Roundtable on Neuromodulators 1 Botulinum Toxin A - - PDF document

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

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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

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Scar Prevention – Botulinum Toxin

• Tension on wound edges leads

to poor aesthetic outcome

• Same reason we place surgical

scars parallel w/ relaxed skin tension lines vs. perpendicular

• Botulinum toxin allows

“Chemoimmobilization” –

• vercome dynamic tension

Proposed Mechanism of Action

• Decreased wound

tension/repetitive microtrauma at wound edge

• Decreased inflammation
• Directly inhibits fibroblast to

myofibroblast differentiation*

• Inhibits fibroblast proliferation and

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

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Botulinum Toxin

Kim YS. et al. Wound Repair Regen. 2014

Baseline 6 Month F/U BTA Control BTA Control

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

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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 abobotulinumtoxinAon 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
• f vesicles in cholinergic nerves

Bloom BS, Payongayong L, Mourin A, Goldberg DJ. Impact of intradermal abobotulinumtoxinAon facial erythema of rosacea. Dermatol Surg. Jan 2015;41 Suppl 1:S9‐16

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Rosacea

Dayan SH, Pritzker RN, Arkins JP. A new treatment regimen for rosacea: onabotulinumtoxinA. J Drugs Dermatol. Dec 2012;11(12):e76‐79.

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

Thoughts? Lower Face/Neck Rejuvenation

Microdroplet Technique

• Placed w/in dermis
• diffusion limited to the superficial

muscle fibers leaving deeper muscle functional

• Sebaceous/sweat glands

deactivated  “Bulk atrophy of 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.” Improvement

• Laxity
• Jowling
• Skin Texture
• Horizontal Rhytides
• Vertical Banding

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. MICROTOXIN MICROTOXIN DIFFUSION WEAKENING OF SUPERFICIAL MUSCLE FIBERS GLANDS DEACTIVATED SKIN CONTRACTION

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Lower Face/Neck Rejuvenation

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.

‐ 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

• f the sternocleidomastoid

*Chin standard dosing with 2.5mL reconstitution **avoid injecting over the depressor anguli oris and over the sternocleidomastoid

Lower Face/Neck Rejuvenation

• 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

• nabotulinumtoxinA
• 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.

Pre‐Tx 2 Weeks Post‐Tx

Thoughts? 19 20 21

Conclusion

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

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