Global Aesthetics Consensus: Botulinum Toxin Type A--Evidence-Based Review, Emerging Concepts, and Consensus Recommendations for Aesthetic Use, Including Updates on Complications

Anatomical considerations of medial eye wrinkles: Guidelines for botulinum neurotoxin injections

Crow's feet lines in the lateral canthal region are a common concern among aging patients, initially appearing as dynamic wrinkles during facial expressions and becoming more pronounced with age. Botulinum neurotoxin temporarily paralyzes muscles by inhibiting acetylcholine release, smoothing wrinkles and enhancing skin's youthful appearance. Effective treatment requires tailored approaches considering individual anatomy and muscle activity. Recent cadaveric studies identified the tear trough muscle, emphasizing its role in infraorbital support and aging. Clinically, patients often present medial eye wrinkles after BoNT treatment for crow's feet, prompting exploration of underlying mechanisms and management strategies. Three cases demonstrated that medial BoNT injections in the orbicularis oculi muscle significantly improve medial eye wrinkles and tear trough appearance. The study underscores the importance of understanding muscle hyperactivity and anatomical variations for precise treatment. Enhanced injection techniques targeting specific areas can achieve better outcomes and minimize complications, particularly in culturally sensitive regions where facial expressions are valued. This research highlights the necessity for comprehensive anatomical knowledge and patient-specific treatment strategies to address medial eye wrinkles effectively.

Comparative study between the efficacy of prabotulinum toxin-A versus onabotulinum toxin-A for the treatment of upper facial expression lines

BACKGROUND

Botulinum Toxin (BoNTA) is the most used nonsurgical aesthetic procedure to treat facial expression lines.

AIMS

This study compared the efficacy of Prabotulinum toxin-A, a novel BoNTA that originates from Clostridium botulinum Hall-A, with onabotulinum toxin-A in treating facial expression lines using the Facial Wrinkle Scale (FWS) and FACE-Q questionnaires.

METHODS

This was an experimental, comparative, longitudinal, open-label, and prospective study. Patients aged between 25 and 40 years with upper-third facial expression lines were included. Follow-ups were made at three, seven, 30, and 120 days.

RESULTS

A total of 26 patients were included: 20 female, and six males, with a mean age of 28.26 years. An average of 31.00 IU and 31.38 IU were administered to the onabotulinum and prabotulinum groups, respectively. The prabotulinum group demonstrated superiority in FWS and Face-Q scores between the first and third days (p ≤ 0.001, p < 0.001, respectively), which continued on day 7. By day 30, there were no differences in the scores of the two questionnaires.

CONCLUSIONS

Prabotulinum toxin-A is a safe and effective treatment for upper-third facial wrinkles. On day three and seven, the results suggest that prabotulinum toxin-A has a quicker onset of action than onabotulinum toxin-A. On days 30 and 120, both groups showed similar FWS and Face-Q scores.

Safe Zones for Facial Fillers: Anatomical Study of SubSMAS Spaces in Asians

The study "Spaces of the Face for Filler Procedures: Identification of subSMAS Spaces Based on Anatomical Study" explores the anatomy of facial spaces crucial for safe and effective filler injections. By delineating the subSMAS (sub-superficial musculoaponeurotic system) spaces, this research highlights how these virtual compartments, bordered by fat, muscles, fascia, and ligaments, facilitate independent muscle movement and reduce the risk of damaging critical structures. The thicker and more robust skin of East Asians necessitates deeper filler injections, emphasizing the significance of accurately identifying these spaces. A cadaver study with dyed gelatin validated the existence and characteristics of these subSMAS spaces, confirming their safety for filler procedures. Key spaces, such as the subgalea-frontalis, interfascial and temporalis, and prezygomatic spaces, were examined, illustrating safe zones for injections. The findings underscore the importance of anatomical knowledge for enhancing facial aesthetics while minimizing complications. This study serves as a guide for clinicians to perform precise and safe filler injections, providing a foundation for further research on the dynamic interactions of these spaces and long-term outcomes.

Cosmetic injectables in skin of color: A review of uses, safety, and effectiveness of neuromodulators and dermal fillers

BACKGROUND

Skin of color (SOC) individuals represent a growing market for cosmetic injectables and can have different aesthetic goals and responses to treatment.

OBJECTIVE

A review of the uses, safety, and effectiveness of injectable neuromodulators and dermal fillers in SOC individuals.

METHODS AND MATERIALS

A search of the PubMed/MEDLINE database was conducted from August 1960 to December 2020. Studies that were included either had a focus on SOC (>20% SOC study participants) or dedicated article content commenting on the safety and/or efficacy of injectables in SOC participants.

RESULTS

Of the 503 publications identified, a total of 88 articles were selected for this review. Differences in aging and cultural factors can influence aesthetic goals amongst SOC populations. Available data suggests that botulinum toxin (BTX) and dermal fillers are safe and effective in SOC populations, with the largest amount of data existing for Asian populations. There remains a paucity of research on Black and Latinx populations.

CONCLUSION

BTX and dermal fillers are generally effective and well tolerated in SOC populations, particularly Asian populations for which the greatest amount of data exists. More high quality, randomized controlled trials in Black and Latinx populations are warranted.

Poly-l-lactic acid microspheres delay aging of epidermal stem cells in rat skin

Objective

Injectable skin fillers offer a wider range of options for cutaneous anti-aging and facial rejuvenation. PLLA microspheres are increasingly favored as degradable and long-lasting fillers. The present study focused solely on the effect of PLLA on dermal collagen, without investigating its impact on the epidermis. In this study, we investigated the effects of PLLA microspheres on epidermal stem cells (EpiSCs).

Methods

Different concentrations of PLLA microspheres on epidermal stem cells (EpiSCs) in vitro through culture, and identification of primary rat EpiSCs. CCK-8 detection, apoptosis staining, flow cytometry, Transwell assay, wound healing assay, q-PCR analysis, and immunofluorescence staining were used to detect the effects of PLLA on EpiSCs. Furthermore, we observed the effect on the epidermis by injecting PLLA into the dermis of the rat skin in vivo.

Results

PLLA microspheres promote cell proliferation and migration while delaying cell senescence and maintaining its stemness. In vitro, Intradermal injection of PLLA microspheres in the rat back skin resulted in delayed aging, as evidenced by histological and immunohistochemical staining of the skin at 2, 4, and 12 weeks of follow-up.

Conclusion

This study showed the positive effects of PLLA on rat epidermis and EpiSCs, while providing novel insights into the anti-aging mechanism of PLLA.

Ready-to-use abobotulinumtoxinA solution versus powder botulinumtoxinA for treatment of glabellar lines: Investigators' and subjects' experience in a Phase IV study

BACKGROUND

Botulinum neurotoxin type A (BoNT-A) is well-established for treatment of glabellar lines (GLs), and mostly formulated as powders requiring reconstitution for injection. The approved liquid formulation, ready-to-use (RTU) abobotulinumtoxinA was developed to ease injection procedures and prevent reconstitution errors. This multicenter, open-label, Phase IV study evaluated GL treatment experience using RTU abobotulinumtoxinA versus powder BoNT-A (onabotulinumtoxinA).

METHODS

Females with experience of BoNT-A facial treatment were randomized 2:1 to GL treatment with 50 U RTU abobotulinumtoxinA (N = 99) or 20 U powder BoNT-A (N = 51) and followed-up for 6 months or 1 month, respectively. Assessments included: time to prepare each product for injection (primary endpoint); investigators' experience with product preparation/reconstitution; investigators' and subjects' treatment experience; safety; and for the RTU product: aesthetic improvement of GLs; subject satisfaction.

RESULTS

Compared with powder BoNT-A, RTU abobotulinumtoxinA required statistically significantly less preparation time (mean 0:33 vs. 1:34 min: s; p < 0.0001). Investigators preferred RTU abobotulinumtoxinA over powder BoNT-A (81% of treatment sessions) and found it allowed more time to communicate with subjects (97%). All investigators (100%) also found it easy-to-use, easy-to-learn, and that it fulfilled their expectations. Subjects found the RTU abobotulinumtoxinA treatment comfortable (91%), and through 6 months posttreatment, most reported satisfaction with their appearance (≥88%), looking natural (≥95%) and refreshed (≥80%). At Month 1, 99% of RTU-treated subjects had investigator-assessed improved aesthetic appearance in GLs, maintained in 76% at Month 6. No serious adverse events occurred.

CONCLUSION

RTU abobotulinumtoxinA for GL treatment is well-tolerated, efficacious, shows high levels of subject satisfaction throughout 6 months, saves time, and is preferred by clinicians over powder BoNT-A.

CLINICALTRIALS

GOV REGISTRY

NCT05277337.

Facial Painting and 3D Stereophotogrammetric Analysis of Facial Dynamics: A Reliable Anatomical Educational Method

(1) Background: Accurate knowledge of the dynamic anatomy of facial muscles is crucial for the use of functional and aesthetic botulinum toxin injections. We studied the reliability and relevance of facial painting as a pedagogic tool for the dynamic anatomy of facial muscles. (2) Methods: Different facial expressions were performed by a female model after a professional makeup artist applied makeup to the various facial muscles on her left hemiface. A 3D photograph was taken at the beginning and end of each movement using the VECTRA H2 Imaging System device. Cutaneous movements were visualized using displacement vectors. The correlation between the theoretical and dynamic positions of the makeup-muscle was assessed by two facial anatomy experts, thanks to a correlation scale. (3) Results: The overall average score for the 11 analyzed muscles or muscle groups was 3.36 out of 4, indicating a "strong" to "very strong" estimated correlation. There was a moderate agreement between Evaluator 1 and Evaluator 2 (ICC: 0.64; 95%CI: [0.244; 0.852]; p-value: 0.005). (4) Conclusions: The educational model with facial makeup provides an indirect but nonetheless precise and reliable representation of all facial muscles on the skin's surface. It is presented as a reliable and reproducible method, which exhibits great potential as a teaching tool.

Early postoperative interventions in the prevention and management of thyroidectomy scars

Thyroidectomy scars, located on the exposed site, can cause distress in patients. Owing to the cosmetic importance of thyroidectomy scars, many studies have been conducted on its prevention and treatment. Scar formation factors mainly include inflammatory cell infiltration, angiogenesis, fibroblast proliferation, secretion of cytokines such as transforming growth factor (TGF)-β1, and mechanical tension on the wound edges. Anti-scar methods including topical anti-scar agents, skin tension-bearing devices, and local injections of botulinum toxin, as well as lasers and phototherapies, that target these scar formation factors have been developed. However, current studies remain fragmented, and there is a lack of a comprehensive evaluation of the impacts of these anti-scar methods on treating thyroidectomy scars. Early intervention is a crucial but often neglected key to control hyperplastic thyroidectomy scars. Therefore, we review the currently adopted early postoperative strategies for thyroidectomy scar reduction, aiming to illustrate the mechanism of these anti-scar methods and provide flexible and comprehensive treatment selections for clinical physicians to deal with thyroidectomy scars.

Comparison of the Effectiveness of Different Methods for Pain Reduction During Injection Procedures in the Frontalis Muscle

BACKGROUND

Forehead aesthetic injections are a well-known source of discomfort, and many analgesic non-invasive techniques have been proposed to ameliorate pain. However, no study has compared all these techniques for aesthetic purposes. Therefore, this study aimed to compare the effectiveness of topical cream anesthesia, vibratory stimulus, cryotherapy, pressure, and even no intervention, on pain during and immediately after injection, when considering aesthetic injections in the forehead.

METHODS

Seventy patients were selected and had their foreheads divided into 5 parts, which received four different analgesic techniques, and one control zone was added. A numeric rating scale was used to assess pain, two direct questions were asked to evaluate patients' preference and discomfort with the techniques, and the adverse events were quantified. The injections were performed in the same sequence, with three minutes of rest between them and in a single session. Comparisons among analgesic methods for pain relief were performed by the one-way analysis of variance (ANOVA), considering a significance level of 5%.

RESULTS

No significant differences were found among the analgesic methods, and between the methods and the control zone, both during and immediately after the injections (p > 0.05). The preferred method for pain relief was the use of topical anesthetic cream (47%), while the most uncomfortable technique was manual distraction (pressure) (36%). Only one patient reported an adverse event.

CONCLUSIONS

No analgesic method to diminish pain was superior to the others or was better than no method. Nevertheless, the topical anesthetic cream was the preferred technique, causing less discomfort.

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 .

Effects of glabellar botulinum toxin injections on resting-state functional connectivity in borderline personality disorder

Meta-analyses suggest a sustained alleviation of depressive symptoms through glabellar botulinum toxin (BTX) injections. This can be explained by the disruption of facial feedback loops, which may moderate and reinforce the experience of negative emotions. Borderline personality disorder (BPD) is characterized by excessive negative emotions. Here, a seed-based resting-state functional connectivity (rsFC) analysis following BTX (N = 24) or acupuncture (ACU, N = 21) treatment in BPD is presented on areas related to the motor system and emotion processing. RsFC in BPD using a seed-based approach was analyzed. MRI data were measured before and 4 weeks after treatment. Based on previous research, the rsFC focus was on limbic and motor areas as well as the salience and default mode network. Clinically, after 4 weeks both groups showed a reduction of borderline symptoms. However, the anterior cingulate cortex (ACC) and the face area in the primary motor cortex (M1) displayed aberrant rsFC after BTX compared to ACU treatment. The M1 showed higher rsFC to the ACC after BTX treatment compared to ACU treatment. In addition, the ACC displayed an increased connectivity to the M1 as well as a decrease to the right cerebellum. This study shows first evidence for BTX-specific effects in the motor face region and the ACC. The observed effects of BTX on rsFC to areas are related to motor behavior. Since symptom improvement did not differ between the two groups, a BTX-specific effect seems plausible rather than a general therapeutic effect.

Clinically Actionable Topical Strategies for Addressing the Hallmarks of Skin Aging: A Primer for Aesthetic Medicine Practitioners

In this narrative review, we sought to provide a comprehensive overview of the mechanisms underlying cutaneous senescence, framed by the twelve traditional hallmarks of aging. These include genomic instability, telomere attrition, epigenetic alterations, loss of proteostasis, impaired macroautophagy, deregulated nutrient sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion, altered intercellular communication, chronic inflammation, and dysbiosis. We also examined how topical interventions targeting these hallmarks can be integrated with conventional aesthetic medicine techniques to enhance skin rejuvenation. The potential of combining targeted topical therapies against the aging hallmarks with minimally invasive procedures represents a significant advancement in aesthetic medicine, offering personalized and effective strategies to combat skin aging. The reviewed evidence paves the way for future advancements and underscores the transformative potential of integrating scientifically validated interventions targeted against aging hallmarks into traditional aesthetic practices.

Efficacy and safety of high-intensity, high-frequency, non-focused ultrasound parallel beams for facial skin laxity

BACKGROUND

Ultrasound energy has been used for dermal rejuvenation to treat fine lines, wrinkles and to lift lax skin. High intensity ultrasound waves induce thermal injury in the dermis, stimulating neocollagenesis and neoelastinogenesis.

OBJECTIVE

To assess the efficacy, utility, and safety of a novel ultrasound device that uses high-intensity, high-frequency, non-focused ultrasound parallel beams to lift lax facial skin in the eyebrow, submental, and neck areas.

MATERIALS AND METHODS

Fifteen subjects aged 40-69 years were enrolled in a prospective clinical trial. Two treatment sessions were performed with the high-intensity non-focused ultrasound parallel beam device followed by 3- and 6-month follow-up visits. Treatment results were assessed by study investigators, evaluating baseline and posttreatment photographs by applying physician global aesthetic improvement scale. Pain was evaluated immediately after each treatment using 0-10 visual analog scale. Any adverse event that occurred during the study period was documented and examined.

RESULTS

Fifteen subjects with a mean age of 55 ± 2 years completed the study. Photographs that were taken at baseline and follow-up visits were compared and examined. An improvement pattern was detected in all treated areas in both follow-up visits and persisted stably throughout the study. The mean pain score was 5.6 according to the visual analog scale.

CONCLUSION

The novel ultrasound device that uses high-intensity, high-frequency, non-focused ultrasound parallel beam was shown to improve safely and efficiently facial lax skin resulting in eyebrow, submental, and neck skin lift while experiencing tolerable pain.

Self-perception of natural outcome, appearance, and emotional well-being after OnabotulinumtoxinA treatment for upper facial lines: Post hoc analysis across age and gender

BACKGROUND

OnabotulinumtoxinA (onabotA) is indicated for upper facial lines (UFL). Fear of unnatural-looking outcomes is a frequently reported treatment barrier.

AIMS

Examine patient-reported outcomes (PROs) after onabotA treatment for UFL.

METHODS

A post hoc analysis was conducted on two 12-month pivotal studies of onabotA for forehead and glabellar lines (20 U each), with/without treatment of crow's feet lines (±24 U). This analysis used PROs from the Facial Line Satisfaction Questionnaire: Items 4 (natural look), 5 (treatment effect), 11 (met expectations), and Impact Domain (appearance and psychological impact). The analysis included 458 neurotoxin-naive adults achieving a ≥2-grade improvement in forehead line (FHL) severity on the Facial Wrinkle Scale at Day 30 (primary endpoint). [Corrections made on 28 December 2023, after first online publication: 'UFL' in the previous sentence has been corrected to 'forehead line (FHL)' in this version.] Data were further stratified into millennials and men.

RESULTS

At Day 30, 90.5% of all participants, 94.6% of millennials, and 85.7% of men were satisfied with receiving a natural look. Millennials had higher odds of being satisfied with natural outcomes at Day 30. This measure remained > 80% for all groups throughout the 12 months. Additionally, ≥80% were satisfied with the treatment effect, and >90% reported results met expectations. At Day 30, ≥50% reported positive impacts on self-perceived appearance and psychological well-being, but millennials had higher, and men had lower odds of reporting these improvements.

CONCLUSIONS

Participants achieving a ≥2-grade improvement in FHL severity after onabotA reported high satisfaction with natural outcomes and the treatment effect, with improved self-perceived appearance and psychological well-being. [Corrections made on 28 December 2023, after first online publication: 'UFL' in the previous sentence has been corrected to 'FHL' in this version.] These results may help aesthetic providers and patients address fears regarding unnatural results with onabotA.

Biochemical Stability and Microbial Control of Reconstituted DaxibotulinumtoxinA-lanm for Injection

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.

Impact of Glabellar Injection Technique With DaxibotulinumtoxinA for Injection on Brow Position

BACKGROUND

Precise injection technique is vital for avoiding suboptimal eyebrow position when treating glabellar lines with botulinum toxin type A.

OBJECTIVES

The aim of this study was to evaluate the impact of glabellar injection technique on eyebrow position in patients treated with DaxibotulinumtoxinA for Injection (DAXI).

METHODS

This retrospective post hoc analysis involved 60 adults who received a single treatment with DAXI 40 U to the glabella and had standardized facial photography. Median vertical and horizontal displacement of the brows (at rest) at baseline and 2 weeks after glabellar injection were measured. Brow position outcomes were evaluated by an oculoplastic surgeon and expert anatomist. Investigators were interviewed to ascertain individual injection techniques.

RESULTS

Precise injection location and depth, and median resting brow position following treatment varied between investigators. Positive brow outcomes were achieved with deep DAXI injections into the medial corrugator, superficial lateral corrugator injections placed between the midpupil and lateral limbus, and deep midline procerus injections. Glabellar injection technique that more precisely targeted the corrugator muscles resulted in longer glabellar line treatment duration compared to a less targeted technique. Medial corrugator injections above the medial brow; lateral corrugator injections administered deeply or more medially, toward the medial third of the brow; and procerus injections superior to the inferomedial brow tended to be associated with suboptimal outcomes that were more apparent during dynamic expression.

CONCLUSIONS

Aesthetically pleasing brow outcomes and greater duration of efficacy can be achieved with an injection pattern that precisely treats the anatomic location of the corrugator supercilii and procerus muscles, avoiding the frontalis.

LEVEL OF EVIDENCE: 4

Decades of beauty: Achieving aesthetic goals throughout the lifespan

BACKGROUND

Several elements, including age, influence judgments of beauty and attractiveness. Aging is affected by intrinsic factors (e.g., genetics, race/ethnicity, anatomical variations) and extrinsic factors (e.g., lifestyle, environment).

AIMS

To provide a general overview of minimally invasive injectable procedures for facial beautification and rejuvenation to meet the aesthetic goals of patients across their lifespan, organized by decade.

METHODS

This case study review describes aesthetic considerations of females in their third to sixth decade of life (i.e., 20-60 years of age or beyond). Each case study reports the treatments, specifically botulinum toxin type A and soft tissue fillers, used to address aesthetic concerns.

RESULTS

Signs of aging, as well as aesthetic goals and motivations, vary by age groups, cultures, and races/ethnicities. However, there are overarching themes that are associated with each decade of life, such as changes in overall facial shape and specific facial regions, which can be used as a starting point for aesthetic treatment planning. Appropriate patient selection, thorough aesthetic evaluation, product knowledge, and injection technique, as well as good physician-patient communication, are essential for optimal treatment outcomes.

CONCLUSIONS

Nonsurgical facial injectable treatments can successfully enhance and rejuvenate facial features across different age ranges. A comprehensive understanding of facial aging and the aesthetic considerations of patients by the decade contributes to optimal treatment planning and maintenance.

Tailored Indications for Different Neurotoxins

Background

Minimally invasive procedures have become increasingly popular because they require minimal downtime and are effective for achieving a more youthful appearance. All U.S. Food and Drug Administration-approved neurotoxins are indicated for achieving similar effects, even though they are different in regard to structure, manufacturing technique, and storage requirements. It is agreed upon that each neurotoxin is unique and therefore not interchangeable. The aim of the author is to provide an approach for choosing the optimal toxin in different indications regarding the area of treatment, the age and characteristics of the patient, potential risks, and ultimate goals.

Methods

As the country that the author practices carries onabotulinum (ONA), prabotulinum (PRA), and abobotulinum (ABO) toxin type-A, one of these three toxins was preferred for each category. ABO toxins were preferred in wide areas due to the broader action halo. Typical examples include hyperhidrosis treatment, wide forehead area, and calf slimming. In areas where very precise and targeted treatment is required, PRA and ONA toxins were preferred to limit potential side effects due to wider diffusion. First-time patients were typically treated with PRA toxins for a softer trial periods where as "repeat" patients were successfully treated with ABO toxins.

Results

No toxin is superior to the other in terms of producing effects. Yet, small differences in their properties can allow the plastic surgeon to cater to each patient's needs while yielding the most optimal results.

Conclusions

This study is meant to serve as a guideline for choosing the ideal toxin in different patient settings and indications.

Botulinum Toxin: A Potential Cardiovascular Agent?

Botulinum neurotoxin (BoNT) is a toxin with a wide repertoire of well-known applications in cosmetics and medicine, such as treating migraine headaches, spasticity, and achalasia, and it has generally been shown to be safe and well-tolerated. In addition to its current successes in clinical practice, studies have also demonstrated the potential of BoNT to be used as a therapeutic agent for many cardiovascular conditions. Prior investigations, as well as trials currently underway, have showcased the safety and potential efficacy of BoNT in applications such as treating ischemia-reperfusion injury, hypertension, atrial fibrillation, and heart failure. While further study in humans, as well as improved statistical power in efficacy studies, are needed before its prospective use as a treatment for the aforementioned conditions, one might consider BoNT a potential cardiovascular agent.

Consensus Statement on the Use of Botulinum Neurotoxin in the Middle East

Background

Aesthetic minimally invasive procedures have become very popular and culturally acceptable among Middle Eastern populations. Botulinum neurotoxin type A (BoNTA) is a valuable treatment modality for many cosmetic as well as therapeutic indications. The presence of BoNTA in our toolkit has revolutionized the field of aesthetic medicine to the point where it is now one of the most commonly performed cosmetic procedures worldwide. This consensus considers popular on- and off-label BoNTA indications in the Middle East.

Methods

A multinational group of ten key opinion leaders, experts in facial plastic surgery and dermatology, convened the Middle East Aesthetics Consensus Group and reviewed the aesthetic applications of BoNTA. Recommendations and position statements were drafted based on the integration of the panel's clinical experience with published data, targeted to the practices implemented in the Middle Eastern and the global population.

Results

Guidance statements are presented covering Middle Eastern facial characteristics and beauty ideals, BoNTA characteristics, pre-operative counselling, treatment indications and anatomical considerations, off-label and special uses including high-dose recommendations, and post-treatment advice. Throughout, an evidence-based approach to selection of products and injection techniques is provided, supplemented by the experts' advice on injections dosages and placement.

Conclusion

This consensus reflects the knowledge and expertise of physicians practicing in the Middle East. The panel acknowledged the use of on-label indications and variability in the toxin formulations and immunogenicity and agreed upon a wide use of "off-label" indications.

Mechanism and clinical use of botulinum neurotoxin in head and facial region

PURPOSE

Botulinum neurotoxin (BoNT) is a biological toxin produced by Clostridium botulinum. BoNT is a potent toxin extensively used in therapeutic interventions. This review provides an updated overview of the mechanisms of action and clinical applications of BoNT in head and facial region.

STUDY SELECTION

MEDLINE/PubMed searches were conducted using the terms "botulinum neurotoxin" and "dentistry" along with a combination of other related terms. In addition, studies were manually selected from reference lists of the selected articles.

RESULTS

The Food and Drug Administration in the United States initially approved BoNT to treat strabismus, blepharospasm, and hemifacial spasms. The use of BoNT in dermatology and cosmetics has been widely established and has created a revolution in these fields. Over the years, its applications in various medical specialties have expanded widely. Owing to its safety, efficacy, and long duration of action, it is well-accepted by patients. BoNT/A and BoNT/B are widely used in clinical practice. Several off-label uses of BoNT in the dental fraternity have yielded promising results. We have elaborated on the speculated mechanism of action, dosage, effective sites of injection, and adverse effects of each therapeutic application. The various clinical indications for BoNT include bruxism, myofascial pain, temporomandibular joint dislocation, hemifacial pain, orofacial dystonia, facial paralysis, chronic migraine, and trigeminal neuralgia.

CONCLUSIONS

BoNT is a safe treatment that can be used effectively, provided that the clinician has adequate knowledge regarding the mechanism, injection techniques, and local and systemic side effects and that it is administered cautiously and purposefully.

Use of LetibotulinumtoxinA for Aesthetic Treatment of Asians: A Consensus

Treatment of wrinkles and dynamic lines with botulinum toxin has been a routine practice for years in aesthetic clinical settings. The effective treatment of wrinkles requires a comprehensive understanding of facial expression muscles and their interactions, the mechanism of action of botulinum toxin, and individual patient preferences. The dose adjustment practice and injection technique of physicians are affected by cultural differences; most Asian patients prefer natural-looking results. This article aims to present an expert consensus on the injection sites, doses, and levels of botulinum toxin for various indications in Asians, with the hope of providing guidance to some clinicians. This consensus paper reviews LetibotulinumtoxinA for patient evaluation, dosage, and delivery techniques in Asians from the time LetibotulinumtoxinA was approved up to December 2022. Panelists proposed individualized treatment plans for botulinum toxin type A (BTxA) treatments in 3 areas-wrinkle removal, contour adjustment, and face lifting-for Asians based on their extensive experience and knowledge of facial anatomy. When using a different BTxA, clinicians should start with a conservative dose and carefully individualize the treatment for each patient, and adjust it according to feedback to obtain a higher satisfaction level.

LEVEL OF EVIDENCE: 5

SAMCEP Society consensus on the treatment of upper facial lines with botulinum neurotoxin type A: A tailored approach

BACKGROUND

The safety and efficacy of botulinum neurotoxin type A (BoNTA) treatments are well established, but injection techniques, target muscles, and toxin doses continue to evolve, with each refinement producing improvements in treatment outcomes. The recommendations in this consensus move away from standard templates and illustrate how to tailor treatments to individual patterns and strengths of muscle activity, and patient preferences.

METHODS

Seventeen experts in the fields of plastic surgery, dermatology, ophthalmology, otorhinolaryngology, and neurology convened in 2022 to develop consensus-based recommendations for the use of botulinum toxin A for the treatment of horizontal forehead lines, glabellar frown lines, and crow's feet lines that reflect current clinical practice. The focus was on how to tailor injections to individual patients to optimize treatment outcomes.

RESULTS

For each upper face indication, consensus members describe how to perform a dynamic assessment to optimize the dose and injection technique for each patient. A tailored treatment protocol is presented for commonly observed patterns of dynamic lines. Units of Inco are defined and the precise location of injection points, illustrated with the use of anatomical images.

CONCLUSION

This consensus provides up-to-date recommendations on the tailored treatment of upper facial lines based on the latest research and collective clinical experience of the expert injectors. Optimal outcomes require thorough patient evaluation, both at rest and during animation, using both visual and tactile cues; detailed understanding of facial muscular anatomy and how opposing muscles interact; and use of a BoNTA with high precision to target identified zones of excess muscle activity.

Surgical or Nonsurgical Facial Rejuvenation: The Patients' Choice

Background

Patients seeking a pan-facial rejuvenation may not receive appropriate medical advice on surgical versus nonsurgical treatments, resulting in those who are best-suited for surgery receiving nonsurgical options, and vice versa. Patients who requested total-face, nonsurgical revitalization were surveyed to understand the factors influencing this decision-making.

Methods

Patients consulting for total facial rejuvenation were surveyed on their reasons for seeking nonsurgical versus surgical interventions by an investigator with 30 years of plastic surgery experience, practicing in a nonsurgical clinic alongside a dermatologist and aesthetic physician.

Results

Of the 92 patients surveyed, 78% completed the survey, 47% of whom had considered facelift surgery, and 14% of whom proceeded to inquiries or consultations with a plastic surgeon about facelift surgery. All respondents were women, and age was not an exclusion factor. Forty-four percent would still consider facelifts in later life. Among the most common reasons for choosing nonsurgical approaches were a desire for natural and subtle results, cost, having flexibility in treatment choice, concerns about surgical and anesthesia risks, downtime, the ability to distribute treatments over time, and scarring.

Conclusions

Many patients book nonsurgical treatments without prior professional advice, and consider these as a temporary solution, but may desire surgery later in life. Before conducting nonsurgical treatments, doctors should identify this group and avoid interventions that may interfere with optimal surgical outcomes later. Also, some patients desire surgical outcomes when surgery is not a feasible option, and thus seek nonsurgical alternatives. For this group, realistic goals must be set before treatment to avoid disappointment.

Complications of toxins and fillers in facial aesthetics

Dermal filler and botulinum toxin injections are among the most performed non-invasive procedures for rejuvenation and contouring, internationally. Although most dermal fillers and approved botulinum toxins are well tolerated with a high safety profile, adverse events and/or complications can happen. Injection-related sequelae and side effects are usually rare, mild, transient, and self-limiting in nature. However, devastating and life-changing complications, such as intravascular occlusion, skin necrosis, permanent visual impairment, and stroke, have been reported. Risk reduction measures include an in-depth knowledge of anatomy, physiology, and pharmacology, correct patient selection, correct identification of clinical indications, and, fundamentally, the importance of appropriate skill and training. In this paper, some of the complications are discussed and advice on how to minimise adverse events and complications from these injectables is provided.

High Levels of Physical Activity Reduce the Esthetic Durability of Botulinum Toxin Type A: A Controlled Single-Blind Clinical Trial

The present study aimed to evaluate the influence of physical activity on the durability of the esthetic effect of botulinum toxin type A (BoNT-A). Sixty female patients were allocated to three groups (n = 20) according to their physical activity level (PA): Low PA, Moderate PA, and High PA. All groups received a single injection of onabotulinumtoxinA, considering standardized doses in the frontalis (12U), corrugator supercilia (7U, each), and procerus muscles (4U). Outcomes were measured using electromyography (EMG), Merz 5-point scales, and Face-Q scales (perceived age and lines between eyebrows). A follow-up occurred after 30, 60, and 90 days. EMG results showed a significant decrease in muscle activity in the Low-PA group at all follow-ups compared with the other groups (p < 0.001). The Merz scale scores showed that the severity of forehead and glabellar lines significantly improved in the Low-PA group throughout this study compared with the other groups (p < 0.001). No significant differences between groups were found in the Face-Q scale for perceived age, while the Face-Q scale for lines between eyebrows showed better results for Low-PA (p < 0.01) and Moderate-PA (p < 0.01) groups compared to the High-PA group at the 30- and 90-day follow-ups. The durability of the esthetic effect of BoNT-A seems to be negatively influenced by the level of physical activity.

Dynamic Evaluation of Skin Displacement by the Frontalis Muscle Contraction Using Three-Dimensional Skin Displacement Vector Analysis

PURPOSE

Understanding the muscle actions and resultant skin movement can enable more safe and effective botulinum toxin injection for the treatment of forehead wrinkles. We aimed to investigate skin displacement patterns of the forehead and adjacent skin due to frontalis muscle contraction using three-dimensional skin vector displacement analysis.

MATERIALS AND METHODS

Thirty healthy individuals were enrolled. Photographs of the face were taken at rest and during maximal contraction of the frontalis muscle. Each expression image was aligned to its respective static image to compute the differences in the skin position.

RESULTS

When frontalis muscle contracts, forehead skin displacement vectors were mostly vertical (63.4%), followed by lateral oblique (33.3%) and medial oblique (3.3%). In 53.3%, only the lower part of the forehead moved upward, while 40.0% showed bidirectional skin movement with transition line at a mean distance of 59.4 mm above the pupil. Moreover, 86.7% showed asymmetric skin displacement, and 83.3% showed both glabellar and eyebrow skin displacement. Frontalis muscle contraction also induced medial 2/3 (50.0%) or entire (33.3%) skin movement of the temple.

CONCLUSION

Botulinum toxin injection into the forehead can be individualized by considering the vector and asymmetry of skin displacement. Vertical or medial vector requires more centrally located injections, while laterial vector requires more laterally located injections. The presence and location of the vertical transition line are important for preventing ptosis when treating forehead lines with botulinum toxin. Glabellar movement during frontalis contraction suggests the need for a concomitant injection into the glabella to prevent glabella wrinkle accentuation.

Treatment of crow's feet lines and forehead lines with Botox (onabotulinumtoxinA): Development, insights, and impact

Extrinsic and age-related intrinsic factors contribute to the development of facial lines, including lateral canthal lines (called crow's feet lines [CFL]) and horizontal forehead lines (FHL). OnabotulinumtoxinA is a highly effective treatment for facial lines that inhibits acetylcholine release at the neuromuscular junction. This temporary chemical denervation leads to localized muscle relaxation and subsequent wrinkle reduction. Early studies of onabotulinumtoxinA treatment for facial neuronal disorders such as dystonia documented improvements in FHL and CFL. After the neurotoxin was approved for treating frown lines (glabellar lines [GL]), individuals requested treatment for other rhytids, and physicians continued assessing use in new areas. Once onabotulinumtoxinA was in clinical trial development, its efficacy and safety for CFL and FHL were successively evaluated as required by the US Food and Drug Administration and by key global health authorities, including those in the European Union, Japan, and China. Allergan, collaborating with leading physicians, established clinical programs that included novel safety and efficacy measures to meet regulatory requirements. Global, phase 3, randomized, controlled studies of CFL and FHL met rigorous primary endpoints. Some countries mandated clinical trial data beyond US and European regulations, and Allergan conducted 11 studies in total, fulfilling diverse regulatory and study population data requirements. Adverse events associated with local spread, including brow and eyelid ptosis, diplopia, headache, and eyelid sensory disorder, were infrequent and well tolerated. Consequently, onabotulinumtoxinA treatment of upper facial lines is now established globally as a highly effective, minimally invasive treatment for patients to achieve a natural appearance and look younger.

Assessment and Treatment Strategies for the Aesthetic Improvement of the Lower Face and Neck

Background

Interest in aesthetic rejuvenation of the lower face and neck is growing, but published expert guidance is limited.

Objective

Review aesthetic concerns of the lower face and neck and provide expert guidance on evaluation and treatment.

Methods

Twelve international experts participated in an advisory board on lower face and neck aesthetic treatment. They completed a premeeting survey and met twice, reviewing responses and discussing patient evaluation and treatment strategies. They developed decision tree algorithms on patient assessment and treatment planning and sequencing, using clinical cases as a reference.

Results

Treatment concerns include neck and lower face skin laxity, structural bone deficiency, insufficient or excess volume, submental fat, jowls, platysma bands, and masseter muscle prominence. Advisors agreed that the lower face and neck may be the most challenging areas to assess and treat; treatment goals include lower facial contour and overall facial harmony/balance. Advisors recommended first ruling out a surgical approach, then determining whether midface treatment is needed to support the lower face, and lastly evaluating the lower face for significant submental fat, excess or insufficient volume, and structural bone deficiency. To treat the lower face and neck, an anatomical layer approach, moving from deep to superficial layers, beginning with structural support, was recommended. Assessment and treatment decision trees were based on this approach.

Conclusion

The lower face and neck are important but underrecognized areas of aesthetic concern. This article provides expert guidance and a suggested algorithm for assessment and treatment aimed at achieving satisfying and harmonious facial aesthetic results.

Evidence-Based Medicine for Lower Facial Rejuvenation

Lower facial rejuvenation is an expanding area in facial plastic surgery with both surgical and nonsurgical treatment options. Evidence-based medicine is essential to providing high-quality care and creating long-lasting results. A systematic approach and understanding of the layers of the aging lower face is important to develop an individualized treatment plan. This review will focus on surgical and nonsurgical treatments for the aging lower face with an emphasis on evidence-based medicine.

Botulinum neurotoxin: A therapeutic powerhouse with broad clinical implications

ABSTRACT

Clostridium botulinum is a Gram-positive bacterium that produces one of the most deadly chemodenervating toxins in the world. To date, six distinct neurotoxins are available for prescription use in the United States. Decades of data across aesthetic therapeutic areas and therapeutic disease states support the safety and efficacy of C. botulinum, providing good symptom management and improved quality of life in appropriately chosen patients. Unfortunately, many clinicians are slow to progress patients to toxin therapy from more conservative measures, and others wrongly interchange the products despite characteristics unique to each. Commensurate with an improved understanding of the complex pharmacology and clinical implications of botulinum neurotoxins is the importance for clinicians to appropriately identify, educate, refer, and/or treat candidate patients. This article provides an overview of the history, mechanism of action, differentiation, indications, and uses for botulinum neurotoxins.

Evidence-Based Medicine for Nonsurgical Facial Rejuvenation

Options for nonsurgical facial rejuvenation treatment have increased significantly in both availability and popularity over the past two decades. However, there remains a paucity of clinical practice guidelines and evidence-based recommendations for these procedures. The purpose of this article is to assess the presence of current high-level research for various methods of nonsurgical facial rejuvenation using the Oxford Centre for Evidence-Based Medicine. Botulinum toxin injections remain the best-studied method, with several randomized controlled trials guiding recommendations for safety and efficacy. Several studies on injectable fillers document complications and recommendations to avoid these, but sample sizes are small and many are noncomparative. Deoxycholic acid has been well examined and Food and Drug Administration approved to address submental fat but has not been studied in other areas of the face. Although chemical peels, laser skin resurfacing, energy-based facial rejuvenation, microneedling, and platelet-rich plasma have a variety of facial rejuvenation applications with minimal side effect profiles, there is significant variability with treatment protocols, outcomes measures, and randomized controlled trials with extended follow-up to develop clinical practice guidelines.

Application of 3-Dimensional Technology for Evaluating Muscular Type and Muscle-Fat Pad Mixed-Type Nasolabial Folds With Botulinum Toxin-A Treatment

BACKGROUND

Botulinum toxin-A (BTX-A) is used in the treatment of nasolabial folds (NLFs). However, lighting and clinician subjectivity play a major role in evaluating the efficacy of this treatment.

OBJECTIVES

By applying 3-dimensional (3D) technology, this study aimed to quantitatively evaluate the effects of BTX-A injection on muscular (M) and muscle-fat pad mixed-type (MF) NLFs.

METHODS

BTX-A was injected into bilateral marked points on the NLFs, where the levator labii alaeque nasi, zygomaticus minor, and zygomaticus major pull the skin to form the NLF (2 U at each injection site). Pretreatment and posttreatment 3D facial images were captured with static and laughing expressions. The curvature, width, depth, and lateral fat volume of the NLFs were measured to compare the therapeutic efficacy for type M and MF NLFs.

RESULTS

Thirty-nine patients with type M and 37 with type MF NLFs completed the follow-up data. In these patients, the curvature, width, and depth of the NLF showed a significant reduction at 1 month and gradually recovered at 3 and 6 months after treatment, with more significant improvement when laughing than when static. Variations compared to the pretreatment values of type MF were greater than those of type M at each time point. The lateral fat volume of the type MF NLF was significantly reduced (P < .05).

CONCLUSIONS

3D technology can quantitatively evaluate the effects BTX-A injection for treating type M and type MF NLFs. BTX-A is more effective on type MF than on type M NLFs.

LEVEL OF EVIDENCE: 4

Perspectives on the Safety of Botulinum Toxin and Facial Filler Injections: A National Survey

BACKGROUND

Although both botulinum toxin and facial filler injections are safe procedures with high efficacy and patient satisfaction, it is unclear how knowledgeable the general public is about the risks of these common cosmetic, nonsurgical procedures. The goal of this study is to assess public knowledge of the risks of botulinum toxin and facial filler injection, as well as perceived comfort with various providers delivering these injections.

METHODS

A cross-sectional survey was performed through Amazon Mechanical Turk regarding knowledge of the risks of botulinum toxin and facial filler injection, as well as provider and location preferences among adults 18 years and older and currently residing in the United States.

RESULTS

When asked to identify potential risks of botulinum toxin injections from a list, asymmetry, bruising, and drooping of parts of the face were correctly identified by 38%, 40%, and 49% of respondents, respectively. Asymmetry, bruising, blindness, and blood vessel clotting (vascular occlusion) were identified as risks of filler injection by 40%, 51%, 18%, and 19% of respondents, respectively. In addition, plastic surgeons were the most preferred provider for botulinum toxin and facial filler injections, preferred by 43% and 48% of participants, respectively.

CONCLUSIONS

Although most people would consider botulinum toxin or facial filler injections, the potential risks of these procedures, especially the serious risks of facial fillers, may be poorly appreciated by the general public.

A Novel 3-Point Injection Technique for OnabotulinumtoxinA in the Upper Depressor Anguli Oris

BACKGROUND AND OBJECTIVE

To evaluate the efficacy and safety of onabotulinumtoxinA (ONA) injections to the depressor anguli oris (DAO) to improve downturned mouth.

PATIENTS AND METHODS/MATERIALS

This prospective, placebo-controlled, study enrolled subjects aged 18 to 65 years. Injections were performed using a novel 3-point technique in the upper DAO (1.5 U/injection site). The primary end point was a DAO contraction scale 1-grade improvement. Subjective evaluation was performed using the Global Aesthetic Improvement Scale (GAIS).

RESULTS

Ten subjects received ONA and 10 placebo (saline) injections. In ONA-treated subjects, DAO scores showed significant improvements at Weeks 4 and 12 ( p < .001) compared with baseline. No significant difference between visits was observed for placebo-injected subjects. Global Aesthetic Improvement Scale scores showed that 100% of subjects were improved compared with baseline at Week 4% and 90% at Week 12. By contrast, 90% and 80% of placebo-treated subjects had "no change" in their DAO appearance at Weeks 4 and 12. Subject GAIS assessments matched the live evaluator at Week 4; 60% continued to report improvement at Week 12. Treatment was well tolerated.

CONCLUSION

OnabotulinumtoxinA injections to the DAO using a 3-point technique provide clinically meaningful improvements in appearance. Treatment was well tolerated and in most individuals lasted at least 12 weeks.

IDENTIFIER

ClinicalTrials.gov NCT04240535.

The Retention-Rate Improvement of Stromal Vascular Fraction Gel in Prefrontal Filling With Botulinum Toxin-A Injection: A Retrospective Analysis

BACKGROUND

As a derivative of adipose tissues, stromal vascular fraction gel has been widely utilized in facial soft tissue filling, but it still does not achieve the expected effect in forehead filling. The reason may be related to the corrugator muscles movements.

OBJECTIVES

The authors aimed to evaluate the effect of botulinum toxin-A (BTX-A) on the retention rate of stromal vascular fraction gel by limiting the corrugator muscles movements and to provide a theoretical basis that short-term inhibition of movement in the affected area could improve the effects of the fat graft.

METHODS

From January 2019 to June 2021, patients with stromal vascular fraction gel facial filling (including frontal and temporal parts) were selected. According to whether or not BTX-A treatment was received, patients were divided into injected and the noninjected groups. A questionnaire and the Global Aesthetic Improvement Scale (GAIS) were administered to evaluate 2-dimensional photos. The retention rate and curvature were calculated with 3-dimensional images utilizing Artec Studio 13 Professional and MATLAB software.

RESULTS

The graft retention, forehead curvature, and GAIS scores were all higher in the injected group than the noninjected group (P < .01). On the questionnaire, the injected group also showed more satisfaction with the treatment effect and were more willing to recommend the treatment to their friends.

CONCLUSIONS

BTX-A injection can improve the retention rate of prefrontal stromal vascular fraction gel filling, with higher patient satisfaction and better postoperative effects.

LEVEL OF EVIDENCE: 5

The Underappreciated Role of the Platysma Muscle in the Perioral Expressions in Young Adults

BACKGROUND

The platysma is involved in lower face movement, yet limited information on its functional role when making perioral expressions is available.

OBJECTIVES

The aim of this study was to use 3-dimensional (3D) photogrammetry to analyze platysma activity when making expressions.

METHODS

Standardized frontal-view 3D images were obtained from 54 volunteers. Three perioral expressions were analyzed: a full smile, mouth corner depression, and a grimace to show the lower teeth. Positive volume change in the "heat map" of the neck skin surface-determined by the superimposed image subtraction technique-served as a sensitive indicator of platysma contraction.

RESULTS

When making the 3 expressions, the proportions of platysma contraction were 42.6%, 75.9%, and 92.6%, respectively. The platysma worked as a more critical dynamic force than expected. In most smiles involving the platysma, its upper portion contracted. With the laterally downward traction on the lower lip increasing, the upper and lower portions of the platysma contracted together and formed muscular bands. The platysma contracted extensively in the other 2 expressions. In some cases, platysma bands were observed to form due to vigorous contraction of muscle fibers. In addition, the platysma was found to be highly functionally active in young individuals.

CONCLUSIONS

This study introduced a simple method that can sensitively identify the functional status of the platysma. The results showed the platysma's highly active function in perioral expressions in young adults. These findings may assist surgeons in personalized decision-making toward platysma muscle-weakening strategies and work as an objective tool for outcome evaluation.

LEVEL OF EVIDENCE: 4

The Efficacy and Duration of Onabotulinum Toxin A in Improving Upper Facial Expression Lines With 64-Unit Dose Optimization: A Systematic Review and Meta-Analysis With Trial Sequential Analysis of the Randomized Controlled Trials

BACKGROUND

Onabotulinumtoxin A (Onabot A) was the first treatment to be approved for aesthetic indications, namely glabellar lines (GLs), crow's feet lines (CFLs), and forehead lines (FHLs), with a cumulative dose of 64 U.

OBJECTIVES

The aim of this study was to conduct a meta-analysis to combine the available data for approved doses for GLs, CFLs, and FHLs to explore the effect and duration of simultaneous treatment with Onabot A.

METHODS

PubMed/MEDLINE, Embase, and other national clinical trial registries were searched for randomized controlled trials from January 2010 to July 2022. The meta-analysis, trial sequential analysis, and investigator-assessed time to return to nonresponder status in GLs, CFLs, and FHLs following Onabot A were plotted to elicit a cumulative dose-adjusted response curve based on Kaplan-Meier analysis with a log-rank test.

RESULTS

Fourteen randomized controlled trials were eligible for quantitative analysis. A total of 8369 subjects were recruited across the trials. The meta-analysis results show that Onabot A is very effective in reducing moderate to severe GLs, CFLs, and FHLs. The cumulative Z-curve for GLs, CFLs, and FHLs also exceeds the required information size (RIS). Kaplan-Meier analysis with a log-rank test demonstrated that simultaneous treatment of GLs, CFLs, and FHLs requires 182 days (95% CI = 179, 215 days) (P < 0.00002) to return to nonresponder status.

CONCLUSIONS

Treatment of the upper facial expression lines with Onabot A is effective, and the approved cumulative dose of 64 U gives longer-lasting effects.

LEVEL OF EVIDENCE: 1

Efficacy and Safety of AbobotulinumtoxinA for the Treatment of Glabellar Lines in Chinese Patients: A Pivotal, Phase 3, Randomized, Double-Blind and Open-Label Phase Study

BACKGROUND

Various botulinumtoxinA formulations are approved for glabellar lines treatment worldwide, including abobotulinumtoxinA (Dysport^®).

OBJECTIVES

Assess abobotulinumtoxinA superiority versus placebo and non-inferiority versus active comparator (onabotulinumtoxinA; Botox^®), for the treatment of Chinese patients with moderate/severe glabellar lines.

METHODS

Phase 3, randomized study (NCT02450526) comprising a double-blind (cycle 1) phase and an open-label (cycles 2-5) phase. Patients received abobotulinumtoxinA 50 units or matching placebo (5:1), active comparator (onabotulinumtoxinA 20 units) or matching placebo (5:1). In cycles 2-5, eligible patients were retreated with abobotulinumtoxinA only. Responders had glabellar lines of none/mild severity.

PRIMARY ENDPOINT

responder rates at cycle 1, day 29 at maximum frown with abobotulinumtoxinA versus placebo (for superiority; by investigator's live assessment [ILA] and subject's self-assessment [SSA]), and versus active comparator (for non-inferiority; by ILA). Treatment-emergent adverse events were recorded.

RESULTS

Overall, 520 patients were randomized. Superiority and non-inferiority, respectively, were demonstrated for abobotulinumtoxinA versus placebo (ILA, SSA; both p < 0.0001) and abobotulinumtoxinA versus active comparator. AbobotulinumtoxinA efficacy was maintained over open-label cycles; median time to onset of efficacy was 2.0 days. After 6 months, 17% of patients treated with abobotulinumtoxinA remained responders. AbobotulinumtoxinA was well-tolerated. Safety results were in line with the known profile of abobotulinumtoxinA; adverse events rate decreased with repeated treatment.

CONCLUSIONS

After a single injection, abobotulinumtoxinA demonstrated superiority versus placebo and non-inferiority versus onabotulinumtoxinA for the treatment of moderate-to-severe glabellar lines in Chinese patients. Multiple injections of abobotulinumtoxinA demonstrated efficacy and safety in the treatment of glabellar lines in Chinese patients.

LEVEL OF EVIDENCE I

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 .

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.

Treatment of Upper Facial Lines With DaxibotulinumtoxinA for Injection: Results From an Open-Label Phase 2 Study

BACKGROUND

Simultaneous treatment of moderate-to-severe upper facial lines is reflective of real-world clinical practice.

OBJECTIVE

To evaluate the efficacy and safety of daxibotulinumtoxinA-lanm for injection (DAXI) for simultaneous treatment of glabellar, forehead, and lateral canthal (LC) lines.

METHODS

In this open-label, single-arm Phase 2 study, patients (48 enrolled, 94% completed, follow-up 24-36 weeks) received DAXI 40U (glabellar), 32U (forehead), and 48U (LC) lines. Key efficacy endpoints: percentages of patients achieving none/mild wrinkle severity (investigator-rated) for each upper facial line scale at Week 4.

RESULTS

At Week 4, most patients achieved none/mild wrinkle severity (investigator-rated): glabellar (96%), forehead (96%), and LC (92%). Median times to loss of none/mild response (investigator- and patient-rated) among all patients were: 24.6 (glabellar), 20.9 (forehead), and 24.9 (LC) weeks; and 25.0, 24.0, and 28.1 weeks, respectively, among Week-4 responders. At Week 4, most patients reported improvements (Global Aesthetic Improvement Scale: 96%-98%) and high satisfaction rates (85%-98%). Five patients experienced treatment-related adverse events: injection-site erythema (3 patients/7 events), facial discomfort (2 patients/2 events), and headache (1 patient/1 event). No patients experienced eyebrow or eyelid ptosis.

CONCLUSION

Simultaneous treatment of upper facial lines with DAXI was well tolerated and demonstrated high response rates, extended duration, and high patient satisfaction.

CLINICAL TRIAL REGISTRY

https://clinicaltrials.gov/ct2/show/NCT04259086.

Effects of Botulinum Toxin Injection on Reducing Myogenic Artifacts during Video-EEG Monitoring: A Longitudinal Study

Medically refractory seizures affect one-third of patients with epilepsy (PwE), for whom epilepsy surgery is considered. Video electroencephalography (vEEG) monitoring is a fundamental tool for pre-operative seizure localization. Facial and cranial myogenic artifacts can obscure vEEG findings, thus interfering with seizure localization. Studies have shown the beneficial effects of botulinum toxin type A (BTX-A) injection into cranial muscles for reducing myogenic artifacts. This longitudinal study aimed to assess the effects of BTX-A injection on these artifacts. Twenty-two patients with medically refractory hypermotor seizures with daily seizure frequency and undetermined epilepsy localization were included in this study and underwent Dysport® injection (200 units) into the frontotemporal region. vEEG recordings were performed at baseline (one week before the injection), and at three days and six days post-injection. Before and after the injection, the amplitudes of myogenic artifacts were compared during various states (ictal, blinking, chewing, bruxism, head lateralization, scowling, talking, and yawning). BTX-A injection significantly reduced the amplitudes of EEG myogenic artifacts, except during blinking (day three) and talking (days three and six). On day six, significant reduction in EEG myogenic artifacts were noted during blinking, chewing, and bruxism for the greatest number of patients (95.5%, 90.9%, 81.8%), while significant reductions in EEG myogenic artifacts during talking, head lateralization, and ictal phase were associated with the least number of patients (22.7%, 36.3%, and 40.9%). Therefore, BTX-A injection could be a convenient method for filtering myogenic contamination, improving EEG interpretation, and facilitating seizure localization in patients with medically refractory seizures.

Efficacy and Safety of DaxibotulinumtoxinA for Injection in the Treatment of Glabellar Lines by Age and Race: Subgroup Analysis of the SAKURA Clinical Trials

BACKGROUND

DaxibotulinumtoxinA for Injection (DAXI) is a novel botulinum toxin type A formulation approved for the treatment of glabellar lines. The efficacy, safety, and extended duration of response of DAXI 40 U for glabellar lines were demonstrated in 2 Phase 3, randomized, double-blind studies (SAKURA 1 and 2) and a Phase 3 open-label trial (SAKURA 3).

OBJECTIVES

The aim of this study was to evaluate the efficacy and safety of the first DAXI 40 U treatment received in SAKURA 1, 2, or 3 across age and race subgroups.

METHODS

Adults with moderate-to-severe glabellar lines (Investigator Global Assessment-Frown Wrinkle Severity [IGA-FWS] and Patient FWS [PFWS] scales) were evaluated for glabellar line severity for ≤36 weeks after the first DAXI treatment. Efficacy and safety were analyzed by age (18-45, >45-55, and >55 years) and race (Asian, Black and African American, and White).

RESULTS

Overall, 2785 patients were included in the efficacy analysis. The proportion of patients achieving none or mild glabellar line severity at maximum frown (IGA-FWS) after DAXI treatment was high in all age and race subgroups (>96% at Week 4). Glabellar line severity of none or mild by composite IGA-FWS and PFWS rating was maintained for a median of 24.0 weeks in all age subgroups, and for 27.0, 25.3, and 24.0 weeks in the Asian, Black and African American, and White subgroups, respectively. Treatment-emergent adverse events were similar across all subgroups.

CONCLUSIONS

Consistent with the overall study population, DAXI 40 U demonstrated a high response rate and duration of effect of ≥24 weeks across all age and race subgroups.

Ultrasonographic Analyses of Crow's Feet and Novel Guideline for Botulinum Toxin Injection

BACKGROUND

Crow's feet are bilateral orbital wrinkles formed by the orbital portion of the orbicularis oculi muscle, which is the target muscle for botulinum neurotoxin (BoNT) injection.

OBJECTIVES

This study's aim was to demonstrate a novel BoNT injection guideline by assessing muscle width, thickness, and dynamic features using ultrasonography.

METHODS

Twenty healthy Korean volunteers (10 men, 10 women; mean age, 25.6) participated. The width, thickness, and dynamic movement of the orbicularis oculi muscle were measured using ultrasonography. Two volunteers were selected to receive BoNT injections. Injections were administered using a novel method with two curved reference lines passing a point 15 mm lateral to the lateral canthus (conventional injection) and a point 5 mm lateral to the lateral margin of the frontal process of zygomatic bone (additional injection).

RESULT

At the lateral canthus level, the distance between the lateral margin of the frontal process and the most lateral margin of the orbicularis oculi muscle was 12.5±1.3 mm. The thickness of the orbicularis oculi muscle at the midpoint of the frontal process, the lateral marginal of the frontal process, and 5 mm lateral to the lateral marginal of the frontal process was 0.7±0.3 mm, 1.1±0.3 mm, and 1.2±0.3 mm, respectively. The crow's feet of the two volunteers began to disappear from day 3 and completely disappeared on day 7 after the injection.

CONCLUSION

The novel injection technique based on the ultrasonographic anatomy resulted in improvements in the appearance of crow's feet.

Botulinum toxin A in dentistry and orofacial surgery: an evidence-based review - part 2: cosmetic applications

Objective An evidence-based review on the role of botulinum toxin type A (BoNTA) on diverse cosmetic applications of interest to dental practitioners and allied specialities. In this context, to identify the cosmetic treatments that have an evidence-based rationale against areas requiring further research, with a view to assess the safety and efficacy of BoNTA.Data source and selection A comprehensive search was conducted using Cochrane Library of Systematic Reviews, Cochrane Central Register of Controlled Trials, and PubMed (Medline) electronic databases. Thirty-nine studies of variable quality were included. The Best Evidence Topics (BETs) Critical Appraisal Tool was used to facilitate the quality assessment of relevant studies.Data extraction Based on current level II evidence, BoNTA was safe and effective to improve facial contour, reduce volume and thickness of bilateral hypertrophic masseter. Conservative doses using a combined approach of BoNTA and hyaluronic acid was recommended as a safe and effective treatment for perioral enhancement supported by level II evidence. There was limited evidence, not higher than level III, to support BoNTA effectiveness for gummy smile associated to perioral musculature hyperactivity, while jawline sculpting targeting the platysma muscle had lower level IV evidence up to this date.Conclusion BoNTA has been widely used off-label for the investigated cosmetic orofacial conditions, with reports of 'good patient and practitioner satisfaction'. However, there is limited high-quality evidence to support the long-term safety and effectiveness of repetitive BoNTA injections. Additionally, no studies were found that provided a cost-effectiveness evaluation of BoNTA formulations against other current cosmetic interventions. Well-designed clinical trials, including long-term follow-up, would help to provide robust evidence-based recommendations for clinical practice, supporting BoNTA popularity, independently or in a combined approach.

A Single-Blinded Prospective Study on Using Botulinum Toxin Type A for Reducing Alar Mobility

BACKGROUND

With widespread utilization of instant social media, people desire a minimally invasive treatment to improve alar dynamic aesthetic, but few practical procedures on reducing alar mobility have been conducted.

OBJECTIVES

This study aimed to verify the effects of botulinum toxin on reducing nasal alar mobility and provide a supplemental treatment of rhinoplasty.

METHODS

This single-blind prospective study included a cohort of 20 participants with the desire to improve their alar dynamic aesthetic. The experimental group was injected with 3U botulinum toxin type A at dilator naris anterior, dilator naris vestibularis, levator labii superioris alaeque nasi, and dilator naris, and the control group received the equivalent of saline. Standardized facial movement (from rest to maximum smile without revealing teeth) was recorded with a 3-dimensional imaging system. The changes between rest and maximum smile statuses represented alar mobility and were generated by MOBILITY=WIDTHsmile-WIDTHrestWIDTHrest×100 % . Alar mobility and root mean square analysis were employed for postoperative evaluations.

RESULTS

In the experimental group, alar flaring mobility decreased from 10.05% ± 6.40% to 4.91% ± 3.48%(P < 0.05), and alar base mobility decreased from 16.83% ± 5.69% to 12.50% ± 4.89% (P < 0.05), whereas no significant changes in alar mobility were found in the control group. In root mean square analysis, changes in the experimental group were significantly higher than in the control group (P < 0.05).

CONCLUSIONS

Botulinum toxin type A can effectively restrain alar mobility without any significant adverse events and improve alar dynamic esthetic, which can serve as a minimally invasive method or supplemental treatment for rhinoplasty.

LEVEL OF EVIDENCE: 2

Facial Aesthetic Priorities and Concerns: A Physician and Patient Perception Global Survey

Background

Minimally invasive and noninvasive facial aesthetic treatments are increasingly popular, and a greater understanding of patient perspectives on facial aesthetic priorities is needed.

Objectives

The authors surveyed facial aesthetic concerns, desires, and treatment goals of aesthetically conscious men and women, and physicians, in 18 countries.

Methods

This was a global, internet-based survey on desired appearance and experiences with, or interest in, facial aesthetic treatments. Eligible respondents were aesthetically conscious adults (21-75 years). Eligible aesthetic physicians were required to see ≥30 patients per month for aesthetic reasons, have 2 to 30 years of experience in clinical practice, and spend ≥70% of their time in direct patient care.

Results

A total of 14,584 aesthetically conscious adults (mean age, 41 years; 70% women) and 1315 aesthetic physicians (mean age, 45 years; 68% men) completed the survey. Most respondents (68%) reported that aesthetic procedures should be sought in their 30s to 40s; physicians recommended patients seek treatment earlier. Respondents expressed greatest concern over crow’s feet lines, forehead lines, facial skin issues, hair-related concerns, and under-eye bags or dark circles; in contrast, physicians tended to underestimate concerns about under-eye bags or dark circles, mid-face volume deficits, and skin quality. Although both physicians and respondents cited cost as a major barrier to seeking aesthetic treatments, respondents also emphasized safety, fear of injections or procedure-related pain, and concern about unnatural-looking outcomes.

Conclusions

This global survey provides valuable insight into facial aesthetic concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.