OnabotulinumtoxinA for Treatment of Forehead and Glabellar Lines: Subject-Reported Satisfaction and Impact From a Phase 3 Double-Blind Study

Assessment of Pain and Satisfaction After Orofacial Harmonization Procedures

AIMS

This long-term study assessed satisfaction and pain levels following facial aesthetic procedures. The study also aimed to correlate expectations, and psychological and social well-being immediately and after one month, describe perceived age, and assess differences in satisfaction between injectable fillers and other Orofacial Harmonization procedures such as hyaluronic acid treatments (for dark circles, nasolabial fold lips, malar, jaw), botulinum toxin injections, enzymatic lipolysis of the double chin, micro-needling, and PDO threads.

METHODS

Data were collected immediately after the procedures and then again 30 days later. Among the participants, 159 (92.4%) were females and 13 (7.6%) were males, who completed FACE-Q questionnaires addressing perceived age, expectations, psychological and social well-being, satisfaction, and facial appearance, as well as the visual pain scale.

RESULTS

The average age of the patients treated in the Dental Clinics in Brazil was 40.4 years (SD± 12.7), with 48.8% of participants perceiving themselves as older immediately after the procedures, decreasing to 47.7% after 30 days, and pain intensity was reported as low. The total number of Orofacial Harmonization procedures performed was 256. Satisfaction after 30 days was high, especially among those who received fillers. The psychological and social function scales were positively correlated with satisfaction with the decision, result, and appearance scales. Fillers showed a significant improvement in perceived age appearance, with half of the patients feeling younger after 30 days. The patients exhibited high satisfaction levels in one-month post-aesthetic orofacial harmonization procedures. Despite initially high expectations, patients reported enhanced psychological and social well-being, along with minimal pain during interventions CONCLUSION: Positive correlations were observed between satisfaction, decision-making, result perception, and appearance. Injectable fillers notably improved perceived aging, with a significant portion of patients initially perceiving themselves as older than their actual age, but later feeling younger post-procedure. Fillers also yielded superior satisfaction and pain relief compared to alternative interventions.

LEVEL OF EVIDENCE II

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.

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

Efficacy and Safety of Botulinum Toxin Type A for Treatment of Glabellar Lines: A Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Botulinum toxin type A (BoNT/A) has been used in aesthetic applications worldwide, including glabellar lines. Currently, four BoNT/A preparations were approved for the improvement of moderate-to-severe glabellar lines: onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, and prabotulinumtoxinA. DaxibotulinumtoxinA is a new form of BoNT/A drug that is developed in clinical application. We performed this network meta-analysis (NMA) to assess the efficacy and safety of all these different BoNT/A formulations for treating glabellar lines.

METHODS

The investigators searched randomized controlled trials (RCTs) using the Medical Subject Headings (MeSH) terms "botulinum toxin" and "glabellar lines." We searched the relevant studies in electronic databases as following: PubMed, Elsevier, EMBASE and the Cochrane Library. The end points included the percentage of subjects with a glabellar line severity (GLS) score of none (0) or mild (1), and the percentage of subjects achieving ≥ 1-point and 2-point improvement in glabellar line severity at maximum frown at approximately month 1 by the investigators' assessment.

RESULTS

All formulations of BoNT/A were far superior to placebo in efficacy. DaxibotulinumtoxinA was the only treatment that significantly increased the proportion of subjects achieving ≥ 1 point improvement in GLS score compared with other BoNT/A formulations. Moreover, daxibotulinumtoxinA was ranked the highest for the proportion of subjects achieving ≥ 2-point improvement in GLS score. No significant differences were revealed for the incidence of any adverse events (AEs) that related to treatment or drug among all BoNT/A preparations.

CONCLUSION

The overall results of this NMA suggested that daxibotulinumtoxinA is a new BoNT/A preparation that may be not only more effective but also well-tolerated for the treatment of glabellar lines.

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 .

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.

Long-term Effects of Repeated Botulinum Toxin Injection in Cosmetic Therapeutics

BACKGROUND

Botulinum toxin (BT), a potent neurotoxin, has been used in clinical medicine since the 1970s for cosmetic and therapeutic purposes. Studies have consistently shown positive outcomes with a very limited adverse effect profile and a conventional understanding that results dissipate after 3 to 5 months. However, more recent evidence suggests that changes in muscle composition, function, and appearance persist for much longer, even years. To examine the potential implications of these findings on cosmetic use of BT injections in reduction of skin lines and wrinkles, we first needed to further our understanding of the current literature on long-term outcomes after repeated BT injections.

METHODS

A comprehensive review of the literature on long-term outcomes after repeated BT injections for cosmetic indications was performed. We evaluated the study designs, and results were compared.

RESULTS

A total of 22 publications met our inclusion criteria, of which 14 were clinical trials. Few studies extended outcome measurement past 6 months postinjection, and many were funded or supported by industry. However, the studies that extended follow-up saw persistent changes after BT injection, in some cases as far as 4 years postinjection.

CONCLUSION

The current body of knowledge on the long-term results after repeated cosmetic BT injections is very limited, and the available literature provides insufficient evidence on how prolonged effects could alter clinical use of BT. Further clinical studies with extended follow-up periods with inclusion of both subjective and objective measured outcomes of appearance and muscle function are required to better understand the long-term impacts of repeated BT injections.

A Randomized, Single-Blind, Crossover Study Evaluating the Impact of OnabotulinumtoxinA Treatment on Mood and Appearance During the COVID-19 Pandemic

Background

The emergence of Coronavirus disease of 2019 (COVID-19), quickly became one of the most severe disease outbreaks in modern history. This caused many aesthetic practices around the country to close temporarily and led to a unique time period to evaluate the impact neurotoxin has in the setting of an ongoing pandemic.

Objectives

To examine whether the administration of onabotulinumtoxinA (BOTOX Cosmetic, Allergan plc, Coolock, Ireland), in regular users, synergistically amplifies the elevation in mood/happiness, self-satisfaction with appearance and overall satisfaction, in the context of the ongoing pandemic.

Methods

A randomized single-blind cross-over study was designed to evaluate the impact of neurotoxin treatment in the upper third of the face on mood, self-satisfaction with appearance, and overall satisfaction. The placebo group crossed over to treatment after 1 month. Surveys evaluating patient happiness, self-satisfaction with appearance and overall efficacy were completed among both groups, and again to the placebo group again following crossover to treatment.

Results

Forty-five subjects were enrolled with 30 in the treatment and 15 in the control/cross-over group. The placebo group demonstrated no change in happiness or self-satisfaction in appearance until cross-over to the treatment group. Both groups, once receiving, onabotulinumtoxinA reported increased happiness, self-satisfaction with appearance and overall treatment satisfaction.

Conclusions

OnabotulinumtoxinA treatment to the upper face in the midst of the COVID-19 pandemic was found to increase patient happiness, self-satisfaction with appearance, and overall treatment satisfaction.

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.

Efficacy and Safety of a New Botulinum Toxin (HU-014) Versus Existing Onabotulinumtoxin A in Subjects With Moderate to Severe Glabellar Lines

BACKGROUND

Recently, the safety of a new botulinum toxin (HU-014) was confirmed through animal experiments. The evaluation of the efficacy and safety of this newly introduced botulinum toxin is required considering the risk of adverse events (AEs) and need for standardization before its universal use.

OBJECTIVE

The aim of this multicenter, double-blind, randomized, parallel, active-controlled phase III clinical trial was to investigate the noninferiority of HU-014 versus existing onabotulinumtoxin A for the treatment of moderate to severe glabellar lines.

METHODS

In total, 267 subjects were randomized to either the test (HU-014) or control (onabotulinumtoxin A) group. At the baseline and at weeks 4, 8, 12, and 16, investigator's live assessment, independent photographic assessment, subjects' improvement assessment, subjects' satisfaction assessment, and safety assessment were performed.

RESULTS

At week 4, the response rate was 90.15% and 92.31% in the test and control groups, respectively, as per investigator's live assessment while frowning, without a significant difference. Both groups also showed no significant differences in response rates in the other assessments. In addition, no serious AEs were reported.

CONCLUSION

HU-014 was noninferior to existing onabotulinumtoxin A in the treatment of glabellar lines at a 1:1 dose ratio, and both products were well tolerated.

Assessing patient cosmetic satisfaction after glaucoma drainage device surgery for different patch grafts

BACKGROUND

The use of a tissue patch graft is common practice with a glaucoma drainage device (GDD). Patch grafts can be visible in the palpebral fissure and may be cosmetically displeasing for some patients. The aim of this study was to report the cosmetic satisfaction of pericardial, scleral, and corneal patch grafts related to superior GDD surgery.

METHODS

Baseline clinical data were collected for consecutive patients with glaucoma operated between 2014 and 2019 at two tertiary eye care institutions (for superiorly-placed) Ahmad glaucoma valve implant using sclera, cornea and pericardium patch graft. A patient questionnaire that contained 4 concise questions, with a Likert-scale grading relating to cosmetic satisfaction was administered by a telephone-based interview. Responses and scores for each question were compared across patients who received the three different types of graft. A binominal logistic regression analysis was used to assess the effects of age, gender, type of graft, number of previous ocular surgeries, and final visual acuity to explain differences.

RESULTS

We included 92 patients who met our inclusion criteria (24 patients received a corneal patch graft, 30 who received sclera and 38 who received pericardium). The mean (±SD) age was 50 (±17.5) years, and the average follow up was 20.7 (± 18.6) months. Regardless of the type of patch graft, most (67-84%) of patients were satisfied with the appearance of their eyes. Patients who received cornea or sclera were more likely to report that their eye looked 'abnormal' by others. Younger age was significantly associated with the response to this question.

CONCLUSION

Patients are generally satisfied with the appearance of their eye following GDD surgery with each of the patch grafts for superiorly-placed GDDs. Younger patients with cornea or sclera were more likely to report that their eyes looked abnormal.

Hyperhidrosis and Aesthetics

When one considers the avalanche of new indications and uses for botulinum toxins, it is truly surprising that this has all happened in such a short time. And the safety and dependability of these products are profound, when used appropriately. There is still much to be discovered about the potential of this agent when you contemplate the profound non-cosmetic benefits reported by clinicians and scientists from around the world. The mechanism of action has been studied in depth, and yet the benefits appreciated by people with chronic migraine or major depressive disorder, for instance, are unlikely to be explained by our current mechanistic understanding. Given that these toxins control acetylcholine at the motor end plates, and given that acetylcholine is central to practically every cell in the body, it will not be surprising to find that botulinum toxin researchers will be enjoying many decades of fruitful studies. The advent of the non-surgical aesthetic physician has helped push the clinical utilization of botulinum toxins well beyond its original adoption by oculoplastic surgeons in their patients with blepharospasm. We can expect that the next edition of this book to have a dozen or more new indications which will surprise us all.