Dilution Volume of Botulinum Toxin Type A for the Treatment of Glabellar Rhytides: Does It Matter?

Neuromodulator Assessment and Treatment for the Upper Face: An Update

Neuromodulator treatment of the upper face has been extensively studied and serves as an excellent tool to enhance facial appearance, non-verbal communication, and social functioning. Optimal outcomes are best achieved when health care providers take an individualized approach, based on knowledge of structural and functional anatomy, thorough facial assessment, and customized injection techniques and patterns.

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.

Office-based facial plastics procedures: Neuromodulators

Botulinum toxin is a potent neuromodulator commonly used for cosmetic applications in the clinic. In this article, we reviewed the various formulations of botulinum toxin type A commercially available in the United States, as well as clinical pearls for preprocedural planning, common in-office injections, and management of complications.

High-Dose Neuromodulators: A Roundtable on Making Sense of the Data in Real-World Clinical Practice

BACKGROUND

For aesthetic treatment with botulinum neurotoxin type A (BoNTA), interest in maximizing treatment duration and efficacy has prompted study of doses higher than those used in registration studies. As data emerge, it is important that physicians understand how to apply study findings to their own practice so that patient demand is satisfied.

OBJECTIVES

To bring together leading experts in neuromodulators for a roundtable discussion on the implications of high-dose BoNTA studies for patient care.

METHODS

The authors reviewed and discussed recent data from high-dose BoNTA studies for abobotulinum toxin A, incobotulinum toxin A, and Oonobotulinumtoxin A.

RESULTS

Discussion focused on the challenges of data interpretation and extrapolation of study findings for real-world patient care. The authors participated in a candid discussion of whether the observed improvements in treatment duration and patient satisfaction warrant treatment with high-dose regimens delivered as high-concentration injections. Safety was also discussed, as well as economic considerations for both practices and patients. Of note, for BoNTA products, the registration dose, when administered in a smaller total volume, appears to give rise to more durable results than those observed in pivotal trials, implicating product concentration as an important consideration. Importantly, at higher doses, extended duration of effect does not appear to be at the expense of natural-looking results.

CONCLUSIONS

While the authors provide considerations for the development of individual clinical practice, there is no one-size-fits-all recommendation. It may be that "high-dose" BoNTA is in reality the optimal dose; however, important economic considerations may prevent rapid uptake for all patients.

An Italian experience of a new personalized injective protocol (Botutouch) for botulinum toxin application in aesthetic medicine

Botulinum toxin typeA (BoNTA) is widely used in aesthetic medicine as primary treatment to reduce facial wrinkles. Major unmet needs in the field of the injection techniques include dilution factor, injected volume and site. Since 2013, an innovative protocol has been developed in our clinic that works on a double dilution volume, identifies the injection site according to the specific anatomical-functional characteristics of each patient's musculature and applies a gentle massage to the injected area to optimize the toxin spread in the muscle. We retrospectively retrieved medical records of subjects that underwent aesthetic treatments in our outpatient Italian clinics from 2013. In cobotulinum toxin A was used in double dilution (100 AU in 5 mL of physiologic solution) and followed by a gentle massage after the injection to increase the distribution into the muscle. 197 subjects, most of them drug-naïve (81.7%), underwent 869 BoNTA treatments. On average, higher total units and volumes were applied in first visits or older subjects whereas the lower ones were preferred in following visits or younger subjects. As perceived by the patients, the effects of BoNTA lasted more than 6 months in about 38% of the cases. 95.9% of subjects declared to be satisfied,whereas 5.2% of adverse events were observed (4.8% hematoma, 0.2% ptosis, and 0.2% tenderness). To date, we offer a BoNTA treatment with the aim to maximize the results and consequent patient's satisfaction, with low incidence of complications.

Botulinum Toxin to Treat Horizontal Forehead Lines: A Refined Injection Pattern Accommodating the Lower Frontalis

BACKGROUND

When treating horizontal forehead lines with botulinum toxin type A the traditional approach requires that injection points should stay 1.5 to 2 cm above the orbital rim to avoid brow ptosis. Failure to treat the lower frontalis may potentially cause worse rhytides in the lower forehead.

OBJECTIVES

The aim of this study was to present a refined injection pattern accommodating the lower frontalis and evaluate its clinical efficacy and safety.

METHODS

Patients were categorized into 4 types according to the patterns of their forehead wrinkles. Moderate and severe wrinkles in the upper forehead were treated by the "safe zone" technique. Mild wrinkles and rhytides in the lower forehead were treated by the Microbotox technique. Standard photographs and measurements were taken before and after treatment. The effect on wrinkle reduction and changes in brow heights were assessed.

RESULTS

In total, 330 treatments were followed up in the clinic, and 246 treatments were followed up by telephone. Among the 330 treatments, 213 were evaluated in our clinic 2 to 4 weeks later, and the patients who received these treatments were recruited for effect evaluation and brow height measurements. The posttreatment severity of forehead wrinkles was significantly reduced (P < 0.05), and brow heights remained unchanged (P > 0.05). No severe adverse events were documented. Patient satisfaction was quite high.

CONCLUSIONS

The refined injection pattern is an effective and safe technique to treat horizontal forehead lines. The Microbotox technique enables treatment of the lower frontalis without changes in brow position.

LEVEL OF EVIDENCE: 3

AbobotulinumtoxinA for Facial Rejuvenation: What Affects the Duration of Efficacy?

AbobotulinumtoxinA (Dysport) has a long history as a safe and effective treatment option for aesthetic rejuvenation. One of the key measures of botulinum toxin efficacy is the persistence of clinically meaningful results. The duration of efficacy depends on different factors, many of which can be controlled by the clinician to better achieve their desired results. In this review, we discuss how dose, individual patient variation, and injection technique affect the duration of botulinum toxins. Increased duration may result from increased dose or more precise placement of the toxin in the muscle. The varying anatomy and behavior of patients can affect duration as well. Measures of duration in clinical studies vary, but both a 1-grade improvement on the glabellar line severity scale and patient-reported outcomes are key measures. The clinical effects of Dysport can last up to 5 months, and patients in Dysport clinical studies remained satisfied with treatment for up to 6 months. Dysport has a legacy of safety, efficacy, and high subject satisfaction demonstrated through studies and clinical experience. Building on that legacy by correctly dosing the subject, properly accounting for the individual subject anatomy and behavior, and using specific injection techniques can help ensure that your patients have the longest lasting results.

Muscle Insertion and Strength of the Muscle Contraction as Guidelines to Enhance Duration of the Botulinum Toxin Effect in the Upper Face

BACKGROUND

In this series of patients the cutaneous insertion and strength of voluntary contraction of the muscles in the upper third of the face were used as guidelines for botulinum toxin application named "BTA Codes."

METHOD

Anatomical dissection of fresh cadavers identified the shape and cutaneous insertions of the muscles in the upper third of the face. Patient voluntary contraction of the muscles in the upper third of the face created different patterns of skin lines classified by the 4-grade Facial Wrinkle Scale. For botulinum toxin application injections points followed the muscle cutaneous insertion and dose the 4-grade Facial Wrinkle Scale.

RESULTS

Injection points ranged from 3 to 23 points per patient, average of 9.4 points. Dose per point varied from 2.5 to 7.5 U, ranging from 12.5 to 72.5 U per patient, average of 33.82 U. Skin lines resulting from the voluntary contraction of the muscle prior to toxin application were stated as baseline 1. The absence of skin lines and muscle activity on day fifteen after toxin application defined baseline 2. Skin lines resulting from the recovered voluntary contraction of the muscle after toxin application like those of baseline 1 established baseline 3. The botulinum toxin effect was the time elapsed between baselines 2 and 3, ranging from 171 to 204 days, average of 183.72 days, greater than the 3 or 4 months reported in the literature.

CONCLUSION

"BTA Codes" is a set of rules to apply botulinum toxin supported by muscle anatomy and degree of voluntary contraction to enhance the duration of its effect.

LEVEL OF EVIDENCE IV

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

Botulinum neurotoxin formulations: overcoming the confusion

Botulinum toxin A is produced by anaerobic spore-forming bacteria and is used for various therapeutic and cosmetic purposes. Botulinum toxin A injections are the most popular nonsurgical procedure worldwide. Despite an increased demand for botulinum toxin A injections, the clinical pharmacology and differences in formulation of commonly available products are poorly understood. The various products available in the market are unique and vary in terms of units, chemical properties, biological activities, and weight, and are therefore not interchangeable. For safe clinical practice and to achieve optimal results, the practitioners need to understand the clinical issues of potency, conversion ratio, and safety issues (toxin spread and immunogenicity). In this paper, the basic clinical pharmacology of botulinum toxin A and differences between onabotulinum toxin A, abobotulinum toxin A, and incobotulinum toxin A are discussed.

Botulinum Toxin in Aesthetic Medicine: Myths and Realities

Several formulations of Botulinum toxin serotype A (BoNT-A) for aesthetic indications are available, with numbers likely to increase. Preparations are not interchangeable, based on dose unit comparisons.

A Randomized, Comparative Study to Evaluate Efficacy and Safety of Two Injection Volumes of AbobotulinumtoxinA in Treatment of Glabellar Lines

BACKGROUND

Different volumes of 0.9% NaCl may be used to reconstitute abobotulinumtoxinA yielding an injection volume that ranges from 0.05 to 0.1 mL per injection point for treatment of glabellar lines.

OBJECTIVE

To evaluate the efficacy, safety, and subject satisfaction of 2 different injection volumes to deliver the same unit dose of abobotulinumtoxinA for treatment of glabellar lines.

MATERIALS AND METHODS

This randomized comparative study was conducted using 2 different reconstitution volumes to deliver a fixed unit dose of 10 Speywood units (sU) of abobotulinumtoxinA in either 0.05 mL (labeled volume) or 0.1 mL (twofold volume) per injection point. Evaluations included wrinkle severity, neurophysiological assessment by compound muscle action potential (CMAP), and subject satisfaction.

RESULTS

Use of either injection volume of abobotulinumtoxinA resulted in the early onset of effect, high effectiveness, and long duration of effect. The safety profile and injection pain levels were similar in both groups. The twofold injection volume was shown to be noninferior to the labeled injection volume based on CMAP results.

CONCLUSION

A twofold increase in injection volume to 0.1 mL per injection point to deliver 10 sU of abobotulinumtoxinA is effective and safe.

The role of neurotoxins in the periorbital and midfacial areas

Initially popularized for the treatment of strabismus and blepharospasm, injection of botulinum neurotoxin has become the most commonly performed cosmetic treatment in the United States. Injection techniques have been particularly well-studied in the midface and periocular region, and patient satisfaction tends to be very high. We review the salient differences among available neurotoxins, how to optimally reconstitute them, how to inject the forehead, glabella, lateral canthal lines ("crow's feet"), infralid region, and transverse nasal lines ("bunny lines"), how to sculpt the brow, and how to manage potential complications.

Botulinum toxin type A products are not interchangeable: a review of the evidence

Botulinum toxin type A (BoNTA) products are injectable biologic medications derived from Clostridium botulinum bacteria. Several different BoNTA products are marketed in various countries, and they are not interchangeable. Differences between products include manufacturing processes, formulations, and the assay methods used to determine units of biological activity. These differences result in a specific set of interactions between each BoNTA product and the tissue injected. Consequently, the products show differences in their in vivo profiles, including preclinical dose response curves and clinical dosing, efficacy, duration, and safety/adverse events. Most, but not all, published studies document these differences, suggesting that individual BoNTA products act differently depending on experimental and clinical conditions, and these differences may not always be predictable. Differentiation through regulatory approvals provides a measure of confidence in safety and efficacy at the specified doses for each approved indication. Moreover, the products differ in the amount of study to which they have been subjected, as evidenced by the number of publications in the peer-reviewed literature and the quantity and quality of clinical studies. Given that BoNTAs are potent biological products that meet important clinical needs, it is critical to recognize that their dosing and product performance are not interchangeable and each product should be used according to manufacturer guidelines.

Accordion wrinkle treatment through the targeted use of botulinum toxin injections

The term "accordion facies" is used to define a face that has been streaked by an extended network of wrinkles stretching from the orbital frame up to the temples and neck. Although the origin of these wrinkles seems to be the mime muscle effect, it also may be linked to the presence of acetylcholine skin receptors in the superficial skin. This would certainly explain the reason for the presence of these wrinkles far from the muscle areas. Therefore, very superficial and targeted injections of diluted botulinum toxin A can be offered. In the case of strongly dehydrated skin, the toxin may be combined with a weak or not reticulated hyaluronic acid. The use of thin cannulas offers an advanced treatment especially in the resistant crow's feet area with a single entry point and a lower risk of ecchymotic incidents. The results are quite impressive and offer real new options in the management of the aging process. The main drawback remains the risk of unexpected diffusions to the great zygomatic muscle, with some distortion in the extreme smile. Therefore, dilution (up to 3 times) and very precise injections are strongly recommended, especially in the para-commissural area. This report presents a case study of 44 patients who received this treatment, with a follow-up period of 1-25 months. To date, these particularly striking facial distortions had not received a satisfactory answer.

LEVEL OF EVIDENCE V

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 .

Differential characteristics of incobotulinumtoxinA and its use in the management of glabellar frown lines

Objectives

This review examines the pharmacologic and clinical characteristics of incobotulinumtoxinA (Xeomin^®/Xeomeen^®/Bocouture^®/XEOMIN Cosmetic™; botulinum toxin type A [150 kDa]), which is free from complexing proteins, and discusses its efficacy and safety in the treatment of glabellar frown lines. Differences between incobotulinumtoxinA and other commercially available botulinum neurotoxin type A (BoNT/A) products that have been approved by the European Medicines Agency, US Food and Drug Administration, and other regulatory agencies for this indication are also discussed.

Findings

IncobotulinumtoxinA differs from other commercially available BoNT/A preparations, in that it is free from complexing proteins and contains only active neurotoxin, minimizing foreign protein load. IncobotulinumtoxinA is commonly used at a 1:1 dose ratio with onabotulinumtoxinA and displays comparable efficacy and safety; furthermore, it is associated with early onset and long duration of effect, and high levels of subject satisfaction. In terms of practical considerations, incobotulinumtoxinA does not require cold storage and demonstrates low spread, enabling precise treatment and good tolerability.

Conclusion

IncobotulinumtoxinA is an efficacious and well-tolerated treatment for glabellar frown lines. It differs from other BoNT/A preparations, in that it is free from complexing proteins and contains only active neurotoxin, which is relevant clinically, as this reduces the foreign protein load and minimizes the risk of neutralizing antibody production. In practical terms, incobotulinumtoxinA has a long shelf-life, remaining stable without the need for refrigeration, and due to its limited spread is a precise localized treatment.

A randomised, double-blind comparison of 20 units of onabotulinumtoxinA with 30 units of incobotulinumtoxinA for glabellar lines

BACKGROUND

Biological activity data indicate that the units of incobotulinumtoxinA are not equivalent to those of onabotulinumtoxinA.

OBJECTIVE

This study compared 20 units of onabotulinumtoxinA with 30 units of incobotulinumtoxinA in the treatment of glabellar lines.

METHODS AND MATERIALS

In this multicenter, randomised, double-blind study, subjects with moderate or severe glabellar lines received a single treatment with 20 units of onabotulinumtoxinA (n = 112), or 30 units of incobotulinumtoxinA (n = 112). The primary endpoint was the percentage of subjects with a reduction of ≥ 1 point on the Facial Wrinkle Scale at maximum contraction as rated by injectors on day 28 post injection. The same variable was evaluated on days 84, 98, and 112.

RESULTS

At the primary endpoint, 20 units of onabotulinumtoxinA was as effective as 30 units of incobotulinumtoxinA (96% vs. 95% responders, respectively; difference in proportion of responders = 0.02, 95% confidence interval [CI] - 0.04, 0.07). At subsequent time points, a trend towards a higher percentage of responders was observed in the group treated with 20 units of onabotulinumtoxinA. Given that the 95% CI surpassed the upper equivalence margin at these time points, equivalence was not established.

CONCLUSION

These data support the non-interchangeability of units of onabotulinumtoxinA and incobotulinumtoxinA, and the absence of a fixed dose ratio in clinical practice.

Current aesthetic use of abobotulinumtoxinA in clinical practice: an evidence-based consensus review

The amount and complexity of scientific and clinical evidence for aesthetic use of botulinum neurotoxin type A (BoNT-A) has expanded rapidly in recent years, especially for abobotulinumtoxinA, necessitating reassessment of current knowledge about aesthetic use of abobotulinumtoxinA and other BoNT-A preparations. A committee of 13 plastic surgeons, facial plastic surgeons, and dermatologists engaged in a live discussion of information from a systematic literature review and an Internet-based survey of their beliefs and practices. The committee achieved consensus on most issues. It was concluded that doses of different BoNT-A preparations cannot be interconverted with a fixed ratio. The size of the "field of effect" is difficult to measure, and comparisons between preparations have yielded equivocal results. Nonresponse due to neutralizing antibodies appears exceedingly rare with currently available BoNT-A preparations and of little concern clinically. BoNT-A dose, injection depth, and injection technique should be adjusted according to the anatomic area being treated and each patient's individual characteristics and goals. Aesthetic use of BoNT-A has a good safety profile. Most adverse events are minor and related to the trauma of injection, although special care is needed in certain anatomic areas. Detailed recommendations for treatment of different anatomic areas are presented. BoNT-A products are often used in conjunction with other treatment modalities (eg, fillers and resurfacing), but little agreement was reached on best practices. The findings reported in this consensus document may serve as a practical guide for aesthetic practitioners as they apply the latest knowledge about BoNT-A in providing their patients with optimal care.

Botulinum neurotoxin A: a review

Despite its ubiquity in cosmetic circles and broad general awareness, a literature search of botulinum neurotoxin in JPRAS and BJPS yielded a mere 4 articles germane to cosmesis. A pair each detailing its application in masseteric hypertrophy(1,2) and the use of cryoanalgesia.(3,4) Given that botulinum neurotoxin A is the most commonly used cosmetic treatment, with American figures being most accurate,(5) a review of the background, development and scientific evidence would be perhaps useful, if not overdue, as Plastic Surgeons increasingly incorporate non-surgical interventions into their practices as part of a comprehensive facial rejuvenation strategy.

[Scratched faces: treatment of dynamic facial wrinkles through the simultaneous combined use of botulinium toxin A and hyaluronic acid]

We use the term "scratched face" to define a face which has been streaked by deep wrinkles stretching from the orbital frame up to the temples and neck. Although the origin of these wrinkles seems to be the mime muscle effect; it may also be linked to the presence of Acetylcholine skin receptors in the superficial skin. This would certainly explain the reason for the presence of these wrinkles far from the muscle areas. We can therefore offer very superficial and targeted injections of diluted botulinium Toxin A. In the case of a strongly dehydrated skin, the toxin will be combined in the same syringe with a weak or not reticulated hyaluronic acid. We present a case study of 25 patients who have received this treatment, with a follow-up from 3 to 18 months. These patients had not received until now a satisfactory answer to the problem of their particularly striking facial distortions.

Skin displacement analysis (SDA): a tool for the quantitative evaluation of skin movements elicited by underlying muscles in the face and neck area

BACKGROUND

Quantitative numerical analysis of skin displacement triggered by muscles inserting the overlaying skin would be useful for monitoring the inhibition of mimetic muscles.

METHODS

By using removable grid markings and digital photographs, skin displacement analysis (SDA) was performed on 13 patients pre-treatment and on Days 1, 2, 3, and 7 after injection of 18 units of botulinum toxin type A (BoNT/A) in the fronto-glabellar area.

RESULTS

At baseline, amplitudes of horizontal skin displacement with fronto-glabellar contraction showed a linear increase along the eyebrow laterally from the midline; mean values (±standard deviation [SD]) 15 and 30 mm lateral to the midline were 3.2 ± 1.0 mm (range, 1.9-4.9 mm) and 6.5 ± 1.4 mm (range 4.0-8.5 mm), respectively. After injection of BoNT/A, maximum horizontal skin displacement 30 mm lateral to the midline showed a mean reduction (±SD) to 62% ± 23% at Day 2 and to 17% ± 16% at Day 7; corresponding values 15 mm lateral to the midline were 62% ± 29% and 15% ± 20%, respectively. In all cases, the reduction in horizontal skin displacement compared with pre-injection levels was statistically significant (P < 0.001).

CONCLUSION

SDA is a feasible method for the quantitative evaluation of skin movements elicited by muscles inserting the overlaying skin in the face and neck area.

Update on botulinum toxin and dermal fillers

PURPOSE OF REVIEW

The art and science of facial rejuvenation is an ever-evolving field of medicine, as evidenced by the continual development of new surgical and nonsurgical treatment modalities. Over the past 10 years, the use of botulinum toxin and dermal fillers for aesthetic purposes has risen sharply. Herein, we discuss properties of several commonly used injectable products and provide basic instruction for their use toward the goal of achieving facial rejuvenation.

RECENT FINDINGS

The demand for nonsurgical injection-based facial rejuvenation products has risen enormously in recent years. Used independently or concurrently, botulinum toxin and dermal filler agents offer an affordable, minimally invasive approach to facial rejuvenation.

SUMMARY

Botulinum toxin and dermal fillers can be used to diminish facial rhytides, restore facial volume, and sculpt facial contours, thereby achieving an aesthetically pleasing, youthful facial appearance.

Botulinum toxin: examining duration of effect in facial aesthetic applications

Patient satisfaction with botulinum toxin treatment is a key success factor in aesthetic procedures and is governed by the interaction of numerous variables. Duration of effect is important because it influences retreatment intervals as well as affecting cost and convenience to the patient. In order to review the evidence on the duration of benefit associated with various commercial formulations of botulinum toxin, MEDLINE was searched using the following terms: 'botulinum' and 'duration'/'retreatment' (limits: 'clinical trials,' 'meta-analyses,' 'English'). I also searched my existing reference files, reference lists of identified articles, and meeting/conference abstracts to ensure completeness. The focus was on clinical medicine and aesthetic trials. To be eligible for the analysis, studies had to include efficacy assessments at multiple timepoints. To estimate duration of benefit, the following outcomes were examined and summarized: responder rates, mean wrinkle severity scores at various timepoints (with or without changes from baseline), and relapse rates. Duration at both repose and maximum attempted muscle contraction was considered when provided. Where possible, duration was assessed by formulation and dose. The initial search yielded 164 articles. Of these, 35 included an adequate measure of duration in aesthetic indications. The majority of these (22) were on the glabellar area. Study designs and endpoints were highly heterogeneous, and duration of effect varied between studies. Several studies with the BOTOX Cosmetic (onabotulinumtoxinA; Allergan, Inc., Irvine, CA, USA) formulation of botulinum toxin type A (BoNTA) included relapse rates, defined conservatively as return to baseline levels of line severity for two consecutive visits approximately 30 days apart (at repose and maximum contraction). In these studies, duration of effect ranged from 3 to 5 months in female patients and from 4 to 6 months in male patients. Individual patients had longer durations of response. Across all studies providing relapse rates, most patients relapsed by 6 months. In studies assessing patient satisfaction, satisfaction remained high throughout the duration of the studies ( approximately 4 months). With the Dysport formulation (abobotulinumtoxinA, clostridium botulinum type A toxin-hemagglutinin complex; Ipsen Biopharm Ltd, Wrexham, England), retreatment intervals were estimated at a mean of 3.9 months (median = 3.3 months). These results were consistent with responder rates from another Dysport study in which the active treatment differed from placebo at 3 but not 4 months. A single comparative study demonstrated that the proportion of patients relapsing at week 16 was 23% (95% CI 11.5, 41.6) in the BOTOX Cosmetic group as compared with 40% (95% CI 25.2, 60.1) in the Dysport group. Myobloc (rimabotulinumtoxinB, botulinum toxin type B; Solstice Neurosciences, Inc., South San Francisco, CA, USA) was associated with shorter durations of action (2-3 months). Data from facial areas other than the glabella, although more limited, supported a duration of at least 3-4 months. The addition of BoNTA to dermal fillers or light/laser therapy appeared to increase the degree of effect. Repeated BoNTA treatments may prolong duration of effect or potentiate the effect. In conclusion, patients can expect treatments to last > or =3 months but often as many as 4-5 months depending on the facial area, dose, and formulation. Additional research should help clarify the impact of age, baseline rhytid severity, patient sex, repeated treatments, and combination treatment on longevity of effect.

Treating glabellar lines with botulinum toxin type A-hemagglutinin complex: a review of the science, the clinical data, and patient satisfaction

Botulinum toxin type A treatment is the foundation of minimally invasive aesthetic facial procedures. Clinicians and their patients recognize the important role, both negative and positive, that facial expression, particularly the glabellar frown lines, plays in self-perception, emotional well-being, and perception by others. This article provides up-to-date information on fundamental properties and mechanisms of action of the major approved formulations of botulinum toxin type A, summarizes recent changes in naming conventions (nonproprietary names) mandated by the United States Food and Drug Administration, and describes the reasons for these changes. The request for these changes provides recognition that formulations of botulinum toxins (eg, onabotulinumtoxinA and abobotulinumtoxinA) are not interchangeable and that dosing recommendations cannot be based on any one single conversion ratio. The extensive safety, tolerability, and efficacy data are summarized in detail, including the patient-reported outcomes that contribute to overall patient satisfaction and probability treatment continuation. Based on this in-depth review, the authors conclude that botulinum toxin type A treatment remains a cornerstone of facial aesthetic treatments, and clinicians must realize that techniques and dosing from one formulation cannot be applied to others, that each patient should undergo a full aesthetic evaluation, and that products and procedures must be selected in the context of individual needs and goals.

Botulinum toxin type A for the management of glabellar rhytids

There is an increasing demand for minimally-invasive cosmetic procedures to arrest the aging process. Botulinum toxin type A injections are the most commonly used nonsurgical cosmetic procedures in the United States. There has been research spanning over two decades dedicated to safety, efficacy, dosing, and complications of botulinum toxin type A. There are now two Food and Drug Administration (FDA) approved botulinum toxin type A options in the United States: Botox(®) and Dysport(™), with new advances being made in the field.

Midface lifting with botulinum toxin: intradermal technique

BACKGROUND

An intradermal injection technique is a variation of the intramuscular or subcutaneous injection technique usually performed with botulinum toxin for facial rejuvenation. The technique applied to realign the imbalance of the facial muscles by weakening the downward pull of the depressors and allowing the levators to contract in a compensatory fashion results in midface lifting and rejuvenation.

AIMS

To address the intradermal injection technique of botulinum toxin for midface lifting.

METHODS

A restrospective review of the patients undergoing midface lifting during the year 2008, the procedure, the details of the injection technique, and outcomes are described.

RESULTS

An intradermal injection technique of botulinum toxin successfully gives rise to midface lifting and rejuvenation.

CONCLUSION

An intradermal injection technique of botulinum toxin treatment is effective for aesthetic improvement in the midface.

The evolution of botulinum neurotoxin type A for cosmetic applications

Very few pharmaceutical preparations share an evolutionary history as remarkable as that of botulinum neurotoxin (BoNT). The exotoxin of the organism Clostridium botulinum, once feared as a terrible poison, has been reborn as a highly regarded and widely used therapeutic and aesthetic agent. In less than two decades since the report of the success of BoNT type A (BoNTA) in reducing glabellar lines, injection of this product has become the most common non-surgical cosmetic procedure performed in the USA and worldwide. In addition to temporarily eliminating rhytids by muscle weakening, other dermatologic applications of BoNTA include correcting facial asymmetries and treating hyperhidrosis. Although BOTOX is the most clinically substantiated and published of the BoNTA preparations, other BoNTA products, as well as a BoNT type B product, are available in some parts of the world, and others are in development.

Diffusion characteristics of botulinum neurotoxin products and their clinical significance in cosmetic applications

Over the past decade, growth in the number and types of aesthetic procedures performed using botulinum neurotoxin has increased, along with the number of these products. As more options, along with emerging counterfeit agents, become available to clinicians, differences among preparations need to be considered in order to ensure optimal outcomes for patients. Once injected into the muscle, botulinum neurotoxin distributes within that tissue to produce the desired local effects. Diffusion, or the distribution of product beyond the target muscle, can be of concern because of the potential for local and systemic effects that result in muscle weakening away from the desired site. Several factors influence diffusion, including preparation characteristics (e.g. molecular size and structure), dosing and injection technique, and muscles injected. In this article, we discuss the accumulating preclinical and clinical data that differentiate botulinum neurotoxin agents with respect to their diffusion characteristics.

The five D's of botulinum toxin: doses, dilution, diffusion, duration and dogma

The purpose of this review is to update cosmetic dermatologists and surgeons on the latest information about botulinum toxin injections for the treatment of the face and neck and to provide a practical guide to effective and safe technique. We review indications, recommended doses and dilutions, storage recommendations and injection techniques.

A randomized, evaluator-blinded, two-center study of the safety and effect of volume on the diffusion and efficacy of botulinum toxin type A in the treatment of lateral orbital rhytides

BACKGROUND

There has been considerable discussion about the effect of the degree of dilution of botulinum toxin (BTX) but very few scientific studies.

OBJECTIVE

The objective was to observe as to whether a fivefold difference in concentration of BTX solution would produce a difference in clinical effect or duration of effect.

METHODS AND MATERIALS

Twenty individuals were enrolled at two sites and a within-subject paired-comparison study was performed on the lateral orbital area with a single injection of 5 U of BTX (BOTOX Cosmetic, Allergan Inc., Irvine, CA). The results were assessed both clinically and using a computer-assisted estimation of the degree of wrinkling.

RESULTS

No statistically significant differences were observed between the two sides.

CONCLUSIONS

This is a small study and it may be that dilution does affect BTX result. We were, however, unable to detect any difference in this study, which suggests that the degree of dilution, at least within a fivefold margin, has only a small effect on the results of BTX injection in the lateral orbital area.