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

January 2021 | Volume 20 | Issue 1 | Original Article | 31 | Copyright © January 2021

Published online December 31, 2020

Carla de Sanctis Pecora MDa, Maria Valéria Bussamara Pinheiro MDa, Vinicius Figueiredo MDb, Rachel Guerra MDc

aDermatologie-Clínica, Cirurgia, Cosmiatria e Laser, São Paulo, SP, Brazil
bHost Clinica, São Paulo, SP, Brazil
cServiço de Dermatologia da Santa Casa de Belo Horizonte, MG, Brazil

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 ≥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 (±2) weeks after treatment injection. The primary outcome was the percentage of subjects with a MAS improvement ≥2 points for dynamic forehead lines at week 4 (±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 ≥2 points for dynamic forehead lines at week 4 (±2); 100% improved ≥1 point. MAS scores for resting and dynamic lines, and eyebrow positioning were significantly improved (P<0.001). Eyebrow positioning MAS improved ≥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.2021.5617


Botulinum neurotoxin A (BoNT-A) injection is a well-established option for the treatment of several disorders,1-3 and one of the most frequently requested non-surgical cosmetic procedures.4 IncobotulinumtoxinA (INCO, Xeomin®/Bocouture®, Merz Pharmaceuticals GmbH) is the only BoNT-A formulation approved in commercial markets worldwide and for the treatment of the upper-face wrinkles in Europe intentionally designed to contain only the active therapeutic component (150 kDa BoNT-A), therefore being free from unnecessary clostridial proteins, reducing the risk of the development of neutralizing antibodies.5-9 In contrast, abobotulinumtoxinA and onabotulinumtoxinA (ONA) contain the 150 kDa BoNT-A complexed with the hemagglutinin and non-toxic non-hemagglutinin proteins.5,7-9

Botulinum toxin treats dynamic wrinkles caused by hyperactive muscles. There are two antagonistic groups of muscles in the upper face: the eyebrow depressors (procerus, corrugator supercilii, and orbicularis oculi) and the frontalis, the only eyebrow elevator.6 This is a large, vertically oriented forehead muscle, originating in the galea aponeurotica and inserting into the skin of the eyebrow and nose root, where it blends with the procerus and orbicularis. Frontalis contractions raise the eyebrows and form horizontal forehead lines.10,11 Abramo et al classified four distinct anatomical types of the frontalis muscle and related them to four clinical patterns of forehead wrinkles.10 Moqadam et al related the “full shape” pattern to straight parallel lines, and the “V-shaped” one to wavy horizontal forehead lines.11 Therefore, based on the appearance of the patient’s forehead lines it is possible to infer the shape and distribution of the frontalis muscle, reinforcing the need for an individualized approach.The action of hyperkinetic muscles associated with the reduction of skin elasticity, flattening of the forehead, atrophy of fat pads and eyelid dropping contribute to the appearance of horizontal forehead wrinkles and eyebrow ptosis.12-14

There has been a progressive change in conceptualizing the aging process and facial rejuvenation, from an essentially two- dimensional to a three-dimensional approach that encompasses fat-pad volume, bone structure, and collagen loss, allowing better selection of aesthetic tools and treatment approaches.15 Treatment of the forehead can be particularly challenging, as