Advanced botulinum toxin techniques against wrinkles in the upper face

[Translated article] Botulinum Toxin for Aesthetic Use in Facial and Cervical Regions: A Review of the Techniques Currently Used in Dermatology

Botulinum toxin infiltration is one of the most widely performed aesthetic procedures at the aesthetic dermatology office. Although infiltrative techniques have been known for quite a few years, several changes have been described so far, mainly based on anatomical knowledge. There are consensus guidelines available for injecting neuromodulators where one can see both the doses of toxin indicated for each muscle and the injection techniques. After a systematic review of the articles currently available, this article intends to summarize the infiltration techniques described both for the face and neck, while considering new anatomical considerations, new injection techniques published to date, and pearls and tricks for a better understanding of how to inject the botulinum toxin and improve our injection techniques. In our opinion it is important to treat the lower third to complement the treatment of the upper third and, in some patients, the partial blocking of some muscles of the middle third. With this comprehensive treatment of face and neck muscles we can achieve more natural and harmonious results.

Botulinum Toxin for Aesthetic Use in Facial and Cervical Regions: A Review of the Techniques Currently Used in Dermatology

Botulinum toxin infiltration is one of the most widely performed aesthetic procedures at the aesthetic dermatology office. Although infiltrative techniques have been known for quite a few years, several changes have been described so far, mainly based on anatomical knowledge. There are consensus guidelines available for injecting neuromodulators where one can see both the doses of toxin indicated for each muscle and the injection techniques. After a systematic review of the articles currently available, this article intends to summarize the infiltration techniques described both for the face and neck, while considering new anatomical considerations, new injection techniques published to date, and pearls and tricks for a better understanding of how to inject the botulinum toxin and improve our injection techniques. In our opinion it is important to treat the lower third to complement the treatment of the upper third and, in some patients, the partial blocking of some muscles of the middle third. With this comprehensive treatment of face and neck muscles we can achieve more natural and harmonious results.

Natural Compounds and Their Analogues as Potent Antidotes against the Most Poisonous Bacterial Toxin

Botulinum neurotoxins (BoNTs), the most poisonous proteins known to humankind, are a family of seven (serotype A to G) immunologically distinct proteins synthesized primarily by different strains of the anaerobic bacterium Clostridium botulinum Being the causative agents of botulism, the toxins block neurotransmitter release by specifically cleaving one of the three soluble N-ethylmaleimide-sensitive factor attachment receptor (SNARE) proteins, thereby inducing flaccid paralysis. The development of countermeasures and therapeutics against BoNTs is a high-priority research area for public health because of their extreme toxicity and potential for use as biowarfare agents. Extensive research has focused on designing antagonists that block the catalytic activity of BoNTs. In this study, we screened 300 small natural compounds and their analogues extracted from Indian plants for their activity against BoNT serotype A (BoNT/A) as well as its light chain (LCA) using biochemical and cellular assays. One natural compound, a nitrophenyl psoralen (NPP), was identified to be a specific inhibitor of LCA with an in vitro 50% inhibitory concentration (IC₅₀) value of 4.74 ± 0.03 µM. NPP was able to rescue endogenous synaptosome-associated protein 25 (SNAP-25) from cleavage by BoNT/A in human neuroblastoma cells with an IC₅₀ of 12.2 ± 1.7 µM, as well as to prolong the time to the blocking of neutrally elicited twitch tensions in isolated mouse phrenic nerve-hemidiaphragm preparations.IMPORTANCE The long-lasting endopeptidase activity of BoNT is a critical biological activity inside the nerve cell, as it prompts proteolysis of the SNARE proteins, involved in the exocytosis of the neurotransmitter acetylcholine. Thus, the BoNT endopeptidase activity is an appropriate clinical target for designing new small-molecule antidotes against BoNT with the potential to reverse the paralysis syndrome of botulism. In principle, small-molecule inhibitors (SMIs) can gain entry into BoNT-intoxicated cells if they have a suitable octanol-water partition coefficient (log P) value and other favorable characteristics (P. Leeson, Nature 481:455-456, 2012, https://doi.org/10.1038/481455a). Several efforts have been made in the past to develop SMIs, but inhibitors effective under in vitro conditions have not in general been effective in vivo or in cellular models (L. M. Eubanks, M. S. Hixon, W. Jin, S. Hong, et al., Proc Natl Acad Sci U S A 104:2602-2607, 2007, https://doi.org/10.1073/pnas.0611213104). The difference between the in vitro and cellular efficacy presumably results from difficulties experienced by the compounds in crossing the cell membrane, in conjunction with poor bioavailability and high cytotoxicity. The screened nitrophenyl psoralen (NPP) effectively antagonized BoNT/A in both in vitro and ex vivo assays. Importantly, NPP inhibited the BoNT/A light chain but not other general zinc endopeptidases, such as thermolysin, suggesting high selectivity for its target. Small-molecule (nonpeptidic) inhibitors have better oral bioavailability, better stability, and better tissue and cell permeation than antitoxins or peptide inhibitors.

Attention to Infection Prevention in Medical Aesthetic Clinics

The risk of infection is a concern for all medical aesthetic industry and all providers. Steps to reduce the risk and improve patient outcomes begin with vigilance to proper aseptic technique and being less concerned about the "beauty image" to attract new patients. This article is based on the guidelines outlined in Infection Prevention and Control for Clinical Office Practice by Public Health Ontario.

Effectiveness of botulinum toxin (type-A) administered by the fixed-site dosing approach versus the muscle area identification

INTRODUCTION

Botulinum toxin is widely used in glabellar musculature. The authors express the need to individualize the approach by means of muscular identification to improve effectiveness. Despite these guidelines, the fixed-point technique is still used.

OBJECTIVE

Comparison of effectiveness of botulinum toxin administration in the glabellar zone by using fixed-site application versus objective-muscle-identification.

MATERIALS AND METHODS

Prolective dynamic cohort study. Patients (after previous informed consent) were assessed on their facial expressions, level of satisfaction, re-interventions, adverse effects, dosage, dilution, and number of injections. All patients who experienced either of both techniques of botulinum toxin administration (fixed-site or objective-muscle-identification) were subjected to followup by the following parameters: statistical analysis: student's t Test (inter-group mean comparisons), paired student's t test (intra-group mean comparisons), χ (2) with Fisher exact text.

RESULTS

Sixty-two patients were evaluated (31 fixed-site approach, 31 objective-muscle-identification). No patient abandoned the trial during followup. Fixed-site injections required larger doses (16 vs 12 U, p = 0.001), greater volume (0.48 vs. 0.37 ml, p = 0.001), and more application sites (4 vs 2, p = 0.001), compared to the objective-muscle-identification approach. Under the objective-muscle-identification technique, facial expressions were better attenuated (52 vs 65%, p = 0.001), with a higher initial satisfaction level (6 vs 9, p = 0.001) and final satisfaction level (9 vs 9.9, p = 0.001).

CONCLUSIONS

Botulinum toxin application is more effective when administered through the objective-muscle-identification approach (less frowning, lower doses, less fixed sites injected, and patients more satisfied at the end).

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Type A botulinum neurotoxin complex proteins differentially modulate host response of neuronal cells

Type A Botulinum neurotoxin (BoNT/A), the most potent poison known to mankind, is produced by Clostridium botulinum type A as a complex with neurotoxin-associated proteins (NAPs). Currently BoNT/A in purified and complex forms are both available in therapeutic and cosmetic applications to treat neuromuscular disorders. Whereas Xeomin(®) (incobotulinumtoxin A, Merz Pharmaceuticals, Germany) is free from complexing proteins, Botox(®) (onabotulinumtoxin A, Allergan, USA) contains NAPs, which by themselves have no known role in the intracellular biochemical process involved in the blockade of neurotransmitter release. Since the fate and possible interactions of NAPs with patient tissues after intramuscular injection are not known, it was the aim of this study to evaluate the binding of BoNT/A and/or the respective NAPs to cells derived from neuronal and non-neuronal human tissues, and to further explore neuronal cell responses to different components of BoNT/A. BoNT/A alone, the complete BoNT/A complex, and the NAPs alone, all bind to neuronal SH-SY5Y cells. The BoNT/A complex and NAPs additionally bind to RMS13 skeletal muscle cells, TIB-152 lymphoblasts, Detroit 551 fibroblasts besides the SH-SY5Y cells. However, no binding to these non-neuronal cells was observed with pure BoNT/A. Although BoNT/A, both in its purified and complex forms, bind to SH-SY5Y, the intracellular responses of the SH-SY5Y cells to these BoNT/A components are not clearly understood. Examination of inflammatory cytokine released from SH-SY5Y cells revealed that BoNT/A did not increase the release of inflammatory cytokines, whereas exposure to NAPs significantly increased release of IL-6, and MCP-1, and exposure to BoNT/A complex significantly increased release of IL-6, MCP-1, IL-8, TNF-α, and RANTES vs. control, suggesting that different components of BoNT/A complex induce significantly differential host response in human neuronal cells. Results suggest that host response to different compositions of BoNT/A based therapeutics may play important role in local and systemic symptoms in patients.

Microarray analysis of differentially regulated genes in human neuronal and epithelial cell lines upon exposure to type A botulinum neurotoxin

Among the seven serotypes (A-G), type A botulinum neurotoxin (BoNT/A) is the most prevalent etiologic agent and the most potent serotype to cause foodborne botulism, characterized by flaccid muscle paralysis. Upon ingestion, BoNT/A crosses epithelial cell barriers to reach lymphatic and circulatory systems and blocks acetylcholine release at the pre-synaptic cholinergic nerve terminals of neuromuscular junctions (NMJs) resulting in paralysis. One of the unique features of BoNT/A intoxication is its neuroparalytic longevity due to its persistent catalytic activity. The persistent presence of the toxin inside the cell can induce host cell responses. To understand the pathophysiology and host response at the cellular level, gene expression changes upon exposure of human HT-29 colon carcinoma (epithelial) and SH-SY5Y neuroblastoma cell lines to BoNT/A complex were investigated using microarray analysis. In HT-29 cells, 167 genes were up-regulated while 60 genes were down-regulated, whereas in SH-SY5Y cells about 223 genes were up-regulated and 18 genes were down-regulated. Modulation of genes and pathways involved in neuroinflammatory, ubiquitin-proteasome degradation, phosphatidylinositol, calcium signaling in SH-SY5Y cells, and genes relevant to focal adhesion, cell adhesion molecules, adherens and gap junction related pathways in HT-29 cells suggest a massive host response to BoNT/A. A clear differential response in epithelial and neuronal cells indicates that the genes affected may play a distinct role in BoNTs cellular mode of action, involving these two types of host cells.