ABOUT FACE SUMMARY POINTS
Four BTXA products are commercially available for cosmetic use
Practitioners who are new to BTXA use should consider gaining expertise with one product before adopting another.
Practitioners might vary the diluent volume used to reconstitute BTXA products, depending on site of injection, treatment goals, patient-specific characteristics, and mathematical ease of dose conversion among products.
An individualized approach to BTXA injection is important for achieving the best results.
- Their potency units are not interchangeable and cannot be directly compared
- All are good products, but some patients respond differently to different BTXA products
- Several reviews and experts suggest the ratio for aboBTXA:onaBTXA is between 2:1 and 3:1
- Several reviews suggest the ratio for incoBTXA:onaBTXA is 1:1, but some experts believe it is higher (between 1.2:1 and 1.5:1)
Practitioners who are new to BTXA use should consider gaining expertise with one product before adopting another.
Practitioners might vary the diluent volume used to reconstitute BTXA products, depending on site of injection, treatment goals, patient-specific characteristics, and mathematical ease of dose conversion among products.
An individualized approach to BTXA injection is important for achieving the best results.
- Dose selection and placement of BTXA injections should consider muscle size, strength, and recruitment along with facial asymmetry and sex differences in anatomy and facial aesthetics
- Optimal rejuvenation of the aging face may require multimodal treatment
- Interventions can be offered to patients bothered by posttreatment bruising, eyelid ptosis, and lid edema
REFERENCES
1. Botox [package insert]. Irvine, CA: Allergan; 2019.
2. Brin MF, James C, Maltman J. Botulinum toxin type A products are not interchangeable: a review of the evidence. Biologics. 2014;8:227-241.
3. Dysport [package insert]. Wrexham, UK: Ipsen Biopharm Ltd; and Dallas, TX: Galderma Laboratories, LP; 2019.
4. Walker TJ, Dayan SH. Comparison and overview of currently available neurotoxins. J Clin Aesthet Dermatol. 2014;7(2):31-39.
5. Xeomin [package insert]. Franksville, WI: Merz North America, Inc; 2019.
6. Jeuveau [package insert]. Santa Barbara, CA: Evolus Inc; 2019.
7. Kumar R, Dhaliwal HP, Kukreja RV, Singh BR. The botulinum toxin as a therapeutic agent: molecular structure and mechanism of action in motor and sensory systems. Semin Neurol. 2016;36(1):10-19.
8. Bryant AM, Davis J, Cai S, Singh BR. Molecular composition and extinction coefficient of native botulinum neurotoxin complex produced by Clostridium botulinum hall A strain. Protein J. 2013;32(2):106-117.
9. Eisele KH, Fink K, Vey M, Taylor HV. Studies on the dissociation of botulinum neurotoxin type A complexes. Toxicon. 2011;57(4):555-565.
10. Ghosal KJ, Patel K, Singh BR, Hale ML. Role of critical elements in botulinum neurotoxin complex in toxin routing across intestinal and bronchial barriers. PLoS One. 2018;13(7):e0199524.
11. Scaglione F. Conversion ratio between Botox®, Dysport®, and Xeomin® in clinical practice. Toxins (Basel). 2016;8(3).
12. Samizadeh S, De Boulle K. Botulinum neurotoxin formulations: overcoming the confusion. Clin Cosmet Investig Dermatol. 2018;11:273-287.
13. Frevert J. Pharmaceutical, biological, and clinical properties of botulinum neurotoxin type A products. Drugs R D. 2015;15(1):1-9.
14. Karsai S, Raulin C. Current evidence on the unit equivalence of different botulinum neurotoxin A formulations and recommendations for clinical practice in dermatology. Dermatol Surg. 2009;35(1):1-8.
15. Prager W, Rappl T. Phase IV study comparing incobotulinumtoxinA and onabotulinumtoxinA using a 1:1.5 dose-conversion ratio for the treatment of glabellar frown lines. J Cosmet Dermatol. 2012;11(4):267-271.
16. Kane MA, Gold MH, Coleman 3rd WP, et al. A randomized, double-blind trial to investigate the equivalence of incobotulinumtoxinA and onabotulinumtoxinA for glabellar frown lines. Dermatol Surg. 2015;41(11):1310-1319.
17. Allergan. Dose, Dilution, Reconstitution, and Injection Techniques. Madison, NJ: Allergan; 2017. https://hcp.botoxcosmetic.com/~/media/Unique Sites/BotoxCosmeticHCP/Files/PDFs/BHCP-0231_Injection_Dosing.pdf. Accessed December 6, 2019.
18. Dysport (abobotulinumtoxinA) 1.5 ML Reconstitution. Dallas, TX: Galderma Laboratories, LP; 2019. https://www.dysportusa.com/Content/pdfs/DYS- 161-Reconstitution-Guide.pdf. Accessed December 6, 2019.
19. Alam M, Dover JS, Arndt KA. Pain associated with injection of botulinum A exotoxin reconstituted using isotonic sodium chloride with and without preservative: a double-blind, randomized controlled trial. Arch Dermatol. 2002;138(4):510-514.
20. Kaufman J, Cohen JL, Peredo MI, Jonas B, Down R, Nogueira A. Clinical assessment of 2 licensed abobotulinumtoxinA injection volumes for the treatment of glabellar lines. Dermatol Surg. 2019;45(10):1274-1284.
21. Carruthers A, Carruthers J, Cohen J. Dilution volume of botulinum toxin type A for the treatment of glabellar rhytides: does it matter? Dermatol Surg. 2007;33(1 spec no.):S97-S104.
22. de Almeida AR, da Costa Marques ER, Banegas R, Kadunc BV. Glabellar contraction patterns: a tool to optimize botulinum toxin treatment. Dermatol Surg. 2012;38(9):1506-1515.
23. Jiang H, Zhou J, Chen S. Different glabellar contraction patterns in Chinese and efficacy of botulinum toxin type A for treating glabellar lines: a pilot study. Dermatol Surg. 2017;43(5):692-697.
24. Macdonald MR, Spiegel JH, Raven RB, Kabaker SS, Maas CS. An anatomical approach to glabellar rhytids. Arch Otolaryngol Head Neck Surg. 1998;124(12):1315-1320.
25. Morton LM, Smith KC, Dover JS, Arndt KA. Treatment of purpura with lasers and light sources. J Drugs Dermatol. 2013;12(11):1219-1222.
26. King M. Management of ptosis. J Clin Aesthet Dermatol. 2016;9(12):E1-E4.
27. Scheinfeld N. The use of apraclonidine eyedrops to treat ptosis after the administration of botulinum toxin to the upper face. Dermatol Online J. 2005;11(1):9.
28. Wijemanne S, Vijayakumar D, Jankovic J. Apraclonidine in the treatment of ptosis. J Neurol Sci. 2017;376:129-132.
29. Chang YS, Chang CC, Shen JH, Chen YT, Chan KK. Nonallergic eyelid edema after botulinum toxin type A injection: case report and review of literature. Medicine (Baltimore). 2015;94(38):e1610.
30. de Almeida ART, Carruthers J. Platysma, Nefertiti lift, and beyond. In: Botulinum Toxin: Procedures in Cosmetic Dermatology. 4th ed. Edinburgh, UK: Elsevier; 2017:145-151.
31. Levy PM. The ‘Nefertiti lift’: a new technique for specific re-contouring of the jawline. J Cosmet Laser Ther. 2007;9(4):249-252.
2. Brin MF, James C, Maltman J. Botulinum toxin type A products are not interchangeable: a review of the evidence. Biologics. 2014;8:227-241.
3. Dysport [package insert]. Wrexham, UK: Ipsen Biopharm Ltd; and Dallas, TX: Galderma Laboratories, LP; 2019.
4. Walker TJ, Dayan SH. Comparison and overview of currently available neurotoxins. J Clin Aesthet Dermatol. 2014;7(2):31-39.
5. Xeomin [package insert]. Franksville, WI: Merz North America, Inc; 2019.
6. Jeuveau [package insert]. Santa Barbara, CA: Evolus Inc; 2019.
7. Kumar R, Dhaliwal HP, Kukreja RV, Singh BR. The botulinum toxin as a therapeutic agent: molecular structure and mechanism of action in motor and sensory systems. Semin Neurol. 2016;36(1):10-19.
8. Bryant AM, Davis J, Cai S, Singh BR. Molecular composition and extinction coefficient of native botulinum neurotoxin complex produced by Clostridium botulinum hall A strain. Protein J. 2013;32(2):106-117.
9. Eisele KH, Fink K, Vey M, Taylor HV. Studies on the dissociation of botulinum neurotoxin type A complexes. Toxicon. 2011;57(4):555-565.
10. Ghosal KJ, Patel K, Singh BR, Hale ML. Role of critical elements in botulinum neurotoxin complex in toxin routing across intestinal and bronchial barriers. PLoS One. 2018;13(7):e0199524.
11. Scaglione F. Conversion ratio between Botox®, Dysport®, and Xeomin® in clinical practice. Toxins (Basel). 2016;8(3).
12. Samizadeh S, De Boulle K. Botulinum neurotoxin formulations: overcoming the confusion. Clin Cosmet Investig Dermatol. 2018;11:273-287.
13. Frevert J. Pharmaceutical, biological, and clinical properties of botulinum neurotoxin type A products. Drugs R D. 2015;15(1):1-9.
14. Karsai S, Raulin C. Current evidence on the unit equivalence of different botulinum neurotoxin A formulations and recommendations for clinical practice in dermatology. Dermatol Surg. 2009;35(1):1-8.
15. Prager W, Rappl T. Phase IV study comparing incobotulinumtoxinA and onabotulinumtoxinA using a 1:1.5 dose-conversion ratio for the treatment of glabellar frown lines. J Cosmet Dermatol. 2012;11(4):267-271.
16. Kane MA, Gold MH, Coleman 3rd WP, et al. A randomized, double-blind trial to investigate the equivalence of incobotulinumtoxinA and onabotulinumtoxinA for glabellar frown lines. Dermatol Surg. 2015;41(11):1310-1319.
17. Allergan. Dose, Dilution, Reconstitution, and Injection Techniques. Madison, NJ: Allergan; 2017. https://hcp.botoxcosmetic.com/~/media/Unique Sites/BotoxCosmeticHCP/Files/PDFs/BHCP-0231_Injection_Dosing.pdf. Accessed December 6, 2019.
18. Dysport (abobotulinumtoxinA) 1.5 ML Reconstitution. Dallas, TX: Galderma Laboratories, LP; 2019. https://www.dysportusa.com/Content/pdfs/DYS- 161-Reconstitution-Guide.pdf. Accessed December 6, 2019.
19. Alam M, Dover JS, Arndt KA. Pain associated with injection of botulinum A exotoxin reconstituted using isotonic sodium chloride with and without preservative: a double-blind, randomized controlled trial. Arch Dermatol. 2002;138(4):510-514.
20. Kaufman J, Cohen JL, Peredo MI, Jonas B, Down R, Nogueira A. Clinical assessment of 2 licensed abobotulinumtoxinA injection volumes for the treatment of glabellar lines. Dermatol Surg. 2019;45(10):1274-1284.
21. Carruthers A, Carruthers J, Cohen J. Dilution volume of botulinum toxin type A for the treatment of glabellar rhytides: does it matter? Dermatol Surg. 2007;33(1 spec no.):S97-S104.
22. de Almeida AR, da Costa Marques ER, Banegas R, Kadunc BV. Glabellar contraction patterns: a tool to optimize botulinum toxin treatment. Dermatol Surg. 2012;38(9):1506-1515.
23. Jiang H, Zhou J, Chen S. Different glabellar contraction patterns in Chinese and efficacy of botulinum toxin type A for treating glabellar lines: a pilot study. Dermatol Surg. 2017;43(5):692-697.
24. Macdonald MR, Spiegel JH, Raven RB, Kabaker SS, Maas CS. An anatomical approach to glabellar rhytids. Arch Otolaryngol Head Neck Surg. 1998;124(12):1315-1320.
25. Morton LM, Smith KC, Dover JS, Arndt KA. Treatment of purpura with lasers and light sources. J Drugs Dermatol. 2013;12(11):1219-1222.
26. King M. Management of ptosis. J Clin Aesthet Dermatol. 2016;9(12):E1-E4.
27. Scheinfeld N. The use of apraclonidine eyedrops to treat ptosis after the administration of botulinum toxin to the upper face. Dermatol Online J. 2005;11(1):9.
28. Wijemanne S, Vijayakumar D, Jankovic J. Apraclonidine in the treatment of ptosis. J Neurol Sci. 2017;376:129-132.
29. Chang YS, Chang CC, Shen JH, Chen YT, Chan KK. Nonallergic eyelid edema after botulinum toxin type A injection: case report and review of literature. Medicine (Baltimore). 2015;94(38):e1610.
30. de Almeida ART, Carruthers J. Platysma, Nefertiti lift, and beyond. In: Botulinum Toxin: Procedures in Cosmetic Dermatology. 4th ed. Edinburgh, UK: Elsevier; 2017:145-151.
31. Levy PM. The ‘Nefertiti lift’: a new technique for specific re-contouring of the jawline. J Cosmet Laser Ther. 2007;9(4):249-252.
Instant CME/CE certificate available with online testing and course evaluation at http://tinyurl.com/AboutFaceJDD.
CME/CE Posttest Questions: To obtain CME/CE credit for this activity, complete the CME/CE Posttest and course evaluation online at http://tinyurl.com/AboutFaceJDD. Upon successful completion of the posttest and evaluation, you will be able to generate an instant certificate of credit. See detailed instructions at How to Obtain CME/CE Credit.
CME/CE Posttest Questions: To obtain CME/CE credit for this activity, complete the CME/CE Posttest and course evaluation online at http://tinyurl.com/AboutFaceJDD. Upon successful completion of the posttest and evaluation, you will be able to generate an instant certificate of credit. See detailed instructions at How to Obtain CME/CE Credit.
