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Emerging Trends in Botulinum Neurotoxin A Resistance: An International Multidisciplinary Review and Consensus. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4407. [PMID: 35747253 PMCID: PMC9208887 DOI: 10.1097/gox.0000000000004407] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/11/2022] [Indexed: 11/26/2022]
Abstract
Botulinum neurotoxin A (BoNT-A) injection is the most widely performed aesthetic procedure and a first-line therapeutic option for various medical conditions. The potential for BoNT-A immunoresistance and secondary nonresponse related to neutralizing antibody (NAb) formation warrants attention as the range of BoNT-A aesthetic applications continues to expand. Methods An international multidisciplinary panel reviewed published evidence on BoNT-A immunoresistance in aesthetic and therapeutic applications and discussed best practices integrating clinical, ethical, and aesthetic considerations. Consensus statements relating to awareness, assessment, and management of the risk of NAb-related secondary nonresponse in aesthetic practice were developed. Results There was a consensus that, as doses used in aesthetic practice become like those in therapeutics, rates of NAb formation may be expected to increase. However, the true extent of NAb formation in aesthetics is likely underestimated due to limitations of published evidence and variability in treatment patterns of aesthetic patients. Since BoNT-A therapy is often lifelong, practitioners need to recognize immunogenicity as a potential complication that might affect future therapeutic use and strive to minimize modifiable risk factors. The selection and use of a BoNT-A product with the least immunogenic potential from the beginning may thus be advantageous, especially when treatment with high doses is planned. Conclusions In view of current trends in BoNT-A aesthetic use, it is essential for practitioners to conduct thorough clinical assessments, inform patients of treatment risks, and develop BoNT-A treatment plans to minimize immunogenicity. This can help preserve the option of continued or future BoNT-A treatment with satisfactory outcomes.
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Immunogenicity Associated with Aesthetic Botulinumtoxin A: A Survey of Asia-Pacific Physicians' Experiences and Recommendations. Plast Reconstr Surg Glob Open 2022; 10:e4217. [PMID: 35450268 PMCID: PMC9015201 DOI: 10.1097/gox.0000000000004217] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/31/2022] [Indexed: 12/27/2022]
Abstract
Background: Most botulinum toxin A (BoNT/A) products contain unnecessary bacterial components that increase the risk of developing neutralizing antibodies (nAbs). Reports of secondary nonresponse and treatment failures (STF) due to nAbs have accompanied a surge in new BoNT/A products. Methods: To formulate recommendations on managing toxin resistance, we reviewed the evidence on BoNT/A-associated immunogenicity and evaluated Asian physicians' current BoNT/A practices, knowledge, and real-world experiences, as provided by survey outcomes conducted with 128 Asian experts (regular botulinum toxin injectors). Results: Most doctors believe STF occurs, some patients exhibit partial symptoms, and impurities (eg, complexing proteins) in BoNT/A preparations risk STF. Bioassays that distinguish non-nAbs from nAbs that hinder toxin function remain unavailable to most doctors, though most would perform testing if given the option. Doctors in the Asia-Pacific region have differing strategies for managing STF, depending on the availability of alternatives or tests. They recommended switching to a highly-purified formulation free of complexing proteins and other impurities to lower the risk of immunogenicity, or offering treatment holidays of 2 -2.5 years. They suggested restarting treatment with the same highly purified formulation, especially for repeated treatments, large-dose injections, and younger patients who will accumulate higher lifetime doses, so as to minimize immunogenic risks and preserve long-term treatment outcomes. Importantly, doctors should always initiate patients on pure formulations rather than switching to these only after resistance develops. Conclusion: Choosing highly purified BoNT/A products at treatment initiation enhances long-term efficacy and patient satisfaction while minimizing the risk of immune activation and nAb formation.
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Vachiramon V, Subpayasarn U, Triyangkulsri K, Jurairattanaporn N, Rattananukrom T. Different injection patterns of incobotulinumtoxinA for crow's feet: a split-face comparative study. J Eur Acad Dermatol Venereol 2020; 35:256-262. [PMID: 33068445 DOI: 10.1111/jdv.16997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND IncobotulinumtoxinA has been previously used for the treatment of lateral periorbital lines (crow's feet). However, a standardized injection technique has not been established. OBJECTIVES To compare the efficacy and effect duration of two injection techniques of incobotulinumtoxinA for crow's feet treatment. METHODS Forty-eight patients with crow's feet were recruited and randomly assigned to receive bilateral treatments using either a 3-point intramuscular or a 6-point intradermal injection technique (8-12 units of incobotulinumtoxinA on each side). Improvement was assessed at 1, 2, 4, 8, 12, 16, 20 and 24 weeks postinjection. An objective evaluation was assessed by the indentation index using a 3D camera and a subjective evaluation was assessed by a blinded dermatologist using the Flynn validated assessment scale (FVAS) for the upper face. The patients assessed the results using the Global Aesthetic Improvement Scale (GAIS). Side-effects were evaluated at each visit. RESULTS After treatment, a significantly greater reduction in the indentation index of periorbital wrinkles on the 3-point intramuscular injection side compared with the 6-point intradermal injection side was observed at 8, 12, and 16 weeks. The results from the FVAS and GAIS scores showed significantly longer median times to relapse of the periorbital wrinkle for the 3-point intramuscular injection compared with the 6-point intradermal injection. Pain and bruising were slightly greater with the 6-point intradermal technique. CONCLUSIONS This study reaffirmed the efficacy of incobotulinumtoxinA for the treatment of crow's feet. The 3-point intramuscular injection technique yielded greater efficacy and longer duration of action than the 6-point intradermal injection technique.
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Affiliation(s)
- V Vachiramon
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - U Subpayasarn
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - K Triyangkulsri
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - N Jurairattanaporn
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - T Rattananukrom
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Srinoulprasert Y, Wanitphakdeedecha R. Antibody-induced botulinum toxin treatment failure: A review and novel management approach. J Cosmet Dermatol 2020; 19:2491-2496. [PMID: 32702171 DOI: 10.1111/jocd.13637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/19/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Botulinum neurotoxin A (BoNT/A) has been used for cosmetic indications for many decades. Consumption of BoNT/A usage has been markedly increased for a few years. Even new formulations of BoNT/A to decrease immunogenicity have been released, repeated treatment to maintain efficacy outcome is inevitable and could finally provoke immune response. In the past, prevalence of botulinum treatment failure (BTF) in cosmetic indication was rare leading to less medical concern. Current decade, case reports on BTF, especially antibody-induced botulinum toxin treatment failure (ABTF), have been increasingly revealed and risk factors associated with ABTF have been intensively studied. AIMS In this article, we will review antibody-induced botulinum toxin treatment failure (ABTF), risk-associated ABTF, prevalence and recent case reports of ABTF, and new approach to deal with ABTF. METHODS Literature search was conducted using PubMed. The relevant literatures published between January 2000 and May 2020 concerning BTF and ABTF including investigation for ABTF were included and analyzed. RESULTS Possible causes of BTF were summarized. ABTF could be a tip of iceberg of BTF, its prevalence, and currently, 10-year case reports of ABTF were published evidence. Risk factors and investigation methods for ABTF were also summarized. Based on previous studies and our experience, novel approach to management of ABTF was described. CONCLUSION Effective management of BTF is to explore causes of treatment failure. Antibodies against BoNT/A complex could be one of many possibilities. Laboratory in vitro tests could be alternative tools to decrease adverse effect and rebooting immune responses in BTF patients.
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Affiliation(s)
- Yuttana Srinoulprasert
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Lai KK, Kuk AK, Chan E, Ko ST. The good toxin: 10 years of experience with botulinum toxin A in the treatment of benign essential blepharospasm. Eur J Ophthalmol 2020; 31:1345-1350. [PMID: 32544987 DOI: 10.1177/1120672120925630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To describe the efficacy and safety of botulinum toxin A (Botox) in patients with benign essential blepharospasm. METHODS Retrospective review of operation, injection, and medical records. RESULTS Information of 29 patients (nine males) was reviewed, and the average age of benign essential blepharospasm onset was 59.1 years. The average number of injections per patient was 14.2 ± 8.2 (5-44) and the average follow-up was 75.8 ± 47.3 months (15-180). The average unit dose was 14.2 ± 8.2 (10-30) ipsilaterally in the patient's first year and was 21.4 ± 5.0 (12.5-30) ipsilaterally in their last year (p = 0.00458). The average onset time was 3.8 ± 1.9 (1-7) days in a patient's first year and was 3.6 ± 1.7 (2-7) days in their last year (p = 0.549). The average effective duration was 2.86 ± 1.1 months in a patient's first year and was 2.53 ± 0.9 in their final year (p = 0.187). The Subjective Spasm Alleviation Scale was 1.72 ± 0.4 at the first year and was 1.79 ± 0.5 in the last year (p = 0.187). Ten (34.5%) patients with eyelid disease had surgical correction. The Subjective Spasm Alleviation Scale was 1.50 ± 0.5 before and was 2.0 ± 0 six months after the operation (p = 0.0268). Post-injection complications were experienced in eight (27.6%) patients. The most common complication was ptosis (n = 7), followed by diplopia (n = 1), dry eye (n = 1), and tearing (n = 1). No life-threatening complication was reported. CONCLUSION Botox was a safe and effective treatment in benign essential blepharospasm which required an increased dosage over time. Ptosis was the most common complication and no life-threatening condition was reported. Surgical correction of those with eyelid diseases showed subjective improvement of subsequent Botox treatment.
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Affiliation(s)
- Kenneth Kh Lai
- Department of Ophthalmology, Tung Wah Eastern Hospital, Causeway Bay, Hong Kong
| | - Andrew Kt Kuk
- Department of Ophthalmology, Tung Wah Eastern Hospital, Causeway Bay, Hong Kong
| | - Edwin Chan
- Department of Ophthalmology, Tung Wah Eastern Hospital, Causeway Bay, Hong Kong
| | - Simon Tc Ko
- Department of Ophthalmology, Tung Wah Eastern Hospital, Causeway Bay, Hong Kong
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Wanitphakdeedecha R, Kantaviro W, Suphatsathienkul P, Tantrapornpong P, Yan C, Apinumtham C, Srinoulprasert Y. Association Between Secondary Botulinum Toxin A Treatment Failure in Cosmetic Indication and Anti-Complexing Protein Antibody Production. Dermatol Ther (Heidelb) 2020; 10:707-720. [PMID: 32445175 PMCID: PMC7367960 DOI: 10.1007/s13555-020-00397-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Botulinum toxin A (BoT/A) treatment failure (BTF) affects patients subjected to repeated BoT/A exposure for cosmetic indications. BoT/A’s general formulation contains core BoT/A and complexing proteins. BTF may be caused by antibody-induced treatment failure. Antibodies against core BoT/A can occur; however, anti-complexing protein antibodies have never been demonstrated, and tools for anti-complexing protein antibody detection have not been developed. The aim of this study was to evaluate immune involvement in BoT/A-nonresponsive patients. Methods Patients suspected of nonresponsiveness to BoT/A for cosmetic indications were recruited. All volunteers were categorized as BoT/A-responsive or BoT/A-tolerant according to frontalis testing with onabotulinumtoxinA (onaA). Twenty-two BoT/A-tolerant volunteers were recruited separately for frontalis testing with incobotulinumtoxinA (incoA). Anti-BoT/A and anti-complexing protein antibodies were quantified by special ELISA using sera from blood sampled before and after frontalis testing. Results Significantly higher levels of IgG against complexing protein were detected in onaA-tolerant sera but not in onaA-responders, leading to proposals that anti-complexing protein antibodies could cause onaA unresponsiveness. Some onaA-tolerant patients according to frontalis test with incoA were responsive to incoA. Newly developed absorption ELISA confirmed that incoA-responsive sera predominantly contained IgG against complexing proteins, whereas incoA-tolerant sera contained significant levels of IgG against core BoT/A. The presence of anti-complexing protein antibodies higher than 90.75% in sera of onaA-tolerant patients could respond to incoA. The ELISA technique might be employed as a tool to predict incoA responsiveness. Our frontalis testing after incoA treatment showed that anti-incoA IgG levels were not increased by incoA. Conclusions BoT/A-exposed patients may develop antibodies against core botulinum toxin and complexing proteins. Our study is the first to demonstrate that anti-complexing protein antibodies cause BTF. High levels of antibodies against complexing proteins can cause onaA unresponsiveness, although some patients were still incoA-responsive. Our developed ELISA to detect anti-complexing protein antibodies can determine whether onaA-tolerant patients respond to incoA without incoA frontalis testing.
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Affiliation(s)
| | - Watsachon Kantaviro
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Panittra Suphatsathienkul
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ploypailin Tantrapornpong
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chadakan Yan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chalermkwan Apinumtham
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Yuttana Srinoulprasert
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Yeh YT, Peng JH, Peng HLP. Literature review of the adverse events associated with botulinum toxin injection for the masseter muscle hypertrophy. J Cosmet Dermatol 2018; 17:675-687. [DOI: 10.1111/jocd.12721] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 07/18/2018] [Accepted: 06/28/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Yu-Ting Yeh
- P-Skin Professional Clinic; Kaohsiung Taiwan
| | - Jui-Hui Peng
- National Yang-Ming University School of Medicine; Taipei Taiwan
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8
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Giordano CN, Matarasso SL, Ozog DM. Injectable and topical neurotoxins in dermatology: Basic science, anatomy, and therapeutic agents. J Am Acad Dermatol 2017; 76:1013-1024. [PMID: 28522038 DOI: 10.1016/j.jaad.2016.11.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 11/03/2016] [Accepted: 11/06/2016] [Indexed: 11/24/2022]
Abstract
Botulinum toxin is a potentially deadly anaerobic bacterial toxin that acts by inhibiting release of acetylcholine at the neuromuscular junction, thereby inhibiting contraction of the exposed striated muscle. There are currently 4 botulinum toxin preparations approved by the US Food and Drug Administration (FDA): onabotulinumtoxin, abobotulinumtoxin, incobotulinumtoxin and rimabotulinumtoxin. While significant overlap exists, each product has unique properties and specifications, including dosing, diffusion, and storage. Extensive physician knowledge of facial anatomy, coupled with key differences of the various neurotoxin types, is essential for safe and successful treatments. The first article in this continuing medical education series reviews key characteristics of each neurotoxin, including new and upcoming agents, and provides an anatomic overview of the most commonly injected cosmetic sites.
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Affiliation(s)
| | - Seth L Matarasso
- Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, California
| | - David M Ozog
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan.
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9
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Giordano CN, Matarasso SL, Ozog DM. Injectable and topical neurotoxins in dermatology: Indications, adverse events, and controversies. J Am Acad Dermatol 2017; 76:1027-1042. [PMID: 28522039 DOI: 10.1016/j.jaad.2016.11.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 11/03/2016] [Accepted: 11/06/2016] [Indexed: 12/27/2022]
Abstract
The use of neuromodulators for therapeutic and cosmetic indications has proven to be remarkably safe. While aesthetic and functional adverse events are uncommon, each anatomic region has its own set of risks of which the physician and patient must be aware before treatment. The therapeutic usages of botulinum toxins now include multiple specialties and multiple indications. New aesthetic indications have also developed, and there has been an increased utilization of combination therapies to combat the effects of global aging. In the second article in this continuing medical education series, we review the prevention and treatment of adverse events, therapeutic and novel aesthetic indications, controversies, and a brief overview of combination therapies.
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Affiliation(s)
| | - Seth L Matarasso
- Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, California
| | - David M Ozog
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan.
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10
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Cohen JL, Scuderi N. Safety and Patient Satisfaction of AbobotulinumtoxinA for Aesthetic Use: A Systematic Review. Aesthet Surg J 2017; 37:S32-S44. [PMID: 28388721 PMCID: PMC5434490 DOI: 10.1093/asj/sjx010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
A systematic review of the published literature (from January 2000 to January 2016) to ascertain the safety of, and patient satisfaction with, the aesthetic use of abobotulinumtoxinA was conducted. In addition to the licensed indications, other special populations were considered for discussion. The potential impact of neutralizing antibodies and systemic toxicity were also addressed. A total of 364 papers were screened and 86 were found to be relevant to the population, intervention(s), and outcomes stipulated in the protocol. The safety and patient satisfaction data from these publications are discussed in this review.
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Affiliation(s)
- Joel L Cohen
- Associate Clinical Professor, Department of Dermatology, University of Colorado, Boulder, CO, USA
- Assistant Clinical Professor, Department of Dermatology, University of California Irvine, Irvine, CA, USA
| | - Nicolo Scuderi
- Full Professor of Plastic and Reconstructive Surgery, Department of Surgery, Sapienza University of Rome, Rome, Italy
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11
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Abstract
Botulinum toxin type A (BTA) can be used for facial aesthetics. The 3 currently available BTA types include onabotulinumtoxinA (Botox; Botox Cosmetic, Allergan, Irvine, CA), abobotulinumtoxinA (Dysport; Ipsen, Ltd, Berkshire, UK), and incobotulinumtoxinA (Xeomin; Merz Pharmaceuticals, Frankfurt, Germany). The mechanism of action and clinical uses for treatment of dynamic lines of the forehead, brow, glabella, lateral orbit, nose, and lips are presented, as well as treatment of masseter hypertrophy, platysmal bands, and improvements of the perioral region. Specific BTA injection sites and suggested doses are presented.
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12
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Abstract
Botulinum neurotoxin injections are a valuable treatment modality for many therapeutic indications and have revolutionized the field of aesthetic medicine so that they are the leading cosmetic procedure performed worldwide. Studies show that onabotulinumtoxinA, abobotulinumtoxinA, and incobotulinumtoxinA are comparable in terms of clinical efficacy. Differences between the products relate to the botulinum neurotoxin complexes, specific biological potency, and their immunogenicity. Protein complex size and molecular weight have no effect on biological activity, stability, distribution, or side effect profile. Complexing proteins and inactive toxin (toxoid) content increase the risk of neutralizing antibody formation, which can cause secondary treatment failure, particularly in chronic disorders that require frequent injections and long-term treatment. These attributes could lead to differences in therapeutic outcomes, and, given the widespread aesthetic use of these three neurotoxin products, physicians should be aware of how they differ to ensure their safe and effective use.
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Affiliation(s)
- Jürgen Frevert
- Head of Botulinum Toxin Research, Merz Pharmaceuticals GmbH, Hermannswerder 15, 14473, Potsdam, Germany,
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13
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Abstract
BACKGROUND The introduction of neuromodulators for aesthetic facial improvements greatly expanded the limits of nonsurgical facial rejuvenation. Although many current uses are considered "off-label," the widespread acceptance and favorable safety profile of properly used botulinum toxins have made them one of the most common aesthetic treatments available. METHODS A literature review of current facial aesthetic uses of various botulinum toxin preparations was done, and general concepts were identified. RESULTS Currently, Food and Drug Administration-approved botulinum toxin preparations onabotulinumtoxinA (Botox), abobotulinumtoxinA (Dysport), and incobotulinumtoxinA (Xeomin) have similar off-label indications and clinical uses. CONCLUSIONS Although not considered interchangeable, administration and clinical outcomes are not much different between the 3 commonly used botulinum products. The impact of botulinum products currently in development has yet to be determined.
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14
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Comparison of OnabotulinumtoxinA and RimabotulinumtoxinB for the Treatment of Axillary Hyperhidrosis. Dermatol Surg 2015. [DOI: 10.1097/dss.0000000000000429] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Torres S, Hamilton M, Sanches E, Starovatova P, Gubanova E, Reshetnikova T. Neutralizing antibodies to botulinum neurotoxin type A in aesthetic medicine: five case reports. Clin Cosmet Investig Dermatol 2013; 7:11-7. [PMID: 24379687 PMCID: PMC3872090 DOI: 10.2147/ccid.s51938] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Botulinum neurotoxin injections are a valuable treatment modality for many therapeutic indications as well as in the aesthetic field for facial rejuvenation. As successful treatment requires repeated injections over a long period of time, secondary resistance to botulinum toxin preparations after repeated injections is an ongoing concern. We report five case studies in which neutralizing antibodies to botulinum toxin type A developed after injection for aesthetic use and resulted in secondary treatment failure. These results add to the growing number of reports in the literature for secondary treatment failure associated with high titers of neutralizing antibodies in the aesthetic field. Clinicians should be aware of this risk and implement injection protocols that minimize resistance development.
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Affiliation(s)
| | | | - Elena Sanches
- EKLAN Co Ltd Medical Center for Aesthetic Correction, Moscow, Russia
| | | | | | - Tatiana Reshetnikova
- Department of Dermatovenereology and Cosmetology, State Medical University, Novosibirsk, Russia
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16
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ARTEMENKO AR, SAIBEL AV, NIKITIN SS, KURENKOV AL. A comparative, prospective, split-face, blind study of the efficacy of two botulinum toxin type A drugs (Disport® and Xeomin®) used to correct lateral periorbital wrinkles. VESTNIK DERMATOLOGII I VENEROLOGII 2013. [DOI: 10.25208/vdv639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
A prospective- blind- split-face- comparative study with evaluation of clinical efficacy- tolerability- and safety parameters of two botulinum toxin A (BTA) products (the one containing complexing proteins — Disport®- Ipsen- France/ abobotulinumtoxinA and the one free from complexing proteins — Xeomin®- Merz Pharma- Germany/incobotulinumtoxinA) used for correction of lateral periorbital wrinkles (crow's feet) was performed (at that- electromyographic evaluation of changes in functions of the orbicular muscle of eye was performed for the first time). Materials and Methods. Single injections of both BTA products with equal dose ratio of 3:1 (27 IU Disport® and 9 IU Xeomin®) were performed simultaneously to the right and left side half of the face (orbicular muscles of eye)- respectively- to each of 20 volunteers (women at the age of 40.9) with marked and moderate lateral periorbital wrinkles (2—3 degree according to 4-point Facial Wrinkle Scale/FWS). Clinical and electromyographic assessment was performed 2 weeks- 4 and 6 months after injections. Results. The effect of single dosing of Disport® and Xeomin® did not significantly differ at all assessment time points: both for primary efficacy criterion and for all secondary efficacy criteria; as well as for clinical evaluation by the investigator-subjects’ self-evaluation- and dynamics of M-response parameters for the orbicular muscle of eye. Good tolerability and safety were registered. Conclusion. Study results provided convincing evidence that Disport® and Xeomin® used in accordance with the proposed protocol had a comparable effect and duration of the effect on lateral periotbital wrinkles and the orbicular muscle of eye.
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17
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Imhof M, Podda M, Sommer B. S1 guideline aesthetic botulinum toxin therapy. J Dtsch Dermatol Ges 2013; 11:e1-13. [DOI: 10.1111/ddg.12195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Matthias Imhof
- Aesthetic Dermatology Department, Medico Palais Bad Soden; Parkstraße 6 65812 Bad Soden Germany
| | - Maurizio Podda
- Department of Dermatology, Municipal Clinic of Darmstadt; Heidelberger Landstrafle 379 64297 Darmstadt Germany
| | - Boris Sommer
- Sommerclinics, Goethestraße; 26-28 60313 Frankfurt/Main Germany
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18
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Lee SK. Multiple intradermal small bolus injection of botulinum toxin: the limit and the potentiality. J COSMET LASER THER 2013; 14:304-6. [PMID: 23057657 DOI: 10.3109/14764172.2012.738914] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Since the first introduction of botulinum toxin in cosmetic surgery, techniques and indications using botulinum toxin, mainly intramuscularly, have expanded greatly. Some of cosmetic surgeons are trying to inject the toxin intradermally and, anecdotally or through clinical studies, they sometimes show positive cosmetic results. The mechanism of which is unclear but we should not always belittle the results of this technique. Also there are lots of confusing terms for this intradermal technique, so I propose a new descriptive term "multiple intradermal small bolus injection of botulinum toxin (MISBIB)". In this article, I reviewed important papers on this topic including my own experiences and summarized possible mechanism of action and, finally, discussed the limitations and potential of MISBIB.
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19
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Prager W. Differential characteristics of incobotulinumtoxinA and its use in the management of glabellar frown lines. Clin Pharmacol 2013; 5:39-52. [PMID: 23516136 PMCID: PMC3600936 DOI: 10.2147/cpaa.s37582] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
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.
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Carruthers A, Kane MAC, Flynn TC, Huang P, Kim SD, Solish N, Kaeuper G. The Convergence of Medicine and Neurotoxins: A Focus on Botulinum Toxin Type A and Its Application in Aesthetic Medicine—A Global, Evidence-Based Botulinum Toxin Consensus Education Initiative. Dermatol Surg 2013; 39:493-509. [DOI: 10.1111/dsu.12147] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lee DH, Jin SP, Cho S, Feneran A, Youn CS, Won CH, Park GH, Kim BW, An J, Chang SE, Lee MW. RimabotulinumtoxinB versus OnabotulinumtoxinA in the Treatment of Masseter Hypertrophy: A 24-Week Double-Blind Randomized Split-Face Study. Dermatology 2013; 226:227-32. [DOI: 10.1159/000349984] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 02/13/2013] [Indexed: 11/19/2022] Open
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Lee D, Kang S, Feneran A, Youn C, Kim J, Cho S, Won C, Chang S, Lee M, Choi J, Moon K. RimabotulinumtoxinB vs. onabotulinumtoxinA for the treatment of forehead lines: an evaluator-blind, randomized, pilot study. J Eur Acad Dermatol Venereol 2012; 27:e1-7. [DOI: 10.1111/j.1468-3083.2012.04681.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Botulinum neurotoxin A: a review. J Plast Reconstr Aesthet Surg 2012; 65:1283-91. [PMID: 22552262 DOI: 10.1016/j.bjps.2012.04.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 01/27/2012] [Accepted: 04/09/2012] [Indexed: 11/24/2022]
Abstract
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.
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Sattler G. What does the future hold for botulinum neuromodulators in facial aesthetics? J Eur Acad Dermatol Venereol 2012; 26:394-5. [DOI: 10.1111/j.1468-3083.2011.04064.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Stengel G, Bee EK. Antibody-induced secondary treatment failure in a patient treated with botulinum toxin type A for glabellar frown lines. Clin Interv Aging 2011; 6:281-4. [PMID: 22162643 PMCID: PMC3230581 DOI: 10.2147/cia.s18997] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Botulinum toxin type A (BTX-A) preparations are widely used nonsurgical treatments for facial wrinkles. Higher doses of BTX-A are also used for therapeutic purposes in the treatment of conditions involving increased muscle tone, such as cervical dystonia. The phenomenon of antibody-induced treatment failure is well known in the therapeutic setting, but reports are also emerging following cosmetic use of BTX-A. We describe the case of a 41-year-old female nurse who developed secondary treatment failure during 6 years of BTX-A treatment for glabellar lines. After a good response to the first BTX-A injection, the intensity and duration of effect decreased after subsequent treatments. Antibody tests revealed a high titer of neutralizing anti-BTX-A antibodies. This case shows secondary treatment failure due to the production of neutralizing antibodies following administration of BTX-A formulations for cosmetic purposes and demonstrates that immunogenicity of BTX-A preparations is an important consideration, even in the cosmetic setting.
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Cartee TV, Monheit GD. An Overview of Botulinum Toxins: Past, Present, and Future. Clin Plast Surg 2011; 38:409-26, vi. [DOI: 10.1016/j.cps.2011.03.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
Since its initial approval by the US Food and Drug Administration (FDA) 20 years ago for the treatment of strabismus, hemifacial spasm, and blepharospasm in adults, botulinum toxin (BTX) has become one of the most frequently requested products in cosmetic rejuvenation around the world. After years of clinical success and consistent safety in the upper face, the use of BTX has expanded and evolved to include increasingly complicated indications. In the hands of adept injectors, the focus has shifted from the treatment of individual dynamic rhytides to shaping, contouring, and sculpting, alone or in combination with other cosmetic procedures, to enhance the aesthetic appearance of the face. Although recent reports have questioned the safety of BTX, 25 years of therapeutic and over 20 years of cosmetic use has demonstrated an impressive record of safety and efficacy when used appropriately by experienced injectors.
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Prager W, Zschocke I, Reich C, Brocatti L, Henning K, Steinkraus V. Beeinflusst die Verdünnung das kosmetische Ergebnis von BoNT/A? Hautarzt 2009; 60:815-20. [DOI: 10.1007/s00105-009-1840-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Chang SP, Tsai HH, Chen WY, Lee WR, Chen PL, Tsai TH. The wrinkles soothing effect on the middle and lower face by intradermal injection of botulinum toxin type A. Int J Dermatol 2008; 47:1287-94. [DOI: 10.1111/j.1365-4632.2008.03895.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jost WH. Efficacy and safety of botulinum neurotoxin type A free of complexing proteins (NT 201) in cervical dystonia and blepharospasm. FUTURE NEUROLOGY 2007. [DOI: 10.2217/14796708.2.5.485] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Botulinum neurotoxin type A (BTX-A) weakens voluntary muscle power and is an effective therapy for focal dystonia, including cervical dystonia (CD) and benign essential blepharospasm (BEB). Antibody formation against BTX-A may lead to failure of treatment. NT 201 (XEOMIN®) is a formulation of pure BTX-A that is free of complexing proteins and therefore may have a reduced immunogenic potential in comparison with other BTX-A preparations. In clinical trials, NT 201 was found to be effective, well-tolerated and at least noninferior to a BTX-A preparation containing complexing proteins in the treatment of CD and BEB. There were no differences between the two therapies in terms of onset of action, duration and waning of effect. Future research is aimed at evaluating the benefits of NT 201.
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Affiliation(s)
- Wolfgang H Jost
- Deutsche Klinik für Diagnostik, Department of Neurology & Clinical Neurophysiology, Aukammallee 33, 65191 Wiesbaden, Germany
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Abstract
Injection of botulinum neurotoxin type A has rapidly become the most common non-surgical cosmetic procedure performed, due to its exceptional safety profile, as well as its ability to rejuvenate and enhance a number of facial areas. There are several marketed botulinum neurotoxin preparations, but products are not interchangeable as each possesses distinctive characteristics that are attributed to the unique toxin purification and manufacturing processes. These differences can emerge in the form of potency, duration of effect and the potential for migration outside targeted tissue, causing unwanted effects. However, although there are established preclinical pharmacologic and therapeutic differences between products, there are few well-controlled clinical comparisons in facial aesthetics. It is important for clinicians using these products to understand these differences as they relate to achieving desired outcomes for patients who seek improved facial aesthetics.
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