Botulinum toxin: procedures in cosmetic dermatology series 4th edition alastair carruthers - Experie

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Clinical performance of incobotulinumtoxinA

Clinical experience with incobotulinumtoxinA

Conclusion

References

Further reading

7 Basic science

Introduction

Mechanismof action

Myobloc formulation and dosage

Immunogenicity of Myobloc

Clinical studies in aesthetic medicine

Side effects

Conclusion future outlook

References

8 Neuronox® and Innotox®

Introduction

Microbiological, physicochemical, and biochemical profiles of Neuronox®

Innotox®: novel liquid botulinumtoxin type Aproduct

Use of Neuronox® and Innotox® in Asians

Further reading

9 Injectable daxibotulinumtoxinA(RT002)

References

10 Comparison of botulinum toxins

Introduction

Types of botulinumtoxin A

Mechanismof action

Compositional differences

Dosing

Efficacy

Duration of action

Diffusion and field of effect

Safety

Resistance

Conclusion

Further reading

11 Topical daxibotulinumtoxinA(RT001)

The need for topical delivery

Topical daxibotulinumtoxinA

Topical daxibotulinumtoxinAfor lateral canthal lines

Topical daxibotulinumtoxinAfor hyperhidrosis

Topical daxibotulinumtoxinAfor migraine

Further reading

12 Topical botulinum toxin type A

Introduction

Barriers to transdermal permeation

Nanoemulsion delivery systems

Allergan botulinumtoxin type Atopical nanoparticle delivery system

Conclusions

Further reading

13 Reconstitution and dilution

Introduction

Reconstitution diluents

Foam, shaking, and stirring

After reconstitution: storage, use, and sterility

Fresh or frozen? Does it matter?

What concentration is adequate for cosmetic and noncosmetic indication?

Conclusion

Further reading

14 Benzyl alcohol

Introduction

Saline with benzyl alcohol: early evidence of anesthetic efficacy and historical concerns

Saline with benzyl alcohol: RCTs with botulinumtoxin

Saline with benzyl alcohol: use in combination with lidocaine infiltration

Saline with benzyl alcohol: use in comparison with lidocaine infiltration

Safety of saline with benzyl alcohol

Summary of key concepts

Anatomy

Treatment techniques

Technical variations for lower face contour with neuromodulators

References

23 The masseters and their treatment with botulinum toxin

Introduction

History

Anatomy

Raison d’être for botulinuminjection to the masseters

Bruxism

Treatment method

Complications

Conclusion

References

Further reading

24 Darker skin types

Introduction

Racial and ethnic differences in photoaging

Safety and efficacy of botulinumtoxins in darker skin types

Ethnic specific applications of botulinumtoxin

Conclusion

Further reading

25 Combination noninvasive facial aesthetic treatments with botulinum toxin type A

Anatomy related to multiple therapeutic modalities

Combination therapy in the upper face

Brow ptosis

Combination therapy in the lower face

Neocollagenesis

Injectables

Skin tightening

Vascular lesions and pigmentation

Topical agents

Sequence and timing of a multimodal approach

Summary

Body Shaping: Skin Fat Cellulite

Jeffrey Orringer MD, Jeffrey S. Dover MD, FRCPC, FRCP and Murad Alam MD, MSCI

ISBN 978-0323321976

Cosmeceuticals

Third edition

Zoe Diana Draelos MD, Murad Alam MD, MSCI and Jeffrey S. Dover MD, FRCPC, FRCP

ISBN 978-0-323-29869-8

Lasers and Lights

Fourth edition

George Hruza MD and Elizabeth Tanzi MD

ISBN 978-0-323-48006-2

Photodynamic Therapy

Second edition

Mitchel P. Goldman MD

ISBN 978-1-4160-4211-2

Liposuction

C. William Hanke MD, MPH, FACP and Gerhard Sattler MD

ISBN 978-1-4160-2208-4

Scar Revision

Kenneth A Arndt MD

ISBN 978-1-4160-3131-4

Hair Transplantation

Robert S Haber MD and Dowling B Stough MD

ISBN 978-1-4160-3104-8

Blepharoplasty

Ronald L Moy MD and Edgar F Fincher MD

ISBN 978-1-4160-2996-0

For Elsevier

Content Strategist: Belinda Kuhn

Content Development Specialist: Humayra Rahman Khan

Project Manager: Srividhya Vidhyashankar

Design: Miles Hitchen

Illustration Manager: Nichole Beard

Video contents

Video 6 Bocouture Injection

Jürgen Frevert, MD, Gerhard Sattler, MD

Video 8 Neuronox

Kyle Koo-II Seo, MD

Video 15 Glabella

Derek H Jones, MD

Video 16 Brow Shaping

Alastair Carruthers, MD

Video 17 Frontalis and HFL

Joel L Cohen, MD

Video 18 1 Crow's Feet

Jean Carruthers, MD

Video 18 2 Lower Eyelid

Alastair Carruthers, MD

Video 19 Technique Demonstrating Pretarsal Injection to Widen Vertical Palpebral Aperture

Shannon Humphrey, MD, Steven Fagien, MD

Video 20 1 Bunny Lines

Jean Carruthers, MD

Video 20.2 Gummy Smile

Jean Carruthers, MD

Video 21 1 Depressor Anguli Oris and Mentalis (1)

Alastair Carruthers, MD

Video 21.2 Depressor Anguli Oris and Mentalis (2)

Jean Carruthers, MD

Video 21 3 Depressor Anguli Oris and Mentalis (3)

Jean Carruthers, MD

Video 26.1 Hyperhidrosis: Palmar Injection Technique

Dee Anna Glaser, MD, Adam R Mattox, MD

Video 26 2 Hyperhidrosis: Axillary HH Treatment and Starch Iodine Test

Dee Anna Glaser, MD, Adam R. Mattox, MD

Series preface

Much has changed since the first edition of this series. Non-invasive and minimally invasive cosmetic procedures, as pioneered by dermatologists, have become increasingly adopted by physicians and wellaccepted by patients. Cosmetic dermatologic surgery procedures have been refined and improved. Interventions have become more effective, and also safer and more tolerable with increasing benefit: risk ratios Combination cosmetic regimens that include multiple procedure types have been shown to achieve results comparable to those with more invasive procedures And newdevices and technologies continue to be introduced

And howbest to keep up with these advances and to ensure your offerings are state of the art and at the cutting edge? The newest edition of the Procedures in Cosmetic Dermatology series keeps you there, and for those starting out in the field these texts quickly introduce you and bring you to the state of the art Each book in this series is designed to quickly impart basic skills as well as advanced concepts in an easy-to-understand manner We focus not on theory but on how-to Our expert book editors and chapter authors will guide you through the learning process efficiently, so you can soon get back to treating patients.

The authors are leading dermatologists in the field Dermatologists' role in cosmetic medicine has continued to expand Research has revealed that primary care physicians and the general public view dermatologists as the experts in less invasive cosmetic procedures Anationwide advanced fellowship program in cosmetic dermatologic surgery has been initiated to train the next generation of dermatologists to the highest standards.

What has not changed is physicians' need for clear, concise, and current direction on procedure techniques Physicians need to be proficient in the latest methods for enhancing appearance and concealing the visible signs of aging

To that end, we hope that you, our reader, find the books enjoyable and educational. We thank our many contributors and wish you well on your journey of discovery

Jeffrey S. Dover MD, FRCPC, FRCP, Murad Alam MD, MSCI

Series preface first edition

Although dermatologists have been procedurally inclined since the beginning of the specialty, particularly rapid change has occurred in the past quarter century. The advent of frozen section technique and the golden age of Mohs skin cancer surgery have led to the formal incorporation of surgery within the dermatology curriculum More recently technological breakthroughs in minimally invasive procedural dermatology have offered an aging population newoptions for improving the appearance of damaged skin

Procedures for rejuvenating the skin and adjacent regions are actively sought by our patients. Significantly, dermatologists have pioneered devices, technologies, and medications, which have continued to evolve at a startling pace Numerous major advances, including virtually all cutaneous lasers and light-source-based procedures, botulinum exotoxin, soft tissue augmentation, dilute anesthesia liposuction, leg vein treatments, chemical peels, and hair transplants, have been invented or developed and enhanced by dermatologists Dermatologists understand procedures, and we have special insight into the structure, function, and working of skin Cosmetic dermatologists have made rejuvenation accessible to risk-averse patients by emphasizing safety and reducing operative trauma. No specialty is better positioned than dermatology to lead the field of cutaneous surgery while meeting patient needs.

As dermatology grows as a specialty, an ever-increasing proportion of dermatologists will become proficient in the delivery of different procedures Not all dermatologists will perform all procedures, and some will perform very few, but even the less procedurally directed among us must be well versed in the details to be able to guide and educate our patients. Whether you are a skilled dermatologic surgeon interested in further expanding your surgical repertoire, a complete surgical novice wishing to learn a fewsimple procedures, or somewhere in between, this book and this series are for you.

The volume you are holding is one of a series entitled Procedures in Cosmetic Dermatology The purpose of each book is to serve as a practical primer on a major topic area in procedural dermatology

If you want to make sure you find the right book for your needs, you may wish to knowwhat this book is and what it is not. It is not a comprehensive text grounded in theoretical underpinnings. It is not exhaustively referenced It is not designed to be a completely unbiased reviewof the world's literature on the subject At the same time, it is not an overviewof cosmetic procedures that describes these in generalities without providing enough specific information to actually permit someone to perform the procedures Importantly, it is not so heavy that it can serve as a doorstop or a shelf filler

What this book and this series offer is a step-by-step, practical guide to performing cutaneous surgical procedures Each volume in the series has been edited by a known authority in that subfield Each editor has recruited other equally practical-minded, technically skilled, hands-on clinicians to write the constituent chapters Most chapters have two authors to ensure that different approaches and a broad range of opinions are incorporated On the other hand, the two authors and the editors also collectively provide a consistency of tone. Auniform template has been used within each chapter so that the reader will be easily able to navigate all the books in the series. Within every chapter, the authors succinctly tell it like they do it. The emphasis is on therapeutic technique; treatment methods are discussed with an eye to appropriate indications, adverse events, and unusual cases. Finally, this book is short and can be read in its entirety on a long plane ride We believe that brevity paradoxically results in greater information transfer because cover-to-cover mastery is practicable

We hope you enjoy this book and the rest of the books in the series and that you benefit from the many hours of clinical wisdom that have been distilled to produce it. Please keep it nearby, where you can reach for it when you need it.

Jeffrey S. Dover MD, FRCPC, FRCP, Murad Alam MD, MSCI

Preface

So why should we expect you to be interested in a newvolume on the cosmetic use of neuromodulators? Well, right there is a reason. Earlier editions talked about botulinum toxin, whereas nowwe are discussing neuromodulators referring to the use of these materials to modulate the subject rather than to achieve the result by controlled paralysis Partly this is due to our better understanding of the method of action of the botulinum toxins, but also it reflects the way we are using the neurotoxins now

Since the third edition in 2012 there have been major advances in the use of neuromodulators, and we have attempted to incorporate these into this volume without being too biased. We have continued the policy begun in volume 3 of asking each of the companies involved in the commercial production of neuromodulators to write a chapter on their product(s), avoiding comparisons as much as possible These chapters contain much useful information to be discovered, and we hope you will enjoy them as well as the other chapters in this volume We think that we have avoided too much of a commercial bias

The chapter on the newer Revance products (RT002) shows a significant change from the third edition, when we thought they would be producing a commercial topical toxin, whereas nowthey appear to be focusing on extending the duration of effect of the toxin We advise you not to give up on the topical toxin, which we believe to have a future in both the cosmetic and therapeutic worlds, and we expect that the other companies with expertise in this area will be producing neuromodulators with unique properties.

Similarly, the cosmetic use has continued to change, and we hope you will appreciate the new chapters Newauthors are giving you their expertise and their newknowledge It is fascinating to see howsomething that we thought was settled (the use of botulinum neurotoxin type Ain the brow) has changed so much! In addition, the use has expanded into newareas, as well as the newmethods of using the botulinum neurotoxin (BoNT)

Overall, our understanding of the clinical use of BoNT, as well as the products themselves, has really changed this area. We hope that you will agree with us after reading this well-produced volume. Enjoy!

Alastair Carruthers MA, BM, BCh, FRCPC, FRCP(Lon), Jean Carruthers MD, FRCSC, FRC (OPHTH), FASOPRS

List of contributors

The editor(s) acknowledge and offer grateful thanks for the input of all previous editions' contributors, without whom this newedition would not have been possible.

Murad Alam MD, MSCI, Professor of Dermatology, Otolaryngology, and Surgery; Chief, Section of Cutaneous and Aesthetic Surgery, Northwestern University, Chicago, IL, USA

Andrew F. Alexis MD, MPH Chairman, Department of Dermatology, Mount Sinai St. Luke's and Mount Sinai West; Associate Clinical Professor, Icahn School of Medicine at Mount Sinai, NewYork, NY, USA

GeeYoung Bae MD, Director of Rose Clinic, Clinical Professor in the Department of Dermatology of Ulsan University, College of Medicine, University of Ulsan, Seoul, Korea

Katie Beleznay MD, FRCPC, FAAD, Clinical Instructor, Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada

Jeanette M. Black MD, Dermatologist, Skin Care and Laser Physicians of Beverly Hills, Los Angeles, CA, USA

Andrew Blitzer MD, DDS, Professor Emeritus of Otolaryngology/Head and Neck Surgery, Columbia University, College of Physicians and Surgeons; Adjunct Professor of Neurology, Icahn School of Medicine at Mt Sinai; Director, NY Center for Voice and Swallowing Disorders; Co-Founder and Director of Research, ADN International, NewYork, NY, USA

Jennifer B. Mancuso MD, Dermatology Resident, Henry Ford Hospital, Detroit, MI, USA

Mitchell F. Brin MD Senior Vice President, Global Drug Development, Chief Scientific Officer, BOTOX®, Allergan, Inc., Irvine, CA; Professor of Neurology, University of California, Irvine, CA, USA

Letícia Cardoso Secco MD, Volunteer Dermatologist, Hospital do Servidor Público Municipal de São Paulo, Brazil

Alastair Carruthers MA, BM, BCh, FRCPC, FRCP(Lon), Clinical Professor, Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada

Jean Carruthers MD, FRCSC, FRC (OPHTH), FASOPRS, Clinical Professor, Department of Ophthalmology and Visual Science, University of British Columbia, Vancouver, BC, Canada

Joel L. Cohen MD Director, AboutSkin Dermatology and DermSurgery, Englewood; Associate Clinical Professor, Department of Dermatology, University of Colorado, Denver, CO, USA

Jeffrey S. Dover MD, FRCPC, FRCP Director, SkinCare Physicians, Chestnut Hill, MA;

Associate Clinical Professor of Dermatology, Yale University School of Medicine;

Adjunct Associate Professor of Dermatology

Brown Medical School, Providence, RI, USA

Steven Fagien MD, FACS, Private Practice, Aesthetic Eyelid Plastic Surgery, Boca Raton, FL, USA

Timothy C. Flynn MD

Clinical Professor, Department of Dermatology, University of North Carolina, Chapel Hill, NC; Medical Director, Cary Skin Center, Cary, NC, USA

Jürgen Frevert PhD, Head of Botulinum Toxin Research, Merz Pharmaceuticals GmbH, Potsdam, Germany

Conor J. Gallagher PhD, Senior Medical Director, Facial Aesthetics, Medical Affairs, Allergan, Plc, Irvine, CA, USA

Dee Anna Glaser MD, Professor and Vice Chairman; Director Cosmetic and Laser Surgery, Department of Dermatology, Saint Louis University School of Medicine, Saint Louis, MO, USA

Richard G. Glogau MD, Clinical Professor of Dermatology, University of California San Francisco, San Francisco, CA, USA

Greg J. Goodman MBBS, FACD, MD, Associate Professor, Monash University; Chief of Surgery, Skin and Cancer Foundation Inc , Carlton, VIC, Australia

Pearl E. Grimes MD, Director, Vitiligo and Pigmentation Institute of Southern California; Clinical Professor, Division of Dermatology, David Geffan School of Medicine, University of California, Los Angeles, CA, USA

Bhushan Hardas MD, MBA, US Head of Research & Development and Vice President, Merz Pharmaceuticals, LLC, Greensboro, NC, USA

Shannon Humphrey MD, FRCPC, FAAD, Clinical Assistant Professor, Director of CME, Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada

Matthias Imhof MD, Dermatologist, Aesthetic Dermatology Department, Medico Palais, Bad Soden, Germany

Derek H. Jones MD, Associate Clinical Professor, Dermatology, David Geffen School of Medicine, University of California, Los Angeles; Dermatologist, Skin Care and Laser Physicians of Beverly Hills, Los Angeles, CA, USA

Dr. Michael Z. Lerner, Assistant Professor of Otolaryngology, Albert Einstein College of Medicine, Bronx, NY, USA

Austin Liu MD, Dermatology & Mohs Surgery Center, Doylestown and Sellersville, PA, USA

Ian A. Maher MD, FAAD, Assistant Professor, Department of Dermatology, Saint Louis University, St Louis, MO, USA

Kavita Mariwalla MD, Assistant Clinical Professor, Department of Dermatology, Columbia University, NewYork, NY, USA

Adam R. Mattox DO, MS, Physician Research Fellow, Department of Dermatology, Saint Louis University School of Medicine, Saint Louis, MO, USA

Gary D. Monheit MD, FAAD, FACS, Private Practice, Total Skin and Beauty Dermatology Center, PC; Associate Clinical Professor, Departments of Dermatology and Ophthalmology, University of Alabama at Birmingham, Birmingham, AL, USA

Jasmine O. Obioha MD, Resident, Department of Dermatology, Icahn School of Medicine at Mount Sinai, NewYork, NY, USA

David M. Ozog MD, FAAD, Director of Cosmetic Dermatology; Vice-Chair of Operations, Division of Mohs and Dermatological Surgery, Henry Ford Hospital, Detroit, MI, USA

Amit A. Patel MD, Otolaryngologist, ENT Allergy Group, Shrewsbury, NJ, USA

Andrew Pickett BSc, PhD

Director and Founder, Toxin Research Limited, Wrexham, UK; Adjunct Professor, Botulinum Research Center, UMASS Dartmouth, MA, USA

Roman G. Rubio MD, MBA, Senior Vice President of Clinical Development, Revance Therapeutics, Inc., Newark, CA, USA

Thomas E. Rohrer MD

Clinical Associate Professor of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI; Director of Mohs Fellowship, SkinCare Physicians, Chestnut Hill, MA, USA

Neil S. Sadick MD, FAAD, FAACS, FACP, FACPh, Clinical Professor, Weill Cornell Medical College, Cornell University; Sadick Dermatology and Research Group, NewYork, NY, USA

Nazanin Saedi, Director, Laser Surgery and Cosmetic Dermatology, Thomas Jefferson University Hospitals, Philadelphia, PA, USA

Gerhard Sattler MD, Fellowof Dermatology; Clinical Director of Rosenparkklinik, Darmstadt, Germany

Kyle Koo-II Seo MD, PhD, Clinical Associate Professor, Dermatology, Seoul National University College of Medicine; Director, Dermatology, Modelo Clinic, Seoul, Korea

Kevin C. Smith MD, FRCPC [Derm], Private Practice, Niagara Falls, ON, Canada

Nowell Solish MD, FRCPC, Assistant Professor of Dermatology, University of Toronto, ON, Canada

Ada R. Trindade de Almeida MD, Dermatologist, Dermatologic Clinic, Hospital do Servidor Público Municipal de São Paulo and private office, São Paulo, Brazil

Jacob M Waugh MD, Illustris Pharmaceuticals, Inc , Palo Alto, CA, USA

Mara Weinstein Velez MD, Dermatologist, SkinCare Physicians of Chestnut Hill, Chestnut Hill, MA, USA

Naissan O. Wesley MD

Clinical Instructor, Medicine, Division of Dermatology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Dermatologist and Dermatologic Surgeon, Skin Care and Laser Physicians of Beverly Hills, Los Angeles, CA, USA

Acknowledgments

Looking back over the past 30 years of our involvement in the clinical use of botulinum toxin there are very many people who have supported and encouraged us. The first to be mentioned, of course, is Alan Scott, MD, who has been consistently generous with his educational efforts, his clinical information, his research results and, with his wife Ruth, hospitality Sitting on their deck above Mill Valley looking towards the Golden Gate Bridge we have learned more about botulinum toxin than in any lecture hall

From the early days of oculinum and then botoxwe have had fascinating and enlightening discussions with Mitchell Brin, MD, and AndrewBlitzer, MD, both from Columbia. The early group of us who formed a core set of advisers for Allergan (our advice was not always well received and usually was ahead of its time) consisted of AndrewBlitzer, MD, Richard Glogau, MD, Nicholas Lowe, MD, Arnold Klein, MD, and the two of us These sessions and teleconferences set the stage for the future education and development of the cosmetic use of botulinum toxin and were a major learning experience for us all The basic science which Roger Aoki, PhD, of Allergan Inc , provided to us gave a solid basis for our understanding of howthe toxin works and the meaning of both basic and clinical studies.

In more recent years we have had valuable assistance from many individuals, many of whom are coauthors in this book We have greatly appreciated the contributions of many of our international colleagues such as Ada Trindade de Almeida, MD, Francisco Perez Atamoros, MD, and Koenraad de Boulle, MD To all of the authors of this text, we salute you! We are so grateful for the hard work you have put into this volume and the tolerance you have shown when faced with yet more unreasonable editorial demands. The proof of your labors and dedication is easily seen between the covers of this book.

Any list of acknowledgments would not be complete without recognizing the people who actually do the work to make it all work: our staff and our patients Our patients have been so very tolerant, especially in the beginning when we did not fully understand the potential benefits as well as the pitfalls of the cosmetic use of botulinum toxin. Our staff have been consistently supportive and helpful (finding photographs from the vaguest descriptions, following up results good and bad, keeping things running smoothly so we could go off and deliver another lecture). We could not have done it without you!

Finally, our friends and family have accepted the fact that we might or might not be in a given place at a given time, that we spend more time thinking about them in airports than actually talking to them, that our crazy idea has generated a crazy life. Many thanks to you all!

Alastair Carruthers MA, BM, BCh, FRCPC, FRCP(Lon), Jean Carruthers MD, FRCSC, FRC (OPHTH), FASOPRS

Dedication

Firstly, and most importantly, we dedicate this volume to our sons and their families. Our sons were young when the botulinum toxin story began and they have regarded the efforts of their parents to cope with this accidental discovery with tolerance and increasing pride over the years. We have appreciated the support and encouragement they have given us. The love they have given us means we are indeed fortunate.

We have been fortunate to have an amazing series of mentors during our careers, Alan Scott and Barrie Jay for Jean and Ted Tromovitch, Sam Stegman, Rick Glogau and Stuart Maddin for us both The interest and imagination stirred by these individuals has been crucial

Finally we have been fortunate to work with outstanding people over the years in our various offices as well as at the American Society for Dermatologic Surgery. They have all been a part of our story and have helped to create our careers and hence the volume which you are holding. Thanks to all of them!

Alastair Carruthers MA, BM, BCh, FRCPC, FRCP(Lon), Jean Carruthers MD, FRCSC, FRC (OPHTH), FASOPRS

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