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.     

Comparison of microwave ablation,botulinum toxin injection,and liposuction-curettage in the treatment of axillary hyperhidrosis: A systematic review

Background: Primary focal axillary hyperhidrosis is a disorder of excessive sweating that can strongly impact quality of life. Objective: The objective if this study was to compare microwave ablation (MA), botulinum toxin (BT) injection, and liposuction-curettage (LC) in the treatment of primary axillary hyperhidrosis based on subjective and objective criteria. Methods: A systematic review of the literature published in French or English between 1 January 1991 and 1 February 2015 was completed using PubMed and Embase databases. Results: 16 of 775 articles were selected based on relevance and criteria of inclusion and exclusion. The three methods proved to be efficient and safe; however, MA and BT had better results when compared to LC in the short term. Both MA and LC showed longer lasting results when compared to BT. However, in the long term, MA was superior to LC. Conclusion: MA, LC, and BT injections are safe and efficient minimally invasive alternatives for the treatment of axillary hyperhidrosis. Well-designed randomized controlled trials are needed to further compare the efficacy of these techniques.     

Dermal and epidermal remodeling using botulinum toxin type A for facial, non reducible, hyperkinetic lines: two case studies

Background  Many studies confirm the safety and efficacy of botulinum toxin type A in a variety of clinical indications. Its use for treatment of hyperfunctional facial lines has become the most popular cosmetic procedure. These case studies comprise an evaluation of the long-term treatment of two subjects treated with botulinum toxin type A (BOTOX®, Allergan, Irvine, CA, USA) for hyperfunctional, nonreducible, facial lines.
Aims  This paper aims to assess the long-term effectiveness of BOTOX treatment for hyperfunctional facial lines in two subjects over 7 years.
Patients/methods  Two subjects (case 1: female aged 53 years; case 2: male age 50 years) presenting with glabelar, forehead, and periorbital facial lines were treated with BOTOX over a 7-year period. Case 1 received a total of 24 treatments at 4-monthly intervals, and case 2 received 21 treatments at 3- to 6-monthly intervals.
Results  Skin quality continued to improve over time, revealing a smoother, enhanced, yet "natural" look. In particular, nonreducible forehead lines were effaced suggesting dermal and epidermal remodeling over long-term treatment. There was no evidence of development of any new wrinkles secondary to BOTOX use, and both subjects continue to report high levels of treatment satisfaction. No safety issues were raised.
Conclusions  These case studies demonstrate that nonreducible horizontal forehead lines can show long-term reduction with BOTOX treatment and high levels of subject satisfaction.     

Treatment of glabellar lines with botulinum toxin type A (Speywood Unit): a clinical overview

Azzalure (Galderma) is a newly approved European botulinum neurotoxin type A (BoNT-A) specifically designed for aesthetic usages. It is sourced from Dysport (Ipsen Ltd.), which has a 20-year product consistency and has been used widely for various therapeutic and aesthetic applications. Azzalure and Dysport are collectively referred to as BoNT-A (Speywood Unit; s.U) (or abobotulinumtoxinA in the U.S.) after their biological activity unit, which is unique and not interchangeable with units of other commercial BoNT-A preparations. Azzalure is approved for the treatment of moderate-to-severe glabellar lines, with a total dose of 50 s.U distributed evenly among 5 injection points. To ensure optimal treatment outcomes with BoNT-A (s.U), it is crucial for injectors to adopt proper methods of reconstitution and injection, which can be acquired through training. We review here the method of reconstitution for BoNT-A (s.U), as well as the injection dose, points and techniques for glabellar line treatment. We also review the efficacy and safety results of BoNT-A (s.U) demonstrated in 11 clinical studies, most of which were randomized, double-blind and placebo-controlled. The studies included assessments after single injections as well as after up to 6 repeated treatment sessions. We summarize the clinical efficacy results, which include the responder rate 1 month post-injection, onset of response and duration of action, as well as safety results, which include incidence of treatment-emergent adverse events and specifically eyelid ptosis. The efficacy and safety profiles reported here are unique to BoNT-A (s.U) and cannot be generalized to other BoNT-A products.     

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.     

Specific aspects of a combined approach to male face correction: botulinum toxin A and volumetric fillers

Cosmetologists in the last decade face a permanently increasing number of male patients. The necessity of a gender‐adjusted approach in treatment of this patient category is obvious. An adequate correction requires consideration of the anatomic and physiologic features of male faces together with a whole set of interrelated aspects of psychologic perception of the male face esthetics, socially formed understanding of masculine features and appropriate emotional expressions, also of the motivations and expectations of men coming to a cosmetologist. The author explains in detail the elaborated out of own vast experience methods of complex male face correction using the above‐mentioned gender‐specific approach to create a naturally looking and harmonic facial expression and appearance. The presented botulinum therapy specifics concern the injection point location and toxin doses for every point. As a result, a rather distinct smoothening of the skin profile without detriment to the facial expressiveness and gender‐related features is achieved. The importance and methods of an extremely delicate approach to volumetric plasty with stabilized hyaluronic acid‐based fillers in men for avoiding hypercorrection and retaining the gender‐specific features are discussed.     

Two cases of Hidradenitis suppurativa and botulinum toxin type a therapy: A novel approach for a pathology that is still difficult to manage

Hidradenitis suppurativa is a chronic skin disease with an intense inflammatory activation. It typically affects the intertriginous areas with cysts, fistulae, and scarring extremely painful. Patients suffer from severe psychological impact. HS still results in a high unmet medical need with several underdiagnosed cases, probably due to the incomplete knowledge of the pathogenesis of HS. The use of botulinum toxin a has recently been proposed as an effective therapy for HS.     

International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit) – part I: upper facial wrinkles

Background Azzalure (Galderma SA) is a newly approved European botulinum neurotoxin type A (BoNT‐A). It is derived from Dysport (Ipsen Pharma), which has a long history of usages in various applications. Azzalure and Dysport are collectively referred to as BoNT‐A (Speywood Unit) and are different from other BoNT‐A preparations. Objective To provide consensus recommendations on the treatment of upper face wrinkles with BoNT‐A (Speywood Unit). Methods The members of the International Board on Botulinum toxin Azzalure (IBBA) convened to develop consensus on the treatment of upper facial wrinkles based on their own extensive experience. Results The consensus recommendations address the general issues regarding treatment and provide specific guidelines on the anatomy, injection points, dose, injection technique and safety precautions concerning each common upper face indication. The recommended final concentration of BoNT‐A (Speywood Unit) is 200 s.U/mL (10 s.U/0.05 mL) after reconstitution. For glabellar lines, the members recommend a total of five injection points with 10 s.U/point. For forehead wrinkles, the members recommend four to six injections into the frontalis with 5–10 s.U/point. For crow’s feet, the members recommend three injections per side with 5–10 s.U/point at the lateral part of the orbicularis oculi. For lateral eyebrow lift , the members recommend one point at each eyebrow tail and an additional one in each side of the frontalis with 5–10 s.U/point. Conclusion This guideline provides a framework for physicians who wish to perform safe and efficacious injection of BoNT‐A (Speywood Unit).     

Rejuvenation of periocular region in Koreans: A multimodal approach combining botulinum toxin,fillers, and micro‐focused ultrasound with visualization for optimal results

Periorbital aging involves all layers of the skin, fat, and the bony orbit. Therefore, a multimodal approach is necessary. Twenty Korean subjects who required periorbital rejuvenation were enrolled in this study. First, micro‐focused ultrasound with visualization (MFU‐V) was performed across the supra‐brow area, lateral canthus, and the infraorbital area. Next, the filler was injected into the sunken upper eyelid, lateral eyebrow, and the infraorbital area. Lastly, botulinum toxin was administered into the forehead, glabella, crow's feet, and the lateral orbital rim below the brow on the same day. Photographs were taken at baseline; immediately after treatment; and at 1, 4, and 12 weeks of follow‐up. The average eyebrow height was increased by 3.5 mm, and the maximum height was elevated by 3.9 mm at week 12. Physician visual analogue scale (VAS) scores regarding the whole periorbital area and eyebrow ptosis were continuously improved throughout the observation period. Physician VAS scores for infraorbital hollow and superior sulcus deformity improved immediately after the procedure and were maintained at week 12. Adverse events were mild and transient. We believe that a multimodal approach combining MFU‐V, fillers, and botulinum toxin results in significant periocular rejuvenation.     

Safety of long-term treatment with cyclosporin A in resistant chronic plaque psoriasis: a retrospective case series

BACKGROUND: An intermittent short course of cyclosporin A (CyA) therapy is a good choice in the treatment of severe psoriasis. Nevertheless, some severe or resistant patients might benefit from long-term treatment. Adverse effects of long-term use of CyA are investigated and the results are compared with the literature. PATIENTS AND METHODS: A retrospective study of adverse effects of CyA treatment in a group of 53 patients suffering from psoriasis. The mean treatment time was 31.4 +/- 23.2 months with a minimum of 4 months to a maximum of 95 months, with very few short interruptions of treatment (from 2 to 5 months in five patients). RESULTS: The group consisted of 29 women and 24 men, ranging in age from 18 to 65 years, with an average age of 44.49 years. Arterial hypertension appeared in 45.3% of patients during treatment. Pharmacological treatment was required in 32% of these patients to control the condition. Serum creatinine levels were transiently elevated in 11.3% of the cases, but withdrawal of treatment was required in none of them. DISCUSSION: Long-term CyA treatment might be necessary in some patients and this study shows that it could be sustained with a close follow-up. This involves regular visits depending on each patient, as well as common test protocol and clinical evaluation. In conclusion, this retrospective study seems to confirm the relative safety of long-term CyA treatment when patients are adequately monitored.     

Successful treatment of interstitial lung disease related to Stevens–Johnson syndrome/toxic epidermal necrolysis overlap with etanercept: A case report and published work review

Interstitial lung disease (ILD) is a rare complication of Stevens–Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). In this study, we present the case of a 33‐year‐old woman who was diagnosed with ILD related to SJS/TEN overlap syndrome. Surprisingly, the patient did not respond to combination therapy with steroids and i.v. immunoglobulin, but rapidly improved after two doses of etanercept treatment. To our knowledge, this is the first case of SJS/TEN‐induced ILD that was successfully treated with etanercept. We reviewed another two cases of ILD associated with SJS/TEN, and found that unlike the other cases, in the present case, ILD occurred early in the course of the disease and rapidly improved after etanercept injection. We discovered that in the present patient, the serum interleukin‐6 level increased during the progressive stage and declined after the initiation of treatment with etanercept.     

Comorbidities and health‐related quality of life in Spanish patients with moderate to severe psoriasis: A cross‐sectional study (Arizona study)

Psoriasis is a common, chronic inflammatory immunologically mediated disease of the skin, showing a high prevalence of associated comorbidities, and strongly affecting patients' health‐related quality of life (HR‐QOL), with profound impact on the psychological aspect. We aimed to establish the correlation between HR‐QOL and the associated comorbidities in patients with moderate to severe psoriasis in Spain. A cross‐sectional, observational, epidemiological study was conducted at 68 dermatology‐based centers across Spain. From October 2010 to June 2011, all adult patients diagnosed with moderate to severe psoriasis at least 6 months prior to the study visit and receiving or not receiving treatment for psoriasis were eligible for inclusion. A total of 1022 patients were included. The study population showed mean 36‐item short‐form (SF‐36) physical and mental health scores and Dermatological Life Quality Index (DLQI) of 49.7, 46.2 and 5.3, respectively. The multiple linear regression models showed that patients with moderate to severe psoriasis and a diagnosis of psoriatic arthritis (PsA), hypertension, diabetes mellitus, sleep disturbances or obesity were found to have lower SF‐36 health physical scores. Female patients with depression or anxiety disorders had lower SF‐36 health mental scores. Patients diagnosed with moderate to severe psoriatic disease and associated anxiety disorder had greater DLQI scores. Moderate to severe psoriasis has a significant burden on the HR‐QOL of patients. Regardless of sex, patients with several comorbidities such as PsA, hypertension or obesity were found to have worse scores in the physical component of the QOL questionnaire, whilst women were more affected in the mental health component than men.