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Wan J, Wu R, Kim HJ, Yi KH. Glabellar dynamics decoded to refine precision in botulinum toxin treatment. J Cosmet Dermatol 2024. [PMID: 38641951 DOI: 10.1111/jocd.16340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/20/2024] [Accepted: 04/14/2024] [Indexed: 04/21/2024]
Affiliation(s)
- Jovian Wan
- Asia Pacific Aesthetic Academy, Hong Kong, China
| | - Raymond Wu
- Asia Pacific Aesthetic Academy, Hong Kong, China
| | - Hee-Jin Kim
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, Seoul, Korea
| | - Kyu-Ho Yi
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, Seoul, Korea
- Maylin Clinic (Apgujeong), Seoul, Korea
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Cavallini M, Dell'Avanzato R, Fundarò SP, Urdiales-Gálvez F, Papagni M, Trocchi G, Raichi M, Zazzaron M. Treating Glabellar Lines With Botulinum Toxin: Does Your Patient Need to Frown Steadily? Aesthet Surg J 2024; 44:421-427. [PMID: 38015803 DOI: 10.1093/asj/sjad349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/02/2023] [Accepted: 11/09/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND The variable relationship between the orbicularis supercilii and frontalis muscles may cause side effects with botulin toxin; steadily frowning is the usual recommendation. Eliminating the need to frown until all injections are over might enhance efficacy and lessen the neurotoxicity risks related to muscle exhaustion. OBJECTIVES The goal of this study was to investigate whether the digital caliper-assessed distances between the medial and lateral corrugator injection sites and the midline differed significantly in patients persistently frowning from patients resting. METHODS Seventy-six individuals with glabellar wrinkles treated with botulinum toxin in the authors' private practices for glabellar lines voluntarily contributed their retrospective data about the positions of injection sites. The investigators had freely chosen to inject the medial and lateral sections of the corrugator supercilii during persistent maximum frown or at rest. RESULTS The mean differences in distances between the medial and lateral injection points and the estimated midline were clinically trivial (1.0 ± 1.28 and 1.5 ± 2.53 mm, respectively), although the distances between the relaxed and contracted medial and lateral injection sites exceeded 1.8 and 2.5 mm in 33.9% and 46.4% of patients, respectively. Distance differences, not significant before 40 years old, were statistically significant only for the lateral injections in older patients (on average, 1.9 ± 3.01 mm). CONCLUSIONS The average distances from the medial and lateral injection points and the midline appear minimally different in patients who frown until all injections are over and, conversely, patients who rest. Persistently frowning might be advisable only in patients older than 40. Facial asymmetries may be a confounding factor. LEVEL OF EVIDENCE: 4
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Bertucci V, Huang C. Neuromodulator Assessment and Treatment for the Upper Face: An Update. Dermatol Clin 2024; 42:51-62. [PMID: 37977684 DOI: 10.1016/j.det.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
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.
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Affiliation(s)
- Vince Bertucci
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Private Practice, 100-8333 Weston Road, Woodbridge, Ontario L4L 8E2, Canada.
| | - Christina Huang
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Bertucci V, Carruthers JD, Sherman DD, Gallagher CJ, Brown J. Integrative Assessment for Optimizing Aesthetic Outcomes When Treating Glabellar Lines With Botulinum Toxin Type A: An Appreciation of the Role of the Frontalis. Aesthet Surg J 2023; 43:S19-S31. [PMID: 36322138 PMCID: PMC10638666 DOI: 10.1093/asj/sjac267] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
Despite the perception that treatment of glabellar lines with botulinum toxin A is straightforward, the reality is that the glabellar region contains a number of interrelated muscles. To avoid adverse outcomes, practitioners need to appreciate how treatment of 1 facial muscle group influences the relative dominance of others. In particular, practitioners need to understand the independent role of the frontalis in eyebrow outcomes and the potential for negative outcomes if the lower frontalis is unintentionally weakened by botulinum toxin A treatment. In addition, practitioners must recognize how inter-individual variation in the depth, shape, and muscle fiber orientation among the upper facial muscles can affect outcomes. For optimal results, treatment of the glabellar complex requires a systematic and individualized approach based on anatomical principles of opposing muscle actions rather than a one-size-fits-all approach. This review provides the anatomical justification for the importance of an integrated assessment of the upper facial muscles and eyebrow position prior to glabellar treatment. In addition, a systematic and broad evaluation system is provided that can be employed by practitioners to more comprehensively assess the glabellar region in order to optimize outcomes and avoid negatively impacting resting brow position and dynamic brow movement. LEVEL OF EVIDENCE: 5
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Affiliation(s)
| | | | | | | | - Jessica Brown
- Corresponding Author: Dr Jessica Brown, Medical Affairs, Revance Therapeutics, Inc., 1222 Demonbreun St, Nashville, TN, 37203, USA. E-mail:
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Liu S, Cong L, Pongprutthipan M, Lee W, Luo X, Han X, Li D, Moon HJ, Wang H. Use of LetibotulinumtoxinA for Aesthetic Treatment of Asians: A Consensus. Aesthet Surg J 2023; 43:NP962-NP974. [PMID: 37220644 PMCID: PMC10575620 DOI: 10.1093/asj/sjad151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/03/2023] [Accepted: 05/22/2023] [Indexed: 05/25/2023] Open
Abstract
Treatment of wrinkles and dynamic lines with botulinum toxin has been a routine practice for years in aesthetic clinical settings. The effective treatment of wrinkles requires a comprehensive understanding of facial expression muscles and their interactions, the mechanism of action of botulinum toxin, and individual patient preferences. The dose adjustment practice and injection technique of physicians are affected by cultural differences; most Asian patients prefer natural-looking results. This article aims to present an expert consensus on the injection sites, doses, and levels of botulinum toxin for various indications in Asians, with the hope of providing guidance to some clinicians. This consensus paper reviews LetibotulinumtoxinA for patient evaluation, dosage, and delivery techniques in Asians from the time LetibotulinumtoxinA was approved up to December 2022. Panelists proposed individualized treatment plans for botulinum toxin type A (BTxA) treatments in 3 areas-wrinkle removal, contour adjustment, and face lifting-for Asians based on their extensive experience and knowledge of facial anatomy. When using a different BTxA, clinicians should start with a conservative dose and carefully individualize the treatment for each patient, and adjust it according to feedback to obtain a higher satisfaction level. LEVEL OF EVIDENCE: 5
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Affiliation(s)
| | | | | | | | | | | | | | | | - Hang Wang
- Corresponding Author: Dr Hang Wang, Sichuan University, West China Coll Stomatol, Dept Oral & Maxillofacial Surg, Chengdu 610041, Peoples R China. E-mail: ; Twitter and Instagram: @plasticsurgeonhang
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Braccini F, Catoni I, Belfkira F, Lagier J, Roze E, Paris J, Huth J, Bronsard V, Cartier H, David M, Galatoire O, Obadia D, Sabatier H, Sarfati E, Kestemont P, Winter C, Redaelli A. SAMCEP Society consensus on the treatment of upper facial lines with botulinum neurotoxin type A: A tailored approach. J Cosmet Dermatol 2023; 22:2692-2704. [PMID: 37408173 DOI: 10.1111/jocd.15768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/06/2023] [Accepted: 03/29/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND The safety and efficacy of botulinum neurotoxin type A (BoNTA) treatments are well established, but injection techniques, target muscles, and toxin doses continue to evolve, with each refinement producing improvements in treatment outcomes. The recommendations in this consensus move away from standard templates and illustrate how to tailor treatments to individual patterns and strengths of muscle activity, and patient preferences. METHODS Seventeen experts in the fields of plastic surgery, dermatology, ophthalmology, otorhinolaryngology, and neurology convened in 2022 to develop consensus-based recommendations for the use of botulinum toxin A for the treatment of horizontal forehead lines, glabellar frown lines, and crow's feet lines that reflect current clinical practice. The focus was on how to tailor injections to individual patients to optimize treatment outcomes. RESULTS For each upper face indication, consensus members describe how to perform a dynamic assessment to optimize the dose and injection technique for each patient. A tailored treatment protocol is presented for commonly observed patterns of dynamic lines. Units of Inco are defined and the precise location of injection points, illustrated with the use of anatomical images. CONCLUSION This consensus provides up-to-date recommendations on the tailored treatment of upper facial lines based on the latest research and collective clinical experience of the expert injectors. Optimal outcomes require thorough patient evaluation, both at rest and during animation, using both visual and tactile cues; detailed understanding of facial muscular anatomy and how opposing muscles interact; and use of a BoNTA with high precision to target identified zones of excess muscle activity.
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Affiliation(s)
| | - I Catoni
- Private clinic, Neuilly-sur-Seine, France
| | | | - J Lagier
- Neurology hospital center, Paris, France
| | - E Roze
- Private clinic, Marseille, France
| | - J Paris
- Private clinic, Marseille, France
| | - J Huth
- Private clinic, Perigueux, France
| | | | | | - M David
- Private clinic, Metz, France
| | | | - D Obadia
- Neurology hospital center, Paris, France
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Anatomical Injection Guidelines for Glabellar Frown Lines Based on Ultrasonographic Evaluation. Toxins (Basel) 2021; 14:toxins14010017. [PMID: 35050994 PMCID: PMC8778322 DOI: 10.3390/toxins14010017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/16/2021] [Accepted: 12/23/2021] [Indexed: 11/23/2022] Open
Abstract
When botulinum neurotoxin (BoNT) is injected to treat glabellar frown lines, the corrugator supercilia muscle (CSM) and procerus muscles are the main targets. Although there have been many studies on the treatment of glabellar frown lines, no study has confirmed the dynamic movement under ultrasonography (US). This study examined and evaluated dynamic muscle movements under US, thereby providing more effective BoNT injection guidelines for glabellar frowning. Glabellar frowning was categorized as either Type A or B. Type A is the general frowning pattern in which vertical wrinkles are made by contracting the CSM and procerus muscles (81%, n = 13). On US images, the procerus muscle thickens and the bilateral CSMs contract. Type B is an upward frowning pattern demonstrating upward elevation of vertical wrinkles due to hyperactive contraction of the frontalis muscle during frowning (19%, n = 3). On US images, the hypoechoic frontalis muscle thickens, forming horizontal forehead lines. After BoNT injection into the CSM and frontalis muscle but not the procerus muscle, Type B patterns showed improvements in the vertical crease and horizontal forehead line. Both types showed improvement in glabellar frown lines after conventional injection, but the horizontal forehead line did not improve in Type B. Type B wrinkles improved after additional injections into the frontalis muscle. This study provided novel anatomical findings related to the injection of glabellar frown lines with BoNT. Preliminary analysis and optimized procedures using US will enable more effective and safer injections.
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Compare and contrast the various types of botulinum toxin on the market. 2. Appropriately select patients for treatment with cosmetic botulinum toxin. 3. Understand the common injection patterns for treating various regions of the face with cosmetic botulinum toxin. 4. List the complications associated with treating various regions of the face with cosmetic botulinum toxin. SUMMARY Nonsurgical rejuvenation of the face with botulinum toxin is one of the most commonly performed procedures in the United States. This article reviews the current evidence in treating different regions of the face: upper face, lower face, masseter, and platysma. Dosing and complications associated with different facial regions are reviewed.
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Neuromodulating the SMAS for Natural Dynamic Results. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3755. [PMID: 34476153 PMCID: PMC8386905 DOI: 10.1097/gox.0000000000003755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/21/2021] [Indexed: 11/26/2022]
Abstract
Physicians using neuromodulators need to develop an in-depth and holistic understanding of the facial musculature as a single, large, functional structure that does not work in isolation. In this Special Topic, I review the anatomy of the continuous fibromuscular layer of the face, discuss how certain age-related indications develop as a consequence of imbalances to this unified structure, and propose considerations for neuromodulator-based interventions of the upper, mid, and lower face. I provide evidence-supported recommendations on the most optimal applications of neuromodulators to help rebalance the musculoaponeurotic layer for more natural outcomes. Through outcomes of my patients, I show how the facial mimetic muscles can be modulated with careful placement of botulinum toxin, without causing unnatural facial expressions, to achieve an expressive, well-balanced face that reflects health, vitality and happiness.
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de Sanctis Pecora C, Pinheiro MVB, Ventura Ferreira K, Jacobino de Barros Nunes G, Miot HA. The One21 Technique: An Individualized Treatment for Glabellar Lines Based on Clinical and Anatomical Landmarks. Clin Cosmet Investig Dermatol 2021; 14:97-105. [PMID: 33564254 PMCID: PMC7866909 DOI: 10.2147/ccid.s281901] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/08/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE Botulinum toxin type A is an effective treatment for glabellar dynamic wrinkles. As the muscular group involved in the contraction of the glabella varies among people, individualized treatment can achieve optimal results. This study evaluates a customized assessment for the treatment of glabellar lines with Incobotulinumtoxin-A, leading to an individualized points distribution and dosage. PATIENTS AND METHODS A single-center, evaluator-blinded, therapeutic cohort study enrolled 130 women with moderate or severe glabellar wrinkles. They underwent Incobotulinumtoxin-A injection following the standard 5-point injection at the glabellar muscles (n = 65) or an individualized assessment and scheme treatment based on anatomical references of contraction, the One21 technique (n = 65). All the patients were photographed under maximum contraction before treatment (T0) and after 4 weeks (T28). The photos were randomly assessed by two blinded, experienced raters to consensually grade the severity according to the Merz Aesthetics Scales (MAS). The primary clinical efficacy was defined as a 2-point reduction in the MAS score, on Day 28. RESULTS The groups were homogeneous regarding age, phototype, and baseline MAS scores. On Day 28 (T28), 64 (98.5%) patients from the One21 group and 52 (80%) from the 5-point group reduced the MAS score by at least two points (p < 0.01). When adjusted by age and phototype, both groups reduced the MAS score at T28 (p < 0.01); nevertheless, patients from the One21 group significantly performed better (p < 0.01), with a much higher rate response rate at T28, in comparison to the 5-point group. Of patients enrolled in the 5-point group, 83.1% utilized muscle groups other than the procerus and corrugator in glabellar wrinkle formation, and 17 (24.6%) presented asymmetrical contraction. Patients from the 5-point group with glabellar asymmetry and those who utilized the frontalis and orbicularis presented inferior performance (p < 0.05), reinforcing the importance of an individualized assessment and treatment plan. CONCLUSION The One21 technique yielded better results than the standard 5-point treatment in reducing glabellar dynamic lines with Incobotulinumtoxin-A, especially for asymmetric lines of the glabella or the involvement of muscle groups other than the procerus and corrugator.
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Landau M, Nestor MS, Almeida AT, Al‐Niaimi F. Botulinum toxin complications in registered and off‐label aesthetic indications. J Cosmet Dermatol 2020; 19:2484-2490. [DOI: 10.1111/jocd.13667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Mark S. Nestor
- Center for Clinical and Cosmetic Research Aventura FL USA
- Department of Dermatology and Cutaneous Surgery, Department of Surgery, Division of Plastic and Reconstructive Surgery University of Miami Miller School of Medicine Miami FL USA
| | - Ada Trindade Almeida
- Dermatology Clinic Hospital do Servidor Público Municipal de São Paulo São Paulo Brazil
| | - Firas Al‐Niaimi
- Department of Dermatology Aalborg University Hospital Aalborg Denmark
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OnabotulinumtoxinA Treatment for Moderate to Severe Forehead Lines: A Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2669. [PMID: 32537333 PMCID: PMC7253259 DOI: 10.1097/gox.0000000000002669] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/08/2020] [Indexed: 11/25/2022]
Abstract
Background: With onabotulinumtoxinA approved for the treatment of glabellar and crow’s feet lines and, most recently, for forehead lines (FHL), it is possible to simultaneously treat multiple areas of the upper face that are of high concern and treatment priority for aesthetically oriented individuals. This review aims to present key insights on the use of onabotulinumtoxinA for the treatment of moderate to severe FHL. Methods: Double-blind, placebo-controlled registration trials of onabotulinumtoxinA for the treatment of FHL were included. Using findings from 3 such published studies, we discuss key concepts and clinical experience for the treatment of moderate to severe FHL with onabotulinumtoxinA (20 U in the frontalis and 20 U in the glabellar complex, with/without 24 U in crow’s feet lines), including injection pattern, dose selection, efficacy and safety data, and considerations for patient selection. Results: Across the 2 pivotal phase 3 studies, responder rates on investigator- and subject-assessed measures of appearance of FHL severity were significantly higher with onabotulinumtoxinA versus placebo for the treatment of FHL at day 30 (P < 0.0001), and results were maintained through 3 cycles of onabotulinumtoxinA. Conclusions: OnabotulinumtoxinA treatment also resulted in high patient satisfaction rates. The incidence of eyebrow and of eyelid ptosis was low, and no new safety signals were detected. OnabotulinumtoxinA is safe and effective and an appropriate option for patients with moderate to severe FHL encountered in clinical practice.
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OnabotulinumtoxinA for the treatment of major depressive disorder: a phase 2 randomized, double-blind, placebo-controlled trial in adult females. Int Clin Psychopharmacol 2020; 35:19-28. [PMID: 31609787 PMCID: PMC6903360 DOI: 10.1097/yic.0000000000000290] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This 24-week double-blind placebo-controlled multicenter randomized phase 2 trial evaluated efficacy and safety of onabotulinumtoxinA (onabotA; BOTOX) vs. placebo for major depressive disorder (MDD) [NCT02116361]. Primary endpoint was the change in Montgomery-Åsberg Depression Rating Scale (MADRS); secondary endpoints were Clinical Global Impressions-Severity and 17-item Hamilton Depression Rating Scale at week 6. A total of 255 adult females were treated. OnabotA 30 U approached significance compared to placebo on MADRS (mixed-effect model repeated measures least-squares mean difference: -3.7; P = 0.053) and reached significance [least-squares mean differences: -3.6 to -4.2; P < 0.05 (two-sided)] at weeks 3 and 9. Secondary endpoints were also significant at several time points. At week 6, onabotA 50 U did not separate from placebo in any parameters. OnabotA was generally well-tolerated: the only treatment-emergent adverse events reported in ≥5% in either onabotA group, and more than matching placebo were headache, upper respiratory infection, and eyelid ptosis. OnabotA 30 U, administered in a standardized injection pattern in a single session, had a consistent efficacy signal across multiple depression symptom scales for 12 or more weeks. OnabotA 30 U/placebo MADRS differences of (observed ANCOVA) ≥4.0 points (up to week 15) and ≥2.0 points (weeks 18-24) agree with the 2-point change threshold considered clinically relevant in MDD. OnabotA is a local therapy and is not commonly associated with systemic effects of conventional antidepressants and may represent a novel treatment option for MDD.
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Beylot C. Vieillissement cutané – Vieillissement facial global : orientation thérapeutique. Ann Dermatol Venereol 2019; 146:41-74. [DOI: 10.1016/j.annder.2018.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Casabona G, Kaye K, Barreto Marchese P, Boggio R, Cotofana S. Six years of experience using an advanced algorithm for botulinum toxin application. J Cosmet Dermatol 2018; 18:21-35. [DOI: 10.1111/jocd.12815] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 08/17/2018] [Accepted: 10/02/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | - Kai Kaye
- Ocean Clinic Marbella Málaga Spain
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Assessment of Subject and Physician Satisfaction after Long-Term Treatment of Glabellar Lines with AbobotulinumtoxinA (Dysport ®/Azzalure ®): Primary Results of the APPEAL Noninterventional Study. Aesthetic Plast Surg 2018; 42:1672-1680. [PMID: 30120518 PMCID: PMC6280832 DOI: 10.1007/s00266-018-1200-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 07/15/2018] [Indexed: 11/30/2022]
Abstract
Background Although the short- and long-term effectiveness of abobotulinumtoxinA (Dysport®/Azzalure®) for glabellar line (GL) treatment is well established, reporting of subject satisfaction over repeat treatment cycles is limited. The APPEAL study aimed to assess subject satisfaction with long-term GL treatment with abobotulinumtoxinA in a real-life setting.
Methods APPEAL was a noninterventional, prospective, longitudinal study in subjects administered ≥ 3 abobotulinumtoxinA injection cycles for moderate-to-severe GL, according to routine clinical practice. Subjects completed a satisfaction questionnaire at 3 weeks (± 7 days) after each cycle. Primary endpoint included subjects’ overall satisfaction with GL after three injection cycles. Secondary endpoints included satisfaction after Cycles 1 and 2 and factors associated with satisfaction after each cycle. Physician satisfaction was also assessed after Cycles 1 and 3.
Results Of 150 subjects enrolled, 135 completed the overall subject satisfaction questionnaire after Cycle 3. At 3 weeks after Cycle 3, 99.3% of subjects were ‘very satisfied’ (74.1%) or ‘satisfied’ (25.2%) with GL. Levels of subject satisfaction and associated factors after Cycles 1 and 2 were as large and significant as after Cycle 3 (83–100%, depending on question). Physicians’ satisfaction with GL appearance, facial expression, and overall satisfaction was almost complete after the first injection (≥ 97.4%) and unanimous after the third (100%).
Conclusions In the APPEAL study, overall satisfaction was high after three abobotulinumtoxinA injection cycles for GL based on both subjects’ (99.3%) and physicians’ (100.0%) assessments. High levels of subject satisfaction reported after Cycle 1 were maintained with repeated injections. No new safety signals were observed. 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. Trial registration NCT02353897 Electronic supplementary material The online version of this article (10.1007/s00266-018-1200-4) contains supplementary material, which is available to authorized users.
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Abramo AC. Muscle Insertion and Strength of the Muscle Contraction as Guidelines to Enhance Duration of the Botulinum Toxin Effect in the Upper Face. Aesthetic Plast Surg 2018; 42:1379-1387. [PMID: 29987485 DOI: 10.1007/s00266-018-1157-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 05/12/2018] [Indexed: 11/29/2022]
Abstract
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 .
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Affiliation(s)
- Antonio Carlos Abramo
- Post-Graduate Course of Plastic Surgery of the Institute of Assistance in Plastic Surgery of São Paulo, Endorsed by the Brazilian Society of Plastic Surgery and Brazilian Medical Association, General Hospital São Luiz - Jabaquara, Rua Afonso de Freitas, 641, São Paulo, SP, 04006-052, Brazil.
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Wu Y, Lu Z, Xie Y, Zhang W, Chen X, Shi Y, Li Q, Halstead M, Rogers JD, Silberberg M. OnabotulinumtoxinA treatment of moderate to severe glabellar lines in Chinese subjects after laser therapy: A prospective, open-label, noncomparative study. J COSMET LASER THER 2018; 20:278-286. [PMID: 29498553 DOI: 10.1080/14764172.2017.1406604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION This study evaluated safety and efficacy of onabotulinumtoxinA for moderate to severe glabellar lines (GL) following laser therapy in Chinese subjects. MATERIALS AND METHODS Subjects (n = 173) were followed for 120 days following a single onabotulinumtoxinA (20 U) treatment for GL after recent laser therapy. Subjects completed validated patient-reported outcomes, including Facial Lines Outcome 11-item (FLO-11) Questionnaire and Facial Lines Satisfaction Questionnaire (FLSQ). Physicians and subjects assessed GL severity at maximum frown and at rest using the Facial Wrinkle Scale with Asian Photonumeric Guide (FWS-A). RESULTS Mean total FLO-11 scores increased from 47.7 (baseline) to 75.9 (day 120) (p < 0.0001), with mean improvement of at least two grades for most items maintained to day 120. Most subjects were mostly or very satisfied, per the FLSQ. Percentages of subjects with at least one-grade improvement in FWS-A (responders) at maximum frown per subjects and physicians were 93.1% and 97.1%, respectively, at day 30, and 72.3% and 81.5% at day 120 (all, p < 0.0001). More than 70% were FWS-A responders at day 120. All adverse events were mild or moderate; none were related to onabotulinumtoxinA. CONCLUSIONS A single onabotulinumtoxinA (20 U) treatment following laser therapy was safe and effective in correcting GL for up to 120 days.
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Affiliation(s)
- Yan Wu
- a Department of Dermatology, Peking University First Hospital , Beijing , China
| | - Zhong Lu
- b Department of Dermatology, Huashan Hospital , Shanghai , China
| | - Yong Xie
- c Department of Dermatology , Peking Union Medical College Hospital , Beijing , China
| | - Wei Zhang
- d Medical Beauty Center, Shanghai Dermatology Hospital , Shanghai , China
| | - Xiangdong Chen
- e Dermatological Department , Shanghai Ninth People's Hospital , Shanghai , China
| | - Yuling Shi
- f Department of Dermatology , Shanghai Tenth People's Hospital, Tongji University School of Medicine , Shanghai , China
| | - Qin Li
- g Department of Plastic Surgery and Laser Center, General Hospital of Guangzhou Military Command of PLA , Guang Dong Province , China
| | | | - John D Rogers
- i Division of Global Medical Affairs , Galderma , Uppsala , Sweden
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Neurophysiological Measures of Efficacy and Safety for Botulinum Toxin Injection in Facial and Bulbar Muscles: Special Considerations. Toxins (Basel) 2017; 9:toxins9110352. [PMID: 29084148 PMCID: PMC5705967 DOI: 10.3390/toxins9110352] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 10/16/2017] [Accepted: 10/27/2017] [Indexed: 12/27/2022] Open
Abstract
Botulinum toxin (BoNT) injections into facial and bulbar muscles are widely and increasingly used as medical treatments for cervical and facial dystonia, facial hemispasm, correction of facial palsy, hyperhidrosis, as well as cosmetic treatment of glabellar lines associated with grief and anger. Although BoNT treatment is generally considered safe, the diffusion of the toxin to surrounding muscles may result in complications, including difficulties swallowing, in a dose-dependent manner. The sensitivity of clinical examination for detecting adverse events after BoNT treatment is limited. Few reports have highlighted the potential effects on other muscles in the facial area due to the spreading of the toxin. The possibilities of spreading and thus unknown pharmacological BoNT effects in non-targeted muscles emphasise the importance of correct administration of BoNT in terms of dose selection, injection points, and appropriate effect surveillance. In this review article, we will focus on novel objective measures of efficacy and safety regarding BoNT treatment of facial muscles and the reasons why this is important.
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Anido J, Arenas D, Arruabarrena C, Domínguez-Gil A, Fajardo C, Mira M, Murillo J, Ribé N, Rivera H, Ruiz Del Cueto S, Silvestre H, Tirado M. Tailored botulinum toxin type A injections in aesthetic medicine: consensus panel recommendations for treating the forehead based on individual facial anatomy and muscle tone. Clin Cosmet Investig Dermatol 2017; 10:413-421. [PMID: 29089780 PMCID: PMC5655032 DOI: 10.2147/ccid.s138274] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Facial lines and wrinkles are strongly influenced by individual differences in anatomy and muscle activity and no single injection protocol will suit all patients. However, there is only limited information in the published literature on how to develop a tailored approach to botulinum toxin treatment. METHODS An expert panel of physicians was convened to establish a consensus on developing an individualized approach to treatment of the forehead with incobotulinumtoxinA. Separate treatment protocols were developed for men and women and subdivided by background level of muscle activity: kinetic, hyperkinetic, and hypertonic. Each muscle tone category was then further subdivided to take account of individual characteristics that can influence treatment. RESULTS Consensus members describe how to perform a dynamic assessment to optimize the dose and injection technique for each patient. A tailored treatment protocol is described for men and women with a wide range of forehead presentations. For each presentation, units of toxin as well as the precise location of injection points were defined by creating a 12-zone map of the forehead. CONCLUSION These recommendations depart from traditional consensus documents by providing detailed incobotulinumtoxinA injection protocols for the forehead based on the major parameters that differ between patients, including muscular anatomy, size, and tone. It is expected that the use of this document will lead to more satisfactory, natural, and individualized aesthetic outcomes for patients.
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Abstract
BACKGROUND The platysma is a superficial muscle involved in important features of the aging neck. Vertical bands, horizontal lines, and loss of lower face contour are effectively treated with botulinum toxin A (BoNT-A). However, its pars facialis, mandibularis, and modiolaris have been underappreciated. OBJECTIVE To demonstrate the role of BoNT-A treatment of the upper platysma and its impact on lower face dynamics and contour. MATERIAL AND METHODS Retrospective analysis of cases treated by an injection pattern encompassing the facial platysma components, aiming to block the lower face as a whole complex. It consisted of 2 intramuscular injections into the mentalis muscle and 2 horizontal lines of BoNT-A injections superficially performed above and below the mandible (total dose, 16 onabotulinumtoxinA U/side). Photographs were taken at rest and during motion (frontal and oblique views), before and after treatment. RESULTS A total of 161 patients have been treated in the last 2 years with the following results: frontal and lateral enhancement of lower facial contour, relaxation of high horizontal lines located just below the lateral mandibular border, and lower deep vertical smile lines present lateral to the oral commissures and melomental folds. CONCLUSION The upper platysma muscle plays a relevant role in the functional anatomy of the lower face that can be modulated safely with neuromodulators.
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Different Glabellar Contraction Patterns in Chinese and Efficacy of Botulinum Toxin Type A for Treating Glabellar Lines: A Pilot Study. Dermatol Surg 2017; 43:692-697. [PMID: 28244900 DOI: 10.1097/dss.0000000000001045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Published research studies have described the existence of 5 glabellar contraction patterns. Botulinum toxin A (BoNTA) has been an approved and effective treatment of glabellar lines. OBJECTIVE To study the pattern and frequency of glabellar contraction patterns in the Chinese population. To compare injection patterns and doses of BoNTA in Westerners within China. METHODS Four hundred fifty-six healthy volunteers were randomly recruited. Photographs both in static and in frown state were taken and classified based on the method of 5 glabellar line patterns. The severity of the glabellar lines both at repose and during forced contraction was assessed by the Facial Wrinkle Scale (FWS). Subsequently, 75 of them were treated with BoNTA. RESULTS The frequency of the various glabellar line patterns differs greatly between Chinese and Westerners with the "Converging arrows" pattern being the most common type and the "V" pattern being the least common when compared with the Westerners. Lower doses of BoNTA significantly improved the static and dynamic glabellar lines in the Chinese. CONCLUSION The classification of 5 glabellar patterns is compatible for the Chinese population despite different proportions. The dosage of BoNTA should be less than 20 U during treatment in China with lowered incidence of complications.
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Sundaram H, Liew S, Signorini M, Vieira Braz A, Fagien S, Swift A, De Boulle KL, Raspaldo H, Trindade de Almeida AR, Monheit G. Global Aesthetics Consensus: Hyaluronic Acid Fillers and Botulinum Toxin Type A-Recommendations for Combined Treatment and Optimizing Outcomes in Diverse Patient Populations. Plast Reconstr Surg 2016; 137:1410-1423. [PMID: 27119917 PMCID: PMC5242215 DOI: 10.1097/prs.0000000000002119] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 12/29/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Combination of fillers and botulinum toxin for aesthetic applications is increasingly popular. Patient demographics continue to diversify, and include an expanding population receiving maintenance treatments over decades. METHODS A multinational panel of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated guidelines with a worldwide perspective for hyaluronic acid fillers and botulinum toxin. This publication considers strategies for combined treatments, and how patient diversity influences treatment planning and outcomes. RESULTS Global Aesthetics Consensus Group recommendations reflect increased use of combined treatments in the lower and upper face, and some midface regions. A fully patient-tailored approach considers physiologic and chronologic age, ethnically associated facial morphotypes, and aesthetic ideals based on sex and culture. Lower toxin dosing, to modulate rather than paralyze muscles, is indicated where volume deficits influence muscular activity. Combination of toxin with fillers is appropriate for several indications addressed previously with toxin alone. New scientific data regarding hyaluronic acid fillers foster an evidence-based approach to selection of products and injection techniques. Focus on aesthetic units, rather than isolated rhytides, optimizes results from toxin and fillers. It also informs longitudinal treatment planning, and analysis of toxin nonresponders. CONCLUSIONS The emerging objective of injectable treatment is facial harmonization rather than rejuvenation. Combined treatment is now a standard of care. Its use will increase further as we refine the concept that aspects of aging are intimately related, and that successful treatment entails identifying and addressing the primary causes of each. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Affiliation(s)
- Hema Sundaram
- Rockville, Md.; Sydney, New South Wales, Australia; Milan, Italy; Rio de Janeiro and Sao Paulo, Brazil; Boca Raton, Fla.; Montreal, Quebec, Canada; Aalst, Belgium; Cannes, France; and Birmingham, Ala
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25
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Sundaram H, Signorini M, Liew S, Trindade de Almeida AR, Wu Y, Vieira Braz A, Fagien S, Goodman GJ, Monheit G, Raspaldo H. Global Aesthetics Consensus: Botulinum Toxin Type A--Evidence-Based Review, Emerging Concepts, and Consensus Recommendations for Aesthetic Use, Including Updates on Complications. Plast Reconstr Surg 2016; 137:518e-529e. [PMID: 26910696 PMCID: PMC5242214 DOI: 10.1097/01.prs.0000475758.63709.23] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/21/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Botulinum toxin type A injection remains the leading nonsurgical cosmetic procedure worldwide, with a high rate of efficacy and patient satisfaction. METHODS A multinational, multidisciplinary group of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated consensus recommendations with a worldwide perspective for botulinum toxin and hyaluronic acid fillers. This publication on botulinum toxin type A considers advances in facial analysis, injection techniques, and avoidance and management of complications. RESULTS Use of botulinum toxin has evolved from the upper face to also encompass the lower face, neck, and midface. The Global Aesthetics Consensus Group emphasizes an integrative, diagnostic approach. Injection dosage and placement are based on analysis of target muscles in the context of adjacent ones and associated soft and hard tissues. The indication for selection of botulinum toxin as a primary intervention is that excessive muscular contraction is the primary etiology of the facial disharmony to be addressed. Global Aesthetics Consensus Group recommendations demonstrate a paradigm shift toward neuromodulation rather than paralysis, including lower dosing of the upper face, more frequent combination treatment with hyaluronic acid fillers, and intracutaneous injection where indicated to limit depth and degree of action. CONCLUSIONS The accumulation of clinical evidence and experience with botulinum toxin has led to refinements in treatment planning and implementation. The Global Aesthetics Consensus Group advocates an etiology-driven, patient-tailored approach, to enable achievement of optimal efficacy and safety in patient populations that are rapidly diversifying with respect to ethnicity, gender, and age. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Affiliation(s)
- Hema Sundaram
- Rockville, Md.; Milan, Italy; Sydney, New South Wales, and Carlton, Victoria, Australia; São Paolo and Rio de Janeiro, Brazil; Beijing, China; Boca Raton, Fla.; Seoul, Korea; and Cannes, France
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Diez errores a evitar en la inyección de toxina botulínica. ACTAS DERMO-SIFILIOGRAFICAS 2015; 106:458-64. [DOI: 10.1016/j.ad.2015.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 04/13/2015] [Accepted: 04/13/2015] [Indexed: 11/15/2022] Open
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Ruiz-Rodriguez R, Martin-Gorgojo A. Ten Mistakes To Avoid When Injecting Botulinum Toxin. ACTAS DERMO-SIFILIOGRAFICAS 2015. [DOI: 10.1016/j.adengl.2015.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Won CH, Kim HK, Kim BJ, Kang H, Hong JP, Lee SY, Kim CS. Comparative trial of a novel botulinum neurotoxin type A versus onabotulinumtoxinA in the treatment of glabellar lines: a multicenter, randomized, double-blind, active-controlled study. Int J Dermatol 2014; 54:227-34. [PMID: 25311357 DOI: 10.1111/ijd.12627] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A novel botulinum neurotoxin type A (DWP450; Daewoong Pharmaceutical, Seoul, Korea) has recently been introduced for the treatment of facial wrinkles. The efficacy of this agent has previously been demonstrated in an in vivo study using an electrophysiological protocol in a rat model. To compare the efficacy and safety of DWP450 with onabotulinumtoxinA (OBoNT) for use in the treatment of glabellar lines, we performed a multicenter, double-blind, randomized, active-controlled trial comparing DWP450 and OBoNT (Allergan Inc., Irvine, CA, USA). A total of 268 subjects with moderate to severe glabellar lines were randomized at a 1:1 ratio. Each patient received treatment with 20 U of study medication. Maximum frown responder rates at week 4 were measured to analyze the primary efficacy endpoint. To evaluate secondary efficacy endpoints, response rates were measured at weeks 8, 12, and 16, at maximum frown and rest. Specifically, responder rates at both maximum frown and at rest were assessed based on clinical photography. Subject degree of satisfaction and self-assessed rate of response were also measured. Adverse events (AEs) were documented to evaluate safety. Responder rate by physician-rating severity at maximal contraction at week 4 was 93.89% in the DWP450 group and 88.64% in OBoNT group. As the lower limit of the 97.5% one-sided confidence interval (-1.53%) surpassed the -15% threshold, we determined that DWP450 was not inferior to OBoNT. For the secondary efficacy endpoint analyses, no significant differences were observed between the two groups for any variable at any point in time. The incidences of AEs were similar for the two groups. Most of AEs were considered mild. DWP450 and OBoNT were comparable in efficacy and safety in the treatment of glabellar lines.
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Affiliation(s)
- Chong Hyun Won
- Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
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Luebberding S, Krueger N, Kerscher M. Quantification of age-related facial wrinkles in men and women using a three-dimensional fringe projection method and validated assessment scales. Dermatol Surg 2013; 40:22-32. [PMID: 24267416 DOI: 10.1111/dsu.12377] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Whereas the molecular mechanisms of skin aging are well understood, little information is available concerning the clinical onset and lifetime development of facial wrinkles. OBJECTIVES To perform the first systematic evaluation of the lifetime development of facial wrinkles and sex-specific differences using three-dimensional (3D) imaging and clinical rating. METHODS 200 men and women aged 20 to 70 were selected. Wrinkle severity of periorbital, glabellar, and forehead lines was evaluated using 3D imaging and validated assessment scales. RESULTS Wrinkle severity was greater at all assessed locations with older age. In men, wrinkles manifested earlier and were more severe than in women. In women, periorbital lines were the first visible wrinkles, in contrast to the forehead lines in men. In both sexes, glabellar lines did not clinically manifest before the age of 40. CONCLUSION The results of the present study confirm a progressive increase of crow's feet and forehead and glabellar lines in men and women. Although the development of facial wrinkles happens earlier and is more severe in men, perimenopause seems to particularly affect development in women. Clinical ratings and 3D measurements are suitable methods to assess facial wrinkle severity in men and women.
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Affiliation(s)
- Stefanie Luebberding
- Division of Cosmetic Science, Department of Biochemistry and Molecular Biology, University of Hamburg, Hamburg, Germany
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Kim H, Kim C, Cho H, Hwang J, Kim Y. A study on glabellar wrinkle patterns in Koreans. J Eur Acad Dermatol Venereol 2013; 28:1332-9. [DOI: 10.1111/jdv.12286] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 09/16/2013] [Indexed: 11/27/2022]
Affiliation(s)
- H.S. Kim
- Dermatology; Incheon St. Mary's Hospital; Incheon Korea
| | - C. Kim
- Dermatology; Yedam Skin Clinic; Seoul Korea
| | - H. Cho
- Dermatology; OhKim's Skin & Laser Clinic; Ilsan Korea
| | - J.Y. Hwang
- Dermatology; The H Dermatology; Seoul Korea
| | - Y.S. Kim
- Dermatology; Kimbelle Catholic Skin Clinic; Daejeon Korea
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