Roundtable on Neuromodulators Botulinum Toxin A OnobotulinumtoxinA - PowerPoint PPT Presentation

Roundtable on Neuromodulators

Botulinum Toxin A • OnobotulinumtoxinA (Botox) • AbobotulinumtoxinA (Dysport) • IncobotulinumtoxinA (Xeomin) • PrabobotulinumA (Jeuveau) • DaxibotulinumtoxinA(Revance)

Botulinum Toxin A • Do you use them all? • Do you prefer one vs. another for any anatomic location • Does cost play a role • Marketing differences

Usual Indications for Botulinum Toxin Injections • Hyperkinetic muscles • Hyperhidrosis

Botulinum Toxin A • Scar Formation • Facial Erythema/Flushing • Neck Rejuvenation • Oily Skin/Acne

Novel Uses of Botulinum Toxins • Scar Prevention • Microdroplet Technique • Facial Erythema/Rosacea • Lower Face and Neck Rejuvenation • Sebum/Sheen/Pore Size

Scar Prevention – Botulinum Toxin • Tension on wound edges leads Proposed Mechanism of Action to poor aesthetic outcome • Decreased wound • Same reason we place surgical tension/repetitive microtrauma scars parallel w/ relaxed skin at wound edge tension lines vs. perpendicular • Decreased inflammation • Directly inhibits fibroblast to • Botulinum toxin allows myofibroblast differentiation* “Chemoimmobilization” – • Inhibits fibroblast proliferation and overcome dynamic tension TGF ‐ B1 expression* Jablonka EM. et al . Facial Plast Surg 2012 Xiao Z. et al . Aesthetic Plast Surg 2010 Jeong HS. et al . PRS 2105

Botulinum Toxin OnabotulinumtoxinA to Improve Facial Wound Healing: A Prospective, Blinded, Placebo ‐ Controlled Study • BTA vs placebo w/in 24hrs of closure • OnabotulinumtoxinA (7.5U per 0.1mL) • 31 pts w/ traumatic lacerations/elective excisions of forehead lesions • BTA group median score 8.9 • Placebo group 7.2 • BTA led to enhanced healing and improved cosmesis Jablonka EM et al . Facial Plast Surg 2012

Botulinum Toxin – Thyroidectomy Scars Early postoperative treatment of thyroidectomy scars using botulinum toxin: A split ‐ scar, double ‐ blind randomized controlled trial • 15 patients randomized to single Tx of BTA to ½ of scar and NS to the control ½ • Tx w/in 10 days of surgery • Botulinumtoxin A – 5U per 0.1mL Kim YS. et al . Wound Repair Regen. 2014

Botulinum Toxin BTA Control BTA Control Baseline 6 Month F/U Kim YS. et al . Wound Repair Regen. 2014

Microdroplet Technique • Injection of multiple microdroplets • Dermis or superficial layer of facial muscles Wu WT. Microbotox of the Lower Face and Neck: Evolution of a Personal Technique and Its Clinical Effects. Plast Reconstr Surg. Nov 2015;136(5 Suppl):92S ‐ 100S.

Microdroplet Technique Microdroplet Standard

Thoughts?

Facial Erythema • Intradermal abobotulinumtoxinA for the facial erythema of rosacea • 25 Subjects; 35 ‐ 70 years of age; Fitzpatrick skin Types I ‐ IV • 15 ‐ 45 units of abobotulinumtoxinA was injected intradermally to the nasal tip, nasal bridge, and nasal alae. [reconstitution: 300U Vial w/ 3mL Bacteriostatic NS] Bloom BS, Payongayong L, Mourin A, Goldberg DJ. Impact of intradermal abobotulinumtoxinA on facial erythema of rosacea. Dermatol Surg. Jan 2015;41 Suppl 1:S9 ‐ 16

Facial Erythema Proposed Mechanism of Action • Rosacea pathophysiology related to neuron ‐ mediated vascular dysfunction • Cutaneous vasodilation is mediated by cholinergic nerve activation (Ach/co ‐ transmitters) • Botulinum toxin inhibits release of vesicles in cholinergic nerves Bloom BS, Payongayong L, Mourin A, Goldberg DJ. Impact of intradermal abobotulinumtoxinA on facial erythema of rosacea. Dermatol Surg. Jan 2015;41 Suppl 1:S9 ‐ 16

Rosacea Pre ‐ Tx 2 Weeks Post ‐ Tx Botulinum Toxin A – Dilution 1.4 U per 0.1 cc ~ 4 U per cheek and 5 U to nasal skin Dayan SH, Pritzker RN, Arkins JP. A new treatment regimen for rosacea: onabotulinumtoxinA. J Drugs Dermatol. Dec 2012;11(12):e76 ‐ 79.

Thoughts?

Lower Face/Neck Rejuvenation WEAKENING OF SUPERFICIAL MICROTOXIN DIFFUSION MICROTOXIN SKIN CONTRACTION GLANDS DEACTIVATED MUSCLE FIBERS Microdroplet Technique Improvement • Placed w/in dermis • Laxity • diffusion limited to the superficial • Jowling muscle fibers leaving deeper • Skin Texture muscle functional • Horizontal Rhytides • Sebaceous/sweat glands deactivated  “Bulk atrophy of • Vertical Banding the sweat and sebaceous glands leads to a decrease in volume and thickness of the dermal layer, which brings about a subtle contraction of the overlying skin envelope and a sensation of “tightening.” Wu WT. Microbotox of the Lower Face and Neck: Evolution of a Personal Technique and Its Clinical Effects. Plast Reconstr Surg. Nov 2015;136(5 Suppl):92S ‐ 100S.

Lower Face/Neck Rejuvenation ‐ OnabotulinumtoxinA, 20 U per mL [2mL for whole neck] ‐ Treatment area: 3 finger breadths above mandibule, posterior to the DAO, the neck and cervicomental region anteriorly, limited posteriorly by the border of the sternocleidomastoid *Chin standard dosing with 2.5mL reconstitution **avoid injecting over the depressor anguli oris and over the sternocleidomastoid Wu WT. Microbotox of the Lower Face and Neck: Evolution of a Personal Technique and Its Clinical Effects. Plast Reconstr Surg. Nov 2015;136(5 Suppl):92S ‐ 100S.

Lower Face/Neck Rejuvenation Pre ‐ Tx 2 Weeks Post ‐ Tx • 56 ‐ yo woman w/ complaints of early neck laxity, deep horizontal neck lines, and crepey, finely wrinkled neck skin. • OnabotulinumtoxinA: Three 1mL syringes of 20 U per mL; Total 60 units onabotulinumtoxinA • Skin appears smoother , improved horizontal neck lines and vertical , better cervicomental contouring. Wu WT. Microbotox of the Lower Face and Neck: Evolution of a Personal Technique and Its Clinical Effects. Plast Reconstr Surg. Nov 2015;136(5 Suppl):92S ‐ 100S.

Thoughts?

Conclusion • Microdroplet Technique • Facial Erythema/Rosacea • Sebum/Sheen/Pore Size • Lower Face and Neck Rejuvenation • Scar Prevention • And the usual stuff!!