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Neurotoxin Treatment of the Upper Face Diane Trieu, MD; Lauren Eckert Ploch, MD, Med; Mary P

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Neurotoxin Treatment of the Upper Face Diane Trieu, MD; Lauren Eckert Ploch, MD, Med; Mary P Review Neurotoxin Treatment of the Upper Face Diane Trieu, MD; Lauren Eckert Ploch, MD, MEd; Mary P. Lupo, MD Neurotoxin injections have continued to increase in popularity over the last decade. Currently, sev- eral different preparations of botulinum toxin type A (BTX-A)(onabotulinumtoxinA [Botox Cosmetic, Allergan, Inc]; abobotulinumtoxinA [Dysport, Medicis Aesthetics Inc]; incobotulinumtoxinA [Xeomin, Merz Aesthetics, Inc]) and botulinum toxin type B (BTX-B)(rimabotulinumtoxinB [Myobloc, Solstice Neurosciences, Inc]) are available in the United States. Although common injection techniques exist for the various muscle groups of the upper face, every patient is unique and should be individually assessed. Evaluating and understanding the muscular anatomy is crucial in mastering injection techniques and avoiding complications. On the horizon are exciting new topical and injectable forms of botulinum toxin (BTX) that will continue to influence the cosmetic art of rejuvenating the aging face. COS DERMCosmet Dermatol. 2012;25:427-432. n the last decade, botulinum toxin (BTX) has revo- BACKGROUND lutionized the art of cosmetic medicine. In 2011, Derived from the spore-forming bacterium Clostridium BTX injections were ranked as the top nonsurgical botulinum, there are 7 different strains of toxin (sero- Do Not1 Copy procedure for the treatment of dynamic rhytides. types A–G); the most commonly used serotypes include Neurotoxins produce a temporary and reversible botulinum toxin type A (BTX-A) and botulinum toxin Ichemical denervation of striated muscles by inhibit- type B (BTX-B).3 Preparations of BTX-A that currently ing the release of acetylcholine at the neuromuscular are available in the United States include onabotu- junction.2 This article will focus on the use of neurotoxins linumtoxinA (Botox Cosmetic, Allergan, Inc), abobot- for the treatment of upper facial rhytides. ulinumtoxinA (Dysport, Medicis Aesthetics Inc), and incobotulinumtoxinA (Xeomin, Merz Aesthetics, Inc). In 2002, the US Food and Drug Administration (FDA) approved Botox Cosmetic for the temporary improve- From the Department of Dermatology, Tulane University School of ment in the appearance of moderate to severe glabellar Medicine, New Orleans, Louisiana. lines in patients 65 years of age or younger; Dysport was Drs. Trieu and Ploch report no conflicts of interest in relation to approved for the same indication in 2009. These prepara- this article. Dr. Lupo is an advisory board member and speaker tions consist of a biologically active 150 kDa neurotoxin for Allergan, Inc; a speaker and trainer for sanofi-aventis US LLC component within a 300 to 900 kDa protein complex. and Valeant Dermatology, a division of Valeant Pharmaceuticals Xeomin is the newest formulation of highly purified International, Inc; a researcher and trainer for Medicis Aesthetics BTX-A and was granted FDA approval in July 2011 for the Inc; and an advisory board member for Merz Aesthetics, Inc. temporary improvement in the appearance of moderate Correspondence: Diane Trieu, MD, Tulane University School of to severe glabellar lines in adult patients. It is exclusively Medicine, Department of Dermatology, 1430 Tulane Ave, TB36, composed of a purely active neurotoxin and is free from New Orleans, LA 70112 ([email protected]). nonactive complexing proteins.4 Because foreign proteins www.cosderm.com VOL. 25 NO. 9 • SEPTEMBER 2012 • Cosmetic Dermatology® 427 Copyright Cosmetic Dermatology 2012. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. NeurotoxiNs for the upper face can induce neutralizing antibody formation, Xeomin is INDICATIONS expected to have minimal immunogenic potential.3 Currently, BTX is available for the treatment of blepha- RimabotulinumtoxinB (Myobloc, Solstice Neurosciences, rospasm, cervical dystonia, chronic migraines, moderate Inc) is the only available form of BTX-B.2 It currently is to severe glabellar lines, severe primary axillary hyper- FDA approved for cervical dystonia but also has been hidrosis, strabismus, upper limb spasticity, and urinary found to be effective in the off-label treatment of dynamic incontinence due to neurologic disease.8-10 rhytides. Botulinum toxin type B has been shown to pro- duce a greater area of diffusion and more rapid onset of CONTRAINDICATIONS action than BTX-A in the treatment of moderate to severe General contraindications for BTX injection include hyper- forehead wrinkles. It also may be effective in the treat- sensitivity reactions to any BTX preparation or any of the ment of glabellar rhytides that are refractory to treatment formulation’s components, including human albumin, lac- with BTX-A. However, study participants have reported tose, and saline.8 Patients with a history of neuromuscular increased burning or stinging at BTX-B injection sites disorders such as myasthenia gravis, Eaton-Lambert syn- that may be attributed to the slightly acidic liquid for- drome, amyotrophic lateral sclerosis, or an infection at the mulation (pH 5.6) of BTX-B compared to BTX-A, which proposed injection site should not receive BTX injections. is reconstituted at a more physiologic pH of 7.4.2 Patients also should be aware that certain medications can potentiate the effects of BTX injections, including MECHANISM OF ACTION aminoglycosides, curarelike nondepolarizing blockers, Botulinum toxin type A exerts its effects by weaken- lincosamides, polymyxins, quinidine, magnesium sulfate, ing skeletal muscle. Normally the presynaptic neu- succinylcholine chloride, cyclosporine, and calcium chan- romuscular nerve ending contains vesicles with the nel blockers. Cholinesterase inhibitors may diminish the neurotransmitter acetylcholine. Neuronal stimulation effects of neuromodulators.8 initiates a cascade of events facilitated by the soluble Botulinum toxin is considered a pregnancy category C N-ethylmaleamide sensitive factor attachment protein drug and should not be administered during pregnancy. It receptor (SNARE)COS complex that leads to the fusion DERM of is not known if the neurotoxin is excreted in breast milk; the acetylcholine-containing vesicle with the nerve cell therefore, it should not be administered to a patient who membrane. Following the fusion of the vesicle with the is breastfeeding. cell membrane, acetylcholine is released into the synap- Relative contraindications include patients with unre- tic cleft where it binds to receptors on muscle, causing alistic goals as well as those with a history of psychiatric muscle contraction. disease such as body dysmorphic disorder.7 The principal mechanism of action for BTX-A involves inhibitionDo of vesicular fusion toNot the cell membrane. METHODS Copy AND TECHNIQUES The neurotoxin first binds to the external surface of the Consultation motor nerve terminal; once bound, it becomes inter- An initial consultation for BTX treatment is essential to nalized and subsequently cleaves synaptosomal associ- discuss treatment goals and patient expectations. Using a ated protein of 25 kDa (SNAP-25), a component of the mirror, ask the patient to point out what he/she consid- SNARE complex. Cleaving SNAP-25 disrupts the synap- ers to be his/her problem areas and address any existing tic fusion complex, so the vesicles storing acetylcholine facial asymmetry with him/her. cannot fuse with the nerve membrane, thus interrupt- There are many factors that determine treatment ing the release of acetylcholine into the neuromuscular sites and doses used, including the brow arch, asym- junction.5,6 Botulinum toxin type B works in a similar metry, ptosis, and muscle mass.11 It recently has been manner but affects synaptobrevin, another component suggested to evaluate patients using an upper face rat- of the SNARE complex and a vesicle-associated mem- ing scale, which assesses the severity of rhytides and brane protein. is considered a reliable tool for valid and reproducible The onset of action is observed 3 days to 2 weeks fol- assessment of the aging process.12 These assessments lowing administration of BTX-A for cosmetic purposes. evaluate glabellar and forehead lines and crow’s-feet, The effects may last for 3 to 6 months, though a lon- most commonly utilizing a 5-point rating scale ranging ger duration of action has been reported.7 Interestingly, from 0 (no sign) to 4 (very intense or observable signs). BTX-A may have a persistent effect at rest, even after These scales can serve as a starting point for patients muscle paralysis has reversed, possibly because of dermal and dermatologists in identifying problem areas as well remodeling, slight muscle atrophy, or behavior modifica- as for demonstrating treatment success during long- tion in the patient’s muscle use. term follow-up.12 428 Cosmetic Dermatology® • SEPTEMBER 2012 • VOL. 25 NO. 9 www.cosderm.com Copyright Cosmetic Dermatology 2012. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. NeurotoxiNs for the upper face Preparation treatment of dynamic glabellar rhytides, BTX-A also has (This section primarily discusses BTX-A preparations, been shown to effectively improve mild resting rhytides of as BTX-B is not yet FDA approved for cosmetic use.) the glabella.15 Currently, Botox Cosmetic, Dysport, and Xeomin are The neurotoxin should be injected intramuscularly via packaged as vacuum-dried powders that must be recon- a syringe using a 30-gauge needle. The patient should be stituted before treatment.13 Prior to
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