Patient selection in the treatment of glabellar wrinkles with botulinum toxin type A injection

Safety, Pharmacodynamic Response, and Treatment Satisfaction With OnabotulinumtoxinA 40 U, 60 U, and 80 U in Subjects With Moderate to Severe Dynamic Glabellar Lines

BACKGROUND

OnabotulinumtoxinA 20 U reduces glabellar line (GL) severity at maximum frown for approximately 3 to 4 months. Small studies have suggested that >20-U doses may increase the efficacy and duration of response for GLs.

OBJECTIVES

The aim of this study was to evaluate safety, pharmacodynamic response, and treatment satisfaction with onabotulinumtoxinA doses ≥20 U for GLs.

METHODS

This 48-week, double-blind study compared 40, 60, and 80 U onabotulinumtoxinA vs 20 U and placebo in women with moderate or severe dynamic GLs on the Allergan Facial Wrinkle Scale. The following parameters were evaluated: the percentage of subjects with investigator-assessed ≥1-grade Facial Wrinkle Scale improvement from baseline at maximum frown (responders) at Week 24; the estimated median duration of response; the proportion of mostly/very satisfied responders on the Facial Line Satisfaction Questionnaire follow-up Items 1 to 5; and treatment-emergent adverse events.

RESULTS

The modified intent-to-treat population (N = 226) had a mean age of 48.0 years, with similar baseline GL severity between treatment groups. Week 24 responder rates were 0% for placebo and 16.0%, 32.0%, 30.6%, and 38.5% for onabotulinumtoxinA 20, 40, 60, and 80 U, with significant (P < 0.05) differences for 40 and 80 U vs 20 U. Median duration of response was longer with all higher doses vs 20 U (≥24.0 vs 19.7 weeks; P < 0.05 vs 20 U at Week 24). Facial Line Satisfaction Questionnaire results indicated high subject satisfaction. The incidence and severity of treatment-emergent adverse events did not exhibit a dose-response effect.

CONCLUSIONS

GL treatment with onabotulinumtoxinA doses >20 U demonstrated longer duration of response and higher patient-reported satisfaction vs the on-label 20-U dose with no apparent impact on safety variables.

LEVEL OF EVIDENCE: 2

"Endolift laser an effective treatment modality for forehead wrinkles and frown line"

The search of beauty and youth has received a lot of attention which is proved by increasing cosmetic techniques. The people prefer non-surgical and invasive method for reduction and wrinkles treatment. In this study we used Endolift laser for forehead wrinkles and frown line treatment to evaluate the clinical safety and effectiveness of this technique for reduction of forehead wrinkles and frown line. A total of 9 patients with forehead wrinkles and frown line were included in the current study. The results were investigated using biometric evaluation. Also, assessment was performed clinically, photographically and physician's assessment and patient satisfaction responses were recorded. According to the biometric results the skin thickness and elasticity significantly increase after Endolift laser treatment. Acording tothe physician's assessment, 90 % of patients displayed very much improved after Endolift laser treatment and according to the patient assessment 91% of patients reported positive satisfaction response. Treatment with Endolift laser is safe and an effective method for decrease of forehead wrinkles and frown line treatment. It offers as a non-invasive alternative technique in compared to other invasive procedures for forehead wrinkles and frown line treatment.

Efficacy of onabotulinumtoxinA in the treatment of unipolar major depression: Systematic review, meta-analysis and meta-regression analyses of double-blind randomised controlled trials

BACKGROUND

OnabotulinumtoxinA is a novel therapeutic intervention whose mechanism of action is believed to modify the negative facial feedback, thus abating symptoms of depression. This putative new antidepressant agent offers minimal systemic side effects and negligible risk of pharmacological interactions. We set out to examine the evidence for the use of onabotulinumtoxinA in major depression.

METHODS

A systematic search of the literature identified double-blind randomised controlled trials (RCTs) investigating the use of onabotulinumtoxinA in the treatment of major depression versus placebo. Data, reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA), was combined in meta-analyses (PROSPERO registration ID: CRD42020183538).

RESULTS

The search identified five RCTs (four double-blind) comparing onabotulinumtoxinA to placebo. OnabotulinumtoxinA was more effective than placebo when administered within the 20-40 IU dose range in double-blind RCTs. The analysis was free of publication bias and significantly heterogeneous. Meta-regression analyses indicated that onabotulinumtoxinA was more efficacious in women and in higher doses in female patients and less effective with polypharmacy, especially when an increasing number of antidepressants were prescribed. The effectiveness of onabotulinumtoxinA was higher in more recently published double-blind RCTs.

CONCLUSION

The meta-analysis supports the efficacy of the intervention with the results being highly heterogeneous across studies. In view of the heterogeneity of the findings and the significant moderators of benefit (sex, year of study completion and the interaction between sex and dose), more research is required to better understand the role of onabotulinumtoxinA in the treatment of depression.

OnabotulinumtoxinA for the treatment of major depressive disorder: a phase 2 randomized, double-blind, placebo-controlled trial in adult females

This 24-week double-blind placebo-controlled multicenter randomized phase 2 trial evaluated efficacy and safety of onabotulinumtoxinA (onabotA; BOTOX) vs. placebo for major depressive disorder (MDD) [NCT02116361]. Primary endpoint was the change in Montgomery-Åsberg Depression Rating Scale (MADRS); secondary endpoints were Clinical Global Impressions-Severity and 17-item Hamilton Depression Rating Scale at week 6. A total of 255 adult females were treated. OnabotA 30 U approached significance compared to placebo on MADRS (mixed-effect model repeated measures least-squares mean difference: -3.7; P = 0.053) and reached significance [least-squares mean differences: -3.6 to -4.2; P < 0.05 (two-sided)] at weeks 3 and 9. Secondary endpoints were also significant at several time points. At week 6, onabotA 50 U did not separate from placebo in any parameters. OnabotA was generally well-tolerated: the only treatment-emergent adverse events reported in ≥5% in either onabotA group, and more than matching placebo were headache, upper respiratory infection, and eyelid ptosis. OnabotA 30 U, administered in a standardized injection pattern in a single session, had a consistent efficacy signal across multiple depression symptom scales for 12 or more weeks. OnabotA 30 U/placebo MADRS differences of (observed ANCOVA) ≥4.0 points (up to week 15) and ≥2.0 points (weeks 18-24) agree with the 2-point change threshold considered clinically relevant in MDD. OnabotA is a local therapy and is not commonly associated with systemic effects of conventional antidepressants and may represent a novel treatment option for MDD.

Overview of Botulinum Toxins for Aesthetic Uses

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.

Aesthetic Uses of Neuromodulators: Current Uses and Future Directions

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.

Aesthetic use of BoNT: Options and outcomes

There are a multitude of uses for BoNT in the aesthetic realm. Efficacy has been shown in softening glabellar creases, crows feet, forehead rhytides, and in correcting facial asymmetries, including mild eyelid ptosis. Facial shape can be altered through injections of BoNT into masseter, and smiles can be altered with BoNT. Clinical examples of the above will be shown, as well as adverse outcomes with inaccurate injection techniques.

Botulinum toxin type a for the treatment of hyperkinetic lines of the face

BACKGROUND

This study sought to determine the efficacy of Botulinum toxin A (BTA) for the treatment of hyperkinetic lines of the face. Twenty three patients who were concerned for facial wrinkles and desiring correction are presented.

METHODS

This clinical study evaluated the postoperative results of 23 patients who underwent treatment for facial wrinkles with BTA. Among the patients included in the study, 20 were males and remaining 3 were females. The age of the patients ranged from 27 to 46 years (mean 34.69 years) and the treatment was done in three different sessions and divided into 3 treatment subgroups of forehead, crow's feet, and glabellar wrinkles.

RESULTS

All the patients were followed up for a period of at least 6 months and graded for the response to treatment with BTA by the operator, observer and the patient independently using the facial wrinkle scale. The patient's satisfaction to the treatment was also noted on all the follow-up visits on the satisfaction scale and the results were subjected to statistical analysis using Kappa analysis, Chi-square test and T test. The results showed that the treatment of facial hyperkinetic lines with BTA is associated with few adverse events like pain on injection, transient headache, and mild change in facial appearance in subjects with high hair line which are not serious and thus safe.

CONCLUSION

The findings of this study support the use of BTA for the treatment of hyperkinetic lines of the face although further studies with more sample size are required.

Botulinum toxin type A gives adjunctive benefit to periorbital laser resurfacing

OBJECTIVE

Periorbital aging and lines are a result of intrinsic skin aging, ultraviolet damage, and repetitive action of periorbital muscles. Rejuvenation of this area should therefore be optimized by combining treatments that approach the different causative factors.

METHODS

This was a single-center, prospective, randomized, placebo-controlled study comparing the efficacy and safety of combining Botox injections (18 units per area) with ablative laser resurfacing versus laser resurfacing alone without Botox in the treatment of periorbital rhytids.

RESULTS

We have concluded a bilateral study comparing the effects of Botox versus saline placebo injections to the periorbital areas before and following erbium: YAG laser resurfacing of the areas in 33 patients. The results demonstrated that the Botox-treated side with laser resurfacing improved significantly more than the contralateral area treated with saline and laser in diminishing periorbital rhytids as well as textural, pigmentation, and other features of periorbital skin aging.

CONCLUSION

This study illustrates the benefits of a combined approach to treating periorbital skin aging.

Botulinum Toxin (Botox) to Enhance Facial Macroesthetics: A Literature Review

Dental implants have emerged as a predictable treatment option for partial edentulism. Their ability to preserve bone and soft tissue yields highly esthetic results in the long term. Increasingly, patients are demanding not only enhancements to their dental (micro) esthetics but also to their overall facial (macro) esthetics. Dynamic wrinkles (caused by hyperfunctional muscles) in the perioral, glabellar, and forehead regions can cause a patient's expressions to be misinterpreted as angry, anxious, fearful, or fatigued. An emerging treatment option to address these issues is the use of a paralyzing material such as botulinum toxin A (Botox) to decrease the appearance of the wrinkles, which yields a more esthetic and youthful facial appearance. Botox is a deadly poison that is produced by the bacterium Clostridium botulinum and causes muscle paralysis by inhibiting acetylcholine release at the neuromuscular junction. When used in areas of hyperfunctional muscles, a transient partial paralysis occurs that diminishes the appearances of wrinkles, Therefore, wrinkles not attributable to hyperfunctional muscles (eg, wrinkles caused by aging, gravity, photodamage, trauma, and scarring) will not be amenable to treatment with the toxin. As a result, proper case selection is essential. A thorough understanding of the indications, techniques, dosages, and complications and their management is imperative to achieve a satisfactory result. This article will review the pathogenesis of facial wrinkles as well as the history, techniques, clinical controversies, and other important considerations for successful treatment of facial wrinkles with Botox.

A randomized, double-blind, placebo-controlled study of botulinum toxin type A for the treatment of glabellar lines: determination of optimal dose

BACKGROUND

Botulinum toxin is used to treat glabellar lines, but the optimal dose of Reloxin (Dysport, Ipsen Biopharm Ltd.) for this indication remains to be established.

OBJECTIVE

The objective was to evaluate three doses of Reloxin to determine its efficacy and safety in treating glabellar lines.

METHODS AND MATERIALS

Participants were given 20, 50, or 75 U of Reloxin, or placebo, injected across the glabella. Follow-up was on Days 7, 30, 60, 90, and 120. Adverse events were also elicited by telephone on Day 3.

RESULTS

From investigators' and participants' assessments at Day 30, there were significantly more responders in each Reloxin-treated group than placebo (p< or = 0.001). The 50-U dose was as effective as the 75-U dose, with a similar duration. The most common adverse events were mild headache and nasopharyngitis, occurring similarly in all groups.

CONCLUSIONS

Reloxin (Dysport/botulinum toxin type A) treatment resulted in a significant improvement in glabellar lines, and the 50-U dose was identified as optimal. All doses were well tolerated.

Dilution Volume of Botulinum Toxin Type A for the Treatment of Glabellar Rhytides: Does It Matter?

BACKGROUND

Because well-controlled studies examining the efficacy and safety of various dilutions of botulinum toxin type A (BTX-A) have not been performed, dilutions used in clinical practice are chosen at the discretion of the clinician.

OBJECTIVES

The objectives were to determine the most effective BTX-A dilution for the glabellar region, the relationship between dilution and duration of effect, and the side effect profile of each dilution in women with glabellar rhytides.

METHODS

Eighty women with moderate-to-severe wrinkles at maximum frown were randomized to one of four dilution groups in a 48-week, single-center, double-blind, parallel-group study. Subjects received 30 U BTX-A (BOTOX, Allergan, Inc.) injected into the glabellar region at dilutions of 100, 33.3, 20, or 10 U/mL. Outcome measures included trained-observer and subject assessment of wrinkle severity at repose and at maximum muscle contraction using the Facial Wrinkle Scale (FWS) and adverse events.

RESULTS

All dilutions of BTX-A effectively improved glabellar rhytides as assessed by both trained observers and subjects using the FWS. No significant differences on FWS scores were seen among the dilution groups by trained observers at any time point. Although a difference among groups was seen in subject-assessed responder rates, there was no obvious relationship between dilution and response. BTX-A treatment was well tolerated, and there were no significant differences between the four dilution groups in the number of subjects reporting adverse effects.

CONCLUSION

In this study, the dilution of BTX-A was not critical to the success of treatment.

Botulinum toxin: Clinical use

Since its development for the use of blepharospasm and strabismus more than 2.5 decades ago, botulinum neurotoxin (BoNT) has become a versatile drug in various fields of medicine. It is the standard of care in different disorders such as cervical dystonia, hemifacial spasm, focal spasticity, hyperhidrosis, ophthalmological and otolaryngeal disorders. It has also found widespread use in cosmetic applications. Many other indications are currently under investigation, including gastroenterologic and urologic indications, analgesic management and migraine. This paper is an extensive review of the spectrum of BoNT clinical applications.

Botulinum toxin - an update on its use in facial rejuvenation

The role of botulinum toxin in facial rejuvenation has been greatly expanded in the last several years. In this article, we first review the traditional approach to botulinum toxin therapy in the forehead and glabella. For the advanced reader, we then discuss both the literature and our personal approaches to treatments of the periocular region, mid face, lower face, and neck. Throughout the discussion, attempts are made to include a description of relevant anatomy, the physiologic result of specific muscle activity and denervation, and perhaps most importantly, precise directions for patient treatment.

Botulinum toxin-physiology and applications in head and neck disorders

This article is structured around a literature review that was carried out using Ovid and Medline with the key words "botulinum," "toxin," and "ENT." Botulinum toxin has been used safely in humans for more than 20 years. The effects are transient, such that treatments are required to be repeated at intervals. Its application to ENT provides a useful tool to treat dystonia, autonomic dysfunction, facial nerve paresis, and hyperfunctional lines. It may also be of benefit in laryngeal rebalancing and the treatment of headaches. Further research is being carried out and new indications for treatment with botulinum toxin may include sialorrhea and rhinorrhea.

Dose-ranging study of botulinum toxin type A in the treatment of glabellar rhytids in females

OBJECTIVE

To compare the efficacy, safety, and duration of effect of four doses of botulinum toxin type A in the treatment of glabellar rhytids in females.

DESIGN

Double-blind, randomized, parallel-group, dose-ranging trial followed by an open-label extension.

SETTING

Private dermatologic clinic.

SUBJECTS

Eighty female subjects with moderate to severe wrinkles at maximum frown entered the study. The first 40 subjects completing the double-blind phase entered the open-label extension.

INTERVENTION

Random administration of 10, 20, 30, or 40 U botulinum toxin type A in divided doses. Open-label trial: 30 U botulinum toxin type A at the same sites in divided doses.

MAIN OUTCOME MEASUREMENTS

Trained observer and subject assessments of wrinkle severity at maximum frown and repose using the Facial Wrinkle Scale (0 = none to 3 = severe), subject satisfaction, and adverse events. Follow-up monthly for up to 1 year postinjection.

RESULTS

Relapse rates and responder rates revealed benefits lasting 3 to 6 months or longer. Objectively, 10 U of botulinum toxin type A was significantly less effective than 20, 30, or 40 U. The relapse rate at 4 months was significantly higher in the 10 U group (83%) versus 40, 30, or 20 U (28%, 30%, and 33%, respectively). Subject satisfaction was high in all groups. Duration of effect and response rates were sustained during the open-label extension. Adverse effects were mild and infrequent.

CONCLUSION

Twenty to 40 U botulinum toxin type A doses were significantly more effective at reducing glabellar lines than 10 U. Most subjects experienced benefits for 3 to 4 months; some subjects demonstrated effect for up to 12 months.

Treatment of nasal wrinkles with botulinum toxin

BACKGROUND

Nasal wrinkles on the dorsum of the nose can frequently be treated with botulinum toxin type A by injecting a few units into the nasalis muscle. Between 2 and 5 U of botulinum toxin have commonly been used. However, clinicians have observed that some nasal wrinkles persist following nasalis treatment.

OBJECTIVE

To detail remaining nasal and perinasal rhytids and further injection sites, which can lead to improvement.

METHODS

Two hundred fifty patients with nasal rhytids were treated between 1997 and 2004. Three units of botulinum toxin type A were injected bilaterally into the nasalis muscle. Patients were seen at 1 month for follow-up, and the remaining rhytids were documented.

RESULTS

Forty percent of patients had satisfactory treatment of nasal wrinkles with the initial bilateral 3 U injections. Sixty percent of subjects had remaining nasal rhytids following the nasalis muscle injections. Thirty percent o f subjects hadpersistent wrinkles at the root of the nose (nasal orbicular wrinkles), and 30% had wrinkles at the nasal root and between the eyes (nasociliary wrinkles). The injection of botulinum toxin into additional locations according to the anatomic differences of each person showed excellent resolution of the rhytids without complications.

CONCLUSION

Understanding nasal wrinkle patterns allows for complete wrinkle treatment of the nose beyond simple bilateral treatment of the nasalis. New points of botulinum toxin application improve not only wrinkles at the root of the nose but also wrinkles in the nasoalar area.

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.

The use of Botox to treat glabellar rhytids

The goal of the article is to allow a physician to become more familiar with Botox as a treatment of glabellar wrinkles. An overview of the anatomy of that region is reviewed. Evaluation of the facial muscles before treatment and injection technique is also covered.

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.

The use of Botox to treat glabellar rhytids

Many areas of the face benefit from Botox. The deep vertical and horizontal creases between the eyebrows or glabellar area are the best known to cosmetically improve with Botox injections. As with almost any cosmetic procedure, adequate evaluation and pre-operative assessment can lead to a good outcome and a satisfied patient.

Botox and Collagen for Glabellar Furrows

Plastic surgeons frequently administer botulinum toxin A (Botox) or collagen as monotherapy to treat glabellar furrows. This study evaluates the possible advantages of combination therapy. Sixty-five patients with moderate to severe glabellar rhytids were prospectively randomized to receive standard injections of Botox, Zyderm II collagen, or a combination. Improvement in rhytids was assessed over 3 months using patient satisfaction scores and an independent physician evaluation. Baseline wrinkle severity was similar in all 3 groups. By 1 month posttreatment, the combination arm showed significantly greater improvement in furrows (79% compared with only 56% and 50% in the Botox and Zyderm arms, respectively; P < 0.05). At 3 months postinjection, the dual-therapy arm maintained better improvement (57% versus 33% and 27% in the monotherapy arms; P < 0.05). Patient satisfaction further highlighted the superiority of the combination approach. By simultaneously addressing the static and dynamic aspects of glabellar furrows, dual therapy provides optimal treatment of this problem.

The Effect of Full-Face Broadband Light Treatments Alone and in Combination With Bilateral Crow's Feet Botulinum Toxin Type A Chemodenervation

BACKGROUND

Broadband light (BBL; Intense Pulsed Light; Lumenis Ltd., Yokneam, Israel) is a powerful, nonablative, light-based technology that targets melanin and hemoglobin and stimulates the formation of collagen and elastin. Botulinum toxin type A (BTX-A; BOTOX; Allergan Inc., Irvine, CA) treatment of the lateral periocular region relaxes the vertical fibers of the orbicularis oculi and results in softening of the lateral orbital crow's feet rhytides and widening of the palpebral aperture.

OBJECTIVE

To compare the effects of full-face BBL in combination with BTX-A and BBL alone in female subjects with Fitzpatrick I-III skin types, Glogau II-III rhytides, and significant associated facial lentigines and telangiectasia.

METHODS

This was a prospective, randomized study of 30 women with moderate to severe crow's feet rhytides. Half of the subjects were treated with BTX-A and BBL and the other half with BBL alone. Their response was assessed clinically and photographically. Skin biopsies of the temporal skin were taken from two subjects in each group and were stained with Masson trichrome.

RESULTS

Patients treated with a combination of BTX-A and BBL experienced a better response to treatment, both at rest and on maximum smile, as well as a slightly improved response in associated lentigines, telangiectasia, pore size, and facial skin texture compared with patients who received BBL treatment alone. Skin biopsies showed an increase in dermal collagen in each group.

CONCLUSIONS

The patients in this study benefited from both treatments. Although BBL led to a remarkable improvement in full-face telangiectasias, lentigines, and skin texture, the improvement increased in all categories with combination therapy. In addition, an added improvement in the full-face aesthetic with both BTX-A and BBL therapy combined was obvious. These results suggest that both treatments--although evidently complementary--may also act synergistically to produce optimal clinical effects, revolutionizing the treatment of facial aging.

Botulinum toxin types A and B: comparison of efficacy, duration, and dose-ranging studies for the treatment of facial rhytides and hyperhidrosis

One of the most common etiologic forces for the persistence of facial rhytides is the repetitive contraction of the intrinsic muscles that are necessary for facial expression. These include the forehead lines, crow's feet, glabellar rhytides, and wrinkles in the lower face. Although filling agents such as collagen and laser procedures can help reduce the appearance of these lines, they do not address the underlying forces that cause these wrinkles to persist. Botulinum toxin type-A and type-B are neurotoxins that address these issues and result in the relaxation of the intrinsic facial muscles and subsequent resolution of these dynamic facial rhytides. This article will compare the efficacy, duration, dose ranging studies, and safety in the treatment of facial rhytides with both types of toxins. In addition, the treatment of hyperhidrosis with type-A and type-B botulinum toxin will also be discussed.

A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with the derivative and BTX-A

BACKGROUND

Over the past 15 years, BTX-A has become the standard treatment for dynamic glabellar furrowing. Some individuals have resting glabellar rhytides that are sufficiently deep that they respond poorly to BTX-A alone.

OBJECTIVE

To compare the efficacy of BTX-A combined with intradermal nonanimal stabilized hyaluronic acid (NASHA) with the efficacy of NASHA alone in females with moderate to severe glabellar rhytides.

METHODS

This was a prospective randomized study of 38 subjects with moderate to severe glabellar rhytides. Half of the subjects were treated with BTX-A and NASHA and the other half with NASHA alone. Their response was assessed clinically and photographically.

RESULTS

By comparison with the NASHA-alone group, the BTX-A plus NASHA group showed a better response both at rest and on maximum frown, and this response was maintained for longer. The median time for return to preinjection furrow status occurred at 18 weeks in the NASHA-alone group compared with 32 weeks for the BTX-A plus NASHA group.

Deep resting glabellar rhytides respond to BTX-A and Hylan B

BACKGROUND

BTX-A is the standard treatment for glabellar furrows. However, some individuals have resting glabellar rhytides that are sufficiently deep that they respond poorly to BTX-A alone.

OBJECTIVE

To compare the efficacy of BTX-A combined with intradermal Hylan B with the efficacy of BTX-A alone in individuals with moderate to severe glabellar rhytides.

METHODS

This was a retrospective study of 16 subjects with moderate to severe glabellar rhytides. Their response to Hylan B plus BTX-A was compared clinically and photographically to their response to BTX-A alone.

RESULTS

All subjects had moderate or severe glabellar rhytides at rest before treatment. After BTX-A alone, none (0%) had achieved no or mild rhytides. After BTX-A and Hylan B injection, only 1 of 16 (6%) had moderate glabellar rhytides, with the remainder (94%) being mild.

CONCLUSION

Moderate to severe glabellar rhytides were treated better by BTX-A combined with Hylan B injection than by BTX-A alone.

Update on botulinum toxin for facial aesthetics

The use of botulinum toxin has revolutionized the treatment of facial lines with an incomparable safety record over the past 14 years. The most common used injection sites are shown in Fig. 9. With the recent FDA approval for Botox in the treatment of glabellar lines, its use will likely increase dramatically. It is essential that practitioners have a detailed and specific knowledge of the facial and neck musculature to be injected to minimize untoward side effects, especially in the early days of new users' learning curve. The specifics of the dilutions and units per amount used for the various different commercial forms of botulinum toxin types A and B need to be understood fully and standardized together with the potential for antigenicity with the higher protein load of type B. In addition, specific indications for the use of botulinum toxin as adjunctive therapy for specific facial surgical procedures (i.e., blepharoplasty, surgical brow lift, and laser resurfacing) will become better understood. [figure: see text] Finally, even though the anatomy of the facial musculature is well described, individual differences in men and women, in different population groups, and in tissue qualities, such as turgor and elasticity [87], are important factors to be considered before undertaking botulinum toxin injections. It is likely that the use of specific measuring devices, such as digital imaging, will further help define the use of botulinum toxin for different muscle groups and facial aesthetic indications.

New indications for botulinum toxin type a in cosmetics: mouth and neck

Botulinum toxin type A is frequently used to smooth hyperkinetic lines in the periocular and forehead areas of the upper face, but it has been used less frequently for indications in the lower face and neck. This study was designed to determine whether botulinum toxin treatment of the mouth and neck areas is as clinically successful as the treatment of the upper face. This was a retrospective study of patients who were treated with botulinum toxin type A (Botox) to soften hyperkinetic facial wrinkles. Of 100 patients randomly selected from a single clinical practice, 91 met the inclusion criteria and were divided into two groups for analysis. The 56 patients in group 1 did not receive treatment in the mouth and neck areas, whereas the 35 patients in group 2 were treated at least once in the mouth and neck areas. Patients were surveyed for periods ranging from 7 to 49 months. Most patients in each group had a single botulinum procedure during this period. Both groups of patients had comparable improvement of wrinkles both at the evaluation immediately after the neuromuscular blockade and during follow-up. In comparison with patients whose treatment was confined to the upper face, patients who received global treatment with botulinum toxin type A, including injections in the mouth and neck areas, were injected in more sites per procedure and had more procedures in combination with other therapies. Patient satisfaction with botulinum toxin treatment and outcomes was high in both groups. Botulinum toxin type A is an important tool within the therapeutic spectrum for the treatment of hyperkinetic facial wrinkles, including those in the areas of the mouth and neck.