The efficacy of intradermal injection of type A botulinum toxin for facial rejuvenation

The aim of this study is to evaluate the efficacy for effectiveness of type A botulinum toxin intradermal injection for facial rejuvenation. Forty female subjects were randomly divided into two groups: BoNTA group and control group. In BoNTA group, each subject's facial skin was treated with intradermal injection of BoNTA, and subjects of the control group were treated with intradermal saline solution injection. Subjects receiving one session of treatment and evaluations were conducted at baseline, four weeks, and twelve weeks after treatment. The outcome assessments included subjective satisfaction scale; blinded clinical assessment; and the biophysical parameters of roughness, elasticity, skin hydration, transepidermal water loss (TEWL), erythema, and melanin index. BoNTA group showed higher physician's global assessment score, subject satisfaction score, roughness, skin hydration, skin elasticity, and lower TEWL compared to that of control group at 12 weeks post‐treatment. No significant difference was found among erythema and melanin index at baseline, four, and twelve weeks after treatment among the two major groups. In conclusion, intradermal BoNTA injection can be considered as an effective method for facial rejuvenation.     

Microbotox injection versus its topical application following microneedling in the treatment of wide facial pores: A split face comparative study

Background

Enlarged facial pores and seborrhea are common cosmetic problems. Mesobotox has been proved to be effective safe therapeutic option.

Objective

To compare the efficacy and longevity of intradermal mesobotox injection versus its topical application with microneedling for treatment of wide facial pores and seborrhea.

Materials and Methods

This split face study was conducted on 20 patients with enlarged facial pores and seborrhea. One side of the face was treated with intradermal injection of botulinum toxin, the other was treated with its topical application following microneedling. Patient evaluation was performed after 1 month then after 4 months.

Conclusion

Microbotox can effectively and safely minimize enlarged facial pores with no downtime. Intradermal injection showed more patient satisfaction on the basis of greater efficacy, longevity of treatment than its topical application following microneedling.     

Midface lifting with botulinum toxin: intradermal technique

Background An intradermal injection technique is a variation of the intramuscular or subcutaneous injection technique usually performed with botulinum toxin for facial rejuvenation. The technique applied to realign the imbalance of the facial muscles by weakening the downward pull of the depressors and allowing the levators to contract in a compensatory fashion results in midface lifting and rejuvenation. Aims To address the intradermal injection technique of botulinum toxin for midface lifting. Methods A restrospective review of the patients undergoing midface lifting during the year 2008, the procedure, the details of the injection technique, and outcomes are described. Results An intradermal injection technique of botulinum toxin successfully gives rise to midface lifting and rejuvenation. Conclusion An intradermal injection technique of botuinum toxin treatment is effective for aesthetic improvement in the midface.     

Botulinum toxin A in the treatment of the wrinkles in the upper third of the face

The practice of botulinum toxin injections is unavoidable in the correction of facial aging. In effect botulinum toxin allows to erase dynamic wrinkles, by transient and reversible muscular relaxation. This is the best wrinkle treatment for the upper part of the face: glabellar lines, horizontal forehead lines and crow's feet. This technique requires a good understanding of facial muscular anatomy, in order to correctly apply the basics of injection. Every patient is unique and only a big experience will allow to refine and personalise injections.     

Locking the line of convergence by botulinum toxin type A for the treatment of dynamic forehead wrinkles

Background

Treatment of horizontal forehead lines with botulium toxin type A is a common procedure that helps achieve a youthful and rejuvenated look. Adequate knowledge of the anatomy and an individualized treatment approach is the key to successful treatment outcome.

Aim

To evaluate the cosmetic outcome following treatment of dynamic forehead wrinkles by locking the line of convergence using botulinum toxin type A.

Patients and Methods

Fifty female patients with dynamic forehead wrinkles were included. The line of convergence was identified, and injection points were determined. Patients received injections of botulinum toxin type A in the upper part of the frontalis along the line of convergence. Patients were evaluated before injection and the response was evaluated after 2 weeks and after 3 months of injection.

Results

Post-treatment significant decrease in dynamic wrinkle scale was detected. The distance between the medial and lateral canthi and their corresponding lower brow margins on maximum brow elevation was also significantly decreased after treatment. Meanwhile, the validated brow positioning score revealed no significant change in the resting brow position when pre-and post-treatment scores were compared.

Conclusions

Treating forehead wrinkles by injecting botulinum toxin along the line of convergence is an effective technique that requires less overall amount of toxin, improves the appearance of the wrinkles and minimizes the risk of development of side effects.     

Consensus recommendations on the use of injectable poly-l-lactic acid in Asian patients

Background

Injectable poly-L-lactic acid (PLLA) has been proven safe and effective with numerous medical applications for more than 25 years. The product has been approved in over 40 countries and is being used for soft tissue augmentation in the face and certain body parts. With the increased demand for subtle and natural-looking aesthetic treatments in the Asia-Pacific region, there is also a heightened need for consistent preparation and effective treatment methodologies to optimize outcomes for Asian patients.

Methods

The body of evidence in medical literature, clinical data of presented case reports, and the collective experience of the authors are reflected in these consensus recommendations, which also take under consideration the availability of biostimulators in the Asia-Pacific region.

Results

The resulting consensus recommendations include patient selection and assessment, management of treatment expectations, appropriate preparation and storage, proper injection techniques and treatment plans, management of adverse effects, PLLA combination with other facial rejuvenation procedures, and other constructive considerations.

Conclusions

In the above consensus recommendations, the authors shared their best practices in accordance with the updated preparation and treatment protocols of PLLA. These recommendations represent the clinical and real-world techniques utilized by authors in providing PLLA treatments for Asian patients.     

The evolution of botulinum neurotoxin type A for cosmetic applications.

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

The 'Nefertiti lift': a new technique for specific re-contouring of the jawline.

Botulinum toxin type A (BoNTA) is now used extensively for rejuvenation of the forehead, glabellar and periocular regions and there is increasing focus on treatment of the lower face. Although there is well-documented evidence for the efficacy of botulinum toxin in the correction of platysmal bands, little work has been done to explore its potential role in rejuvenation of the jawline. To date, effects in this area have been reported as a consequence of platysmal banding treatment and are inconsistent. Hesitancy to explore treatment may be due to evidence of a greater, more durable response to the toxin in the lower facial muscles as well as reports of increased potential migration and subsequent side effects. This paper describes a new technique using BoNTA (Vistabel); Allergan, Irvine, CA, USA) to drape the skin of the jawline contour and provide the visual effect of a 'mini lift'. Experience with 130 patients with doses of BoNTA up to 20 U is described. Patient satisfaction is extremely high and the specificity of dosing and technique has led to a low incidence of adverse effects. The 'Nefertiti lift' is a minimally invasive, effective and acceptable alternative for those patients seeking an effective way to push back surgery.     

The evolution of botulinum neurotoxin type A for cosmetic applications

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

The ‘Nefertiti lift’: A new technique for specific re‐contouring of the jawline

Botulinum toxin type A (BoNTA) is now used extensively for rejuvenation of the forehead, glabellar and periocular regions and there is increasing focus on treatment of the lower face. Although there is well‐documented evidence for the efficacy of botulinum toxin in the correction of platysmal bands, little work has been done to explore its potential role in rejuvenation of the jawline. To date, effects in this area have been reported as a consequence of platysmal banding treatment and are inconsistent. Hesitancy to explore treatment may be due to evidence of a greater, more durable response to the toxin in the lower facial muscles as well as reports of increased potential migration and subsequent side effects.

This paper describes a new technique using BoNTA (Vistabel®; Allergan, Irvine, CA, USA) to drape the skin of the jawline contour and provide the visual effect of a ‘mini lift’. Experience with 130 patients with doses of BoNTA up to 20 U is described. Patient satisfaction is extremely high and the specificity of dosing and technique has led to a low incidence of adverse effects. The ‘Nefertiti lift’ is a minimally invasive, effective and acceptable alternative for those patients seeking an effective way to push back surgery.     

Decades of beauty: Achieving aesthetic goals throughout the lifespan

Background

Several elements, including age, influence judgments of beauty and attractiveness. Aging is affected by intrinsic factors (e.g., genetics, race/ethnicity, anatomical variations) and extrinsic factors (e.g., lifestyle, environment).

Aims

To provide a general overview of minimally invasive injectable procedures for facial beautification and rejuvenation to meet the aesthetic goals of patients across their lifespan, organized by decade.

Methods

This case study review describes aesthetic considerations of females in their third to sixth decade of life (i.e., 20–60 years of age or beyond). Each case study reports the treatments, specifically botulinum toxin type A and soft tissue fillers, used to address aesthetic concerns.

Results

Signs of aging, as well as aesthetic goals and motivations, vary by age groups, cultures, and races/ethnicities. However, there are overarching themes that are associated with each decade of life, such as changes in overall facial shape and specific facial regions, which can be used as a starting point for aesthetic treatment planning. Appropriate patient selection, thorough aesthetic evaluation, product knowledge, and injection technique, as well as good physician-patient communication, are essential for optimal treatment outcomes.

Conclusions

Nonsurgical facial injectable treatments can successfully enhance and rejuvenate facial features across different age ranges. A comprehensive understanding of facial aging and the aesthetic considerations of patients by the decade contributes to optimal treatment planning and maintenance.     

Pharmacologic denervation of frown muscles enhances baseline expression of happiness and decreases baseline expression of anger,sadness, and fear

BACKGROUND: Individuals with intense frowning are commonly perceived as expressing negative emotions. Anger, fear, and sadness are associated with corrugator ("frown") muscle activity. OBJECTIVE: We sought to study how faces were perceived by others after denervation of frown muscles with localized botulinum toxin injections for treatment of facial frown lines. METHODS: Facial photographs were taken from volunteers before and after botulinum toxin injection. These photographs were shown to viewers who were naive to the procedure and asked to rate the expressed intensity of anger, sadness, fear, and happiness. As reference for this task we used a standard set of pictures of facial affect displaying different intensity levels for each emotion tested. RESULTS: Of 40 viewers, 39 were able to discriminate different intensity levels (0%, 25%, 50%, 75%, and 100%) of emotional affect in the control task. According to their ratings faces with denervated frown muscle activity expressed relatively less anger (-40%), fear (-49%), sadness (-10%), and more happiness (+71%). CONCLUSION: Frown muscle activity is essential for both negative and positive emotional expressions. Temporary denervation using botulinum toxin enhances the facial expression of positive emotion resulting in a shift rather than a loss of facial affect.     

Botulinum toxin A in the therapy of mimic facial lines

In aesthetic medicine, many different methods of skin rejuvenation are available. At the end of the 1980s, the neurotoxin Botulinum toxin A (BT-A) led to a revolution in aesthetic-corrective dermatology for the treatment of mimic facial wrinkles. The toxin is produced by Clostridium botulinum and causes a reversible, selective muscle relaxation that leads to a temporary flattening of the mechanical part of wrinkling without the stigmata of invasive surgery. After two decades of experience in different medical disciplines, there has been remarkable clinical development and progress in research, the identification of new botulinum toxin serotypes, and also innovation in indications and combined modalities. These lead to new and interesting questions. BT-A offers the experienced, critical dermatologist a time-saving, effective, cosmetically satisfactory, non-invasive treatment for mimic facial wrinkles and neck and decollete lines, with only minor side effects. Dermatologists should have a profound anatomical knowledge and should be able to perform all injection techniques to meet the needs of ever more demanding patients and to ensure optimization of patient satisfaction. The following review summarizes the historical development and the mechanism of action of both frequently and rarely used injection techniques with BT-A for the treatment of wrinkles and lines of the upper face, neck and décolleté, and gives an update of different experiences encountered.     

A case of dysphagia following botulinum toxin injection for neck rejuvenation

Botulinum toxin type A (BTX‐A) is now extensively employed for cosmetic concerns. Upper face rejuvenation, including glabella frown lines and crow's feet lines, received FDA approval for cosmetic uses. However, other off‐label uses for lower face conditions have been employed for texture and contouring purposes, including masseter hypertrophy and vertical banding of the neck. BTX‐A for rejuvenation of the aging neck is an effective and popular treatment with high patient satisfaction rates. Alleviating the aging appearance of the neck by BTX‐A is the result of denervation of hyperkinetic platysma. Concerning an extensive area of treatment and the relationship of treated muscles with other nearby muscles, dermatologists should be aware of potential adverse effects of the BTX‐A injection. We herein present a case of dysphagia following botulinum toxin injection for the treatment of platysma bands.     

The cosmetic use of botulinum toxin type B in the upper face

Facial wrinkles involving the forehead, glabellar, and/or periorbital regions are a common esthetic problem and are directly related to overactivity of the underlying facial musculature. For instance, the development of glabellar wrinkles is related, at least in part, to the dynamics of the underlying procerus, corrugator supercilii, and orbicularis oculi muscles. Facial lines are considered problematic because they produce the appearance of aging. In some cases, they can also be misinterpreted as manifestations of negative emotions (eg, anger, anxiety, sadness), fatigue, or stress. In recent years, botulinum toxin injections have become one of the most popular therapies for the treatment of hyperfunctional facial lines. After injection, the toxin acts to paralyze or weaken facial mimetic muscles. This reduces or eliminates the appearance of wrinkles and is extremely safe.     

International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit) – part II: wrinkles on the middle and lower face,neck and chest

Background Azzalure^® (Galderma SA), a newly approved European botulinum neurotoxin type A (BoNT‐A), is derived from Dysport? (Ipsen Ltd.), which has a 20‐year history of product consistency and has been widely used for various aesthetic and therapeutic applications. Azzalure^® and Dysport? are collectively referred to as BoNT‐A (Speywood Unit) after the unit of their activity, and are distinct from other commercial BoNT‐A preparations. Consensus has been developed for the treatment of upper facial wrinkles with BoNT‐A (Speywood Unit). Objective To provide consensus recommendations on the treatment with BoNT‐A (Speywood Unit) for wrinkles on the middle and lower face, neck and chest region. Methods The members of the International Board on Botulinum toxin Azzalure (IBBA) convened to develop consensus based on their extensive experience. Results The recommended final concentration of BoNT‐A (Speywood Unit) is 200 Speywood Units/ml after reconstitution. The consensus recommendations were provided for nine indications, including lower eyelid wrinkles, bunny lines, drooping nasal tip, perioral wrinkles, masseter hypertrophy, drooping mouth corners, dimpled chin, platysmal bands and décolleté wrinkles. For each indication, anatomy of the region to be treated was discussed, as were potential side‐effects. The consensus recommendations included the number and location of the injection points, dose range of each point and the total injection, as well as specific injection technique. Conclusion These recommendations provide a guideline for physicians who wish to perform safe and efficacious treatment with BoNT‐A (Speywood Unit) on the less commonly treated middle and lower face, neck and chest region.     

Advanced botulinum toxin techniques against wrinkles in the upper face

The use of botulinum toxin type A for facial rejuvenation is one of the most common procedure in esthetic medicine. Overall clinical and study experience with botulinum toxin type A for facial enhancement has confirmed that it is effective and safe even in the long term. The different injection techniques, the starting doses, the sex, the dilution, and the storing of the product, nevertheless, may influence the final result of the treatment. In this article we propose some recommendations including general principles as well as information about its specific use. Perhaps one of the most important perspectives is that, based on a well-established knowledge of the technique, individualized esthetic planning is the key to success. This depends on a precise understanding of the underlying anatomy and physiology of the individual muscles and their interactions, as well as on individual patient's characteristics, including goals and expectations.     

射频联合A型肉毒毒素改善下面部松弛的临床观察

 

目的:探讨射频联合A型肉毒毒素注射改善下面部松弛的临床疗效及安全性。方法：纳入40例要求改善下面部松弛的求美者,随机分为对照组和试验组各20例,对照组采用A型肉毒毒素颈阔肌注射治疗,试验组采用下面部射频治疗联合A型肉毒毒素颈阔肌注射治疗,分别于治疗前,治疗后1、3及6个月对求美者进行标准化摄影,采用Photoshop CS6测量两组治疗前后下面部提升的距离和角度,采用重复测量方差分析方法对数据进行统计学处理。结果：40例求美者均完成治疗。对照组与试验组相比,治疗1、3个月后下颌缘轮廓缩小及提升差异不明显;治疗后6个月下颌缘轮廓缩小及提升差异明显（P值均＜0.05）。结论：射频联合A型肉毒毒素注射可改善下面部松弛,提高远期疗效,且疗效可靠、安全,值得临床推广应用。

     

Botulinum toxin types A and B: comparison of efficacy, duration, and dose-ranging studies for the treatment of facial rhytides and hyperhidrosis

One of the most common etiologic forces for the persistence of facial rhytides is the repetitive contraction of the intrinsic muscles that are necessary for facial expression. These include the forehead lines, crow's feet, glabellar rhytides, and wrinkles in the lower face. Although filling agents such as collagen and laser procedures can help reduce the appearance of these lines, they do not address the underlying forces that cause these wrinkles to persist. Botulinum toxin type-A and type-B are neurotoxins that address these issues and result in the relaxation of the intrinsic facial muscles and subsequent resolution of these dynamic facial rhytides. This article will compare the efficacy, duration, dose ranging studies, and safety in the treatment of facial rhytides with both types of toxins. In addition, the treatment of hyperhidrosis with type-A and type-B botulinum toxin will also be discussed.     

Botulinum Toxin

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