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Ellis K, Thach T, Gallagher CJ. Biochemical Stability and Microbial Control of Reconstituted DaxibotulinumtoxinA-lanm for Injection. Toxins (Basel) 2023; 15:683. [PMID: 38133187 PMCID: PMC10747821 DOI: 10.3390/toxins15120683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/24/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023] Open
Abstract
DaxibotulinumtoxinA-lanm for injection (DAXI) is a unique US Food and Drug Administration-approved product comprising daxibotulinumtoxinA and a stabilizing excipient peptide (RTP004). DAXI has a longer-labeled shelf life (72 h) following reconstitution than other botulinum toxin type A products. Here, we report the stability and microbial control of reconstituted DAXI when stored at 2 °C-8 °C over a period of 36 days (Study 1) and 7 days (Study 2) following reconstitution with unpreserved or preserved saline. The pH and biological activity of reconstituted DAXI in the 50 U/vial and 100 U/vial formats remained stable at the final assessed time point in both preserved and unpreserved saline when refrigerated (2 °C-8 °C). No changes in recoverable 150 kDa neurotoxin (measured by enzyme-linked immunosorbent assay) were observed over 6 days of refrigeration. Bacterial growth or pathogen proliferation was not observed in DAXI reconstituted in preserved or unpreserved saline in both studies.
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2
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Johnson AJ, Chen DS. Office-based facial plastics procedures: Neuromodulators. World J Otorhinolaryngol Head Neck Surg 2023; 9:220-226. [PMID: 37780669 PMCID: PMC10541165 DOI: 10.1002/wjo2.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 06/22/2023] [Accepted: 06/28/2023] [Indexed: 10/03/2023] Open
Abstract
Botulinum toxin is a potent neuromodulator commonly used for cosmetic applications in the clinic. In this article, we reviewed the various formulations of botulinum toxin type A commercially available in the United States, as well as clinical pearls for preprocedural planning, common in-office injections, and management of complications.
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Affiliation(s)
- Andrew J. Johnson
- Department of Otolaryngology ‐ Head & Neck SurgeryUniversity of Arizona College of MedicineTucsonArizonaUSA
| | - David S. Chen
- Department of Otolaryngology ‐ Head & Neck SurgeryUniversity of Arizona College of MedicineTucsonArizonaUSA
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Dirr MA, Christensen RE, Anvery N, Nadir U, Schaeffer M, Veledar E, Minkis K, Nodzenski M, Whittington A, Brieva JC, Tung R, Poon E, Alam M. Pain of local anesthetic injection of lidocaine during subsequent stages of Mohs micrographic surgery: A multicenter prospective cohort study. J Am Acad Dermatol 2023; 89:114-118. [PMID: 36907555 DOI: 10.1016/j.jaad.2023.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/26/2023] [Accepted: 02/25/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Patients awake during staged cutaneous surgery procedures may experience procedure-related pain. OBJECTIVE To determine whether the level of pain associated with local anesthetic injections prior to each Mohs stage increases with subsequent Mohs stages. METHODS Multicenter longitudinal cohort study. Patients rated pain (visual analog scale: 1-10) after anesthetic injection preceding each Mohs stage. RESULTS Two hundred fifty-nine adult patients presenting for Mohs who required multiple Mohs stages at 2 academic medical centers were enrolled; 330 stages were excluded due to complete anesthesia from prior stages, and 511 stages were analyzed. Mean visual analog scale pain ratings were nominally but not significantly different for subsequent stages of Mohs surgery (stage 1: 2.5; stage 2: 2.5; stage 3: 2.7: stage 4:2.8: stage 5: 3.2; P = .770). Between 37% and 44% experienced moderate pain, and 9.5% and 12.5% severe pain, during first as versus subsequent stages (P > .05) LIMITATIONS: Both academic centers were in urban areas. Pain rating is inherently subjective. CONCLUSIONS Patients did not report significantly increased anesthetic injection pain level during subsequent stages of Mohs.
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Affiliation(s)
- McKenzie A Dirr
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rachel E Christensen
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Noor Anvery
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Umer Nadir
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matthew Schaeffer
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Emir Veledar
- Center for Advanced Analytics, Baptist Health South Florida, Florida; Department of Biostatistics, Robert Stempel College of Public Health, Miami, Florida; Department of Biostatistics, Florida International University, Miami, Florida; Division of Cardiology Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kira Minkis
- Department of Dermatology, Weill Cornell Medicine, New York, New York
| | - Michael Nodzenski
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Adam Whittington
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Joaquin C Brieva
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rebecca Tung
- Department of Dermatology, University of Central Florida, Orlando, Florida; Florida Dermatology and Skin Cancer Centers, Winter Haven, Florida
| | - Emily Poon
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Murad Alam
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Otolaryngology- Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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4
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Kung D, Rodriguez G, Evans R. Chronic Migraine. Neurol Clin 2022; 41:141-159. [DOI: 10.1016/j.ncl.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Alghonaim Y, Hijazi LO, Alraee SA, Alqubaisy Y. Injection Site Pain, Onset and Duration of Action of Botulinum Toxin Reconstituted in Normal Saline With and Without Sodium Bicarbonate: A Prospective, Single Center, Randomized, Double-Blind Interventional Study. Plast Surg (Oakv) 2022; 30:227-232. [PMID: 35990391 PMCID: PMC9389062 DOI: 10.1177/22925503211011971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/01/2021] [Accepted: 03/07/2021] [Indexed: 08/03/2023] Open
Abstract
Purpose: This study was designed to investigate the effects of botulinum toxin type A injections diluted with the mixture of sodium bicarbonate and normal saline on pain reduction, onset of action, and duration of action. Methods: This is a prospective, randomized, double-blind clinical study, which included 30 female patients (age >25). The patients were randomized to receive botulinum toxin injections diluted with normal saline and sodium bicarbonate on one side of the face and saline control injections on the other side. Pain severity was assessed using visual analogue scale. The onset and duration of action were recorded according to the patients' subjective opinions after 1 week and 3 months, respectively. Results: Lower pain intensity ratings were observed when botulinum toxin was diluted with 0.05 and 0.1 mL of sodium bicarbonate as compared to saline. Regarding the onset of action, the botulinum toxin injections diluted with saline and 0.1-mL sodium bicarbonate side showed faster response in many patients than other dilutions (P < .001). Both the 0.05-mL and 0.1-mL sodium bicarbonate concentrations showed longer duration effects on patients than other concentrations. Conclusion: The use of sodium bicarbonate and saline in a mixture for the dilution of botulinum toxin can decrease patients' discomfort and provide a faster action with longer duration effects.
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Affiliation(s)
- Yazeed Alghonaim
- Division of Otolaryngology—Head and Neck Surgery, Department of
Surgery, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz
Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Leen O. Hijazi
- King Saud Bin Abdulaziz University for Health Sciences, King
Abdullah International Medical Research Center, Ministry of National Guard–Health
Affairs (NGHA), Riyadh, Saudi Arabia
| | - Sondus A. Alraee
- King Saud Bin Abdulaziz University for Health Sciences, King
Abdullah International Medical Research Center, Ministry of National Guard–Health
Affairs (NGHA), Riyadh, Saudi Arabia
| | - Yasser Alqubaisy
- Head of Dermatology and Dermatologic Surgery Department, Prince
Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia
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Bacteriostatic preserved saline for pain-free periocular injections: review. Eye (Lond) 2022; 36:1546-1552. [PMID: 35017698 PMCID: PMC8749351 DOI: 10.1038/s41433-021-01925-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/20/2021] [Accepted: 12/22/2021] [Indexed: 11/26/2022] Open
Abstract
We review evidence regarding the use of 0.9% benzyl alcohol in 0.9% sodium chloride solution for periocular injections (‘preserved saline’) including botulinum toxin A injections and local anaesthesia. A literature search was undertaken using search terms ‘bacteriostatic saline’, ‘benzyl-alcohol saline’, ‘benzyl alcohol sodium chloride’ and ‘preserved saline’. Bibliographies identified further sources. There have been 62 studies published on the subject of preserved-saline since 1928. Significantly lower injection-associated pain levels for periocular/facial botulinum toxin injections reconstituted with preserved-saline rather than preservative-free saline are reported by 5 studies. Significantly lower injection-associated pain with preserved-saline diluted lidocaine and epinephrine solution for eyelid anaesthesia compared with unmodified or buffered lidocaine with epinephrine, and adequate anaesthesia, was reported by one study. Thirty-one studies have explored preserved-saline for anaesthetic and seven for bacteriostatic properties, with very low infection rates after periocular botulinum toxin injections, and reduced rates of infection in indwelling catheters when preserved saline is used to flush. A meta-analysis concluded that lidocaine-containing solutions are more effective at reducing pain from insertion of intravenous catheters. Patient-perceived pain related to periorbital injections of local anaesthesia is reduced when the anaesthetic is diluted with benzyl alcohol-preserved saline compared with other dilution or buffering options. Pain is similarly reduced for periocular botulinum toxin injections reconstituted with preserved saline compared with unpreserved saline. Benzyl-alcohol preserved-saline is inexpensive but costlier than unpreserved-saline, with minimal reported complications, particularly with periocular administration, and offers the opportunity to improve the patient experience.
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Compare and contrast the various types of botulinum toxin on the market. 2. Appropriately select patients for treatment with cosmetic botulinum toxin. 3. Understand the common injection patterns for treating various regions of the face with cosmetic botulinum toxin. 4. List the complications associated with treating various regions of the face with cosmetic botulinum toxin. SUMMARY Nonsurgical rejuvenation of the face with botulinum toxin is one of the most commonly performed procedures in the United States. This article reviews the current evidence in treating different regions of the face: upper face, lower face, masseter, and platysma. Dosing and complications associated with different facial regions are reviewed.
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Kanerva M. Buccinator synkinesis treated by botulinum toxin in facial palsy and hemifacial spasms. J Plast Reconstr Aesthet Surg 2020; 74:1464-1469. [PMID: 33358465 DOI: 10.1016/j.bjps.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 10/28/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess botulinum toxin treatment for buccinator muscle synkinesis including: how often the synkinesis was troublesome; who benefitted and how from the treatment; and what were the adverse effects, ideal dosage, and injection site. SUBJECTS AND METHODS Facial palsy (FP) patients and patients with hemifacial spasms who were attending for multiple site botulinum-toxin treatment for facial sequelae were assessed for buccinator synkinesis. The study group comprises those experiencing buccinator synkinesis with associated bothering symptoms who were willing to try injection also to the buccinator muscle. RESULTS During 9/2017-12/2019, 126 different patients with facial sequelae were treated with multiple-site botulin-toxin injections by the author. Of them, 83 (66%) received injection also for buccinator synkinesis and 66/82 (80%) wanted to continue with the buccinator injections. The most remarkable results were seen with FP patients biting the mucus membrane of their cheek: usually the biting ceased totally. Patients with powerful hemifacial cheek spasms also experienced cessation of the spasms, contrasting any previous treatments. Adverse effects were mostly mild: slight weakness of the corner of the mouth or additional leakage of saliva or liquids. Only a few patients experienced more pronounced adverse effects. The most posterior contracting part of the buccinator muscle proved to be the best site for the injection. CONCLUSIONS Buccinator synkinesis was very common and its treatment gave many patients additional relief from facial sequelae symptoms. Professionals treating patients with synkinesis and hemifacial spasms should add well-tolerated buccinator injections to their repertoire of injection sites.
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Affiliation(s)
- Mervi Kanerva
- Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, PO Box 263, FI-00029 HUS, Helsinki, Finland.
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Zidan A, Hussaini S, Gibson S, Brooks G, Mejico L. Onabotulinumtoxin Type A reconstitution with preserved versus preservative-free saline in chronic migraine (B-RECON). A randomised, double-blind trial. Int J Clin Pract 2020; 74:e13522. [PMID: 32350975 DOI: 10.1111/ijcp.13522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/13/2020] [Accepted: 04/27/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Onabotulinumtoxin type A (BoNTA) is manufactured as powder that requires reconstitution with normal saline prior to injection. Previous literature has suggested that preserved saline (PS) exerts a local anaesthetic effect, and reduces the procedure discomfort when used in reconstitution in lieu of preservative-free saline (PFS). However, this was mainly studied in the aesthetics indications of BoNTA, and never in its use for the treatment of chronic migraine. The distinction is important as chronic migraine population suffers high incidence of scalp allodynia which makes it more prone to injection site pain. In addition, the pain of the procedure itself may be related to the spike of migraine frequency in the immediate postprocedural period which can occur in up to 5% of patients receiving the treatment. Our trial aimed to study the difference in procedural pain scale, and postprocedural headache rating with the use of PS vs PFS in constitution of BoNTA when used as a treatment for chronic migraine. METHODS 68 subjects were consecutively enrolled in an outpatient setting at a large tertiary headache centre over a period of 6 months. Subjects were randomised into PS or PFS group. BoNTA was administered as per standard protocol in both groups. Injection site pain scores and frequency of headache days in the immediate following week were recorded. Wilcoxon rank sum tests were used to compare differences in between groups using SPSS software. RESULTS Analysis (SAS V 9.4) revealed that those receiving [PF] had significantly higher procedure pain scores than those receiving [P] (5.3 vs 3.2, respectively). There was no difference in the headache or migraine frequency in the immediate postprocedural period. CONCLUSION This study supports the use of PS (bacteriostatic) over PFS for reconstitution of BoNTA in chronic migraine as it reduces the discomfort of the injection sites.
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Affiliation(s)
- Awss Zidan
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Sharmeen Hussaini
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Sandra Gibson
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Gary Brooks
- Center for Research and Evaluation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Luis Mejico
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
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Manufacturing and Clinical Formulations of Botulinum Neurotoxins. Handb Exp Pharmacol 2020. [PMID: 31932989 DOI: 10.1007/164_2019_311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
Abstract
Botulinum Neurotoxins have always existed in nature, but its paralytic effect on humans due to the consumption of poorly preserved food was not recognized until 18th century. There are 8 serotypes of botulinum neurotoxins (A, B, C, D, E, F, G, H). Serotype A have been the most recognized one and was initially developed for large scale production in 1940's. The first batch for clinical use was produced by Edward Schantz, who collaborated with Dr. Alan Scott, an ophthalmologist, evaluating botulinum neurotoxin to treat strabismus. The process Schantz used had variability and led to inconsistent batch production. However, this process is still used by various manufacturers of commercial botulinum neurotoxin products as the foundation. These manufacturers have refined the manufacturing of botulinum neurotoxins by implementing new advanced techniques, including better potency assays. Despite the improvements in the manufacturing process, botulinum neurotoxins are still one of the most potent molecules and therefore, require special handing and additional safety/security measurements during production.
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Re: "A Systematic Review and Meta-analysis of Methods for Reducing Local Anesthetic Injection Pain Among Patients Undergoing Periocular Surgery". Ophthalmic Plast Reconstr Surg 2019; 35:412-413. [PMID: 31283696 DOI: 10.1097/iop.0000000000001417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Injection technique in neurotoxins and fillers: Indications, products, and outcomes. J Am Acad Dermatol 2018; 79:423-435. [DOI: 10.1016/j.jaad.2018.01.037] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Samizadeh S, De Boulle K. Botulinum neurotoxin formulations: overcoming the confusion. Clin Cosmet Investig Dermatol 2018; 11:273-287. [PMID: 29910630 PMCID: PMC5988049 DOI: 10.2147/ccid.s156851] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Botulinum toxin A is produced by anaerobic spore-forming bacteria and is used for various therapeutic and cosmetic purposes. Botulinum toxin A injections are the most popular nonsurgical procedure worldwide. Despite an increased demand for botulinum toxin A injections, the clinical pharmacology and differences in formulation of commonly available products are poorly understood. The various products available in the market are unique and vary in terms of units, chemical properties, biological activities, and weight, and are therefore not interchangeable. For safe clinical practice and to achieve optimal results, the practitioners need to understand the clinical issues of potency, conversion ratio, and safety issues (toxin spread and immunogenicity). In this paper, the basic clinical pharmacology of botulinum toxin A and differences between onabotulinum toxin A, abobotulinum toxin A, and incobotulinum toxin A are discussed.
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Abstract
Several formulations of Botulinum toxin serotype A (BoNT-A) for aesthetic indications are available, with numbers likely to increase. Preparations are not interchangeable, based on dose unit comparisons.
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Heikkilä HM, Jokinen TS, Syrjä P, Junnila J, Hielm-Björkman A, Laitinen-Vapaavuori O. Assessing adverse effects of intra-articular botulinum toxin A in healthy Beagle dogs: A placebo-controlled, blinded, randomized trial. PLoS One 2018; 13:e0191043. [PMID: 29320549 PMCID: PMC5761897 DOI: 10.1371/journal.pone.0191043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 12/27/2017] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To investigate the clinical, cytological, and histopathological adverse effects of intra-articularly injected botulinum toxin A in dogs and to study whether the toxin spreads from the joint after the injection. METHODS A longitudinal, placebo-controlled, randomized clinical trial was conducted with six healthy laboratory Beagle dogs. Stifle joints were randomized to receive either 30 IU of onabotulinum toxin A or placebo in a 1:1 ratio. Adverse effects and spread of the toxin were examined by evaluating dynamic and static weight-bearing of the injected limbs, by assessing painless range of motion and pain on palpation of joints, and by performing synovial fluid analysis, neurological examination, and electrophysiological recordings at different examination time-points in a 12-week period after the injections. The dogs were then euthanized and autopsy and histopathological examination of joint structures and adjacent muscles and nerves were performed. RESULTS Intra-articular botulinum toxin A did not cause local weakness or injection site pain. Instead, static weight-bearing and painless range of motion of stifle joints decreased in the placebo limbs. No clinically significant abnormalities associated with intra-articular botulinum toxin A were detected in the neurological examinations. Electrophysiological recordings showed low compound muscle action potentials in two dogs in the botulinum toxin A-injected limb. No significant changes were detected in the synovial fluid. Autopsy and histopathological examination of the joint and adjacent muscles and nerves did not reveal histopathological adverse effects of the toxin. CONCLUSION Intra-articular botulinum toxin A does not produce significant clinical, cytological, or histopathological adverse effects in healthy dogs. Based on the electrophysiological recordings, the toxin may spread from the joint, but its clinical impact seems to be low.
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Affiliation(s)
- Helka M. Heikkilä
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
- * E-mail:
| | - Tarja S. Jokinen
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - Pernilla Syrjä
- Department of Veterinary Biosciences, Veterinary Pathology, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | | | - Anna Hielm-Björkman
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - Outi Laitinen-Vapaavuori
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
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The Use of Botulinum Neurotoxin Type A in Aesthetics: Key Clinical Postulates. Dermatol Surg 2017; 43 Suppl 3:S344-S362. [PMID: 33065958 DOI: 10.1097/dss.0000000000001412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The most common aesthetic procedure performed worldwide is the injection of botulinum neurotoxin Type A (BoNT-A). Aesthetic providers must fully comprehend the objective scientific data, theoretical mechanisms of action, and differences between brands of BoNT-A. OBJECTIVE To determine and review the relevant clinical postulates for the use of botulinum toxin in aesthetics. MATERIALS AND METHODS The BoNT-A clinical postulates presented here discuss how each brand of BoNT-A acts identically, how the molecular potency may vary between the different products, how patient age, gender, genetics, and muscle mass cause variation in toxin receptor number and density, and how both practitioner and patient can affect toxin distribution. RESULTS A total of 8 clinical postulates have been identified that are key to understanding the use of botulinum toxin in aesthetics and to obtaining the best clinical results. CONCLUSION All of these factors affect the potential efficacy of the injected toxin and hence the aesthetic results obtained.
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Giordano CN, Matarasso SL, Ozog DM. Injectable and topical neurotoxins in dermatology: Basic science, anatomy, and therapeutic agents. J Am Acad Dermatol 2017; 76:1013-1024. [PMID: 28522038 DOI: 10.1016/j.jaad.2016.11.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 11/03/2016] [Accepted: 11/06/2016] [Indexed: 11/24/2022]
Abstract
Botulinum toxin is a potentially deadly anaerobic bacterial toxin that acts by inhibiting release of acetylcholine at the neuromuscular junction, thereby inhibiting contraction of the exposed striated muscle. There are currently 4 botulinum toxin preparations approved by the US Food and Drug Administration (FDA): onabotulinumtoxin, abobotulinumtoxin, incobotulinumtoxin and rimabotulinumtoxin. While significant overlap exists, each product has unique properties and specifications, including dosing, diffusion, and storage. Extensive physician knowledge of facial anatomy, coupled with key differences of the various neurotoxin types, is essential for safe and successful treatments. The first article in this continuing medical education series reviews key characteristics of each neurotoxin, including new and upcoming agents, and provides an anatomic overview of the most commonly injected cosmetic sites.
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Affiliation(s)
| | - Seth L Matarasso
- Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, California
| | - David M Ozog
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan.
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Nestor M, Ablon G, Pickett A. Key Parameters for the Use of AbobotulinumtoxinA in Aesthetics: Onset and Duration. Aesthet Surg J 2017; 37:S20-S31. [PMID: 28388717 PMCID: PMC5434495 DOI: 10.1093/asj/sjw282] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Time to onset of response and duration of response are key measures of botulinum toxin efficacy that have a considerable influence on patient satisfaction with aesthetic treatment. However, there is no overall accepted definition of efficacy for aesthetic uses of botulinumtoxinA (BoNT-A). Mechanical methods of assessment do not lend themselves to clinical practice and clinicians rely instead on assessment scales such as the Frontalis Activity Measurement Standard, Frontalis Rating Scale, Wrinkle Severity Scale, and Subject Global Assessment Scale, but not all of these have been fully validated. Onset of activity is typically seen within 5 days of injection, but has also been recorded within 12 hours with abobotulinumtoxinA. Duration of effect is more variable, and is influenced by parameters such as muscle mass (including the effects of age and sex) and type of product used. Even when larger muscles are treated with higher doses of BoNT-A, the duration of effect is still shorter than that for smaller muscles. Muscle injection technique, including dilution of the toxin, the volume of solution injected, and the positioning of the injections, can also have an important influence on onset and duration of activity. Comparison of the efficacy of different forms of BoNT-A must be made with the full understanding that the dosing units are not equivalent. Range of equivalence studies for abobotulinumtoxinA (Azzalure; Ipsen Limited, Slough UK/Galderma, Lausanne CH/Dysport, Ipsen Biopharm Limited, Wrexham UK/Galderma LP, Fort Worth, TX) and onabotulinumtoxinA (Botox; Allergan, Parsippany, NJ) have been conducted, and results indicate that the number of units of abobotulinumtoxinA needs to be approximately twice as high as that of onabotulinumtoxinA to achieve the same effect. An appreciation of the potential influence of all of the parameters that influence onset and duration of activity of BoNT-A, along with a thorough understanding of the anatomy of the face and potency of doses, are essential to tailoring treatment to individual patient needs and expectations.
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Affiliation(s)
- Mark Nestor
- Voluntary Associate Professor, Department of Dermatology and Cutaneous Surgery, Department of Surgery, Division of Plastic Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL, USA
| | - Glynis Ablon
- Associate Clinical Professor of Dermatology, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Andy Pickett
- Director and Founder of Toxin Science Limited, Wrexham, UK
- Adjunct Professor at the Botulinum Research Center, Institute of Advanced Sciences, Dartmouth, MA, USA
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Prevention and Management of Injection-Related Adverse Effects in Facial Aesthetics: Considerations for ATX-101 (Deoxycholic Acid Injection) Treatment. Dermatol Surg 2016; 42 Suppl 1:S300-S304. [DOI: 10.1097/dss.0000000000000898] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Abstract
The use of neuromodulators has increased by approximately 748 percent from 2000 to 2014 and has become an integral adjunct for facial rejuvenation. Knowledge of facial anatomy, accurate facial analysis, and familiarity with neurotoxin characteristics will minimize complications and optimize results. Current U.S. Food and Drug Administration-approved neurotoxins in the United States include onabotulinumtoxin A (Botox), abobotulinumtoxin A (Dysport), and incobotulinumtoxin A (Xeomin). The dosage and effect of these products are not interchangeable, so practitioners should master the utility and response of one product before trying the other products. All products have equivalent success in appropriately trained hands; the senior author (R.J.R.) favors no particular neurotoxin. This article provides a stepwise approach to treat dynamic facial rhytides with neuromodulators, including indications, facial analysis, preparation and injection technique, post-procedure care, and complications.
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21
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Dickey RM, Louis MR, Cox JA, Mohan K, Lee EI, Nigro MG. Noninvasive Facial Rejuvenation. Part 2: Physician-Directed-Neuromodulators and Fillers. Semin Plast Surg 2016; 30:134-42. [PMID: 27478422 DOI: 10.1055/s-0036-1584819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A proper knowledge of noninvasive facial rejuvenation is integral to the practice of a cosmetic surgeon. Noninvasive facial rejuvenation can be divided into patient- versus physician-directed modalities. Patient-directed facial rejuvenation combines the use of facial products such as sunscreen, moisturizers, retinoids, α-hydroxy acids, and various antioxidants to both maintain youthful skin as well as rejuvenate damaged skin. Physicians may recommend and often prescribe certain products, but patients are in control with this type of facial rejuvenation. On the other hand, physician-directed facial rejuvenation entails modalities that require direct physician involvement, such as neuromodulators, filler injections, laser resurfacing, microdermabrasion, and chemical peels. With the successful integration of each of these modalities, a complete facial regimen can be established and patient satisfaction can be maximized. This article is the second in a three-part series describing noninvasive facial rejuvenation. Here the authors discuss neuromodulators and fillers in detail, focusing on indications for use, techniques, and common side effects.
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Affiliation(s)
- Ryan M Dickey
- Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew R Louis
- Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joshua A Cox
- Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Kriti Mohan
- Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Edward I Lee
- Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas
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22
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Zaiac M, Shah VV, Mlacker S, Bray FN, Alsaidan M. Local anesthesia injection technique for aesthetic removal of dermal nevi. J Cosmet Dermatol 2016; 15:559-560. [DOI: 10.1111/jocd.12240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Martin Zaiac
- Department of Dermatology; Herbert Wertheim College of Medicine; Florida International University; Miami FL USA
- Greater Miami Skin and Laser Center; Mount Sinai Medical Center; Miami Beach FL USA
| | - Vidhi V Shah
- Department of Dermatology and Cutaneous Surgery; University of Miami Miller School of Medicine; Miami FL USA
| | - Stephanie Mlacker
- Department of Dermatology and Cutaneous Surgery; University of Miami Miller School of Medicine; Miami FL USA
| | - Fleta N Bray
- Department of Dermatology and Cutaneous Surgery; University of Miami Miller School of Medicine; Miami FL USA
| | - Mohammed Alsaidan
- Department of Dermatology and Cutaneous Surgery; University of Miami Miller School of Medicine; Miami FL USA
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Abstract
Botulinum toxin type A (BTA) can be used for facial aesthetics. The 3 currently available BTA types include onabotulinumtoxinA (Botox; Botox Cosmetic, Allergan, Irvine, CA), abobotulinumtoxinA (Dysport; Ipsen, Ltd, Berkshire, UK), and incobotulinumtoxinA (Xeomin; Merz Pharmaceuticals, Frankfurt, Germany). The mechanism of action and clinical uses for treatment of dynamic lines of the forehead, brow, glabella, lateral orbit, nose, and lips are presented, as well as treatment of masseter hypertrophy, platysmal bands, and improvements of the perioral region. Specific BTA injection sites and suggested doses are presented.
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Dressler D, Adib Saberi F, Bigalke H. Botulinum toxin therapy: reduction of injection site pain by pH normalisation. J Neural Transm (Vienna) 2016; 123:527-31. [PMID: 27002815 DOI: 10.1007/s00702-016-1522-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 02/05/2016] [Indexed: 10/22/2022]
Abstract
Botulinum toxin (BT) is injected intramuscularily and may produce injection site pain (ISP). We wanted to explore whether the pH value of the reconstituted BT drug contributes to ISP and, if so, what strategies can be applied to reduce it. In part 1 of the study, pH values of different reconstitution solutions and of major BT drugs reconstituted with different reconstitution solutions were assessed. In part 2, the effects of reconstitution with normal saline (NS) and Ringer acetate (RA) were compared intraindividually and in a double blind fashion in 34 patients with blepharospasm. pH values of reconstitution solutions were 5.52 ± 0.02 for NS, 6.98 for RA, 6.31 for Ringer lactate, 6.56 for electrolyte and 5.31 for bacteriostatic solution. pH values for NS-reconstitution were 6.09 ± 0.20 for Botox(®), 5.95 ± 0.24 for Dysport(®) and 5.81 ± 0.18 for Xeomin(®). pH values for RA-reconstitution were 6.95 ± 0.03 for Botox(®), 7.01 ± 0.02 for Dysport(®) and 6.87 ± 0.06 for Xeomin(®). By using RA instead of NS the pH could be increased by 0.86 for Botox(®), by 1.06 for Dysport(®) and by 1.06 for Xeomin(®). 47 % of the patients experienced less ISP when Botox(®)-RA was given rather than Botox(®)-NS, 76 % when Xeomin(®)-RA was given rather than Xeomin(®)-NS. None of the patients reported a difference in efficacy between NS- and RA-reconstitution. Despite previous reports, reconstituted BT type A drugs show acidic pH values. Normalising these pH values by use of RA instead of NS reduces ISP considerably without sacrificing clincial efficacy.
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Affiliation(s)
- Dirk Dressler
- Movement Disorders Section, Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Fereshte Adib Saberi
- Movement Disorders Section, Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Hans Bigalke
- Movement Disorders Section, Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,Institute of Toxicology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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25
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Sundaram H, Signorini M, Liew S, Trindade de Almeida AR, Wu Y, Vieira Braz A, Fagien S, Goodman GJ, Monheit G, Raspaldo H. Global Aesthetics Consensus: Botulinum Toxin Type A--Evidence-Based Review, Emerging Concepts, and Consensus Recommendations for Aesthetic Use, Including Updates on Complications. Plast Reconstr Surg 2016; 137:518e-529e. [PMID: 26910696 PMCID: PMC5242214 DOI: 10.1097/01.prs.0000475758.63709.23] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/21/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Botulinum toxin type A injection remains the leading nonsurgical cosmetic procedure worldwide, with a high rate of efficacy and patient satisfaction. METHODS A multinational, multidisciplinary group of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated consensus recommendations with a worldwide perspective for botulinum toxin and hyaluronic acid fillers. This publication on botulinum toxin type A considers advances in facial analysis, injection techniques, and avoidance and management of complications. RESULTS Use of botulinum toxin has evolved from the upper face to also encompass the lower face, neck, and midface. The Global Aesthetics Consensus Group emphasizes an integrative, diagnostic approach. Injection dosage and placement are based on analysis of target muscles in the context of adjacent ones and associated soft and hard tissues. The indication for selection of botulinum toxin as a primary intervention is that excessive muscular contraction is the primary etiology of the facial disharmony to be addressed. Global Aesthetics Consensus Group recommendations demonstrate a paradigm shift toward neuromodulation rather than paralysis, including lower dosing of the upper face, more frequent combination treatment with hyaluronic acid fillers, and intracutaneous injection where indicated to limit depth and degree of action. CONCLUSIONS The accumulation of clinical evidence and experience with botulinum toxin has led to refinements in treatment planning and implementation. The Global Aesthetics Consensus Group advocates an etiology-driven, patient-tailored approach, to enable achievement of optimal efficacy and safety in patient populations that are rapidly diversifying with respect to ethnicity, gender, and age. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Affiliation(s)
- Hema Sundaram
- Rockville, Md.; Milan, Italy; Sydney, New South Wales, and Carlton, Victoria, Australia; São Paolo and Rio de Janeiro, Brazil; Beijing, China; Boca Raton, Fla.; Seoul, Korea; and Cannes, France
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Erickson BP, Lee WW, Cohen J, Grunebaum LD. The role of neurotoxins in the periorbital and midfacial areas. Facial Plast Surg Clin North Am 2016; 23:243-55. [PMID: 25921574 DOI: 10.1016/j.fsc.2015.01.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Initially popularized for the treatment of strabismus and blepharospasm, injection of botulinum neurotoxin has become the most commonly performed cosmetic treatment in the United States. Injection techniques have been particularly well-studied in the midface and periocular region, and patient satisfaction tends to be very high. We review the salient differences among available neurotoxins, how to optimally reconstitute them, how to inject the forehead, glabella, lateral canthal lines ("crow's feet"), infralid region, and transverse nasal lines ("bunny lines"), how to sculpt the brow, and how to manage potential complications.
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Affiliation(s)
- Benjamin P Erickson
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136, USA
| | - Wendy W Lee
- Department of Clinical Ophthalmology and Dermatology Oculofacial Plastic & Reconstructive Surgery, Orbit and Oncology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136, USA
| | - Joel Cohen
- AboutSkin Dermatology, 499 East Hamden Avenue, Suite 450, Englewood, CO 80113, USA
| | - Lisa D Grunebaum
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology and Dermatology, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136, USA.
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27
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Abstract
BACKGROUND Patients increasingly request rejuvenation of the aging and photodamaged décolletage. Rhytides in this area can be addressed with injectables such as poly-L-lactic acid and hyaluronic acid products and energy-based devices, such as fractionated ablative and nonablative lasers and microfocused ultrasound with visualization. METHODS This article will review the anatomy of the chest wall as it pertains to injectables that can be utilized in this area and injection technique. A review of the literature and the authors' experience will be discussed. CONCLUSION Cosmetic injectables can be utilized safely and effectively to improve the appearance of rhytides on the décolletage.
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28
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Abstract
BACKGROUND The introduction of neuromodulators for aesthetic facial improvements greatly expanded the limits of nonsurgical facial rejuvenation. Although many current uses are considered "off-label," the widespread acceptance and favorable safety profile of properly used botulinum toxins have made them one of the most common aesthetic treatments available. METHODS A literature review of current facial aesthetic uses of various botulinum toxin preparations was done, and general concepts were identified. RESULTS Currently, Food and Drug Administration-approved botulinum toxin preparations onabotulinumtoxinA (Botox), abobotulinumtoxinA (Dysport), and incobotulinumtoxinA (Xeomin) have similar off-label indications and clinical uses. CONCLUSIONS Although not considered interchangeable, administration and clinical outcomes are not much different between the 3 commonly used botulinum products. The impact of botulinum products currently in development has yet to be determined.
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Abstract
BACKGROUND Esthetic interventions are an integral part of today's dermatology. A plethora of novel agents and techniques is currently being launched on the market accompanied by a variety of side effects. METHOD We summarize the most common adverse events of fillers, laser treatments, and injection of botulinum toxin and present feasible means of prevention and management. RESULTS The profile of adverse events is more favorable in temporary fillers such as hyaluronic acid than in permanent ones. The most common filler-related adverse events include changes of skin color and unspecific swelling. Neural and vascular dysfunctions are observed less frequently, but may result in severe tissue necrosis or loss of vision. Undesirable events of laser treatments largely depend on the applied modality, localization, and indication. Local effects comprise erythema, swelling, crusting, blister formation, and weeping in extreme cases. The formation of laser-induced scarring is more likely to occur in lasers with high energies. Most adverse events of botulinum toxin are mild and transient. Pain and redness around the sites of injection are common. However, a poor injection technique and injection of too many units can trigger major motoric impairment with ptosis and dysarthria. CONCLUSION Excellent results can be achieved with esthetic interventions. To guarantee a maximum amount of safety and to minimize risks it is of paramount importance to work with clear indications and respect contraindications. It is important to recognize early adverse events to achieve satisfactory results and avoid severe complications.
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Affiliation(s)
- D Hartmann
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität München, Frauenlobstr. 9-11, 80337, München, Deutschland.
| | - M Heppt
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität München, Frauenlobstr. 9-11, 80337, München, Deutschland
| | - G G Gauglitz
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universität München, Frauenlobstr. 9-11, 80337, München, Deutschland
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30
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Zdilla MJ. Screening for variations in anterior digastric musculature prior to correction of post-traumatic anterior open bite by injection of botulinum toxin type A: a technical note. J Korean Assoc Oral Maxillofac Surg 2015; 41:165-7. [PMID: 26131435 PMCID: PMC4483532 DOI: 10.5125/jkaoms.2015.41.3.165] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 03/23/2015] [Accepted: 03/25/2015] [Indexed: 11/29/2022] Open
Abstract
It has recently been reported that long-standing post-traumatic open bite can be successfully corrected with botulinum toxin type A (BTX-A) injection into the anterior belly of the digastric muscle (ABDM). The report documented an individual with bilaterally symmetrical and otherwise unremarkable anterior digastric musculature. However, the existence of variant anterior digastric musculature is common and may complicate the management of anterior open bite with BTX-A injection. Screening for variant ABDM can be accomplished via ultrasound, computed tomography, and magnetic resonance imaging. Screening for variant ABDM should be performed prior to BTX-A injection in order to account for musculature that may exert undesired forces, such as inferolateral deviation, on the anterior mandible in patients with anterior open bite.
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Affiliation(s)
- Matthew J Zdilla
- Department of Natural Sciences and Mathematics, West Liberty University, West Liberty, WV, USA
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31
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Alam M, Bolotin D, Carruthers J, Hexsel D, Lawrence N, Minkis K, Ross EV. Consensus statement regarding storage and reuse of previously reconstituted neuromodulators. Dermatol Surg 2015; 41:321-6. [PMID: 25705950 DOI: 10.1097/dss.0000000000000303] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Legacy recommendations suggest that vials of botulinum toxin be used within 24 hours of reconstitution and in a single patient. Current standard of care is consistent with storage after reconstitution and use of a single vial for several patients. OBJECTIVE To develop expert consensus regarding the effectiveness and safety of storage and reuse of botulinum toxin. MATERIALS AND METHODS The American Society for Dermatologic Surgery authorized a task force of content experts to review the literature and provide guidance. Data extraction was followed by clinical question review, a consensus Delphi process, and validation of the results by peer review. RESULTS After 2 rounds of Delphi process, the task force concluded by unanimous consensus and with the highest level of confidence that a vial of toxin reconstituted appropriately can, for facial muscle indications, be (1) refrigerated or refrozen for at least 4 weeks before injection without significant risk for contamination or decreased effectiveness and (2) used to treat multiple patients, assuming appropriate handling. CONCLUSION The standard of care, which allows for use of botulinum toxin more than 24 hours after reconstitution and in more than 1 patient per vial, is appropriate and consistent with the safe and effective practice of medicine.
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Affiliation(s)
- Murad Alam
- Departments of *Dermatology, †Otolaryngology, and ‡Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; §Section of Dermatology, University of Chicago Medicine, Chicago, Illinois; ‖Department of Ophthalmology, University of British Columbia, Vancouver, BC, Canada; ¶Department of Dermatology, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil; #Brazilian Center for Studies in Dermatology, Porto Alegre, Brazil; **Division of Dermatology, Cooper University Hospital Medical Center, Marlton, New Jersey; ††Department of Dermatology, Weill Cornell Medical College, Cornell University, New York, New York; ‡‡Division of Dermatology, Scripps Clinic, San Diego, California
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Nonsurgical periocular rejuvenation: advanced cosmetic uses of neuromodulators and fillers. Curr Opin Ophthalmol 2014; 25:461-9. [PMID: 24926573 DOI: 10.1097/icu.0000000000000074] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review the current literature regarding aesthetic enhancement using facial neuromodulators and fillers and to present advanced techniques using facial injectables for periocular rejuvenation. RECENT FINDINGS The authors provide a summary of traditional periocular locations for the injection of neuromodulators and dermal fillers. The authors also present novel and advanced techniques utilizing injectables in the periocular region. SUMMARY Minimally invasive procedures with little-to-no recovery time are continuing to increase in popularity. Neuromodulators and hyaluronic acid gel fillers have been shown to be well tolerated and efficacious nonsurgical alternatives in periocular rejuvenation.
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Abstract
PURPOSE OF REVIEW Primary focal hyperhidrosis is a common condition that negatively impacts quality of life for many pediatric patients and can be challenging to treat. Standard treatments for hyperhidrosis can be used with success in many patients, and newer therapies and techniques offer options that have demonstrated efficacy and safety. This review highlights standard therapies for primary focal hyperhidrosis as well as the most recent technique advancements and alternative treatment options. RECENT FINDINGS The standard approach to treating primary focal hyperhidrosis remains initiation of topical preparations, followed by advancement to systemic medications, local administration of medication and/or surgical procedures. Recent studies focus on enhancing tolerability of topical preparations as well as evaluating the efficacy of neuromodulator injections, oral anticholinergic medications and laser therapy. Microwave technology has also been introduced for the treatment of focal hyperhidrosis with promising results. SUMMARY Many therapies exist for hyperhidrosis, and each treatment plan must be evaluated on a patient-by-patient basis. Advances in standard therapies and emergence of new treatment techniques are the main emphases of current published literature on hyperhidrosis. This article presents recent therapeutic options as well as updates on more established strategies to help practitioners treat this challenging condition.
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Sezgin B, Ozel B, Bulam H, Guney K, Tuncer S, Cenetoglu S. The Effect of Microneedle Thickness on Pain During Minimally Invasive Facial Procedures: A Clinical Study. Aesthet Surg J 2014; 34:757-65. [PMID: 24787992 DOI: 10.1177/1090820x14532941] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Minimally invasive procedures are becoming increasingly popular because they require minimal downtime and are effective for achieving a more youthful appearance. The choice of needle for minimally invasive procedures can be a major factor in the patient's comfort level, which in turn affects the physician's comfort level. OBJECTIVES In this comparative study, the authors assessed levels of pain and bruising after participants were injected with 30-gauge or 33-gauge (G) microneedles, which are commonly used for minimally invasive injection procedures. METHODS Twenty healthy volunteers were recruited for this prospective study. Eight injection points (4 on each side of the face) were determined for each patient. All participants received injections of saline with both microneedles in a randomized, blinded fashion. Levels of pain and bruising were assessed and analyzed for significance. RESULTS The highest level of pain was in the malar region, and the lowest level was in the glabella. Although all pain scores were lower for the 33-G microneedle, the difference was significant only for the forehead. Because most minimally invasive procedures require multiple injections during the same sitting, the overall procedure was evaluated as well. Assessment of the multiple-injection process demonstrated a significant difference in pain level, favoring the 33-G needle. Although the difference in bruising was not statistically significant between the 2 needles, the degree of bruising was lower with the 33-G needle. CONCLUSIONS For procedures that involve multiple injections to the face (such as mesotherapy and injection of botulinum toxin A), thinner needles result in less pain, making the overall experience more comfortable for the patient and the physician. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Billur Sezgin
- Dr Sezgin is an Attending Physician in the Department of Plastic, Reconstructive and Aesthetic Surgery, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Bora Ozel
- Drs Ozel and Guney are residents, Dr Tuncer is an Associate Professor, and Dr Cenetoglu is a Professor and the Department Head, in the Department of Plastic, Reconstructive and Aesthetic Surgery, Gazi University Hospital, Ankara, Turkey
| | - Hakan Bulam
- Dr Bulam is an Attending Physician in the Department of Plastic, Reconstructive and Aesthetic Surgery, Numune Research and Training Hospital, Ankara, Turkey
| | - Kirdar Guney
- Drs Ozel and Guney are residents, Dr Tuncer is an Associate Professor, and Dr Cenetoglu is a Professor and the Department Head, in the Department of Plastic, Reconstructive and Aesthetic Surgery, Gazi University Hospital, Ankara, Turkey
| | - Serhan Tuncer
- Drs Ozel and Guney are residents, Dr Tuncer is an Associate Professor, and Dr Cenetoglu is a Professor and the Department Head, in the Department of Plastic, Reconstructive and Aesthetic Surgery, Gazi University Hospital, Ankara, Turkey
| | - Seyhan Cenetoglu
- Drs Ozel and Guney are residents, Dr Tuncer is an Associate Professor, and Dr Cenetoglu is a Professor and the Department Head, in the Department of Plastic, Reconstructive and Aesthetic Surgery, Gazi University Hospital, Ankara, Turkey
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Kakar R, Ibrahim O, Disphanurat W, Pace N, West DP, Kwasny M, Shah S, Alam M. Pain in Naïve and Non-naïve Subjects Undergoing Nonablative Skin Tightening Dermatologic Procedures: A Nested Randomized Control Trial. Dermatol Surg 2014; 40:398-404. [DOI: 10.1111/dsu.12440] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Complications from Toxins and Fillers in the Dermatology Clinic. Facial Plast Surg Clin North Am 2013; 21:663-73. [DOI: 10.1016/j.fsc.2013.07.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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37
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Carruthers J, Fournier N, Kerscher M, Ruiz-Avila J, Trindade de Almeida AR, Kaeuper G. The Convergence of Medicine and Neurotoxins: A Focus on Botulinum Toxin Type A and Its Application in Aesthetic Medicine—A Global, Evidence-Based Botulinum Toxin Consensus Education Initiative. Dermatol Surg 2013; 39:510-25. [DOI: 10.1111/dsu.12148] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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38
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Lorenc ZP, Kenkel JM, Fagien S, Hirmand H, Nestor MS, Sclafani AP, Sykes JM, Waldorf HA. Consensus panel's assessment and recommendations on the use of 3 botulinum toxin type A products in facial aesthetics. Aesthet Surg J 2013; 33:35S-40S. [PMID: 23515197 DOI: 10.1177/1090820x13480479] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In this summary article, the authors discuss the characteristics of abobotulinumtoxinA, incobotulinumtoxinA, and onabotulinumtoxinA. With 3 neuromodulators available in the US market, comparisons between and among products will invariably be made, so arguments for the most effective facial aesthetic uses of each neuromodulator are presented. Topics addressed in this article include patient expectations, toxin reconstitution and preparation, patient positioning, differences among products, the role of complexing proteins, and dosing and injection strategies. Recommendations are also provided by treatment area.
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39
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Liu A, Carruthers A, Cohen JL, Coleman WP, Dover JS, Hanke CW, Moy RL, Ozog DM. Recommendations and current practices for the reconstitution and storage of botulinum toxin type A. J Am Acad Dermatol 2012; 67:373-8. [DOI: 10.1016/j.jaad.2011.10.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 06/28/2011] [Accepted: 10/06/2011] [Indexed: 11/29/2022]
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40
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Maas C, Kane MAC, Bucay VW, Allen S, Applebaum DJ, Baumann L, Cox SE, Few JW, Joseph JH, Lorenc ZP, Moradi A, Nestor MS, Schlessinger J, Wortzman M, Lawrence I, Lin X, Nelson D. Current aesthetic use of abobotulinumtoxinA in clinical practice: an evidence-based consensus review. Aesthet Surg J 2012; 32:8S-29S. [PMID: 22941910 DOI: 10.1177/1090820x12455192] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The amount and complexity of scientific and clinical evidence for aesthetic use of botulinum neurotoxin type A (BoNT-A) has expanded rapidly in recent years, especially for abobotulinumtoxinA, necessitating reassessment of current knowledge about aesthetic use of abobotulinumtoxinA and other BoNT-A preparations. A committee of 13 plastic surgeons, facial plastic surgeons, and dermatologists engaged in a live discussion of information from a systematic literature review and an Internet-based survey of their beliefs and practices. The committee achieved consensus on most issues. It was concluded that doses of different BoNT-A preparations cannot be interconverted with a fixed ratio. The size of the "field of effect" is difficult to measure, and comparisons between preparations have yielded equivocal results. Nonresponse due to neutralizing antibodies appears exceedingly rare with currently available BoNT-A preparations and of little concern clinically. BoNT-A dose, injection depth, and injection technique should be adjusted according to the anatomic area being treated and each patient's individual characteristics and goals. Aesthetic use of BoNT-A has a good safety profile. Most adverse events are minor and related to the trauma of injection, although special care is needed in certain anatomic areas. Detailed recommendations for treatment of different anatomic areas are presented. BoNT-A products are often used in conjunction with other treatment modalities (eg, fillers and resurfacing), but little agreement was reached on best practices. The findings reported in this consensus document may serve as a practical guide for aesthetic practitioners as they apply the latest knowledge about BoNT-A in providing their patients with optimal care.
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Affiliation(s)
- Corey Maas
- University of California-San Francisco, CA 94115, USA
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Botulinum neurotoxin A: a review. J Plast Reconstr Aesthet Surg 2012; 65:1283-91. [PMID: 22552262 DOI: 10.1016/j.bjps.2012.04.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 01/27/2012] [Accepted: 04/09/2012] [Indexed: 11/24/2022]
Abstract
Despite its ubiquity in cosmetic circles and broad general awareness, a literature search of botulinum neurotoxin in JPRAS and BJPS yielded a mere 4 articles germane to cosmesis. A pair each detailing its application in masseteric hypertrophy(1,2) and the use of cryoanalgesia.(3,4) Given that botulinum neurotoxin A is the most commonly used cosmetic treatment, with American figures being most accurate,(5) a review of the background, development and scientific evidence would be perhaps useful, if not overdue, as Plastic Surgeons increasingly incorporate non-surgical interventions into their practices as part of a comprehensive facial rejuvenation strategy.
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Allen SB, Goldenberg NA. Pain difference associated with injection of abobotulinumtoxinA reconstituted with preserved saline and preservative-free saline: a prospective, randomized, side-by-side, double-blind study. Dermatol Surg 2012; 38:867-70. [PMID: 22268727 DOI: 10.1111/j.1524-4725.2011.02284.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Food and Drug Administration has approved the reconstitution of botulinum toxin A with preservative-free saline. Reconstitution of onabotulinumtoxinA with preserved saline has been previously reported to decrease the pain of injections. We present the first split-face study investigating differences in subjective pain when using preserved and preservative-free saline as the reconstituent of choice for abobotulinumtoxinA. OBJECTIVE To determine whether patients notice a difference in pain when injecting abobotulinumtoxinA diluted with preserved saline versus preservative-free saline. MATERIALS AND METHODS A prospective, randomized, double-blind, side-by-side trial was conducted in a private practice dermatology office in Boulder, Colorado. Twenty volunteer patients received injections on one side of their face with abobotulinumtoxinA reconstituted with preservative-free saline and with abobotulinumtoxinA reconstituted with preserved saline on the other side. Patients reported their pain on a 10-point visual analogue pain scale after each side was injected. Patients kept a diary for the first 48 hours after treatment to track any continued pain, onset of action, or adverse events. Patients were seen at a follow-up visit at 2 weeks, and any adverse events were recorded. RESULTS Ninety percent of patients reported less pain on the side injected with preserved saline than on the side injected with preservative-free saline. Pain on the preserved saline side was 60% less than on the preservative-free side. Neither the patients nor the investigators noted any difference in onset of action between the two sides. CONCLUSIONS Reconstitution of abobotulinumtoxinA with preserved saline results in significantly less pain on injection than with preservative-free saline. Preserved saline may be the reconstituent of choice for reconstitution of abobotulinumtoxinA.
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Affiliation(s)
- Shawn B Allen
- Department of Dermatology, School of Medicine, University of Colorado, Denver, Colorado, USA.
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Alam M, Olson JM, Asgari MM. Needs Assessment for Cosmetic Dermatologic Surgery. Dermatol Clin 2012; 30:177-87, x. [DOI: 10.1016/j.det.2011.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Barrett SL, Maxka J, Mieras JN, Cooper KE. Reducing the pain of local 1% lidocaine infiltration with a preceding bacteriostatic saline injection: a double-blind prospective trial. J Am Podiatr Med Assoc 2011; 101:223-30. [PMID: 21622634 DOI: 10.7547/1010223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Lidocaine injection for local anesthesia is a common podiatric medical procedure. We tested the hypothesis that injection of bacteriostatic saline solution containing 0.9% benzyl alcohol before the lidocaine infiltration can reduce the burning caused by lidocaine injection. METHODS This double-blind prospective trial involved 45 participants who each received four injections in two areas of the dorsum of the foot and rated the perceived pain on a visual analog scale. The order of the injections was designed to disguise the control and intervention arms of the study. RESULTS The sensation of the lidocaine injection after the injection of saline was reduced significantly (P = .028). The percentage of lidocaine injections with visual analog scale scores of 0 increased by 36% after preinjection with bacteriostatic saline solution containing 0.9% benzyl alcohol. CONCLUSIONS The fact that 40% of the intervention visual analog scale pain scores for lidocaine injections were 0 suggests that a near painless lidocaine injection technique is an achievable goal and that the present technique is a simple and inexpensive method of reducing the pain of lidocaine injections.
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Affiliation(s)
- Stephen L Barrett
- Arizona School of Podiatric Medicine, Midwestern University, Glendale, AZ 85308, USA.
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Abstract
Cosmetic botulinum toxin type A (Botox, Allergan, Inc., Irvine, CA) has revolutionized minimally invasive treatment of the upper face. Increasingly sophisticated outcomes result in facial symmetry in motion. The face is a three-dimensional moving unit, not an isolated photograph. This is why the advanced injector must hone an astute ability to observe casual microexpressions. Consideration is then given to the patient's age, facial anatomy, facial asymmetry, and dynamic rhytids. The ratio of dosing to agonist and antagonist muscles that allows unopposed action is determined. Nuance in placement and dose combined with adjunct therapy results in natural and appropriate facial emotion and avoids unnatural or bizarre patterns of movement. Asymmetrical scenarios are presented to exemplify this process of analysis and treatment. Many authors have detailed the mechanism of action, history of Botox development, and specific muscle group treatment in the periorbital region. In this discussion, I leave behind rigorous academic analysis and wish to offer my approach, which has evolved through 15 years experience treating the aesthetic patient with Botox. The clinician can read about recommended patterns of injection, and the procedure is quite simple. It is only through skilled observation and understanding of expressive nuance and anatomy that the advanced injector will meet the goal of a natural communicative result with chemodenervation. Experience is accumulated through critical analysis of patient results over time. This discussion first directs attention to why it is important to learn how to look at the face in motion as well as at facial rhytids. A plan is developed for treatment including drug preparation, dosing decisions, precise three-dimensional delivery, and adjunct therapy. Perils may generally be avoided by choosing appropriate dosing and placement. The asymmetrical patient scenario is used to demonstrate nuance in evaluation and treatment.
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Affiliation(s)
- Jane J Olson
- Department of Ophthalmology, Yale University School of Medicine, New Haven, Connecticut
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Kaynak-Hekimhan P. Noncosmetic periocular therapeutic applications of botulinum toxin. Middle East Afr J Ophthalmol 2011; 17:113-20. [PMID: 20616916 PMCID: PMC2892125 DOI: 10.4103/0974-9233.63069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Botulinum toxin blocks acetylcholine release at the neuromuscular junction. The drug which was initially found to be useful in the treatment of strabismus has been extremely effective in the treatment of variety of conditions, both cosmetic and noncosmetic. Some of the noncosmetic uses of botulinum toxin applications include treatment of spastic facial dystonias, temporary treatment of idiopathic or thyroid dysfunction-induced upper eyelid retraction, suppression of undesired hyperlacrimation, induction of temporary ptosis by chemodenervation in facial paralysis, and correction of lower eyelid spastic entropion. Additional periocular uses include control of synchronic eyelid and extraocular muscle movements after aberrant regeneration of cranial nerve palsies. Cosmetic effects of botulinum toxin were discovered accidentally during treatments of facial dystonias. Some of the emerging nonperiocular application for the drug includes treatment of hyperhidrosis, migraine, tension-type headaches, and paralytic spasticity. Some of the undesired side effects of periocular applications of botulinum toxin inlcude ecchymosis, rash, hematoma, headache, flu-like symptoms, nausea, dizziness, loss of facial expression, lower eyelid laxity, dermatochalasis, ectropion, epiphora, eyebrow and eyelid ptosis, lagophthalmos, keratitis sicca, and diplopia.
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Markarian MK, Hovsepian RV. The Interface of Cosmetic Medicine and Surgery: Working from the Inside and the Outside. Clin Plast Surg 2011; 38:335-45, v. [DOI: 10.1016/j.cps.2011.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Cartee TV, Monheit GD. An Overview of Botulinum Toxins: Past, Present, and Future. Clin Plast Surg 2011; 38:409-26, vi. [DOI: 10.1016/j.cps.2011.03.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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