Advanced Injection of Botulinum Toxin in the Nasal Muscles: A Novel Dynamic Change in Facial Expression

BACKGROUND

Among the nasal muscles, the levator labii superior alaeque nasi (LLSAN) acts as a transitional muscle that conjugates with other nasal and perinasal muscles. Thus, when treating the nasal region with Botulinum toxin (BTX), it is important to understand local nasal muscular dynamics and how they can influence the muscular dynamics of the entire face.

METHODS

This is a retrospective analysis of cases treated by an injection pattern encompassing the face, including nasal muscles. Photographs were taken at rest and during motion (frontal and oblique views), before and after treatment.

RESULTS

A total of 227 patients have been treated in the last 18 months with the following results: eyebrow tail lifting, softness of crow's feet, improvement of the drooping of the tip of the nose, and shortening of the lip philtrum when smiling. We present cases illustrating the use of this approach.

CONCLUSIONS

Treating the facial muscles globally (including the frontal, corrugators, procerus, orbicularis oculi, platysma, DAO, and nasal muscles) can improve the smile and facial expressions. This is believed to occur because the elevated portion of the upper lip muscle becomes stronger as the nasal part of the LLSAN is paralyzed.

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 .

Mapping the Vascular and Muscular Topography of the Glabellar Region: Implication for Improving Safety and Efficacy of the Glabellar Injections

BACKGROUND

Botulinum neurotoxin (BoNT) and filler injections into the highly vascularized glabellar region for aesthetical purposes are extremely common. Injections into the glabellar region without precise anatomical knowledge of its vascular and muscular topography may pose the risk of severe complications.

OBJECTIVES

We aimed to improve the safety and efficacy of the glabellar injections by mapping the regional muscles and vasculature in relation to the medial canthus and the defined reference lines.

METHODS

Meticulous dissection was performed to reveal glabellar region muscles and arteries under surgical microscope, in 16 hemifaces of whom arteries are injected with red-dyed latex. Location of the angular artery (AA) along with its branches was noted in relation to glabellar muscles.

RESULTS

The AA was always located superficial to the levator labii superioris alaeque nasi muscle (LLSAN) and then coursed toward the medial canthus to anastomose with the supratrochlear artery deep to the origin of the depressor supercilii (DS). The AA gave subcutaneously located central and paracentral branches coursing close to the mid-face line in 14 out of 16 hemifaces. Variable muscular connections were also present between the LLSAN, the DS and the procerus (P) muscles. No arteries were detected at the base of the medial eyebrow to which the DS, the P, and the frontalis (F) inserted.

CONCLUSIONS

This study provides a detailed map of muscular and vascular anatomy of the glabellar region to facilitate safe and efficient filler and BoNT injections without complications.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Application of 3-Dimensional Technology for Evaluating Muscular Type and Muscle-Fat Pad Mixed-Type Nasolabial Folds With Botulinum Toxin-A Treatment

BACKGROUND

Botulinum toxin-A (BTX-A) is used in the treatment of nasolabial folds (NLFs). However, lighting and clinician subjectivity play a major role in evaluating the efficacy of this treatment.

OBJECTIVES

By applying 3-dimensional (3D) technology, this study aimed to quantitatively evaluate the effects of BTX-A injection on muscular (M) and muscle-fat pad mixed-type (MF) NLFs.

METHODS

BTX-A was injected into bilateral marked points on the NLFs, where the levator labii alaeque nasi, zygomaticus minor, and zygomaticus major pull the skin to form the NLF (2 U at each injection site). Pretreatment and posttreatment 3D facial images were captured with static and laughing expressions. The curvature, width, depth, and lateral fat volume of the NLFs were measured to compare the therapeutic efficacy for type M and MF NLFs.

RESULTS

Thirty-nine patients with type M and 37 with type MF NLFs completed the follow-up data. In these patients, the curvature, width, and depth of the NLF showed a significant reduction at 1 month and gradually recovered at 3 and 6 months after treatment, with more significant improvement when laughing than when static. Variations compared to the pretreatment values of type MF were greater than those of type M at each time point. The lateral fat volume of the type MF NLF was significantly reduced (P < .05).

CONCLUSIONS

3D technology can quantitatively evaluate the effects BTX-A injection for treating type M and type MF NLFs. BTX-A is more effective on type MF than on type M NLFs.

LEVEL OF EVIDENCE: 4

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS AND CONCLUSION

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

Long-term stable efficacy of botulinum toxin A in facial movement disorders with no need for increasing dose

Botulinum toxin A is considered an effective treatment for involuntary facial movements. We examined whether treatment efficacy maintained or changed over time with two products, Botox and Dysport, in patients with hemifacial spasm, facial synkinesis and benign essential blepharospasm.We retrospectively investigated 87 consecutive patients (51 women, 36 men) who had undergone treatment for ≥6 years. Long-term effects, as well as side effects of Botox or Dysport local injections were evaluated. The first three treatments were considered the titration period and not taken into account when testing for dose changes.Mean treatment duration was 10 years (range 6-11, SD 1.0), 2441 treatments were administered, 1162 with Botox and 1279 with Dysport, the two brands were interchanged as needed. Good to full improvement was seen in 90% of patients both with both brands. Injection doses and treatment responses were consistent during the study with both drugs. No major side effects were reported, and relatively few minor adverse events were reported, with clear reduction from the titration period (6.1%), to the remainder of the study (3.9%).Botulinum toxin (BTX-A) is a satisfactory long-term treatment without need for dose increase over. Both Botox and Dysport were effective when used interchangeably.

IncobotulinumtoxinA Demonstrates Safety and Prolonged Duration of Effect in a Dose-Ranging Study for Glabellar Lines

BACKGROUND

Recently reported clinical data provides evidence that increasing the dose of botulinum toxin A increases the duration of efficacy. A 2-stage Phase 2, randomized, double-blind study investigated the duration of effect and safety of IncobotulinumtoxinA (INCO; Xeomin&reg;, Bocouture&reg;; Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany) at doses higher than the approved 20 units (U) for glabellar frown lines (GFL). Primary safety and efficacy endpoints of Stage 1 are reported here.

METHODS

151 subjects with moderate-to-severe GFL were randomized 1:2:2 to receive a single treatment with 20U, 50U, or 75U INCO. The primary efficacy endpoint was median duration of at least 1-point improvement from baseline as assessed by investigator at maximum frown on the Facial Wrinkle Scale.

RESULTS

The median duration of effect was 185 days for the 50U dose group (95% CI:[182, 205]) and 210 days for the 75U dose group (95% CI:[182, 217]). Duration of effect was significantly longer for 75U vs 50U (P=0.0400) and 20U (P=0.0166) despite the study not being powered for confirmatory statistical significance testing between the dose groups. Duration of effect was also longer for 50U vs 20U, however; statistical significance was not reached (P=0.4349). The incidence of treatment-related adverse events was low across all doses (20U:2[6.7%], 50U:6[10.0%] and 75U:8[13.1%]).

CONCLUSIONS

These results demonstrate a dose effect of at least 6 months duration with higher doses in the majority of GFL subjects. All doses were well tolerated and safety was consistent with the known safety profile of 20U INCO for GFL. J Drugs Dermatol. 2020;19(10):985-991. doi:10.36849/JDD.2020.5454.

Aesthetic ONE21 Technique for Injecting IncobotulinumtoxinA into the Forehead: Initial Experience With 86 Patients

BACKGROUND

Treatment of upper facial lines is a common aesthetic practice; however, there is limited information on systematic tailored approaches for the treatment of forehead wrinkles using botulinum toxin A.

OBJECTIVE

To describe the safety and efficacy of the ONE21 technique using incobotulinumtoxinA (INCO) for the treatment of forehead wrinkles.

METHODS

Single-center, retrospective study with 86 females presenting a baseline Merz Aesthetic Scale (MAS) score &ge;2 for dynamic forehead lines who had been treated with INCO using the ONE21 technique. Assessment was performed by two independent blinded raters using MAS for forehead lines (dynamic and at rest), and eyebrow positioning, based on standardized pictures taken before (baseline) and 4 (&plusmn;2) weeks after treatment injection. The primary outcome was the percentage of subjects with a MAS improvement &ge;2 points for dynamic forehead lines at week 4 (&plusmn;2). Secondary outcomes were MAS scores for resting forehead lines and for eyebrow positioning.

RESULTS

The mean age was 46.2 years, and mean total dose of INCO, 20.3 U. Most (97.7%) subjects had a MAS improvement of &ge;2 points for dynamic forehead lines at week 4 (&plusmn;2); 100% improved &ge;1 point. MAS scores for resting and dynamic lines, and eyebrow positioning were significantly improved (P&lt;0.001). Eyebrow positioning MAS improved &ge;1 point in 56.9% of subjects, and 39.5% maintained the original shape.

CONCLUSION

INCO injection using the ONE21 technique is effective and safe in treating forehead wrinkles, providing a natural result, with a customized treatment and a predictable eyebrow shape. J Drugs Dermatol. 2021;20(1):31-37. doi:10.36849/JDD.5617.

Long-Term Patient Experience with Tetracycline Injections for Festoons

BACKGROUND

The purpose of this study was to evaluate the long-term patient experience with tetracycline injections for treatment of festoons.

METHODS

Charts of all patients undergoing tetracycline injection for treatment of lower eyelid festoons at the Cole Eye Institute, Cleveland Clinic, between 2008 and 2018 were identified using billing records. Patients were invited to participate in a questionnaire based on the FACE-Q checklist, a previously validated questionnaire for studying cosmetic procedure outcomes. Data from the questionnaire were summarized with size, mean, and frequency.

RESULTS

One hundred two patients who received tetracycline injection during the study period were identified and 61 responses were obtained. The average follow-up time after injection was 3.6 years. Of 61 respondents, 36 (59 percent) noted improvement in their festoons after treatment, and 27 of 33 (82 percent) noted that improvement occurred within 2 months of treatment. Overall, 40 of 60 respondents (67 percent) would consider repeating tetracycline treatment. The most common adverse effects included discomfort (18 percent), swelling (15 percent), and bruising (13 percent). There was no statistically significant difference in questionnaire responses between men and women, except that men were more likely to consider repeated injection (92 percent versus 58 percent; p = 0.005).

CONCLUSION

Tetracycline injection appears to improve festoons in a majority of patients, with an acceptable side-effect profile, although more data are needed to determine the optimal dose and frequency and to identify possible rare and/or significant side effects.

The Bidirectional Movement of the Frontalis Muscle: Introducing the Line of Convergence and Its Potential Clinical Relevance

BACKGROUND

Cosmetic treatment of the forehead using neuromodulators is challenging. To avoid adverse events, the underlying anatomy has to be understood and thoughtfully targeted. Clinical observations indicate that eyebrow ptosis can be avoided if neuromodulators are injected in the upper forehead, despite the frontalis muscle being the primary elevator.

METHODS

Twenty-seven healthy volunteers (11 men and 16 women) with a mean age of 37.5 ± 13.7 years (range, 22 to 73 years) and of diverse ethnicity (14 Caucasians, four African Americans, three Asians, and six of Middle Eastern descent) were enrolled. Skin displacement vector analyses were conducted on maximal frontalis muscle contraction to calculate magnitude and direction of forehead skin movement.

RESULTS

In 100 percent of investigated volunteers, a bidirectional movement of the forehead skin was observed: the skin of the lower forehead moved cranially, whereas the skin of the upper forehead moved caudally. Both movements converged at a horizontal forehead line termed the line of convergence, or C-line. The position of the C-line relative to the total height of the forehead was 60.9 ± 10.2 percent in men and 60.6 ± 9.6 percent in women (p = 0.941). Independent of sex, the C-line was located at the second horizontal forehead line when counting from superior to inferior (men, n = 2; women, n = 2). No difference across ethnicities was detected.

CONCLUSIONS

The identification of the C-line may potentially guide practitioners toward more predictable outcomes for forehead neuromodulator injections. Injections above the C-line could mitigate the risk of neuromodulator-induced brow ptosis.

Re-examining the Optimal Use of Neuromodulators and the Changing Landscape: A Consensus Panel Update

Since initial US Food and Drug Administration approval of botulinum toxin type A (BoNT-A) for aesthetic use in 2002, clinical evidence and experience with BoNT-A and understanding of facial anatomy have greatly increased, leading to rapid advances in treatment planning and implementation. BoNT-A use has expanded from the upper face to the midface, lower face, and neck, so that BoNT-A injection is the most common cosmetic procedure worldwide. Trends in facial aesthetics reflect growing patient diversity with respect to age, gender, and ethnicity. In October 2019, a multidisciplinary panel of 6 experts in minimally invasive injectable procedures in the specialties of dermatology and plastic surgery convened at the 2019 American Society for Dermatologic Surgery (ASDS) meeting in Chicago, IL. Their goal was to discuss recent advances in BoNT-A use in facial aesthetics, including implications of the introduction of new agents in light of an evolving patient population. J Drugs Dermatol. 2020;19(4 Suppl 1):s5-15 To receive a CME certificate of participation, you should: •Read the entire publication, including the CME information. •Register or log in at www.paradigmmc.com/822 to complete and submit the online posttest and evaluation. Following online completion of the posttest and evaluation, a certificate of participation will be available for download/printing immediately.

ABOUT FACE: Navigating Neuromodulators and Injection Techniques for Optimal Results

Interest in the cosmetic use of neuromodulators for facial rejuvenation is increasing among physicians, other practitioners, and patients alike, and an expanding array of formulations and reported applications might be helping to drive this trend. Safety, efficacy, and a high level of patient satisfaction can be achieved with all the available botulinum neurotoxin type A (BTXA) products. With any of the formulations, optimal results require knowledge of the individual product’s unique properties and dosing, along with an understanding of the patient’s goals, relevant anatomy, and proper injection technique. This educational activity reviews these topics on the basis of the published literature and expert opinion. A series of case narratives is also included that provides readers with information and insights for achieving success in clinical practice. J Drugs Dermatol. 2020;19(4 Suppl 2):s5-15.

Acute onset of orofacial dystonia from promethazine treatment: A case report

RATIONALE

Promethazine is an antihistamine agent used commonly for nausea and allergy. Along with its anticholinergic and antidopaminergic functions, promethazine is also used for psychiatric symptoms, such as troubling sleep, anxiety, and agitation. Previous studies have reported that promethazine may occasionally elicit acute dystonia in some individuals, especially for young children and pregnant women.

PATIENT CONCERNS

The 68-year-old female patient was admitted to our hospital because of feeling anxious and intermittent palpitation for over 1 year. She developed acute orofacial dystonia following promethazine treatment.

DIAGNOSES

Her diagnoses was generalized anxiety disorder.

INTERVENTIONS

Discontinuation of the offending agent, promethazine, and injection of Botulinum toxin.

OUTCOMES

The acute orofacial dystonia was finally alleviated by local injection of Botulinum toxin.

LESSONS

Careful assessment of the risk of developing acute dystonia is also needed in old patients when initiating the promethazine treatment.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE IV

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

Preoperative Use of Neuromodulators to Optimize Surgical Outcomes in Upper Blepharoplasty and Brow Lift

BACKGROUND

Upper eyelid dermatochalasis often triggers frontalis hyperactivity in an effort to elevate the upper lids away from the visual axis. Similarly, prior neuromodulator treatment of the brow depressors may cause false elevation of the brows, diminishing the extent of preoperative brow ptosis or dermatochalasis. Studies have quantified postoperative brow ptosis and recurrent dermatochalasis following upper blepharoplasty, but a methodology to predict the postoperative brow position remains to be elucidated.

OBJECTIVES

The authors present our comprehensive perioperative protocol utilizing neuromodulators to optimize results of upper blepharoplasty and brow lift.

METHODS

In patients presenting with upper lid dermatochalasis and frontalis hyperactivity, who request upper blepharoplasty, the authors apply a neuromodulator treatment protocol. Patients with prior neuromodulator treatment of brow depressors wait four months after the last treatment to allow for product attrition. Two weeks prior to surgery, the authors treat the frontalis with 15 to 20 units of Botox Cosmetic.

RESULTS

From 2002 to 2016, the authors treated 521 patients (458 women, 63 men) with frontalis hyperactivity who presented for periorbital rejuvenation. This method has led to neither excessive resection of upper eyelid skin tissue nor lagophthalmos. Preoperatively, the authors have unveiled upper eyelid ptosis in 39 patients (31 women, 8 men) and brow ptosis in 131 patients (97 women, 34 men).

CONCLUSIONS

Brow position and frontalis hyperactivity should be taken into consideration during preoperative evaluation for upper blepharoplasty and brow lift. Routine preoperative treatment of the hyperactive frontalis with neuromodulator, along with attrition of prior neuromodulator in the brow depressors, reveals the true anatomic brow position to optimize surgical planning.

LEVEL OF EVIDENCE 4

Polar-phase indices of perioral muscle reciprocity during syllable production in Parkinson's disease

PURPOSE

This research characterised perioral muscle reciprocity and amplitude ratio in lower lip during bilabial syllable production [pa] at three rates to understand the neuromotor dynamics and scaling of motor speech patterns in individuals with Parkinson's disease (PD).

METHOD

Electromyographic (EMG) signals of the orbicularis oris superior [OOS], orbicularis oris inferior [OOI] and depressor labii inferioris [DLI] were recorded during syllable production and expressed as polar-phase notations.

RESULT

PD participants exhibited the general features of reciprocity between OOS, OOI and DLI muscles as reflected in the EMG during syllable production. The control group showed significantly higher integrated EMG amplitude ratio in the DLI:OOS muscle pairs than PD participants. No speech rate effects were found in EMG muscle reciprocity and amplitude magnitude across all muscle pairs.

CONCLUSION

Similar patterns of muscle reciprocity in PD and controls suggest that corticomotoneuronal output to the facial nucleus and respective perioral muscles is relatively well-preserved in our cohort of mild idiopathic PD participants. Reduction of EMG amplitude ratio among PD participants is consistent with the putative reduction in the thalamocortical activation characteristic of this disease which limits motor cortex drive from generating appropriate commands which contributes to bradykinesia and hypokinesia of the orofacial mechanism.

New Uses of AbobotulinumtoxinA in Aesthetics

BotulinumtoxinA (BoNT-A) is now widely established for the main approved indication of reducing glabellar lines, and is also widely used off-label to improve the appearance of wrinkles and lines in other parts of the face. The number of aesthetic procedures continues to increase as the patient population becomes more diverse, in particular with increasing numbers of people of color and men. Further developments in treatment may continue to expand the audience for BoNT-A by making procedures more comfortable and by delivering a more natural, less static appearance. These may be achieved through use of combinations of BoNT-A with other aesthetic procedures, tailoring the dose of toxin to the patient's muscle mass or by using novel injection and application techniques. Beyond amelioration of facial lines, encouraging results have been seen with the use of BoNT-A to improve the appearance of hypertrophic and keloid scars and even to prevent them. Studies have been conducted with scars in various parts of the body and further research is ongoing. Dermatological and other medical uses for BoNT-A are also active areas of research. Injections of BoNT-A have been shown to reduce signs and symptoms of acne, rosacea, and psoriasis, to reduce neuromuscular pain, and to bring about significant improvements in a number of rare diseases that are caused or exacerbated by hyperhidrosis. This paper reviews these new uses for BoNT-A, looking at the rationale for their use and discussing the results of published case studies and clinical trials. These areas have shown great promise to date, but more and larger clinical studies will be required before these treatments become a clinical reality. To this end details are also provided of clinical trials currently listed in the main clinical trials database to highlight research areas of particular interest.

Key Parameters for the Use of AbobotulinumtoxinA in Aesthetics: Onset and Duration

Time to onset of response and duration of response are key measures of botulinum toxin efficacy that have a considerable influence on patient satisfaction with aesthetic treatment. However, there is no overall accepted definition of efficacy for aesthetic uses of botulinumtoxinA (BoNT-A). Mechanical methods of assessment do not lend themselves to clinical practice and clinicians rely instead on assessment scales such as the Frontalis Activity Measurement Standard, Frontalis Rating Scale, Wrinkle Severity Scale, and Subject Global Assessment Scale, but not all of these have been fully validated. Onset of activity is typically seen within 5 days of injection, but has also been recorded within 12 hours with abobotulinumtoxinA. Duration of effect is more variable, and is influenced by parameters such as muscle mass (including the effects of age and sex) and type of product used. Even when larger muscles are treated with higher doses of BoNT-A, the duration of effect is still shorter than that for smaller muscles. Muscle injection technique, including dilution of the toxin, the volume of solution injected, and the positioning of the injections, can also have an important influence on onset and duration of activity. Comparison of the efficacy of different forms of BoNT-A must be made with the full understanding that the dosing units are not equivalent. Range of equivalence studies for abobotulinumtoxinA (Azzalure; Ipsen Limited, Slough UK/Galderma, Lausanne CH/Dysport, Ipsen Biopharm Limited, Wrexham UK/Galderma LP, Fort Worth, TX) and onabotulinumtoxinA (Botox; Allergan, Parsippany, NJ) have been conducted, and results indicate that the number of units of abobotulinumtoxinA needs to be approximately twice as high as that of onabotulinumtoxinA to achieve the same effect. An appreciation of the potential influence of all of the parameters that influence onset and duration of activity of BoNT-A, along with a thorough understanding of the anatomy of the face and potency of doses, are essential to tailoring treatment to individual patient needs and expectations.

AbobotulinumtoxinA: A 25-Year History

During the late 1960s and early 1970s, Alan Scott showed that intramuscular injections of botulinum toxin (BoNT) corrected nonaccommodative strabismus without resorting to surgery. The UK doctors who trained with Scott soon realized the significant potential offered by BoNT type A as a therapeutic option for several difficult-to-treat diseases. This led to a collaboration between these pioneering clinicians and the Centre for Applied Microbiology and Research at Porton Down, United Kingdom, and, in turn, to the development and commercialization of abobotulinumtoxinA as Dysport (Dystonia/Porton Down; Ipsen Biopharm Ltd., Wrexham, UK). Dysport was approved in Europe for the treatment of specific dystonias in December 1990 and now has marketing authorizations in 75 countries. Since then, the use of BoNT in therapeutic and aesthetic indications has grown year-on-year, and continues to expand well beyond Scott’s initial aim. For example, ongoing trials are assessing potential new indications for BoNT-A, including acne and psoriasis. Furthermore, a growing number of other BoNT products, often termed “biosimilars,” together with innovative formulations of well-established BoNT types, are likely to reach the market over the next few years. This review focuses on the history of Dysport to mark the 25th anniversary of its first launch in the United Kingdom.

The Practical Use of AbobotulinumtoxinA in Aesthetics

Botulinum toxin (BoNT) has been approved for aesthetic use since 2002. Since then, clinical studies and expert use have informed our understanding of how BoNT exerts its clinical effect and the practical use of this product across a number of aesthetic applications. This review discusses the clinical properties and characteristics of abobotulinumtoxinA, which patients are suitable for its use, and how it can be utilized to treat facial rhytides.

Safety and Patient Satisfaction of AbobotulinumtoxinA for Aesthetic Use: A Systematic Review

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.

Application of Local Injection of Botulinum Toxin A in Cosmetic Patients with Congenital Drooping Mouth Corner

OBJECTIVE

This study aimed to investigate the clinical application and efficacy of local injection of botulinum toxin A (BTX-A) at the depressor anguli oris in patients with congenital drooping mouth corner.

METHODS

From September 2013 to March 2015, 36 cosmetic patients received local injections of botulinum toxin A at the depressor anguli oris, with 1-3 injection sites in the moving region of the depressor anguli oris on each side. At each injection site, 2-4 U of BTX-A was injected, and the total dose for any unilateral treatment did not exceed 8 U. The change in the degree of drooping of the mouth corner before and after the injection was analyzed using statistical methods. The clinical efficacy, preservation time, and adverse reactions were observed.

RESULTS

The degree of drooping of the mouth corners of the cosmetic patients before the treatment was compared with that at 1 month after using a paired t test, and the difference was statistically significant, with P < 0.01. The treatment results were satisfactory, and the effect was preserved for 6-9 months. None of the 36 cosmetic patients had any complications of bruising, infection, dysfunction in opening and closing the mouth, smile asymmetry, drooling, or dysarthria after the injection.

CONCLUSIONS

The local injection of BTX-A at the depressor anguli oris can effectively lift a drooping mouth corner, thereby improving the depressed, stern, and aged appearance of the face. The performance of this treatment is simple, safe, and easy to perform in clinical applications.

LEVEL OF EVIDENCE V

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

OnabotulinumtoxinA for Treatment of Moderate to Severe Crow's Feet Lines: A Review

Lateral canthal lines or crow's feet lines (CFL) may be treated with onabotulinumtoxinA. We identified several key concepts important to understanding the use of onabotulinumtoxinA for treatment of moderate-to-severe CFL. To contextualize and integrate data on the recommended dose and injection patterns of onabotulinumtoxinA for treatment of CFL, we summarized data from pivotal clinical studies in the development of onabotulinumtoxinA for treatment of CFL. Data from key studies of onabotulinumtoxinA for CFL are presented. The efficacy and safety of onabotulinumtoxinA treatment of moderate-to-severe CFL were evaluated in 2 randomized, controlled phase 3 studies comprising 1362 patients. The 24U total dose of onabotulinumtoxinA used in these studies was based on a phase 2 dose-ranging trial. Two injection patterns were available to investigators; each involved 3 injection sites per side in the lateral orbicularis oculi muscle. A cross-sectional analysis of photographs from the phase 3 trials provided detailed information on the frequency of 4 distinct CFL patterns. In the primary efficacy analysis for each phase 3 trial, CFL responder rates were significantly greater with onabotulinumtoxinA vs placebo at day 30 (P< .001). Eyelid edema (1%) was the only adverse event reported in ≥ 1% of patients receiving onabotulinumtoxinA, occurring more frequently with onabotulinumtoxinA than with placebo. The studies showed that onabotulinumtoxinA is effective and generally well-tolerated for CFL treatment. Additionally, 2 different injection patterns allow physicians to tailor treatment based on a patient's CFL pattern.

Regional diffusion of botulinum toxin in facial muscles: a randomised double-blind study and a consideration for clinical studies with split-face design

Despite the extensive use of botulinum toxin A (BoNTA) in medical and cosmetic treatments, the potential spreading of BoNTA to surrounding tissues remains unknown. A patient with hemifacial paralysis upon blepharospasm treatment with low dose of BoNTA, prompted us to investigate the spreading effect. A randomised, double-blind study was conducted in which 5 healthy women (33-52 years) were treated with different doses of onabotulinum toxin unilaterally in the corrugator muscle. Parameters of efficacy and diffusion (CMAP; EMG and jitter analysis) in both glabellar and frontalis muscles were assessed at baseline, 2 and 4 weeks following BoNTA injection. CMAP of the treated glabellar muscles was reduced to approximately 40% in all dose groups. Additionally, contralateral CMAP reduction was observed in 3 of 5 subjects. These data confirm regional diffusion of BoNTA in facial muscle application, which raises question on the reliability of split-face models in BoNTA studies.

Relevance of sonography for botulinum toxin treatment of cervical dystonia: an expert statement

Botulinum neurotoxin A (BoNT A) is the first-line treatment for cervical dystonia. However, although BoNT A has a favorable safety profile and is effective in the majority of patients, in some cases the treatment outcome is disappointing or side effects occur when higher doses are used. It is likely that in such cases either the target muscles were not injected accurately or unintended weakness of non-target muscles occurred. It has been demonstrated in clinical trials for spastic movement disorders that sonography-guided BoNT A injections could improve treatment outcome. As the published evidence for a benefit of sonography-guided BoNT injection in patients with cervical dystonia is scarce, it is the aim of this review to discuss the relevance of sonography in this indication and provide a statement from clinical experts for its use. The clear advantage of sonography-guided injections is non-invasive, real-time visualization of the targeted muscle, thus improving the precision of injections and potentially the treatment outcomes as well as avoiding adverse effects. Other imaging techniques are of limited value due to high costs, radiation exposure or non-availability in clinical routine. In the hands of a trained injector, sonography is a quick and non-invasive imaging technique. Novel treatment concepts of cervical dystonia considering the differential contributions of distinct cranial and cervical muscles can reliably be implemented only by use of imaging-guided injection protocols.

Depression--An emerging indication for botulinum toxin treatment

The treatment of glabellar frown lines with botulinum toxin injection is one of the most prevalent procedures in esthetic medicine. It is possible that the popularity of this intervention is not only owing to its cosmetic effect but also to modulatory effects on mood and affectivity. Recently, a series of studies including three randomized controlled trials have consistently shown that such effects can be used in the treatment of depression. Predominantly female patients suffering from partly chronic and treatment resistant unipolar depression experienced a quick, strong and sustained improvement in depressive symptoms after a single glabellar treatment with botulinum toxin A as a sole or adjunctive therapy. If these findings are further corroborated in additional studies, the ever-growing spectrum of applications for botulinum toxin may spread into the field of psychiatry, showing that the superficial paralysis of facial muscles may, probably via proprioceptive feedback mechanisms, have profound effects on the emotional brain.

Topographic Relationship between the Supratrochlear Nerve and Corrugator Supercilii Muscle--Can This Anatomical Knowledge Improve the Response to Botulinum Toxin Injections in Chronic Migraine?

Chronic migraine has been related to the entrapment of the supratrochlear nerve within the corrugator supercilii muscle. Recently, research has shown that people who have undergone botulinum neurotoxin A injection in frontal regions reported disappearance or alleviation of their migraines. There have been numerous anatomical studies conducted on Caucasians revealing possible anatomical problems leading to migraine; on the other hand, relatively few anatomical studies have been conducted on Asians. Thus, the aim of the present study was to determine the topographic relationship between the supratrochlear nerve and corrugator supercilii muscle in the forehead that may be the cause of migraine. Fifty-eight hemifaces from Korean and Thai cadavers were used for this study. The supratrochlear nerve entered the corrugator supercilii muscle in every case. Type I, in which the supratrochlear nerve emerged separately from the supraorbital nerve at the medial one-third portion of the orbit, was observed in 69% (40/58) of cases. Type II, in which the supratrochlear nerve emerged from the orbit at the same location as the supraorbital nerve, was observed in 31% (18/58) of cases.

Face-referenced measurement of perioral stiffness and speech kinematics in Parkinson's disease

PURPOSE

Perioral biomechanics, labial kinematics, and associated electromyographic signals were sampled and characterized in individuals with Parkinson's disease (PD) as a function of medication state.

METHOD

Passive perioral stiffness was sampled using the OroSTIFF system in 10 individuals with PD in a medication ON and a medication OFF state and compared to 10 matched controls. Perioral stiffness, derived as the quotient of resultant force and interoral angle span, was modeled with regression techniques. Labial movement amplitudes and integrated electromyograms from select lip muscles were evaluated during syllable production using a 4-D computerized motion capture system.

RESULTS

Multilevel regression modeling showed greater perioral stiffness in patients with PD, consistent with the clinical correlate of rigidity. In the medication-OFF state, individuals with PD manifested greater integrated electromyogram levels for the orbicularis oris inferior compared to controls, which increased further after consumption of levodopa.

CONCLUSIONS

This study illustrates the application of biomechanical, electrophysiological, and kinematic methods to better understand the pathophysiology of speech motor control in PD.

Update on neurotoxins for facial rejuvenation: what they are, how they work, and how to effectively and safely use them

The formal aesthetic introduction of botulinum toxin (i.e., neurotoxins) more than a decade ago has revolutionized the nonsurgical aesthetic market and transformed society's view of facial rejuvenation. Understanding the similarities and differences between U.S. commercially available neurotoxins, their characteristics and composition, where they are effective, their mechanism of action, and how to safely administer them will enable the aesthetic provider to successfully utilize this powerful tool and ultimately deliver optimal facial rejuvenation outcomes. An update on neurotoxins on the horizon is also provided. Please note that this article discusses neurotoxin use in treatment areas that are considered "off label" by the Food and Drug Administration.

Half-mirror biofeedback exercise in combination with three botulinum toxin A injections for long-lasting treatment of facial sequelae after facial paralysis

OBJECTIVES/HYPOTHESIS

The present study was conducted to develop a new method for maintaining the effect of botulinum toxin treatment for facial sequelae. We used a combination strategy including the administration of botulinum toxin three times at 6-8-month intervals followed by daily newly developed half-mirror biofeedback rehabilitation for about 2 years from the first injection.

STUDY DESIGN

This was a prospective study.

METHODS

Seventeen patients with unilateral facial palsy for >1 year were included in the study. The amount injected per site varied from 1.5 to 3 U. The purpose of the first injection was to reduce the most inconvenient facial problem such as facial synkinesis or hyperkinetic movement at the points of the periocular area and the zygomaticus major and minor muscles with an average dosage of 17.4 ± 13.9 U. The second injection was to enhance facial symmetry at prominent hypertrophic areas on the contralateral side with 36.5 ± 15.4 U, and the third injection was to add cosmetic configuration at the points of deep furrows and creases caused by facial muscular hyperkinesis or atrophy with 15.6 ± 8.4 U.

RESULT

After three injections of botulinum toxin A and 2 years of half-mirror biofeedback exercises, all patients showed marked relief of facial synkinesis and facial asymmetry. Before treatment, the mean ± standard deviation (SD) Sunnybrook (SB) score was 36.8 ± 8.76. After the first injection, the score increased by 11.4. After the second injection, the score increased by 14.6; it further increased by 15.6 after the third injection.

CONCLUSION

This facial rehabilitation strategy, consisting of three injections of botulinum toxin and half-mirror biofeedback exercises, proceeds over the course of 2 years and offers a long-lasting cure for facial synkinesis and facial symmetry as well as improved facial aesthetics.

Quantitative evaluation of the onset and longevity of the action of incobotulinumtoxinA by skin displacement analysis in the treatment of glabellar frown lines

BACKGROUND

A quantitative numerical method for assessing the extent and duration of the inhibitory action of botulinum neurotoxin type A on mimetic muscles would potentially enable more detailed evaluation of the overall efficacy of this aesthetic treatment.

AIM

To evaluate skin displacement analysis (SDA) as a tool for assessment of the extent and duration of effect of incobotulinumtoxinA on mimetic muscles in the glabellar region in routine daily practice.

METHODS

A total dose of 30 U incobotulinumtoxinA was injected into the fronto-glabellar region of 16 subjects. SDA was performed at baseline and during onset and recovery from incobotulinumtoxinA treatment at various timepoints up to 24 weeks after treatment. The reference point for SDA was located at the upper margin of the eyebrow, 30 mm lateral to the median line. To correlate and validate SDA results, semi-quantitative wrinkle score assessments were performed in parallel.

RESULTS

At baseline, the mean horizontal skin displacement was 5.4 mm (standard deviation: ± 1.4 mm). During onset of action after treatment, skin displacement values decreased from baseline (100%) by 46%, 85%, and 90% at day 2, week 1, and week 2, respectively. During recovery from incobotulinumtoxinA action, skin displacement values increased to 33%, 50%, and 93% of the baseline value at 6, 12, and 24 weeks after treatment, respectively. The inhibitory effect of incobotulinumtoxinA was highly variable among subjects, ranging from 25% to 68% of the baseline value 12 weeks after treatment. Overall agreement between SDA values and wrinkle scores was good.

CONCLUSION

SDA represents a novel, objective method for the quantitative evaluation of the effect of incobotulinumtoxinA on mimetic muscles underlying the fronto-glabellar region, and showed good correlation with wrinkle score assessments. Both SDA and wrinkle score indicated the persistence of treatment effects 24 weeks after injection.

[Comparative evaluation of efficacy of the upper part of the face endoscopic lifting in dynamics of postoperative period]

Comparative estimation of results for endoscopic lifting of the face upper part in dynamics of early and late postoperative period was adduced. In accordance to results of analysis, concerning the eyebrows height in a control terms, there was established, that through one year postoperatively the eyebrows have a tendency towards ptosis due to activity of the eyes circular muscles. Deterioration of the result achieved post-operatively is less prominent in patients after preliminary chemical denervation of mimic muscles. Chemical denervation of the eyes circular muscles, using injections of botulinic toxine type A before 2 weeks preoperatively secures a stable fixation of tissues in early postoperative period, what permits to escape loss of the result achieved, secures the results improvement in late postoperative period in 3.7 times.

OnabotulinumtoxinA for the treatment of a "gummy smile"

BACKGROUND

Excessive gingival display, or a "gummy smile," is defined as 2 mm or more of gingival exposure upon smiling. Such excessive gingival exposure can be aesthetically unappealing to patients. One factor that contributes to a gummy smile is hyperfunctional lip elevator muscles.

OBJECTIVES

The authors evaluate onabotulinumtoxinA as a safe and minimally invasive treatment for a gummy smile.

METHODS

In this prospective study, 14 patients (13 women, 1 man) underwent pretreatment photographs and measurements, followed by bilateral injection of onabotulinumtoxinA into their lip elevator muscles. All patients selected for the study had more than 2mm of gingival show and were classified as having a "cuspid smile," where action of all elevator muscles raised the upper lip- like a window shade-to expose the upper teeth and gingival scaffold; these patients were thought to have a better chance for a more superior result. Repeat measurements and photographs were collected at 2 weeks and 3 months. Patient-reported outcomes were collected at 2 weeks, and data were compared to determine the correlative relationship.

RESULTS

An average of 5 units (range, 4-6 U) of onabotulinumtoxinA were injected into 3 sites bilaterally. The average preinjection gingival show over the central incisors and canines were 4.89 mm and 4.25 mm, respectively. Postinjection gingival show decreased to an average of 0.75 mm (85% improvement) and 0.74 mm (83% improvement) over the central incisors and canines, respectively. Average follow-up time was 12.6 days. One patient felt the resulting smile was unattractive and opted not to undergo repeat injections, while all other study participants experienced no negative effects and wished to undergo repeat treatment.

CONCLUSIONS

As treatment for a "gummy smile," onabotulinumtoxinA provides an effective, minimally invasive, and safe therapy. This treatment option can lead to significant improvement in smile aesthetics with high patient satisfaction.

LEVEL OF EVIDENCE

3.

Redefining treatment of gummy smile with Botox--a report of three cases

Excessive contraction of upper lip elevator muscles is one of the many ascribed reasons of gummy smiles for which patients seek treatment. Myriad numbers of invasive surgical procedures have been employed for the improvement of the condition, but increased cost and involved risks act as major deterrent. Botulinum toxin type A (BTX-A) has been widely used in the management of several conditions associated with excessive muscular contraction and pain. This article aims to highlight the efficacy of BTX-A in treatment of gummy smiles. Three adult patients with gummy smiles due to hyperfunctional upper lip muscles were injected with BTX-A injections under electromyographic guidance. This minimally invasive treatment modality produced esthetically pleasing smiles in these patients, lasting up to 3-5 months. BTX-A injections at preselected hyperactive muscle sites provides novel and cosmetically viable alternative for management of gummy smiles caused by hypefunctional upper lip musculature.

Correlation of botulinum toxin dose with neurophysiological parameters of efficacy and safety in the glabellar muscles: a double-blind, placebo-controlled, randomized study

Despite the extensive use of botulinum toxin type A (BoNT-A) in treatments for glabellar frown lines, the dose-response effect in the glabellar muscles remains unknown. The aim of this randomized, double-blind, placebo-controlled prospective study was to characterize the neurophysiological parameters that correlate with the effect of BoNT-A in the glabellar muscles and its diffusion to surrounding ocular muscles. Sixteen healthy women were recruited and randomized to 3 different dose-groups of onabotulinumtoxin A (Vistabel®) or placebo and followed 24 weeks by neuro-physiological examinations. Efficacy of treatment on corrugator supercilii muscles was measured by compound motor action potential (CMAP) and electromyography (EMG). Photographs were used to score glabellar frown lines. Diffusion of the drug to surrounding muscles was assessed by CMAP of the nasalis muscle, EMG and concentric needle electrode jitter analysis (CNE) of the orbicularis oculi muscle. CMAP reduction correlated well with intramuscular BoNT-A dose. Muscle paralysis, measured by EMG, began from 2 weeks and was not entirely reversed at 24 weeks in individuals who received high dose of onabotulinumtoxin. Limited diffusion of orbicularis oculi was detected with CNE. In conclusion, we developed a novel neurophysiological strategy for effect evaluation of BoNT-A in glabellar muscles. CMAP and EMG correlated with given BoNT-A dose and are more defined effect measures than clinical glabellar photo scales.

Understanding the functional anatomy of the frontalis and glabellar complex for optimal aesthetic botulinum toxin type A therapy

BACKGROUND

Botulinum neurotoxin type A (BoNTA) is approved for the treatment of glabellar lines and also is commonly injected in an off-label fashion in the frontalis (i.e., frontalis epicranius) muscle to improve the appearance of horizontal forehead lines. This study aimed to review and discuss both the anatomy and physiology of the frontalis muscle and its relationship with antagonist muscles in the upper face and to provide a guide for the use of BoNTA to treat forehead rhytides while minimizing the occurrence of complications such as brow ptosis.

METHODS

A PubMed search was conducted to identify practitioner opinion and clinical publications on the efficacy and safety of BoNTA for aesthetic treatment of the upper face.

RESULTS

The use of BoNTA produces durable improvement in the appearance of moderate to severe horizontal forehead lines. Dose and injection technique must be adjusted and individualized based on the variable anatomy and function/mass of muscles in the forehead and upper face as well as on patient goals. Optimal aesthetic outcomes can be achieved by skillfully balancing the opposing effects of the frontalis muscle and its intricate interactions with the procerus, corrugator supercilii, depressor supercilii, and orbicularis oculi muscles.

CONCLUSIONS

The use of BoNTA to improve the aesthetic appearance of horizontal forehead lines is optimized when clinicians take into account variations in frontalis muscle function and position, anatomy of the brow, and proper injection technique when they devise individualized treatment regimens.

A two-center, open-label, randomized, split-face study to assess the efficacy and safety of one versus three intradermal injection sites of abobotulinumtoxinA in the treatment of lateral periocular rhytides

BACKGROUND

Lateral canthal rhytides partly result from repetitive muscular actions of the orbicularis oculi.

OBJECTIVE

To determine the efficacy of one versus three injection sites of AbobotulinumtoxinA (ABO) in the treatment of lateral canthal rhytides.

METHODS

This was a two-center, evaluator-masked, 120 day study in which 40 patients with moderate to severe hyperdynamic lateral canthal rhytides at maximal contracture were randomized to receive one injection of 36 Units of ABO into the middle of the lateral orbital rhytides on one side, with the contralateral side treated with the same total dose of ABO, divided into three intradermal injections of 12 Units each, along the lateral canthal area. A blinded evaluator assessed lateral orbital rhytides at rest and maximal contraction at baseline, 7, 42, 90, and 120 days post treatment. Standardized digital photography and subject self- assessment were performed at each visit.

RESULTS

No statistically significant difference was seen at any visit between sides treated with one injection and those treated with three injections in any evaluation category. There was no difference in adverse events between the two sides.

CONCLUSION

Sites treated with three injections of ABO showed no statistically significant difference from those treated with one injection.

[Denervation of mimic muscles during endoscopic lifting of the upper part of face]

Endoscopic lifting of the upper part of face carry out in 28 patients Chemical or surgical denervation had been done for decreasing of mimic muscles activity. Medical glue with folic acid had been used for tissues fixation. Use of medical glue in conjunction with preliminary chemical denervation of mimic muscles with botulin toxin application decreases surgery duration, prevents complications and increases satisfaction of patients.

Botulinum toxin type A reconstituted in lidocaine with epinephrine for facial rejuvenation: results of a participant satisfaction survey

To assess the feasibility, safety, and lack of inferiority of reconstituting botulinum toxin type A (BTX-A) in 1% lidocaine hydrochloride with epinephrine 1:100,000, 181 participants were asked to complete a satisfaction survey 3 to 6 months after treatment with the reconstituted formulation for facial rejuvenation. The addition of lidocaine was believed to achieve an immediate paralyzing effect on the injected muscles, and the addition of epinephrine was hypothesized to minimize diffusion to adjacent muscles. Participants were treated in the areas of the forehead and glabella, as well as the orbicularis oculi, orbicularis oris, and procerus muscles, in varying doses (10-60 U). Fifty-eight percent (91/157) of participants reported being more satisfied with BTX-A reconstituted in 1% lidocaine with epinephrine 1:100,000, with 85.7% (78/91) of these participants reporting that the immediate results made the formulation superior; 35.7% (56/157) were indifferent and 6.4% (10/157) reported that the modified formulation did not work better. The injection of BTX-A reconstituted in 1% lidocaine with epinephrine 1:100,000 presented no increased adverse effects (AEs), no decrease in pharmacologic potency, immediate feedback to the clinician, and higher satisfaction for the participants who previously had been treated with BTX-A reconstituted in unpreserved saline. Botulinum toxin type A reconstituted in 1% lidocaine with epinephrine 1:100,000 may increase the duration and efficacy of this widely used toxin.

Evoked electromyography to rocuronium in orbicularis oris and gastrocnemius in facial nerve injury in rabbits

BACKGROUND

Muscles innervated by the facial nerve show different sensitivities to muscle relaxants than muscles innervated by somatic nerves, especially in the presence of facial nerve injury. We compared the evoked electromyography (EEMG) response of orbicularis oris and gastrocnemius in with and without a non-depolarizing muscle relaxant in a rabbit model of graded facial nerve injury.

METHODS

Differences in EEMG response and inhibition by rocuronium were measured in the orbicularis oris and gastrocnemius muscles 7 to 42 d after different levels of facial nerve crush injuries in adult rabbits.

RESULTS

Baseline EEMG of orbicularis oris was significantly smaller than those of the gastrocnemius. Gastrocnemius was more sensitive to rocuronium than the facial muscles (P < 0.05). Baseline EEMG and EEMG amplitude of orbicularis oris in the presence of rocuronium was negatively correlated with the magnitude of facial nerve injury but the sensitivity to rocuronium was not. No significant difference was found in the onset time and the recovery time of rocuronium among gastrocnemius and normal or damaged facial muscles.

CONCLUSIONS

Muscles innervated by somatic nerves are more sensitive to rocuronium than those innervated by the facial nerve, but while facial nerve injury reduced EEMG responses, the sensitivity to rocuronium is not altered. Partial neuromuscular blockade may be a suitable technique for conducting anesthesia and surgery safely when EEMG monitoring is needed to preserve and protect the facial nerve. Additional caution should be used if there is a risk of preexisting facial nerve injury.

[Diplopia following subcutaneous injections of botulinum toxin for cosmetic or medical use]

BotuLinum toxin A (Botox, Allegan) is a potent neurotoxin that blocks the release of acetylcholine at the neuromuscular junction of cholinergic nerves. Botulinum toxin was introduced to clinical medicine in 1980. Since then it has become a major therapeutic drug in many medical sub-specialties and its use for facial rejuvenation has become increasingly popular. Diplopia after botulinum toxin injection for facial rejuvenation is a rare and transient complication which is related to chemodenervation of adjacent muscle groups. We would like to report 3 cases of double vision related to extra-ocular muscle paresis after an injection of botulinum toxin for facial rejuvenation and blepharospasm. In all 3 cases recovery occurred, without any treatment, over 3 to 4 months (apparently from regeneration of inactivated proteins necessary for degranulation of acetylcholine vesicles). The clinicians engaged in botulinum toxin injections for facial rejuvenation or blepharospasm, should be aware of the possible complications, and inform the patients about the risk of developing double vision. The clinicians should take into account and ask about Botox when treating patients complaining of diplopia.

Reversal of haloperidol-induced orofacial dyskinesia by Murraya koenigii leaves in experimental animals

CONTEXT

Orofacial dyskinesia (OD) is a late complication of prolonged neuroleptic treatment characterized by involuntary movements of the oral region. Chronic treatment with neuroleptics leads to development of vacuous chewing movements (VCMs). VCMs in rats are widely accepted as an animal model of OD.

OBJECTIVE

To study the effect of Murraya koenigii L. (Rutaceae) leaves on haloperidol-induced OD.

MATERIALS AND METHODS

Effect of alcohol extract of M. koenigii leaves (EEMK) and its alkaloid fraction (AMK) on body weight, locomotor activity, behavioral parameters, such as VCMs, tongue protrusions (TPs), orofacial bursts (OBs), and biochemical parameters such as antioxidant defense enzymes levels [superoxide dismutase (SOD) and catalase (CAT)], glutathione (GSH) levels, and lipid peroxidation (LPO) in the forebrain region was studied in haloperidol-treated rats.

RESULTS

Rats chronically treated with haloperidol (1 mg/kg, i.p., 21 days) significantly decreased locomotion and developed VCMs, OBs, and TPs. Biochemical analysis reveals that chronic haloperidol-treated rats also showed decreased levels of SOD and CAT. Chronic haloperidol treatment significantly induced LPO and decreased the forebrain GSH levels in the rats. Co-administration of EEMK (100 and 300 mg/kg, p.o.) and AMK (30 and 100 mg/kg, p.o.) along with haloperidol significantly reversed the effect on locomotion. EEMK and AMK significantly reversed the haloperidol-induced decrease in forebrain SOD and CAT levels in rats and significantly reduced the LPO and restored the decreased GSH levels by chronic haloperidol treatment.

CONCLUSION

The study concludes that M. koenigii could be screened as a potential drug for the prevention or treatment of neuroleptic-induced OD.

Field effect of two commercial preparations of botulinum toxin type A: a prospective, double-blind, randomized clinical trial

BACKGROUND

The dose equivalence of commonly used commercial preparations of botulinum toxin type A, Dysport (abotulinumtoxinA [ABO] 500 U, Ipsen Biopharm Limited, Wrexham, United Kingdom) and Botox (onabotulinumtoxinA [ONA] 100 U, Allergan, Irvine, CA), remains unclear.

OBJECTIVE

We sought to evaluate the field effect for ABO and ONA at dose equivalences of 2.5:1.0 U and 2.0:1.0 U, in both muscular and sweat gland activity.

METHODS

In all, 59 female patients with forehead wrinkles were enrolled. Patients were randomized for dose equivalence between ABO and ONA, group A (2.0:1.0 U, ABO:ONA) or group B (2.5:1.0 U, ABO:ONA) administered in the frontalis muscles. Clinical assessment, Minor test, and electromyography evaluations were performed at baseline, 28 days, and 112 days.

RESULTS

In group B, the field of anhidrotic effect of ABO showed a greater area and larger horizontal diameter than ONA at 28 and 112 days. At maximum frontalis muscle activity (day 112) patients receiving ABO demonstrated greater improvement based on the Wrinkle Severity Scale. No differences were found in frontalis muscle activity at rest between groups A and B based on results of Wrinkle Severity Scale, electromyography, and interindividual variability data at 28 and 112 days.

LIMITATIONS

Currently, there are no objective measurements other than electromyography to evaluate the field effect of botulinum toxin type A in muscles.

CONCLUSION

At a dose equivalence of 2.0:1.0 U (ABO:ONA), similar field effects were found for both muscle and sweat gland activity. At a higher dose equivalence of 2.5:1.0 U (ABO:ONA), injections of ABO showed greater area and larger horizontal diameter in field of anhidrotic effect at 28 and 112 days than ONA.

Comparing the clinical attributes of abobotulinumtoxinA and onabotulinumtoxinA utilizing a novel contralateral Frontalis model and the Frontalis Activity Measurement Standard

BACKGROUND

Studies on the pharmacodynamics of abobotulinumtoxinA (ABO) and onabotulinumtoxinA (ONA) have produced inconsistent results. This may be due to the lack of objective measurement methods.

OBJECTIVE

To assess and compare pharmacodynamic attributes, including onset of action, spread and efficacy of ABO and ONA using a novel Frontalis Activity Measurement Standard (FMS) and 4-point Frontalis Rating Scale (FRS).

METHODS

Twenty subjects with severe frontalis lines at maximum elevation received equal volumes of ABO or ONA using a dose ratio of 2.5:1 in five injection points on contralateral sides of the frontalis (statistical n=40). Subjects were evaluated using the FMS and FRS for 30 days using pre-defined endpoints for onset and effectiveness. Other assessments included areas of effectiveness and injection pain.

RESULTS

For ABO vs. ONA, the FMS revealed a median Initial Onset of 12 vs. 48 hours (P is less than 0.001), Full Onset of 24 vs. 72 hours (P is less than 0.001) and Complete Onset of three vs. five days (P=0.01). The FRS indicated an Initial Onset for ABO and ONA of 18 hours vs. two days (P=0.002), Full Onset of two vs. three days (P=0.001) and Complete Onset of four days vs. eight days (P=0.01). The FMS showed 90 percent of ABO treatment achieved Complete Efficacy vs. 75 percent for ONO, while 90 percent of ABO treatments reached Complete Efficacy using the FRS vs. 65 percent for ONO. No differences in area of effectiveness or spread were observed. Most subjects (80%) reported ABO injections were less painful than ONA injections (P< 0.05).

CONCLUSION

The FMS appears to be a sensitive, objective tool for measuring ABO and ONA pharmacodynamics. Using a dose ratio of 2.5:1, ABO displayed significantly earlier onset of effect and less injection pain than ONA but similar areas of effectiveness.

The Frontalis Activity Measurement Standard: a novel contralateral method for assessing botulinum neurotoxin type-A activity

BACKGROUND

There are conflicting data regarding the specific attributes of botulinum neurotoxin type-A (BoNTA) products including onset of action, duration and spread because accurate, objective methods for assessing their clinical activity are lacking.

OBJECTIVE

To refine definitions for BoNTA activity utilizing the frontalis muscle and describe the Frontalis Activity Measurement Standard (FMS), an objective method for measuring changes in frontalis muscle activity as a metric for assessing BoNTA pharmacodynamics.

METHODS

As part of a study to assess BoNTA activity, 20 subjects with severe frontalis lines at maximum elevation were injected with two BoNTA products at five points on contralateral sides of the frontalis. Changes in maximum baseline frontalis elevation were measured by a blinded investigator using the previously-validated Frontalis Rating Scale (FRS) and the FMS. Frontalis activity endpoints were redefined to include Initial, Full and Complete Onsets of action and Partial, Full and Complete efficacy.

RESULTS

Differences in the onset of effect of the BoNTA products were detected with both the FRS and FMS; however, the FMS detected changes in frontalis activity earlier than the FRS. A significant correlation between the FRS and FMS was documented.

CONCLUSION

The frontalis muscle activity allows for enhanced assessment of BoNTA activity and attributes. The FMS appears to be a sensitive and objective tool for measuring pharmacodynamic parameters of BoNTA. Refining definitions of BoNTA activity provides a more accurate means for describing the clinical effects of BoNTA.