Frown Lines Research Articles

Percutaneous Myotomy With a Small Needle-Knife and Lipoinjection for Treatment of Glabellar Frown Lines

Glabellar frown lines are a common aesthetic concern, and minimally invasive techniques to treat frown lines have become popular. The authors developed a technique to minimize frown lines by means of percutaneous myotomy with a small needle-knife and lipoinjection. Sixty-nine patients underwent treatment of the glabellar frown lines in a prospective study. Percutaneous myotomy of the corrugator supercilii and procerus was conducted with a small needle-knife, and autologous fat was transferred to the glabellar region. Two independent investigators assessed improvement of the glabellar frown lines by applying the Merz Facial Wrinkle Scale preoperatively and 6 months postoperatively. Improvement by ≥1 point was regarded as a response to treatment. Patients also conducted a self-assessment based on the Global Aesthetic Improvement Scale. The mean follow-up period was 8 months. The evaluators determined that the glabellar frown lines of 62 patients (89.9%) responded to treatment. For 4 patients (5.8%), the frown lines were partially improved, and the frown lines did not improve for 3 patients (4.3%). In a self-assessment, 64 patients (92.8%) perceived improvement in their frown lines 6 months postoperatively. No serious complications were recorded. Treatment of glabellar frown lines by percutaneous myotomy with a small needle-knife and lipoinjection is reliable and minimally invasive. 4.

Duration and onset of glabellar frown line reduction after an injection of daxibotulinumtoxinA: Results of the BELMONT study

Duration and onset of glabellar frown line reduction after an injection of daxibotulinumtoxinA: Results of the BELMONT study

Classification of facial wrinkles among Chinese women

It is generally recognized that Caucasians and Asians have different skin aging features. The aim of this study was to develop a facial wrinkle grading scale for Chinese women. Standard photographs were taken of 242 Chinese women. Six sets of 0 to 9 wrinkle scales with reference photographs and descriptions were selected, including grading scales for resting and hyperkinetic crow's feet, frontalis lines, glabellar frown lines, and nasolabial folds. To identify the scale by objective quantitative measurement, skin surface measurements from the Visioscan® VC98 were used. To test the reliability and validity of our wrinkle scale, a multi-rater consensus method was used. A double-blind, randomized, vehicle-controlled 12-week study was conducted to use this clinical photo-score to evaluate the efficacy and safety of Centella triterpenes cream® in treating crow's feet. A newly developed 10-point photographic and descriptive scale emerged from this study. The final atlas of these photographs contained a total of 6 sets with 10 pictures each. From 0 to 9, surface evaluation of smoothness (SEsm) parametric measurements decreased progressively, indicating that the scale increased inversely. Weighted kappa coefficients for intra-assessor were between 0.75-0.87. The overall Kendall's coefficient is 0.86 on the first rating and 0.87 on the second rating. Thirty-six volunteers were recruited and 35 subjects completed a 12-week trial. Clinical photo-score by investigator showed a significant difference (P<0.05) between the treatment side and control side after 4 weeks. Use of these scales in clinical settings to evaluate facial wrinkles in Asians individuals is recommended.

Transpalpebral Eyebrow Lift.

Forehead rejuvenation goals are to raise the eyebrow, attenuate forehead wrinkles, and decrease glabellar frown lines. Endoscopic forehead lift represents a significant progress, even replacing the classic coronal and pretriquial techniques. The transpalpebral eyebrow lift allows safe direct visualization of anatomic structures comparable to the allowed by the endoscopic-assisted technique but dispenses the endoscopic instrumentation, is less expensive, and takes less time to learn. Transpalpebral eyebrow lift is a technique that produces satisfactory results in mild-to-moderate eyebrow ptosis improving eyebrow lateral third ptosis and glabellar wrinkles.

The efficacy of two formulations of botulinum toxin type A for masseter reduction: a split-face comparison study

Background: Botulinum toxin type A (BTA) is now extensively used to address cosmetic concerns. OnabotulinumtoxinA (ONA, Botox; Allergan Inc., Irvine, CA) received FDA approval for upper face rejuvenation, including glabella frown lines and crow’s-feet lines. The other off-label uses for lower face conditions have been utilized for contouring purposes, especially masseter hypertrophy. Recently, a new Daewoong BTA, (NABOTA®, NBT, Daewoong Pharmaceutical, Seoul, Korea), was recently introduced.Objective: To compare efficacy and safety of ONA and NBT for masseter reduction.Methods: Thirty-five subjects with masseter hypertrophy were randomly injected with 25 units of ONA on one side and 25 units of NBT on the other side into masseter. Standardized photographic documentation was obtained at baseline, 1, 3 and 6 months after treatment. The mean volume of masseter was acquired by using three-dimensional computed tomography (3-D CT) at baseline, 3-, and 6-month follow-up visits. In addition, patients’ satisfaction and side effects were also record at every follow-up visits.Results: The mean masseter volume on the sides treated with ONA and NBT at baseline were 21.20 ± 4.23 cm3 and 21.26 ± 4.58 cm3, respectively. There was no statistically significant difference in the mean volume of both sides (p= 0.827). The mean masseter volume at 3- and 6-month follow-up visits reduced significantly on both ONA and NBT sides (p< 0.001 and p< 0.001, respectively). However, there was no statistically significant difference in mean masseter volume when comparing between ONA and NBT sides at 3 and 6 months after treatment (p= 0.769 and p = 0.346, respectively). There was also no statistically significant difference in masseter reduction when compared between ONA and NBT sides evaluated by physicians and patients at each follow-up visit. No side effect on both sides was reported after injection.Conclusions: This study demonstrated that ONA and NBT provided comparable efficacy and safety for masseter reduction.

061 Premature aging in Cockayne syndrome due to a failure in ribosomal biogenesis?

061 Premature aging in Cockayne syndrome due to a failure in ribosomal biogenesis? M Alupei, P esser, K Scharffetter-Kochanek and S Iben 1 University of Ulm, Ulm, Germany and 2 University of freiburg, Freiburg, Germany Cockayne syndrome (CS) is a progeroid disease characterized by growth failure, neurological degeneration, loss of subcutaneous fat and cachexia. The mutations of this polygenic disease inactivate a subbranch of the DNA-repair pathway nucleotide excision repair (NER), thus Cockayne syndrome is regarded as a DNA-repair disease. As the total loss of DNA repair by the NER in xeroderma pigmentosum does not lead to childhood degeneration, alternative functions of the CS proteins might account for the disease. One common alternative function of the Cockayne syndrome proteins is the key step in ribosomal biogenesis, transcription by RNA polymerase I in the nucleolus. We investigated the cellular consequences of a failure of RNA polymerase I transcription in CS-cells and discovered a circulus vitiosus repressing ribosomal biogenesis. A disturbed RNA polymerase I transcription gives rise to ribosomes with a low translational fidelity that produce misfolded proteins. Misfolded proteins provoke endoplasmic reticulum stress and an unfolded protein response that represses RNA polymerase I transcription. The oxidative hypersensitivity of Cockayne syndrome cells might be due to oxidation of misfolded proteins. The elevated apoptosis rate of CS cells after oxidative challenge can be overcome by pharmacological chaperones that dampen endoplasmic reticulum stress and the unfolded protein response. Pharmacological chaperones are restoring proper RNA polymerase I transcription by de-repression thus breaking the circulus vitiosus. This might be a treatment opportunity for children suffering from premature aging. Moreover, loss of proteostasis due to a reduced translational fidelity of ribosomes might be a mechanism contributing to aging and aging associated diseases in humans. 062 Stress perception impacts on clinical signs of skin ageing and modifies the epigenome R Pattinson, C Bundy, L Cordingley, S Kyle, W Yeung, G Beauchef, A Nkengne, A O’Callaghan, CE Griffiths and RE Watson 1 University of Manchester, Manchester, United Kingdom, 2 Laboratoire CLARINS, Pontoise, France and 3 Fios Genomics Ltd., Edinburgh, United Kingdom In this study we tested the commonly held assumption that stress affects the appearance of skin through the premature occurrence of clinical features of skin ageing (lines, wrinkles and dark under-eye circles). We recruited 84 healthy adult female volunteers (age range, 24 e 40 years; mean 30.7 4.7 years); each volunteer completed a comprehensive battery of psychological and sleep questionnaires (State-Trait Anxiety Inventory, Perceived Stress Score, Hospital Anxiety and Depression Scale, Pittsburgh sleep quality index [PSQI], Ford insomnia response to stress test [FIRST] and consensus sleep diary), clinical photography (VISIA-CR ) and provided a sample of whole blood for epigenetic analysis. Image analysis of clinical photographs allowed the objective quantification of wrinkles around the eye (eye bag and crow’s feet), the nasolabial fold and deep mid-forehead frown lines. Initial analysis correlated perceived stress with worse sleep patterns; those volunteers who perceived stress more keenly had significantly disturbed sleep as measured by PSQI and FIRST with reduced sleep efficiency (r1⁄4-0.22; P<0.05) and increased wakefulness after sleep onset (r1⁄40.32; P<0.01). In addition, sleep onset latency positively correlated with increased measures for nasolabial folds, frown lines and crow’s feet wrinkles (r1⁄4-0.47; p<0.01). We next stratified the volunteers on the basis of their stress perception response to identify extreme groups (high stress response, n1⁄412; low stress response, n1⁄412) for epigenetic analysis of whole blood. Using Infinium HumanMethylation450BeadChip, principal component analysis identified significant clustering of methylation signatures between the two groups, with 484 differentially methylated regions observed (P<0.001). Hence, how an individual perceives psychological stress appears to impact on physical signs of skin ageing although the precise mechanism remains unclear.

062 Stress perception impacts on clinical signs of skin ageing and modifies the epigenome

061 Premature aging in Cockayne syndrome due to a failure in ribosomal biogenesis? M Alupei, P esser, K Scharffetter-Kochanek and S Iben 1 University of Ulm, Ulm, Germany and 2 University of freiburg, Freiburg, Germany Cockayne syndrome (CS) is a progeroid disease characterized by growth failure, neurological degeneration, loss of subcutaneous fat and cachexia. The mutations of this polygenic disease inactivate a subbranch of the DNA-repair pathway nucleotide excision repair (NER), thus Cockayne syndrome is regarded as a DNA-repair disease. As the total loss of DNA repair by the NER in xeroderma pigmentosum does not lead to childhood degeneration, alternative functions of the CS proteins might account for the disease. One common alternative function of the Cockayne syndrome proteins is the key step in ribosomal biogenesis, transcription by RNA polymerase I in the nucleolus. We investigated the cellular consequences of a failure of RNA polymerase I transcription in CS-cells and discovered a circulus vitiosus repressing ribosomal biogenesis. A disturbed RNA polymerase I transcription gives rise to ribosomes with a low translational fidelity that produce misfolded proteins. Misfolded proteins provoke endoplasmic reticulum stress and an unfolded protein response that represses RNA polymerase I transcription. The oxidative hypersensitivity of Cockayne syndrome cells might be due to oxidation of misfolded proteins. The elevated apoptosis rate of CS cells after oxidative challenge can be overcome by pharmacological chaperones that dampen endoplasmic reticulum stress and the unfolded protein response. Pharmacological chaperones are restoring proper RNA polymerase I transcription by de-repression thus breaking the circulus vitiosus. This might be a treatment opportunity for children suffering from premature aging. Moreover, loss of proteostasis due to a reduced translational fidelity of ribosomes might be a mechanism contributing to aging and aging associated diseases in humans. 062 Stress perception impacts on clinical signs of skin ageing and modifies the epigenome R Pattinson, C Bundy, L Cordingley, S Kyle, W Yeung, G Beauchef, A Nkengne, A O’Callaghan, CE Griffiths and RE Watson 1 University of Manchester, Manchester, United Kingdom, 2 Laboratoire CLARINS, Pontoise, France and 3 Fios Genomics Ltd., Edinburgh, United Kingdom In this study we tested the commonly held assumption that stress affects the appearance of skin through the premature occurrence of clinical features of skin ageing (lines, wrinkles and dark under-eye circles). We recruited 84 healthy adult female volunteers (age range, 24 e 40 years; mean 30.7 4.7 years); each volunteer completed a comprehensive battery of psychological and sleep questionnaires (State-Trait Anxiety Inventory, Perceived Stress Score, Hospital Anxiety and Depression Scale, Pittsburgh sleep quality index [PSQI], Ford insomnia response to stress test [FIRST] and consensus sleep diary), clinical photography (VISIA-CR ) and provided a sample of whole blood for epigenetic analysis. Image analysis of clinical photographs allowed the objective quantification of wrinkles around the eye (eye bag and crow’s feet), the nasolabial fold and deep mid-forehead frown lines. Initial analysis correlated perceived stress with worse sleep patterns; those volunteers who perceived stress more keenly had significantly disturbed sleep as measured by PSQI and FIRST with reduced sleep efficiency (r1⁄4-0.22; P<0.05) and increased wakefulness after sleep onset (r1⁄40.32; P<0.01). In addition, sleep onset latency positively correlated with increased measures for nasolabial folds, frown lines and crow’s feet wrinkles (r1⁄4-0.47; p<0.01). We next stratified the volunteers on the basis of their stress perception response to identify extreme groups (high stress response, n1⁄412; low stress response, n1⁄412) for epigenetic analysis of whole blood. Using Infinium HumanMethylation450BeadChip, principal component analysis identified significant clustering of methylation signatures between the two groups, with 484 differentially methylated regions observed (P<0.001). Hence, how an individual perceives psychological stress appears to impact on physical signs of skin ageing although the precise mechanism remains unclear.

An objective 3D photographic reconstruction analysis of frown lines after incobotulinumtypeA treatment

An objective 3D photographic reconstruction analysis of frown lines after incobotulinumtypeA treatment

Facing depression with botulinum toxin: Literature review

IntroductionAffecting over 120 million people, major depressive disorder (MDD) is characterized by low mood, lack of interest and a cluster of other vegetative and cognitive symptoms causing significant distress of functioning. It has a relapsing and recurring course and frequently becomes chronic. Thus, there is a need to further develop therapeutic techniques to improve the course and the prognosis of depressive disorders. Recent clinical trials suggest that botulinum toxin (BTX) treatment may also have an antidepressant effect.ObjectiveThe authors aim to conduct a non-systematic review in order to understand the relationship between MDD and BTX treatment.AimsTo assess whether current evidence supports the BTX to treat major depressive patients.MethodsA non-systematic review of English scientific literature was conducted through research in the PubMed search engine, using the keywords “botulinum toxin” and “depression”.ResultsThere is a small but growing body of evidence suggesting that botulinum toxin may be useful for the treatment of depression. The main hypothesis for the proposed beneficial effects of botulinum toxin is through the facial feedback. Low mood and depression are often associated with a sad facial expression. Injecting botulinum toxin and improving facial expression would lead to the improvement of depression symptoms.ConclusionsPositive effects on mood have been observed in subjects who underwent treatment of glabellar frown lines with botulinum toxin. It supports the concept that the facial musculature not only expresses, but also regulates mood states.Disclosure of interestThe authors have not supplied their declaration of competing interest.

A Randomized, Double-Blind Trial to Investigate the Equivalence of IncobotulinumtoxinA and OnabotulinumtoxinA for Glabellar Frown Lines.

IncobotulinumtoxinA and onabotulinumtoxinA are indicated for the temporary improvement in the appearance of glabellar frown lines (GFL). This is the first randomized direct comparator study to date, at the Food and Drug Administration-recommended dose of 20 units (U), for the treatment of GFL. To investigate the dose equivalence of incobotulinumtoxinA (20 U) and onabotulinumtoxinA (20 U) for the treatment of moderate-to-severe GFL. Prospective, randomized (1:1), double-blinded, parallel-group study in 250 females (18-50 years), employing a single treatment with incobotulinumtoxinA or onabotulinumtoxinA, followed by a 4-month observational period. At the primary efficacy endpoint (1 month after treatment), incobotulinumtoxinA was equivalent to onabotulinumtoxinA in the treatment of GFL at the 20 U dose within the prespecified ± 15% margin of equivalence. Efficacy remained similar between treatment groups through 4 months after treatment as assessed by the independent masked panel and the masked treating physicians. Patient satisfaction ratings were similar between groups and favorable (>90%) throughout. Both treatments were well tolerated. Equivalence was demonstrated at the primary endpoint between incobotulinumtoxinA and onabotulinumtoxinA in the treatment of GFL at the 20 U dose at 1 month. Similar efficacy and tolerability profiles were observed through 4 months after treatment.

Neurotoxins: Current Concepts in Cosmetic Use on the Face and Neck--Lower Face.

Botulinum toxin A was Food and Drug Administration approved in 2002 for the temporary correction of glabellar frown lines. Since that time, a variety of neuromodulators have established a convincing profile for both safety and efficacy in the treatment hyperdynamic rhytides of the upper face. With increasing clinical experience and expertise, these applications have been expanded to include targeted treatment of muscles in both the mid and lower face. This article details common techniques using botulinum toxin to treat orbicularis oris, depressor anguli oris, mentalis, and masseter muscles for the temporary correction of unwanted lower face hyperdynamic rhytides and facial contouring. Although we detail our suggested quantity of units per injection site based on onabotulinumtoxinA, all neuromodulators can be used in all of these suggested treatment areas with adjustment of the quantity of units based on the efficacy of the specific neuromodulator. A more compete discussion on the relative efficacy of all neuromodulators is beyond the scope of this article.

Depression – An emerging indication for botulinum toxin treatment

The treatment of glabellar frown lines with botulinum toxin injection is one of the most prevalent procedures in esthetic medicine. It is possible that the popularity of this intervention is not only owing to its cosmetic effect but also to modulatory effects on mood and affectivity.Recently, a series of studies including three randomized controlled trials have consistently shown that such effects can be used in the treatment of depression. Predominantly female patients suffering from partly chronic and treatment resistant unipolar depression experienced a quick, strong and sustained improvement in depressive symptoms after a single glabellar treatment with botulinum toxin A as a sole or adjunctive therapy.If these findings are further corroborated in additional studies, the ever-growing spectrum of applications for botulinum toxin may spread into the field of psychiatry, showing that the superficial paralysis of facial muscles may, probably via proprioceptive feedback mechanisms, have profound effects on the emotional brain.

Response of depression to botulinum toxin treatment: agitation as a predictor.

Major depressive disorder (MDD) is a mental disorder, characterized by low mood, lack of interest or pleasure, and a cluster of other vegetative and cognitive symptoms, occurring for a period of time and causing significant distress or impairment of functioning. It has a relapsing and recurring course, sometimes becomes chronic. It is a common disorder with a life time prevalence of 16.6% (1) and 12 months prevalence of 6.7% (2). MDD affects patients’ functioning and is associated with significant personal and societal burden. It was predicted that MDD would rank second by disability adjusted life years (DALY) among all disorders worldwide in year 2020, contributing with 5.7% of DALY and second only to ischemic heart disease (3). The episodes of depression in MDD, if left untreated, may last for months or years. There are many treatments available for depression including psychotherapy (4), pharmacotherapy (5), neurostimulation (6), and other complementary and alternative medicine methods (7), as summarized in the CANMAT clinical practice guidelines. Although there are numerous treatments available, the results are far from ideal, with significant proportion of patients not achieving remission and continuing to suffer with symptoms of the disorder and functional impairment. Therefore, the quest for new and better treatment approaches is continuing. There is a small but growing body of evidence suggesting that botulinum toxin may be useful for treatment of depression. Botulinum toxin is a protein produced by Clostridium Botulinum and is highly toxic and lethal. In medical use, when injected, it induces strong flaccid muscle paralysis, and this effect is used in the treatment of a variety of different disorders characterized by muscle over activity and spasticity and in hyperhidrosis. More recently, botulinum toxin use has skyrocketed in cosmetic medicine, where it leads to significant visual improvement of wrinkles, due to the paralysis of the underlying muscles. The main hypothesis for the proposed beneficial effects of botulinum toxin in depression is through the facial feedback. Low mood and depression are often associated with sad facial expression. It has long been observed that MDD patients often have deep vertical frown lines and different signs, such as “omega melancholicum” sign and Veraguth’s folds, have been described (8). Injecting botulinum toxin and improving facial expression would lead to improvement of symptoms of depression. In an open study of botulinum toxin injected into the frown muscles of 10 depressed patients, Finzi and Wasserman (9) reported that 8 of the 10 patients went into remission after one treatment of botulinum toxin. This observation was followed by a small randomized, double blind, controlled trial by Wollmer et al. (10), who examined 30 patients randomly assigned to receive injection of botulinum toxin or saline placebo. The patients were mainly women and the authors reported response rate [as measured by 50% improvement on Hamilton Depression Rating Scale (HAM-D)] of 60% in the active group vs 13.3% in the placebo group. Of interest, the presence of significant vertical frown line was required in order to be included in this study. Soon after, a larger randomized controlled trial was reported by Finzi and Rosenthal (11), which included 85 patients. This study used Montgomery–Asberg Depression Rating Scale (MADRS) as the primary outcome measure and did not require a pronounced vertical frown for inclusion in the study, but the results were very similar to the study by Wollmer. One issue discussed in both randomized and controlled trials was the fact that most patients guessed correctly whether they were in the placebo group or in the botulinum toxin active group, which might have also influenced their response rates. In the current post hoc analysis (12) of their original study (10), Wollmer et al. are trying to determine predictors for better response to botulinum toxin in patients with MDD. After conducting further analysis of the data, they found that high baseline agitation (as measured on item 9 of HAM-D) is the main predictor of response to botulinum toxin with sensitivity of 100%, specificity of 56%, and overall precision of 87%. Agitation may be associated with more dynamic motor activity, leading to more changes in the facial expression. The baseline appearance of the glabellar frown line was not a predictor in this analysis. All the limitations of this study (e.g., small size, post hoc analysis, etc.) are known and clearly stated. Nevertheless, this type of analysis brings an important clinical point: we not only need to know which treatment works, but also who are the patients that would likely benefit most! The authors are to be commended on this fine attempt to answer that.

IncobotulinumtoxinA use in aesthetic indications in daily practice: a European multicenter, noninterventional, retrospective study.

PurposeTo characterize utilization patterns and treatment satisfaction with incobotulinumtoxinA for aesthetic indications and assess adherence to the Summary of Product Characteristics.Patients and methodsData were collected retrospectively from physicians in Germany, France, and the UK regarding patients (n=638) treated with incobotulinumtoxinA for aesthetic indications. Data on indication, treatment interval, dose injected, physician and patient satisfaction, and adverse drug reactions were recorded according to routine daily practice.ResultsMost patients (76.0%) received incobotulinumtoxinA for glabellar frown lines (GFL) and were given doses of ≤20 U. The majority of treatment intervals were 5 months or longer. Overall, 64.1% of patients were treated for off-label indications, sometimes in combination with treatment for GFL. The most frequently treated off-label indications were horizontal forehead lines (38.6%) and/or crow’s feet (CF; 31.7%); for CF, >95% of injected doses were ≤24 U. In Germany, a smaller proportion of patients were given incobotulinumtoxinA treatment for CF (27.6%), compared with France (40.4%) and the UK (33.2%), although country-specific differences were less prominent when treatment cycle data for CF were examined. Treatment satisfaction among physicians and patients (overall, and for GFL specifically) was very high, with excellent tolerability and only one mild adverse drug reaction reported.ConclusionIn daily practice, incobotulinumtoxinA is mainly used for GFL; however, its use for CF and horizontal forehead lines (often in combination with GFL) is relatively common. Treatment satisfaction across aesthetic indications is high, and incobotulinumtoxinA is well tolerated, with time intervals of 5 months or longer between injections in the majority of cases. When considering factors such as dose and treatment interval, adherence to the Summary of Product Characteristics when treating GFL in daily practice is good. These results support previous reports that incobotulinumtoxinA is an effective treatment for GFL, with an excellent safety profile. Furthermore, incobotulinumtoxinA may display efficacy and tolerability in other indications.

Efficient information for recognizing pain in facial expressions.

The face as a visual stimulus is a reliable source of information for judging the pain experienced by others. Until now, most studies investigating the facial expression of pain have used a descriptive method (i.e. Facial Action Coding System). However, the facial features that are relevant for the observer in the identification of the expression of pain remain largely unknown despite the strong medical impact that misjudging pain can have on patients' well-being. Here, we investigated this question by applying the Bubbles method. Fifty healthy volunteers were asked to categorize facial expressions (the six basic emotions, pain and neutrality) displayed in stimuli obtained from a previously validated set and presented for 500ms each. To determine the critical areas of the face used in this categorization task, the faces were partly masked based on random sampling of regions of the stimuli at different spatial frequency ranges. Results show that accurate pain discrimination relies mostly on the frown lines and the mouth. Finally, an ideal observer analysis indicated that the use of the frown lines in human observers could not be attributed to the objective 'informativeness' of this area. Based on a recent study suggesting that this area codes for the affective dimension of pain, we propose that the visual system has evolved to focus primarily on the facial cues that signal the aversiveness of pain, consistent with the social role of facial expressions in the communication of potential threats.

Optimal dosage of botulinum toxin type A for treatment of glabellar frown lines: efficacy and safety in a clinical trial.

Various preparations of botulinum toxin type A (BTX-A) are used to reduces glabellar (frown) lines. However, dose-related safety and efficacy of intramuscular injections of a widely used, locally produced BTX-A in China has not been established. Assessment of dose-dependent safety and efficacy of Chinese botulinum toxin type A (Hengli BTX-A [HBTX-A]) intramuscular injections on glabellar lines. Four hundred eighty-eight BTX-A-naive participants were included in the double-blind trial and randomly divided into placebo (n = 122), low-dose (n = 183), and high-dose (n = 183) treatment groups for injection with saline solution, 10 units and 20 units of HBTX-A, respectively, at 4 sites in the corrugator muscle and 1 site in the procerus muscle. Outcomes were recorded before treatment and after 7, 30, 60, and 120 days, including glabellar line severity at maximum contraction and relaxation. Significantly greater improvement was observed in both HBTX-A groups in comparison with the placebo group (p < .05). Better efficacy was obtained in the high-dose treatment group. More participants developed adverse events after treatment with HBTX-A doses, than with the placebo (p < .05). Twenty-unit HBTX-A provided optimal improvement in glabellar lines, and its use might minimize injection frequency while maintaining acceptable safety.

Patient-centric dose equivalency pilot study of incobotulinumtoxin a (xeomin) vs. abobotulinumtoxin a (dysport) in the treatment of glabellar frown lines

Aim: Incobotulinumtoxin A (xeomin) has been proposed as an alternative to abobotulinumtoxin A (dysport) and onabotulinumtoxin A (Botox) in the treatment of glabellar frown lines. A recent study is comparing abobotulinumtoxin A and onabotulinumtoxin A revealed equivalent efficacy with a dose conversion ratio of 2.5:1. We sought to establish effectiveness and dosing equivalency of incobotulinumtoxin A vs. abobotulinumtoxin A. Methods: Inclusion criteria for this pilot study included patients of a single surgeon (LAC) who had previously received a constant dose of abobotulinumtoxin A over at least four consecutive treatment sessions for the previous 12 months to achieve an 85-90% elimination of dynamic glabellar frown lines. The primary outcome sought dose comparison between established maintenance abobotulinumtoxin A dosing and incobotulinumtoxin A first-time dosing. A 2:1 conversion (abobotulinumtoxin A: incobotulinumtoxin A) was chosen in most patients. Secondary outcomes were patient-reported onset of effect, physician-assessed effect at 10-12 weeks, pain associated with administration, and patient perceived need for re-treatment at 2 weeks. Results: A total of 32 subjects were included. The mean dose of incobotulinumtoxin A was 17.1 units (± 6.1, the median dose 20 units). The mean dose of abobotulinumtoxin A was 27.6 (± 11.7, the median dose 27.5 units). The mean difference in treatment units was -10.5 (95% confidence interval, P vs. 90.3% (± 1.8) with abobotulinumtoxin A ( P Conclusion: We found incobotulinumtoxin A at 17.1 (± 6.1) units to be less effective than abobotulinumtoxin A at 27.6 (± 11.7) units in the treatment of glabellar frown lines at 10-12 weeks postadministration. Dosing was less predictable than dosing associated with abobotulinumtoxin A treatment. Larger, randomized controlled trials are indicated to further delineate these differences and to clarify whether this difference from previously published incobotulinumtoxin A dosing may have been due to the small sample size.

Management of the aging forehead and brow.

The appearance of the forehead and brow conveys both a state of aging as well as the dynamic status of human emotion. Maintaining a youthful and pleasant appearance of this region is often integral to facial rejuvenation. Conditions that are often addressed include transverse rhytids and glabellar frown lines, ptotic eyebrows, skin deterioration, and volume loss. Surgical treatments to improve the forehead/brow might be open, endoscopic or combined. Common nonsurgical methods used to improve the region include neuromodulation, volume replacement, ablative and nonablative skin resurfacing, as well as phototherapy. Whatever treatments might be indicated, aim is to achieve optimum and natural-looking results.

Efficacy of incobotulinumtoxinA for treatment of glabellar frown lines: a post hoc pooled analysis of 2 randomized, placebo-controlled, phase 3 trials.

Botulinum neurotoxin type A trials in aesthetic indications have used differing efficacy parameters and responder definitions. To analyze the treatment efficacy and duration of incobotulinumtoxinA for glabellar frown lines using pooled data from 2 large, Phase 3, placebo-controlled trials, and end points similar to those used in previous botulinum neurotoxin type A studies. IncobotulinumtoxinA and placebo groups comprised 366 and 181 subjects, respectively. The efficacy of a single 20-U treatment of incobotulinumtoxinA or placebo was evaluated by investigator-assessed and subject-assessed responder rates (≥ 1-point improvement from baseline), mean score, and mean change from the baseline glabellar frown line severity score. At all follow-up visits, responder rates and mean change from the baseline score (investigator-assessed and subject-assessed) were significantly greater for incobotulinumtoxinA versus placebo (p < .0001). The maximum investigator-assessed responder rate (93.1%) was achieved at Day 30 after treatment, when the mean improvement on the 4-point facial wrinkle scale peaked at 1.88. Treatment effect declined over time but the investigator-assessed responder rate was 45.7% at the end of the study. Superiority of incobotulinumtoxinA over placebo for treating glabellar frown lines was confirmed. IncobotulinumtoxinA achieved a maximum responder rate of 93.1% and a long duration of treatment effect: 45.7% of subjects showed efficacy at 120 days.

Eighteen-Point Abobotulinum Toxin A Upper Face Rejuvenation

To report the method and results of 18-point Abobotulinum toxin A (ABO-BTA, Dysport) upper face rejuvenation on 845 subjects. In a retrospective chart review, all subjects (the first cycle of injection) with ABO-BTA upper face rejuvenation from 2003 to 2009 were included. Excluded were subjects with facial spastic disorders, injection after upper face lifting, and aberrant regeneration of facial nerves. Upper face rejuvenation included 18 points of injection at forehead creases (4), frown lines (5), bunny line (1), crow's feet (4 on both sides), and lower eyelid crease (4 on both sides). They were revisited in 10 to 14 days for assessment of the effects and possible touch-up injection. Demographics, year of injection, topical anesthetic usage, touch-up injection, and adverse effects (AE) were recorded. There were 845 subjects (85.8% women) whose age was below 40 in 49.3%. All but 68 (8%) were happy with the touch-up visit, 10 to 14 days after injection. Touch-up injection was performed in 8% of subjects mainly for the eyebrow asymmetry. AE (22/845, 2.6%) were bruise (15/845, 1.8%), blepharoptosis (3/845, 0.3%), remained eyebrow asymmetry after touch-up injection (2/845, 0.2%), and headache (2/845, 0.2%). They were significantly more in subjects with touch-up injection, younger than 40 years, and in the first and second year of experience (especially for the bruise). Eighteen-point ABO-BTA upper face rejuvenation had a low rate of AE in this series in which majority was bruise at the lateral canthal area. They were significantly more in the first years of experience, subjects younger than 40, and who had touch-up injections.