during botulinum toxin type-A injections and the troubled and distressed treatment it induces is common and well known for the patient and the doctor applying the treatment. This problem is further intensified on the patients who have needle phobia. The effect of ice application on the treatment zone before botulinum toxin type-A treatment on the pain felt during injections is investigated. Totally, 24 patients who underwent botulinum toxin type-A treatment in upper face region for esthetic purposes are included in the study. Ice was applied 5 minutes before the injections on the right lateral orbital zones (crow's feet area) of the patients, whereas on their left sides, toxin was injected without applying any ice. All the drugs were diluted by normal saline; 5 U of active botulinum toxin type-A was used in each diziem (0.1 mL). Total injection number was determined both in right and left areas as 8. Visual analog scale (VAS) was used for pain intensity and evaluation. On the side where ice was applied, the treatment was completed in 1 session and lasted shorter when compared with that of the control side. However, the average VAS values defining the pain that the patients felt in their right and left sides were found as 1.1 and 5.9, respectively. The clinical findings obtained indicated that pain is significantly reduced on the side where ice is applied. The statistical significance of the test results were evaluated by Student's t test, and the difference between VAS values was found statistically significant (P = 0.000).

Consensus recommendations on the use of botulinum toxin type a in facial aesthetics

The use of botulinum toxin type A for facial enhancement is the most common cosmetic procedure currently undertaken in the United States. Overall clinical and study experience with botulinum toxin type A treatment for facial enhancement has confirmed that it is effective and safe in both the short and long term. Nevertheless, consistent guidelines representing the consensus of experts for aesthetic treatments of areas other than glabellar lines have not been published. Therefore, a panel of experts on the aesthetic uses of Botox Cosmetic (botulinum toxin type A; Allergan, Inc., Irvine, Calif.) was convened to develop consensus guidelines. This publication comprises the recommendations of this panel and provides guidelines on general issues, such as the importance of the aesthetic evaluation and individualization of treatment, reconstitution and handling of the botulinum toxin type A, procedural considerations, dosing and injection-site variables, and patient selection and counseling. In addition, specific considerations and recommendations are provided by treatment area, including glabellar lines, horizontal forehead lines, "crow's feet," "bunny lines" (downward radiating lines on the sides of nose), the perioral area, the dimpled chin, and platysmal bands. The review of each area encompasses the relevant anatomy, specifics on injection locations and techniques, starting doses (total and per injection point), the influence of other variables, such as gender, and assessment and retreatment issues. Factors unique to each area are presented, and the discussion of each treatment area concludes with a review of key elements that can increase the likelihood of a successful outcome. Summary tables are provided throughout.

Dilution, storage, and electromyographic guidance in the use of botulinum toxins

Botulinim toxin A (BTX-A) is available commercially in two formulations: Botox (Allergan, Inc. Irvine, California) and Dysport (Ipsen Limited, Berkshire, United Kingdom). To use BTX-A successfully for cosmetic purposes, it is important to understand the basic principles of BTX-A therapy and the specific guidelines for its use, including dilution and storage. Injection using electromyographic guidance is helpful in achieving correct placement of BTX-A by locating the muscle responsible for a particular facial line.

Increased Patient Comfort Utilizing Botulinum Toxin Type A Reconstituted with Preserved Versus Nonpreserved Saline

PURPOSE

To demonstrate that injection of botulinum toxin type A is less painful when mixed with preserved saline compared with the suggested preservative-free saline reconstitution.

METHODS

Two different injections were compared on 20 patients who had prior botulinum toxin type A treatments. Each side was injected with toxin reconstituted with either preserved or nonpreserved (0.9%) saline. The investigators and patients were blinded, and outcome was assessed with a verbal scale. Clinical outcome was subjectively and informally assessed by patient questioning and physician observation.

RESULTS

Injection of botulinum toxin type A was noted to be less painful with the use of the preserved compared with the nonpreserved preparation (P<0.0001). The preserved reconstitution appeared to have no effect on clinical outcome.

CONCLUSIONS

Injection of botulinum toxin reconstituted with preserved saline is less painful than nonpreserved saline preparations.

Botulinum toxin A in the mid and lower face and neck

Botulinum toxins have been smoothing hyperkinetic lines in the upper face for over 15 years. More recently, their use has widened to include applications in the mid and lower face and neck to smooth, shape, and sculpt, blurring the line between science and art. Their use in the lower face, however, requires a thorough and detailed knowledge of not only facial and cervical anatomy, but also the complex interactions of muscles and the aesthetic and implications of a misplaced injection. Although proper patient selection and injection techniques do not guarantee optimal results, poor selection and techniques almost certainly guarantee disappointing results. In addition to its use as primary procedure, botulinum toxin is also an effective adjunct to other cosmetic procedures, enhancing and prolonging the benefits of surgery, soft tissue augmentation, and laser resurfacing.

Type A botulinum toxin in the upper aspect of the face

The use of botulinum toxin type A (BTX-A) for facial rejuvenation was first systematically developed by Carruthers and Carruthers on the upper aspect of the face. In the early 1990s, the first studies of the cosmetic use of BTX-A were published. BTX-A was only approved in 2002, however, by the U.S. Food and Drug Administration when extensive cosmetic studies were evaluated. The treatment of facial wrinkles with BTX-A has truly changed the concepts held by physicians regarding facial rejuvenation, mainly on the upper aspect of the face. It is one of the most common cosmetic procedures currently performed by physicians.

Botulinum toxin A: its expanding role in dermatology and esthetics

The use of botulinum toxin A in cosmetic dermatology has increased in popularity due to the efficacy and relative safety of the treatment. Botulinum toxin A is one of eight exotoxins produced by Clostridium botulinum, a Gram-positive, spore-forming anaerobe. Flaccid paralysis results from the denervation of muscle fibers at the neuromuscular junction after botulinum toxin A administration. While treating blepharospasm, the Carruthers incidentally found that botulinum toxin A improved glabellar frown lines. Dynamic rhytides occur in areas of dynamic motion. These types of lines may be improved with botulinum toxin A. There are two types of botulinum toxin A commercially available (BOTOX and Dysport); only BOTOX is currently available in the US. The efficacy and tolerability of BOTOX was best demonstrated with a multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines in 264 patients. There was a significantly greater reduction in glabellar line severity with BOTOX. The effect was maintained for the duration of the study (120 days). There was low occurrence (5.4%) of mostly mild blepharoptosis in the BOTOX group. In another prospective study, it was found that about 1% of BOTOX patients reported severe headache. Botulinum toxin A can provide an alternative treatment of palmar and axillary hyperhidrosis when options such as topical agents (aluminum chloride) and iontophoresis have failed.

Cosmetic uses of botulinum toxins for lower aspects of the face and neck

The ability of botulinum toxin A (BTX-A) to improve the appearance of facial lines was first reported among patients who had been receiving injections for facial dystonias or surgical procedures. Since that time, there has been very extensive use of this treatment for relaxation of a wide variety of facial muscles and also for platysmal lines of the neck. Considerable experience over the last decade or longer confirms the safety and efficacy of BTX-A in the treatment of upper facial lines. BTX-A has been used also lower facial indications, but published papers are mainly uncontrolled observations on patients. Unlike the placebo-controlled studies on the upper face, there is a lack of controlled studies for lower face and neck BTX-A treatment. This article will summarize the use of BTX-A for the lower face and its role as combination treatment. Examples of combinations that may be used with BTX-A resurfacing, nonablative skin rejuvenation and skin fillers. Although little used at present, Botulinum Toxin B will be briefly discussed.

Periocular botulinum toxin

Botulinum toxin type A (BOTOX, Dysport) has revolutionized treatment of wrinkles around the eyes. Since the first publications of its cosmetic benefit by Drs. Jean and Alastair Carruthers, hundreds of articles have been published about its cosmetic use. BOTOX holds U.S. Food and Drug Administration approval in the United States for treatment of glabellar lines. BOTOX is in widespread use worldwide and is currently the most popular cosmetic treatment in the United States.

Complications of botulinum toxin A use in facial rejuvenation

The esthetic application of botulinum toxin type A is a safe treatment modality; nevertheless, complications can occur as a result of patient- and physician-related factors. Fortunately, adverse effects and undesirable sequelae after Botox injections are temporary. Complications may be more serious in patients who have more severe rhytids (which require more Botox), have undergone previous facial plastic surgery (altered anatomy), and those who have preexisting neuromuscular disease. The physician can reduce complications by using proper injection techniques, appropriate regional Botox dosing, and by being conservative in the overall approach to Botox-mediated facial rejuvenation.

Commercial preparations and handling of botulinum toxin type A and type B

The recognition of botulinum toxin as a therapeutic tool has revolutionized the approach to facial esthetics. In the 1970s, Dr. Alan B. Scott pioneered the use of botulinum toxin type A (BTX-A) for strabismus. This discovery led to further studies examining other clinical applications of BTX-A and, more recently, botulinum toxin type B (BTX-B). Despite its widespread use and the more than two decades of experience with BTX-A, controversy remains over the preparation and handling of the toxin.

Reduction in injection pain with botulinum toxin type B further diluted using saline with preservative: a double-blind, randomized controlled trial

BACKGROUND

Injection with botulinum A exotoxin reconstituted with preserved saline has been shown to be less uncomfortable than injection with the same toxin reconstituted with preservative-free saline.

OBJECTIVE

We sought to determine whether injection with botulinum toxin type B is similarly less painful when preservative-containing saline is used to further dilute the product.

METHODS

We conducted a double-blind, randomized controlled trial. A total of 15 consecutive adult patients presenting for treatment of upper face dynamic lines received treatment to one side (left or right) of the face with toxin type B further diluted with preservative-containing saline, and to the other side with toxin type B further diluted with preservative-free saline.

RESULTS

Of 15 patients, 13 (87%) reported less pain in the halves of their faces treated with the preservative-containing saline (P =.0006). Pain on the preservative-containing side was on average 32% less among patients as a whole, and 39% less among patients noting some reduction. The 95% confidence interval for pain reduction associated with preservative-containing injection was -46.9% to -16.1%. Neither investigators nor patients observed any difference in clinical efficacy between the 2 treatment sides.

CONCLUSIONS

Use of preservative-containing saline to further dilute botulinum toxin type B can significantly decrease patient discomfort on injection.