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

April 2020 | Volume 19 | Issue 4 | Supplement Individual Articles | 35 | Copyright © April 2020

Published online March 20, 2020

Michael S. Kaminer MD,a-c Sue Ellen Cox MD,d Steven Fagien MD FACS,e Joely Kaufman MD,f Mary P. Lupo MD,g Ava Shamban MDh

aDepartment of Dermatology, Yale School of Medicine, New Haven, CT bDepartment of Dermatology, Brown Medical School, Providence, RI cSkin Care Physicians, Inc, Chestnut Hill, MA dAesthetic Solutions PA, Chapel Hill, NC eSteven Fagien MD, Boca Raton, FL fSkin Associates of South Florida/Skin Research Institute, Coral Gables, FL gLupo Center for Aesthetic and General Dermatology, New Orleans, LA hAVA MD, SKIN FIVE, Los Angeles, CA

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

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Erratum published for this article here.


Selective weakening of the muscles of facial expression with BoNT-A has been found to improve the appearance of the overlying rhytides caused by muscle activity. Since the first BoNT-A was approved for aesthetic use, the evolution and creativity of BoNT-A use have been swift and ever changing. The number of approved BoNT-A agents and their indications have grown, with additional approvals expected in the future. With their high level of patient satisfaction,1 BoNT-A injections are the most common nonsurgical cosmetic procedures in the United States,2 confirming their integral role in facial aesthetics.

The aesthetic use of BoNT-As is driven by general principles common to all 4 BoNT-A products as well as unique characteristics of each. Knowledge of the science and innovation behind these different agents and the underlying anatomy enables aesthetic physicians to provide patients with a variety of treatment options.3 Individual patient assessment, injection site selection, dosing, and follow-up are critical for optimal results.4 Over time, there has been a paradigm shift toward neuromodulation with BoNT-As rather than paralysis5 and an evolution in the patient base with regard to age, gender, and ethnicity, so that aesthetic physicians who want to excel must be dedicated to continued learning. 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 ASDS meeting in Chicago, IL. Their objective was to assess recent advances in BoNT-A use in facial aesthetics. This publication summarizes key discussions from the meeting and provides clinical considerations for current use of BoNT-A, including changes in the patient population, the impact of patient anatomy, similarities of and differences between the 4 approved agents, evolving use of BoNT-As throughout the face, how approval of a new BoNT-A affects clinical practice, and agents on the horizon. Nonreferenced statements represent the opinions of the panel and are not intended to be statements of fact.

While there has always been variation amongst practices, there has recently been an increase in the number of patients under age 30 coming in for initial BoNT-A treatment. Many aesthetic practices are also seeing a growing number of people age 70 and above for the first time, who traditionally hadn’t come in before. There are many reasons for these demographic changes. Social media has become an essential way for people to connect and communicate. The importance of physical appear-