Phase 3 Study of OnabotulinumtoxinA Distributed Between Frontalis, Glabellar Complex, and Lateral Canthal Areas for Treatment of Upper Facial Lines

Versatility of OnabotulinumtoxinA in Aesthetic Medicine

BACKGROUND

OnabotulinumtoxinA is an injectable product that was introduced into medicine in the 1970s and has been the subject of thousands of clinical and nonclinical publications.

OBJECTIVE

To review the data related to the versatility of onabotulinumtoxinA in medical aesthetics.

METHODS

PubMed was searched to identify literature evaluating the effects of onabotulinumtoxinA, with preference given to randomized, placebo-controlled trials and safety meta-analyses.

RESULTS

OnabotulinumtoxinA is effective and safe across multiple facial indications, racial and ethnic groups, age groups, genders, and facial line severities. Patient-reported outcomes have been prioritized in aesthetic clinical trials and indicate high patient satisfaction and appearance-related psychological outcomes. Integrated safety meta-analysis and immunogenicity analyses have documented acceptable adverse event rates and low immunogenicity of onabotulinumtoxinA.

CONCLUSION

OnabotulinumtoxinA is a versatile aesthetic product supported by a strong literature base and positive physician and patient-reported outcomes that reflect a meaningful impact on patient's quality of life.

High-Resolution Ultrasound for Complications of Botulinum Toxin Use: A Case Series and Literature Review

Botulinum toxin (BTX) has revolutionized both aesthetic and therapeutic medicine by selectively inhibiting acetylcholine release at the neuromuscular junction, inducing localized muscle relaxation. However, its use can be associated with various complications. As a diagnostic modality, high-resolution ultrasound can better characterize these complications. Here, we present four clinical cases of complications associated with the application of BTX, along with their corresponding ultrasonographic findings. In this study, cases were selected randomly, irrespective of the timing of BTX injections, to illustrate a spectrum of complications observed in clinical practice. Despite its benefits, BTX can have adverse effects ranging from mild to severe, including aesthetic and functional complications, such as hematoma, ptosis, facial asymmetry, nodules, or pseudoaneurysm. High-resolution ultrasound emerges as a crucial tool in the multidisciplinary management of these complications, allowing for accurate evaluation and effective therapeutic guidance.

Profiloplasty and facial contouring with injectables: A holistic, practical, and user-friendly approach

BACKGROUND

Expansion of the aesthetic treatment armamentarium with novel injectable products has greatly improved our ability to reshape and enhance the facial profile. However, full-face "profiloplasty" with injectables remain a nascent concept and is insufficiently considered in daily practice. While techniques have been widely published for treating the individual facial areas that constitute an attractive profile-including the forehead, nose, lips, jawline, and chin-the literature remains fragmented on more universal methods for profile improvement.

AIMS

To collate disparate knowledge on profile optimization with injectables, and define a holistic, practical, and user-friendly approach to profiloplasty and facial contouring.

METHODS

Consideration is given to key anatomical aspects and the changes that occur with age; patient assessment parameters for planning profiloplasty; and the technical specifications, product selection, and essential safety considerations for minimizing the risk of complications and optimizing the effectiveness of treatment.

RESULTS

Relevant case studies are presented.

CONCLUSIONS

Holistic approaches of this type are essential if we are to maximize the potential of full-face treatment with injectables-both now and in the future.

Safety and tolerability of onabotulinumtoxinA in the treatment of upper facial lines from global registration studies in 5298 participants: A meta-analysis

Background

Since its discovery as a facial aesthetic treatment >30 years ago, onabotulinumtoxinA has received worldwide approval for dynamic upper facial line treatment.

Objective

Meta-analysis examining the safety of onabotulinumtoxinA for treatment of glabellar lines (GL), crow's feet lines (CFL), and forehead lines (FHL).

Methods

Participants (N = 5298) with moderate to severe GL, CFL, or FHL at maximum contraction received onabotulinumtoxinA or placebo in 1 of 18 registration studies (14 double-blind, placebo-controlled [DBPC]; 1 double-blind; 3 open-label). Adverse events (AEs) were analyzed by descriptive statistics and fixed-effects meta-analysis.

Results

In the overall double-blind placebo-controlled (DBPC) population, AEs were reported in 1443 (42.1%) and 486 (35.8%) participants in the onabotulinumtoxinA (n = 3431) and placebo (n = 1359) groups, respectively. Serious AEs were reported in 54 (1.6%) and 17 (1.3%) participants; 1 (spontaneous abortion) was considered possibly treatment related by the investigator. Using fixed-effects statistical meta-analysis, AEs of interest that were found to be statistically higher for onabotulinumtoxinA than placebo in the DBPC population were eyelid ptosis, eyelid sensory disorder, skin tightness, brow ptosis, eyelid edema, and facial pain (P ≤ .05).

Limitations

Retrospective, ad hoc analysis.

Conclusion

This meta-analysis confirms the onabotulinumtoxinA safety profile for GL, CFL, and FHL treatment, with no new onabotulinumtoxinA-associated AEs.

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.

Applying the MD Codes™ to Treat Emotional and Social Attributes with HA Fillers: A Retrospective Serial Case Study

Background

Aesthetic treatment directed at improving facial emotional messages and social attributes may maximize patient satisfaction with treatment results. The MD Codes™ is an approach to facial aesthetic treatment that accounts for emotional messages and social attributes while minimizing variability in patient assessment, injection technique, injection sites, and treatment outcomes.

Objective

To assess the impact of the MD Codes systematic treatment approach on emotional and social attributes and natural appearance after facial aesthetic treatment with hyaluronic acid (HA) fillers.

Methods

A retrospective analysis was performed in patients treated with 12 mL of HA fillers (Juvéderm® Vycross™ products) per patient using the MD Codes. Study injectors, experienced clinician observers, clinical staff, laypeople, and patients evaluated impact of treatment on emotional and social attributes and natural appearance based on pre- and post-treatment photographs of patients.

Results

Twelve patients and 49 external observers, from 12 countries, evaluated the images. More than 90% of patients named "eye bags" as the facial area most in need of aesthetic treatment; >55% of external observers identified "cheeks." The top 3 facial emotional attributes noted by all evaluators after treatment were, in order, "less tired", "less saggy", and "younger." All patients reported a visible and positive change in emotional attributes except for "less sad." After 9 months, most patients reported looking "less tired" (n=11/12), "less saggy" (n=8/12), and "less sad" (n=6/12). At months 6 and 9, all patients rated their appearance as natural looking. At least 90% of external observers considered the frontal view results natural for all but 1 patient. Patients reported improved positive social attributes (eg, "looking friendlier") and improvements in well-being after treatment. No serious side effects were reported.

Conclusion

Implementing the MD Codes for facial aesthetic treatment may improve facial emotional attributes as well as enhance social attributes and well-being, with natural-looking results.

Treatment of hyperhidrosis with Botox (onabotulinumtoxinA): Development, insights, and impact

Hyperhidrosis (chronic excessive sweating) may substantially affect an individual's emotional and social well-being. Therapies available before onabotulinumtoxinA were generally topical, with limited effectiveness, application-site skin reactions, and frequent, time-consuming treatments. Intradermal injection of onabotulinumtoxinA to treat sweat glands arose as a novel therapeutic approach. To develop this treatment, appropriate dosing needed to be established, and training on administration was required. Further, no previous scale existed to measure the effects of hyperhidrosis on patients' lives, leading Allergan to develop and validate the 4-point Hyperhidrosis Disease Severity Scale (HDSS), which measures the disease's impact on daily activities. The onabotulinumtoxinA clinical development program for hyperhidrosis included 2 double-blind, placebo-controlled pivotal trials, immunogenicity studies, long-term studies of safety and efficacy, and quality of life assessments. In Europe and North America, the primary efficacy measures were, respectively, axillary sweat production measured gravimetrically and HDSS improvement. Compared with placebo, onabotulinumtoxinA treatment significantly reduced axillary sweat production and axillary hyperhidrosis severity, as measured by a 2-point or greater reduction on the HDSS. The effects of onabotulinumtoxinA occurred rapidly, within 1 week after injection, and lasted ≥6 months. Treatment with onabotulinumtoxinA was associated with significant quality of life improvements based on Short Form-12 physical and mental component scores. The Hyperhidrosis Impact Questionnaire also indicated greater treatment satisfaction, reduced negative impact on aspects of daily life, and improved emotional well-being with onabotulinumtoxinA versus placebo. The clinical development program and subsequent clinical experience showed that onabotulinumtoxinA treatment for hyperhidrosis was well tolerated with no new safety signals, and led to greater disease awareness.

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.

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

Safety of Botulinum Toxin A Injections for Facial Rejuvenation: A Meta-Analysis of 9,669 Patients

PURPOSE

To quantitatively evaluate safety profile for botulinum toxin A (BTX-A) injections among patients undergoing treatment for cosmetic indications is produced, with special attention to clinically relevant covariates and their relative impact on safety.

METHODS

A systematic literature search was performed using PubMed (1996-January 2020) and Embase (1947-January 2020) to identify all randomized controlled trials (RCTs) that reported safety data for patients receiving BTX-A for cosmetic indications compared to placebo. A meta-analysis was performed to determine pooled risk ratios (RR) for treatment-related adverse events (TRAEs) and for specific adverse events. Meta-regression and additional analyses were performed for significant and/or clinically relevant covariates.

RESULTS

Following the review of 8,690 studies, 32 RCTs involving 9,669 patients were included. The pooled RR of any TRAE occurring after BTX-A injection compared to placebo injection was 1.53 (95% CI, 1.33-1.77; p < 0.001). Statistically significant covariates included individual injection volume and total injection volume. The type of BTX-A formulation, treatment site, total BTX-A units, and BTX-A units per injection were not significant. Specific adverse events more likely to occur following BTX-A injection rather than placebo injection included eyelid/eyebrow malposition (RR 3.55; p < 0.001), facial paresis (RR 2.42; p = 0.316), and headache (RR 1.45; p = 0.003). Injection site reactions and injection site bruising occurred at similar rates in both groups.

CONCLUSIONS

The overall safety profile of BTX-A is acceptable and consistent with previous publications. The authors' additional analyses provide a relative comparison of the impact of various treatment parameters on safety.

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.

Impact of botulinum toxin for facial aesthetics on psychological well-being and quality of life: Evidence-based review

BACKGROUND

There has been a steady growth of non-surgical minimally invasive procedures. In parallel, an ever-broadening range of clinicians has been engaging with botulinum toxin (BoNT) for aesthetic procedures, with reportedly compound positive impact on social health and psychological well-being.

OBJECTIVE

To identify and critically appraise current literature on the impact of BoNT injections into the upper face, as a sole treatment/combination with other modalities on facial aesthetics, psychological well-being, and quality-of-life.

METHODS

An evidence-based review was performed using advanced search from PubMed, Cochrane Library of Systematic Reviews, and Central Register of Controlled Trials databases . Only literature from inception to August, 2021 were considered. Eligibility criteria included human studies, FDA-approved BoNT applications, formulations, and dosages as a sole/multimodal approach; studies including patient-reported outcome tools psychometrically validated and facial lines-specific. Observer-reported outcome instruments were also considered for a thorough evaluation of outcomes.

RESULTS

Based on data investigations and participant assessments, all studies showed statistically significant improvement in psychosocial well-being and quality-of-life domains with a trend for highest impact when multiple upper facial areas are treated in a multimodal approach.

CONCLUSION

Aesthetic BoNT showed links to true health benefits for well-selected patients in addition to physical amelioration. However, the biological rational remains ambiguous. Well-designed controlled trials are needed, without pharmaceutical laboratories bias, in real clinical scenarios of patients paying for the interventions, often involving multiple areas with/without combined treatments. The persistence of positive outcomes following repetitive treatments provided by less experienced practitioners, potentially involving suboptimal patient selection and/or aesthetic results, warrants further investigation.

High Patient Satisfaction for up to 6 Months With OnabotulinumtoxinA Treatment for Upper Facial Lines

BACKGROUND

OnabotulinumtoxinA safety and efficacy are well established for upper facial lines (UFL), including forehead lines (FHL), glabellar lines (GL), and crow's feet lines (CFL).

OBJECTIVE

To investigate the association of onabotulinumtoxinA efficacy with patient-reported psychological impacts and satisfaction in UFL.

MATERIALS AND METHODS

A pooled analysis of data from 4 pivotal Phase 3 trials (onabotulinumtoxinA vs placebo in FHL ± GL, FHL + GL ± CFL, CFL, and CFL + GL for ≤180 days) evaluated investigator-assessed ≥1-grade severity improvement on the Allergan Facial Wrinkle Scale at Day 30 (responders). Facial Line Outcomes (FLO-11) Questionnaire, Facial Line Satisfaction Questionnaire (FLSQ), and Subject Assessment of Satisfaction of Appearance (SASA) were used to evaluate responder appearance-related psychological impacts and satisfaction.

RESULTS

OnabotulinumtoxinA patients, by primary study focus (FHL, GL, or CFL), totaled 921, 921, and 833, respectively; 786 patients received placebo. Most patients were female, White, and aged 45 to 50 years (median). Through 150 days, >42% FHL, >43% GL, and ≥32% CFL patients were onabotulinumtoxinA responders. Responders reported improvements in appearance-related psychological impacts (FLO-11) and high satisfaction (FLSQ and SASA), sustained through ≥150 days.

CONCLUSION

A ≥1-grade improvement with onabotulinumtoxinA is a clinically meaningful outcome in UFL, associated with long-lasting improved patient-reported psychological impacts and high satisfaction.

Complications of Cosmetic Botulinum Toxin A Injections to the Upper Face: A Systematic Review and Meta-Analysis

Background

Botulinum toxin A (BoNT-A) injections are a popular non-surgical procedure for facial rejuvenation. Its increase in popularity and utilization is met with limited regulations, potentially posing a significant risk to patient safety and public health.

Objectives

The authors sought to assess the safety profile of cosmetic glabellar and forehead BoNT-A injections and evaluate BoNT-A type on complication rate.

Methods

A systematic search of MEDLINE and EMBASE was performed for studies reporting complications after cosmetic BoNT-A in the glabellar or in the forehead region in the glabellar or in the forehead region. A random effects meta-analysis was carried out to assess complication rate. Where there were sufficient randomized-controlled trials, a network meta-analysis was performed.

Results

Of 556 identified articles, 24 were included in the final quantitative analysis, with 4268 BoNT-A injection sessions and 1234 placebos. Frequently observed treatment-related complications in the BoNT-A intervention group included headache, local skin reactions, and facial neuromuscular symptoms. The overall BoNT-A complication rate was 16%. The odds ratio of developing complications from abobotulinum toxin injections compared with placebo was 1.62 (1.15, 2.27; P > 0.05) and that from onabotulinum toxin injections compared with placebo was 1.34 (0.52, 3.48; P > 0.05). In 30% of the studies, the injectors were doctors, whereas the training status of the practitioner was not reported in the remaining 70%.

Conclusions

Cosmetic BoNT-A injections in the glabellar and forehead region appear to be safe, and most complications are mild and transient. Nevertheless, the literature demonstrates heterogeneous reporting of complications and a lack of consistency of the definition of treatment-related complications.

Level of Evidence: 2

Forehead Movement Discrepancies After Botulinum Toxin Injections: A Review of Etiology, Correction, and Prevention

BACKGROUND

Forehead rhytides are a popular target for botulinum toxin injections, but neuromodulation of the frontalis can be fraught with complications because of its anatomic complexity and integral role in brow position and expressivity.

OBJECTIVE

This article explores common forehead movement discrepancies that can occur after neuromodulation of the frontalis, as well as how to correct and prevent them.

METHODS

A review of the literature was conducted and combined with clinical experience to examine underlying forehead anatomy, etiology and correction of forehead movement discrepancies, and important factors to consider before injecting the frontalis with botulinum toxin.

RESULTS AND CONCLUSION

Variable anatomy from person to person necessitates an individualized treatment approach to achieve the best cosmetic results and prevent the occurrence of forehead movement discrepancies.

Distributed treatment of rural environmental wastewater by artificial ecological geographic information system

County rural sewage geographic information system, is the use of geographic information technology and computer graphics, digital storage and management of sewage treatment facilities, the sewage treatment plant equipment management, water purification and sewage network and its surrounding corresponding facilities location information and physical attributes of the two combined, according to the needs of users, the sewage treatment process required data in the form of graphics and text to show to According to the user's needs, the data required in the process of sewage treatment is displayed to the user in a graphic way, so as to meet the needs of government departments for comprehensive control of the operation and maintenance management of sewage treatment facilities. Solve the problem of slow update of basic data in sewage treatment projects and ambiguous presentation of water quality monitoring data caused by paper records. The system uses Web-GIS technology, combined with NET development platform, using MVC model design and implementation. The front-end Bootstrap framework for interface optimization display, the back-end ORM framework to provide persistence classes and database tables between the mapping relationship, convenient to complete the migration of the database. The system function design uses the visualization and analysis function of GIS to manage the wastewater treatment facilities and the wastewater purification process for real-time operation and maintenance supervision, and uses the three-dimensional engine to visualize and display the study of the wastewater pipe network on the Web side. Mainly divided into the following modules: water quality parameters supervision module, mainly real-time monitoring of the sewage treatment process, the parameters are in line with the sewage purification indicators, to play a monitoring and early warning role; equipment operation and maintenance module, mainly for the sewage treatment facilities for fault detection and maintenance of property information; statistical analysis module, the water quality information of different sewage treatment plants for horizontal and vertical comparison and analysis, to improve the sewage treatment The statistical analysis module, which provides data for improving the sewage treatment process; and the 3D pipe network visualization module, which uses virtual reality technology to visualize the sewage pipe network on the Web side to make up for the lack of information on the pipe network in the third dimension.

A severe case of non-infective myositis six weeks post intramuscular injections of Onabotulinum toxin A (Botox) in a young man with tetraplegia: case report

INTRODUCTION

Myositis of unknown aetiology might be a very rare complication of intramuscular injections of onabotulinum toxin A (Botox) for spasticity treatment.

CASE PRESENTATION

We describe a case of significant myositis of unknown aetiology in a 17-year-old man, who was admitted for rehabilitation 4 months after his initial spinal cord injury (SCI) as a result of a mountain bike accident. He has an incomplete tetraplegia, C4 AIS B international Standards for Neurological Classification for Spinal Cord Injury (ISNCSCI) [1] due to C5 vertebra 3 column fracture [2]. He had severe spasticity of his lower limb muscles treated with Botox, following which, he required two acute hospital transfers for diagnosis and management of myositis.

DISCUSSION

This is a severe unusual presentation of myositis caused by intramuscular botulinum toxin for treatment of spasticity, in the frequent setting of spasticity where intramuscular botulinum toxin injections are routinely used.

Botulinum toxin type A for facial wrinkles

BACKGROUND

Botulinum toxin type A (BontA) is the most frequent treatment for facial wrinkles, but its effectiveness and safety have not previously been assessed in a Cochrane Review.

OBJECTIVES

To assess the effects of all commercially available botulinum toxin type A products for the treatment of any type of facial wrinkles.

SEARCH METHODS

We searched the following databases up to May 2020: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

We included RCTs with over 50 participants, comparing BontA versus placebo, other types of BontA, or fillers (hyaluronic acid), for treating facial wrinkles in adults.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcomes were participant assessment of success and major adverse events (AEs) (eyelid ptosis, eyelid sensory disorder, strabismus). Secondary outcomes included physician assessment of success; proportion of participants with at least one AE and duration of treatment effect. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 65 RCTs, involving 14,919 randomised participants. Most participants were female, aged 18 to 65 years. All participants were outpatients (private office or day clinic). Study duration was between one week and one year. No studies were assessed as low risk of bias in all domains; the overall risk of bias was unclear for most studies. The most common comparator was placebo (36 studies). An active control was used in 19 studies. There were eight dose-ranging studies of onabotulinumtoxinA, and a small number of studies compared against fillers. Treatment was given in one cycle (54 studies), two cycles (three studies), or three or more cycles (eight studies). The treated regions were glabella (43 studies), crow's feet (seven studies), forehead (two studies), perioral (two studies), full face (one study), or more than two regions (nine studies). Most studies analysed moderate to severe wrinkles; mean duration of treatment was 20 weeks. The following results summarise the main comparisons, based on studies of one treatment cycle for the glabella. AEs were collected over the duration of these studies (over four to 24 weeks). Compared to placebo, onabotulinumtoxinA-20 U probably has a higher success rate when assessed by participants (risk ratio (RR) 19.45, 95% confidence interval (CI) 8.60 to 43.99; 575 participants; 4 studies; moderate-certainty evidence) or physicians (RR 17.10, 95% CI 10.07 to 29.05; 1339 participants; 7 studies; moderate-certainty evidence) at week four. Major AEs are probably higher with onabotulinumtoxinA-20 U (Peto OR 3.62, 95% CI 1.50 to 8.74; 1390 participants; 8 studies; moderate-certainty evidence), but there may be no difference in any AEs (RR 1.14, 95% CI 0.89 to 1.45; 1388 participants; 8 studies; low-certainty evidence). Compared to placebo, abobotulinumtoxinA-50 U has a higher participant-assessed success rate at week four (RR 21.22, 95% CI 7.40 to 60.56; 915 participants; 6 studies; high-certainty evidence); and probably has a higher physician-assessed success rate (RR 14.93, 95% CI 8.09 to 27.55; 1059 participants; 7 studies; moderate-certainty evidence). There are probably more major AEs with abobotulinumtoxinA-50 U (Peto OR 3.36, 95% CI 0.88 to 12.87; 1294 participants; 7 studies; moderate-certainty evidence). Any AE may be more common with abobotulinumtoxinA-50 U (RR 1.25, 95% CI 1.05 to 1.49; 1471 participants; 8 studies; low-certainty evidence). Compared to placebo, incobotulinumtoxinA-20 U probably has a higher participant-assessed success rate at week four (RR 66.57, 95% CI 13.50 to 328.28; 547 participants; 2 studies; moderate-certainty evidence), and physician-assessed success rate (RR 134.62, 95% CI 19.05 to 951.45; 547 participants; 2 studies; moderate-certainty evidence). Major AEs were not observed (547 participants; 2 studies; moderate-certainty evidence). There may be no difference between groups in any AEs (RR 1.17, 95% CI 0.90 to 1.53; 547 participants; 2 studies; low-certainty evidence). AbobotulinumtoxinA-50 U is no different to onabotulinumtoxinA-20 U in participant-assessed success rate (RR 1.00, 95% CI 0.92 to 1.08, 388 participants, 1 study, high-certainty evidence) and physician-assessed success rate (RR 1.01, 95% CI 0.95 to 1.06; 388 participants; 1 study; high-certainty evidence) at week four. Major AEs are probably more likely in the abobotulinumtoxinA-50 U group than the onabotulinumtoxinA-20 U group (Peto OR 2.65, 95% CI 0.77 to 9.09; 433 participants; 1 study; moderate-certainty evidence). There is probably no difference in any AE (RR 1.02, 95% CI 0.67 to 1.54; 492 participants; 2 studies; moderate-certainty evidence). IncobotulinumtoxinA-24 U may be no different to onabotulinumtoxinA-24 U in physician-assessed success rate at week four (RR 1.01, 95% CI 0.96 to 1.05; 381 participants; 1 study; low-certainty evidence) (participant assessment was not measured). One participant reported ptosis with onabotulinumtoxinA, but we are uncertain of the risk of AEs (Peto OR 0.02, 95% CI 0.00 to 1.77; 381 participants; 1 study; very low-certainty evidence). Compared to placebo, daxibotulinumtoxinA-40 U probably has a higher participant-assessed success rate (RR 21.10, 95% CI 11.31 to 39.34; 683 participants; 2 studies; moderate-certainty evidence) and physician-assessed success rate (RR 23.40, 95% CI 12.56 to 43.61; 683 participants; 2 studies; moderate-certainty evidence) at week four. Major AEs were not observed (716 participants; 2 studies; moderate-certainty evidence). There may be an increase in any AE with daxibotulinumtoxinA compared to placebo (RR 2.23, 95% CI 1.46 to 3.40; 716 participants; 2 studies; moderate-certainty evidence). Major AEs reported were mainly ptosis; BontA is also known to carry a risk of strabismus or eyelid sensory disorders.

AUTHORS' CONCLUSIONS

BontA treatment reduces wrinkles within four weeks of treatment, but probably increases risk of ptosis. We found several heterogeneous studies (different types or doses of BontA, number of cycles, and different facial regions) hindering meta-analyses. The certainty of the evidence for effectiveness outcomes was high, low or moderate; for AEs, very low to moderate. Future RCTs should compare the most common BontA (onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, daxibotulinumtoxinA, prabotulinumtoxinA) and evaluate long-term outcomes. There is a lack of evidence about the effects of multiple cycles of BontA, frequency of major AEs, duration of effect, efficacy of recently-approved BontA and comparisons with other treatments.

Complications of facial cosmetic botulinum toxin A injection: analysis of the UK Medicines & Healthcare Products Regulatory Agency registry and literature review

BACKGROUND

Botulinum toxin A (BoNT-A) injection is one of the most frequently undertaken procedures in aesthetic medicine. The Medicines & Healthcare products Regulatory Agency (MHRA) is the government body in the United Kingdom (UK) mandated to ensure that the provision and administration of medicines is safe. We analyzed adverse events of facial cosmetic BoNT-A injections reported to the MHRA and assessed whether the incidence of reported adverse events in this government registry is comparable to published retrospective and prospective studies.

METHODS

A freedom of information (FOI) request was submitted to the MHRA to obtain recorded complications of BoNT- A. Complications reported to the MHRA between 1991 and 2020 were analyzed. Only cases with BoNT-A where the indication was specified as for facial cosmetics were included in the analysis. Additionally, the literature was reviewed on adverse events of facial cosmetic BoNT- A injections, and a statistical meta-analysis of complication rates was carried out.

RESULTS

A total of 188 adverse events of aesthetic BoNT-A injections were reported to the MHRA. The literature search resulted in 30 studies and a total of 17,352 injection sessions, where the complication rate was 16% (95% CI = 8% to 25%). Frequent adverse events included localized skin reactions such as bruising with an incidence of 5% (95% CI = 3% to 7%), headache in 3% (95% CI = from 1% to 5% ), and facial paresis in 2% (95% CI = 1% to 3%) of injection sessions.

CONCLUSIONS

This is the first paper to obtain and evaluate data on adverse events of BoNT-A from the MHRA. An estimate of the likely complication rate of aesthetic BoNT-A in the UK, according to the MHRA database, is significantly lower than the rate recorded from our meta-analysis of the international literature. This suggests that the MHRA may be underestimating the adverse events of aesthetic BoNT-A treatment, which would have implications for patient safety and informed consent. Therefore, legislative changes may be required to ensure more robust reporting of aesthetic BoNT-A in the UK.

The mechanisms of action and use of botulinum neurotoxin type A in aesthetics: Key Clinical Postulates II

BACKGROUND

The literature on botulinum neurotoxin type A (BoNT-A) is extensive, often contradictory, and confounded by a competitive market of products and research attempting to distinguish brand individuality.

METHODS

A comprehensive review of literature on the principles of BoNT-A in aesthetics as well as clinical examples.

RESULTS

In 2017, the Eight Key Clinical Postulates were formulated as a guide for the aesthetic practitioner in understanding BoNT-A pharmacodynamics and to compare different toxins. These are now updated to include (a) All type A toxins act identically; (b) The mathematical relationship between toxin and receptor is the basis of efficacy, and clinical efficacy is influenced by molecular potency and patient attributes including muscle mass, gender, age, and ethnicity; (c) Efficacy, onset, and duration are functions of "molecular potency" defined as the number of active 150 kDa molecules available for binding; (d) "Molecular potency" is difficult to objectively quantify for commercially available toxins; (e) Up to a point, increased molecular potency decreases time to onset and increases duration of effect, and the "Molecular Potency Quotient" is a construct for comparing molecular potency commercial cost; (f) The area of effect of a toxin injection is dependent upon molecular potency, diffusion (passive), and spread (active); (g) Differing reconstitution volumes; and (h) Increased number of injection sites can affect spread, onset, and duration of effect.

CONCLUSIONS

The principles of BoNT-A use in aesthetics are complex yet understandable as outlined in the framework of the updated Eight Key Clinical Postulates and serves as a useful tool for providing the most effective treatment and interpreting research on present and future toxin formulations.

Non surgical facial reshaping using MD Codes

BACKGROUND

Both age-related and congenital volume deficiencies may be addressed through the injection of hyaluronic acid (HA) fillers. Deep injection provides structural support, more superficial fat-tissue injection mediates contouring, and superficial intradermal use of HA filler and/or onabotulinumtoxinA may be used for refinement.

AIMS

To evaluate the clinical efficacy, patient satisfaction, and safety of the MD Codes approach as a proposed standardized methodology for full-face rejuvenation.

METHODS

This was a retrospective, single-center study of 250 consecutive adult patients undergoing full-face rejuvenation with HA fillers (Vycross) and onabotulinumtoxinA based on the MD Codes approach.

RESULTS

The mean age was 39.4 ± 11.6 years, and 80.4% were female. All patients were treated with HA filler in the midface; 89.6% were also treated in the upper face, and 63.2% in the lower face. The mean number of syringes used was 14 ± 4 (range 4-25), with more syringes typically required in older versus younger patients. All patients received onabotulinumtoxinA treatment. Mean FACE-Q Appearance-Related Psychosocial Distress score decreased from 54.3 ± 9.3 pretreatment to 36.1 ± 8.9 at 3 months post-treatment (P < .05). The most common complications were bruising (35.2%), transient soft-tissue edema (14.0%), and prolonged periorbital edema (3.6%).

CONCLUSIONS

Full-face rejuvenation based on the MD Codes approach provides significant esthetic improvements, with no major safety issues observed.

OnabotulinumtoxinA Treatment for Moderate to Severe Forehead Lines: A Review

Background:

With onabotulinumtoxinA approved for the treatment of glabellar and crow’s feet lines and, most recently, for forehead lines (FHL), it is possible to simultaneously treat multiple areas of the upper face that are of high concern and treatment priority for aesthetically oriented individuals. This review aims to present key insights on the use of onabotulinumtoxinA for the treatment of moderate to severe FHL.

Methods:

Double-blind, placebo-controlled registration trials of onabotulinumtoxinA for the treatment of FHL were included. Using findings from 3 such published studies, we discuss key concepts and clinical experience for the treatment of moderate to severe FHL with onabotulinumtoxinA (20 U in the frontalis and 20 U in the glabellar complex, with/without 24 U in crow’s feet lines), including injection pattern, dose selection, efficacy and safety data, and considerations for patient selection.

Results:

Across the 2 pivotal phase 3 studies, responder rates on investigator- and subject-assessed measures of appearance of FHL severity were significantly higher with onabotulinumtoxinA versus placebo for the treatment of FHL at day 30 (P < 0.0001), and results were maintained through 3 cycles of onabotulinumtoxinA.

Conclusions:

OnabotulinumtoxinA treatment also resulted in high patient satisfaction rates. The incidence of eyebrow and of eyelid ptosis was low, and no new safety signals were detected. OnabotulinumtoxinA is safe and effective and an appropriate option for patients with moderate to severe FHL encountered in clinical practice.

OnabotulinumtoxinA for Simultaneous Treatment of Upper Facial Lines: Subject-Reported Satisfaction and Impact From a Phase 3 Study

BACKGROUND

Patient-reported outcomes are increasingly recognized as important measures of treatment benefit.

OBJECTIVE

To evaluate subject-reported satisfaction and impact outcomes with onabotulinumtoxinA treatment in neurotoxin-naive adults with forehead lines (FHL), glabellar lines (GL), and crow's feet lines (CFL).

METHODS

This Phase 3 study randomized 787 subjects to onabotulinumtoxinA 64 U (FHL 20 U, GL 20 U, and CFL 24 U), 40 U (FHL 20 U, GL 20 U, and CFL placebo), or placebo in double-blind Period 1. Subjects could receive up to 2 additional 64 U treatments in open-label Period 2. Patient-reported outcomes were assessed using the validated Facial Line Satisfaction Questionnaire (FLSQ) and 11-item Facial Line Outcomes (FLO-11) Questionnaire.

RESULTS

The proportion of subjects mostly or very satisfied was significantly greater with onabotulinumtoxinA 64 U and 40 U versus placebo (87.9% and 81.4% vs 3.2%; p < .0001). Responder rates on FLSQ Impact Domain, FLO-11 Items 1, 4, 5, and total score were significantly greater with onabotulinumtoxinA versus placebo on Day 30 (p < .0001). Responder rates favoring onabotulinumtoxinA in Period 1 were maintained with repeated onabotulinumtoxinA 64 U treatment in Period 2.

CONCLUSION

OnabotulinumtoxinA treatment was associated with high subject satisfaction and significant improvements in appearance-related psychological and emotional impacts.

The Psychological Impacts of Upper Facial Lines: A Qualitative, Patient-Centered Study

Background

The 11-item Facial Line Outcomes (FLO-11) questionnaire is content validated for measuring the negative psychological impacts of crow’s feet lines (CFL).

Objectives

The aims of this study were to determine psychological impacts of forehead lines (FHL) alone and upper facial lines (UFL: FHL + CFL + glabellar lines [GL]) and to assess adequacy of FLO-11 to measure these impacts.

Methods

Participants aged at least 18 years participated in concept elicitation and cognitive interviews to identify and define psychological impacts of UFL. They completed the FLO-11 questionnaire to assess its ability to measure psychological impacts of facial lines and its comprehensiveness in doing so.

Results

Forty interviews were completed by 29 participants. Twenty participants each provided interviews for FHL and for UFL. The most commonly reported psychological impacts for FHL and UFL, respectively, were feeling unattractive (85%, 80%), looking less attractive than desired (85%, 70%), feeling bothered (80%, 70%), feeling good/bad about appearance (80%, 70%), looking older than actual age (75%, 65%), and feeling stressed (70%, 70%). For FHL, 70% of participants also reported looking older than desired as a psychological impact. More than 50% of participants agreed that all 11 FLO-11 items measured a psychological impact for FHL. More than 50% reported that 9 of 11 items measured a psychological impact for UFL. The majority of participants (FHL, 65%; UFL, 60%) reported that the FLO-11 questionnaire is comprehensive in measuring psychological impacts of facial lines.

Conclusions

FHL and UFL have psychological impacts on patients, and FLO-11 is a content valid, comprehensive instrument for measuring them.