Botulinum Toxin in Facial Rejuvenation: An Update

Enhancing Facial Aesthetics Using a Novel Technique: A Case Report

A person's facial appearance matters in both social and professional contexts. Losing teeth has an impact on phonetics and mastication, but it also has an aesthetic effect on the lower face's appearance. Cheek sinking is caused by a decrease in muscular tone and an increase in the rate of resorption of the alveolar ridges. An edentulous patient will transform aesthetically if they receive facial as well as dental rehabilitation. The patient's social contacts and sense of self-worth both improve as a result. When an individual exhibits significant alveolar process resorption, traditional dentures are unable to offer sufficient support, hence requiring supplementary cheek support. Appliances for elevating or plumping the cheeks can be used for this. A 68-year-old male patient reported to the department of prosthodontics with a chief complaint of missing teeth and poor aesthetics. After a complete examination, a complete denture prosthesis with a detachable cheek plumper was planned. Press button retention for cheek plumpers is an advantage due to its easy installation and use. This article outlines a straightforward, inexpensive, and non-invasive process for creating a non-detachable cheek plumper using a press button for those who are edentulous. The two-in-one prosthesis enhances the appearance of the face while also replacing lost teeth.

Facial Rejuvenation: A Global Trend of Dermatological Procedures in the Last Decade

Background

We aimed to track the global trend of cosmetic treatment outcomes for facial rejuvenation and the differences in modalities used in East Asian and Western populations.

Methods

Articles reporting on facial rejuvenation procedures (invasive/noninvasive) were identified in PubMed from 2013 to March 2023 and bibliometrically analyzed for type of published document, citation frequency, authors with most articles, author's affiliation, and frequency distribution of keywords.

Results

From 553 articles, most were published in 2021 (n = 86, 15.6%). Western countries (n = 323, 58.4%) contributed more than East Asian (n = 230, 41.6%), with more invasive interventions (n = 355, 64.2%) than noninvasive techniques (n = 198, 35.8%). Numbers of invasive techniques in West versus East Asian countries were 225 (40.7%) versus 135 (24.4%). Main indications were the reduction of facial wrinkles and antiageing treatments. Hyaluronic acid, fillers, and botulinum toxin were the main hotspots for invasive treatments, whereas laser, platelet-rich plasma, and radiofrequency were for noninvasive treatments. Nasolabial folds (13.4%) and glabellar lines (12.4%) were the top research hotspots in the East Asian and Western regions. Common adverse events were pain, erythema, swelling, and bruising. Approximately, 89.3% of publications were from single countries, whereas 10.7% of publications were from international collaborations. Most articles (n = 387; 69.95%) presented their findings using level II evidence. Dermatological surgery (IF = 2.914) had the greatest number of publications (n = 109; 19.71%).

Conclusions

The main hotspots were antiaging and youthfulness. This study provides a trend and a new perspective on the future research directions in the field of facial rejuvenation.

Cosmetic Treatment Using Botulinum Toxin in the Oral and Maxillofacial Area: A Narrative Review of Esthetic Techniques

Botulinum toxin (BoNT) is an anaerobic rod-shaped-neurotoxin produced by Clostridium botulinum, that has both therapeutic and lethal applications. BoNT injection is the most popular cosmetic procedure worldwide with various applications. Patients with dynamic wrinkles in areas such as the glabella, forehead, peri-orbital lines, nasal rhytides, and perioral rhytides are indicated. Excessive contraction of muscles or hyperactivity of specific muscles such as bulky masseters, cobble stone chins, gummy smiles, asymmetric smiles, and depressed mouth corners can achieve esthetic results by targeting the precise muscles. Patients with hypertrophic submandibular glands and parotid glands can also benefit esthetically. There are several FDA-approved BoNTs (obabotuli-numtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, letibotulinumtoxinA, prabotulinumtox-inA, daxibotulinumtoxinA, rimbotulinumtoxinB) and novel BoNTs on the market. This paper is a narrative review of the consensus statements of expert practitioners and various literature on the injection points and techniques, highlighting both the Asian and Caucasian population separately. This paper can serve as a practical illustrative guide and reference for optimal, safe injection areas and effective doses for application of BoNT in the face and oral and maxillofacial area. The history of BoNT indications, contraindications, and complications, and the merits of ultrasonography (US)-assisted injections are also discussed.

Management of Shrunken Cheeks by Hollow Buccal Cheek Plumper Prosthesis

Aging and a long period of edentulousness causes resorption of the maxillary residual ridge, resulting in narrowing of the arch and loss of facial muscle support that leads to the sunken appearance of cheeks. In completely edentulous patients, though the conventional complete denture does offer provision to the muscles encircling the mouth, yet the cheek plumber prosthesis is required to improve the muscle tone. This case report highlights the advantages and the sequential steps required in the indigenous method of fabricating a hollow cheek plumper appliance for a completely edentulous patient with a sunken appearance.

Intramuscular BoNT/A injections cause an inflammatory response in the muscle tissue of rats

Objectives

The purpose of the present study was to investigate whether intramuscular BoNT/A injections cause an systemic inflammatory response and a local inflammatory response in the muscle tissue.

Methods

Thirty-two male Sprague Dawley rats treated with BoNT/A (i.m., 1IU) were divided in four groups, depending on the time of BoNT/A injection (2 days before, 1, 2, and 4 weeks before the experiment). Bio-Plex Pro Rat Cytokine 23-plex Multiplex Assay (Bio-Rad, USA).

Results

Systemic inflammation: 17 cytokines (IL1-α ( p = 0.005), IL-1β ( p = 0.01), IL-2 ( p = 0.04), IL-4 ( p = 0.03), IL-6 ( p = 0.03), IL-10 ( p = 0.02), IL12(p70) ( p = 0.03), IL-13 ( p = 0.04), IL-17 ( p = 0.03), GM-CSF ( p = 0.03), INF-γ ( p = 0.03), MIP-1α ( p = 0.03), MIP-3α ( p = 0.04), RANTES ( p = 0.001), TNF-α ( p = 0.04), vascular endothelial growth factor ( p = 0.03), and MCP-1 ( p = 0.02)) showed significantly higher expression levels 2 days after intramuscular BoNT/A injections compared to other time points (1, 2, and 4 weeks). Local inflammation: 12 cytokines (IL-1β ( p = 0.02), IL-6 ( p = 0.002), IL-10 ( p = 0.02), IL-13 ( p = 0.04), IL-17 ( p = 0.02), TNF-α ( p = 0.001), GM-CSF ( p = 0.01), M-CSF ( p = 0.04), MIP-1α ( p = 0.04), MIP-3α ( p = 0.002), RANTES ( p = 0.02), and MCP-1( p = 0.004)) showed higher expression levels 2 and/or 4 weeks after intramuscular BoNT/A injections compared to the other time points (2 days and 1 week).

Conclusion

Intramuscular BoNT/A injections result in a rapid systemic inflammatory response that only lasts a couple of days. At the same time, intramuscular BoNT/A injections cause an inflammatory response locally in the muscle with significantly higher cytokine levels 2 and/or 4 weeks after injections.

[Hemifacial spasm. Etiology and management]

INTRODUCTION

Hemifacial spasm (HFS) is an involuntary contracture of the facial muscles innervated by the ipsilateral facial nerve. We studied the etiology of these HFS.

MATERIALS AND METHODS

This retrospective study included 233 patients with HFS who came to the ophthalmologist for quarterly botulinum neurotoxin A injection. Of these, we analyzed the 198 patients for whom MRI scans were performed. We recorded patient clinical data and clarified the etiology of their HFS.

RESULTS

The 198 patients (62.6% women) had a mean age of 55.7±14years. An etiology was found in 52.5% of cases. In 34.5% of HFS, MRI revealed vascular compression where the facial nerve emerged from the brainstem. We specify the arteries involved. Brain tumors accounted for 1.5% of cases. MRI was normal in 64.5% of cases. In these secondary cases of HFS, we found 8.5% peripheral facial palsy, 4% post-traumatic HFS and 4% secondary to an eye injury. Stress was found in 17% of patients.

DISCUSSION AND CONCLUSION

This study illustrates the need for MRI with attention to the posterior fossa in the work-up of HFS in order to identify primary HFS associated with vascular compression of the facial nerve and to rule out a rare but serious posterior fossa tumor. The treatment of HFS is based on quarterly injections of botulinum neurotoxin/A (NTBo/A), the three brands of which have market approval. The injection pattern and frequency is customized according to the results. In cases of insufficient response to injections of NTBo/A, neurosurgical microvascular decompression may be considered for cases of primary HFS.

PrabotulinumtoxinA-xvfs for the Treatment of Moderate-to-Severe Glabellar Lines

OBJECTIVE

PrabotulinumtoxinA-xvfs (Jeuveau), a botulinum toxin type A, was approved by the Food and Drug Administration for the temporary improvement in the appearance of moderate-to-severe glabellar lines in February 2019. This article will review phase II and III clinical trials to assess the efficacy, safety, and clinical application of this novel, aesthetic-only drug.

DATA SOURCES

A systematic literature review was performed using the terms "glabellar lines AND prabotulinumtoxinA" in the PubMed database. ClinicalTrials.gov was searched to identify nonpublished studies.

STUDY SELECTION AND DATA EXTRACTION

Articles written in English between November 2019 and June 2020 discussing phase II and phase III clinical trials were evaluated.

DATA SYNTHESIS

By the primary efficacy end point on day 30, more patients achieved a greater than 2-point improvement on the Glabellar Line Scale (GLS) at maximum frown compared with baseline on day 0. The proportions of participants who responded to treatment with prabotulinumtoxinA were 67.5% and 70.4% versus 1.2% and 1.3% in placebo groups across 2 identical clinical trials (P < 0.001). Patients receiving prabotulinumtoxinA experienced greater improvement in GLS at maximum frown on day 30 (87.2%) compared with onabotulinumtoxinA (82.8%) and placebo (4.2%; P < 0.001). PrabotulinumtoxinA was well tolerated across all studies.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

This review provides a detailed analysis of the safety and efficacy of prabotulinumtoxinA-xvfs and includes special considerations to help guide patients and clinicians.

CONCLUSION

PrabotulinumtoxinA is a safe and effective new addition to the repository of available treatments for the appearance of glabellar lines.

Injection of high dose botulinum-toxin A leads to impaired skeletal muscle function and damage of the fibrilar and non-fibrilar structures

Botulinum-toxin A (BoNT/A) is used for a wide range of conditions. Intramuscular administration of BoNT/A inhibits the release of acetylcholine at the neuromuscular junction from presynaptic motor neurons causing muscle-paralysis. The aim of the present study was to investigate the effect of high dose intramuscular BoNT/A injections (6 UI = 60 pg) on muscle tissue. The gait pattern of the rats was significantly affected 3 weeks after BoNT/A injection. The ankle joint rotated externally, the rats became flat footed, and the stride length decreased after BoNT/A injection. Additionally, there was clear evidence of microstructural changes on the tissue level by as evidenced by 3D imaging of the muscles by Synchrotron Radiation X-ray Tomographic Microscopy (SRXTM). Both the fibrillar and the non-fibrillar tissues were affected. The volume fraction of fibrillary tissue was reduced significantly and the non-fibrillar tissue increased. This was accompanied by a loss of the linear structure of the muscle tissue. Furthermore, gene expression analysis showed a significant upregulation of COL1A1, MMP-2, TGF-b1, IL-6, MHCIIA and MHCIIx in the BoNT/A injected leg, while MHVIIB was significantly downregulated.

IN CONCLUSION

The present study reveals that high dose intramuscular BoNT/A injections cause microstructural damage of the muscle tissue, which contributes to impaired gait.

Aesthetic and Non-aesthetic Indications for Orbicularis Oculi Myectomy

INTRODUCTION

Crows' feet wrinkles are caused by the action of the orbicularis oculi muscle on overlying skin. Treatment options range from botulinum toxin to a multitude of surgical methods. We first described our technique in 2003 and refined it in 2006. We highlight the evolution of our technique and look at our results to assess the effectiveness of our technique.

OBJECTIVE

The aim of this article is to show our experience of 13 years in 134 patients with our technique of orbicularis oculi myectomy.

METHODS

From September 2000 to July 2013, we operated on 134 patients with an age range of 28-77 years. Of these patients, 104 had myectomies via lifting and 22 via a blepharoplasty approach. Five patients had myectomies for treatment of blepharospasm and a further three patients to restore symmetry in facial palsy. An evaluation of the results was performed by two medical students.

RESULTS

Our results showed reduction of the wrinkles in all cases. For the statistical analysis the Wilcoxon test was performed. The p value was less than 0.001 showing a significant reduction of crows' feet wrinkles in both sides when the orbicularis myectomy was performed, via blepharoplasty or lifting. For myectomy performed for blepharospasm or facial palsy, the statistical analysis was not done due to the low numbers.

CONCLUSION

In the appropriate patient, orbicularis oculi myectomy is an effective and long-term treatment for crows' feet wrinkles with a low risk of complications and high patient satisfaction.

LEVEL OF EVIDENCE IV

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 .

The role of neurotoxins in the periorbital and midfacial areas

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.

Multicenter, randomized, phase III study of a single dose of incobotulinumtoxinA, free from complexing proteins, in the treatment of glabellar frown lines

BACKGROUND

Botulinum toxin type A is a proven, effective aesthetic treatment for glabellar frown lines. IncobotulinumtoxinA (NT 201, Xeomin/Xeomeen/Bocouture, Merz Pharmaceuticals GmbH, Frankfurt, Germany) is a 150-kDa botulinum toxin type A free of complexing proteins.

OBJECTIVE

To assess the efficacy and safety of incobotulinumtoxinA in a randomized, double-blind, placebo-controlled, Phase III study in patients with moderate to severe glabellar frown lines.

MATERIALS AND METHODS

Two hundred seventy-six patients were randomized 2:1 to receive a single injection of 20 U of incobotulinumtoxinA or placebo, respectively. Efficacy was assessed at day 30 using a Food and Drug Administration-mandated composite endpoint; a responder was defined as a patient with a 2-point or greater improvement in glabellar frown lines on a 4-point scale as assessed by investigator and patient. Safety was assessed periodically through Day 120.

RESULTS

Treatment with a single dose of incobotulinumtoxinA was significantly superior to placebo in the treatment of glabellar frown lines at Day 30 using the composite endpoint (p < .001), with investigators and patients assessing glabellar frown lines as significantly more improved after incobotulinumtoxinA injection than with placebo (p < .001). IncobotulinumtoxinA was well tolerated.

CONCLUSION

A single dose of 20 U of incobotulinumtoxinA demonstrated efficacy and safety in the treatment of glabellar frown lines using new Food and Drug Administration efficacy variables.

An open-label prospective clinical study of the efficacy and safety of botulinus toxin type A for the correction of age-related neck skin changes

Objective. Assessment of the efficacy and safety of the correction of age-related neck skin changes with the use of botulinus toxin type A (Xeomin). Materials and methods. The study involved 25 women aged 39—65 enrolled according to the inclusion and exclusion criteria. The patients were administered a single subcutaneous injection of Xeomin 60 U in the neck. The efficacy and safety of this procedure was assessed based on the Global Aesthetic Improvement Scale (GAIS) on Day 14 as well as after 2 and 3 months. Results. High efficacy and safety of intracutaneous Xeomin injections at the submaximum dose of 60 u in the medial and lateral platysma bands have been confirmed clinically. The authors suggest an experimental gradining of the age-related neck making it possible to assess and statistically process clinical results of the new method.

Oculofacial contour asymmetries: Management of combined treatment with hyalurostructure and botulinum toxin injections

PURPOSE

To assess the long-term results of the treatment of oculofacial asymmetries using a combined injection schedule for injections of hyaluronic acid, with a specific micro cannula and botulinum toxin.

METHOD

A retrospective study was conducted from January 2009 to January 2010. Patients were treated in the Alcazar Eye Clinic and Oculoplastic Department in Princess Grace Hospital, Monaco. We selected patients complaining of asymmetrical periorbital features who received treatment with hyalurostructure and botulinum toxin injection in one or more sessions. Nine patients were selected and presented with the following symptoms: asymmetry of eyebrow position (2 patients), superior orbital hollow (2 patients), tear trough (2 patients) and orbital volume (ocular prosthesis) (3 patients). The objective was to evaluate the efficiency of combined treatment in one or more sessions on these oculofacial asymmetries. Hyaluronic acid injections were done using hyalurostructure. Hyaluronic acid gel (Restylane Lidocaine) was used with a 25 gauge reinforced micro-cannula (pix'l +, Thiebaud). This was combined with injections of botulinum toxin (azzalure*) to areas of muscular hyperaction. Follow-up was done at 1 year by clinical examination, photography and patient satisfaction. Complications of this combined treatment have been identified.

RESULTS

At 1-year follow-up, 88% of patients were satisfied or very satisfied with their results. There were no more complications secondary to both treatments in the same session. It was not noticed more hematomas and bruises than in classical injection method. The action of toxin is constant over time despite the association of hyaluronic acid injections.

CONCLUSION

Combined treatments with toxin and hyaluronic acid in oculofacial asymmetries are efficient and can be proposed in the same session. These treatments must be repeated to maintain and optimize muscle contraction and volume loss. Use of hyalurostructure and botulinum toxin treatment in the same session is effective and safe.

Compositional differences among commercially available botulinum toxin type A

PURPOSE OF REVIEW

Since the advent of botulinum neurotoxin (BoNT) in the facial cosmetic field, it has become the leading nonsurgical cosmetic procedure in the USA, and several different formulations are currently in use. The aim of this study is to review the major 'players' in order to help the physician understand the clinically relevant dissimilarities between the products and by that promote treatment efficacy and patient satisfaction.

RECENT FINDINGS

The different available formulations can be classified into two groups by the existence of absence of complexing proteins. Most of the influence that was previously attributed to these proteins has been found to be less relevant clinically, the immune response being the only remaining issue with supporting evidence in the literature.

SUMMARY

Botulinum toxin type A is widely utilized in the cosmetic field, and it seems that all available and approved formulations are both well tolerated and effective in treating facial rhytids. The treating physician must be familiar with the differences between all the products, especially the fact that they are not interchangeable in respect to their recommended dosage.

Facial rejuvenation for middle-aged women: a combined approach with minimally invasive procedures

Facial rejuvenation is a significant process involved in restoring youthfulness. The introduction of less invasive procedures has increased acceptance of such procedures. Often a combination of different techniques allows individualized treatment with optimal outcomes. Furthermore, this leads to a natural look without a significant downtime. We report herein the use of such a combined approach in middle-aged women with particular emphasis on botulinum toxin type A, dermal fillers, and chemical peels.