A Quantitative Analysis of OnabotulinumtoxinA, AbobotulinumtoxinA, and IncobotulinumtoxinA: A Randomized, Double-Blind, Prospective Clinical Trial of Comparative Dynamic Strain Reduction.

BACKGROUND: U.S. Food and Drug Administration-approved formulations of botulinum toxin include onabotulinumtoxinA (Botox; Allergan, Inc., Irvine, Calif.), abobotulinumtoxinA (Dysport; Galderma Pharma S.A., Lausanne, Switzerland), and incobotulinumtoxinA (Xeomin; Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany). This study uses digital image correlation to compare dynamic strain reduction between available neurotoxins. METHODS: Seventy-three treatment-naive female patients aged were randomized to injection with onabotulinumtoxinA (20 units), abobotulinumtoxinA (60 units), or incobotulinumtoxinA (20 units) in the glabella. Imaging was conducted at 4, 14, and 90 days after injection. Change in average dynamic strain of the glabella was compared using ANOVA. RESULTS: At day 4, there was a 42.1 percent strain reduction in the onabotulinumtoxinA group, a 39.4 percent strain reduction in the abobotulinumtoxinA group, and a 19.8 percent strain reduction in the incobotulinumtoxinA group (onabotulinumtoxinA versus abobotulinumtoxinA, p = 0.77; onabotulinumtoxinA versus incobotulinumtoxinA, p = 0.02; and abobotulinumtoxinA versus incobotulinumtoxinA, p = 0.04). At day 14, there was a 66.1 percent strain reduction in the onabotulinumtoxinA group, a 51.4 percent strain reduction in the abobotulinumtoxinA group, and a 42.8 percent strain reduction in the incobotulinumtoxinA group (onabotulinumtoxinA versus abobotulinumtoxinA, p = 0.14; onabotulinumtoxinA versus incobotulinumtoxinA, p = 0.02; and abobotulinumtoxinA versus incobotulinumtoxinA, p = 0.36). At day 90, there was a 43.5 percent strain reduction in the onabotulinumtoxinA group, a 38.4 percent strain reduction in the abobotulinumtoxinA group, and a 25.3 percent strain reduction in the incobotulinumtoxinA group (onabotulinumtoxinA versus abobotulinumtoxinA, p = 0.66; onabotulinumtoxinA versus incobotulinumtoxinA, p = 0.12; and abobotulinumtoxinA versus incobotulinumtoxinA, p = 0.24). CONCLUSIONS: Using digital image correlation, the tested neuromodulators do not have equivalent strain reduction in the glabella at the doses used. These results confirm assertions of noninterchangeability. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Current Applications of Facial Volumization with Fillers.

LEARNING OBJECTIVES: After reading this article and watching the accompanying videos, the participant should be able to: 1. Assess patients seeking facial volumization and correlate volume deficiencies anatomically. 2. Identify appropriate fillers based on rheologic properties and anatomical needs. 3. Recognize poor candidates for facial volumization. 4. Recognize and treat filler-related side effects and complications. SUMMARY: Facial volumization is widely applied for minimally invasive facial rejuvenation both as a solitary means and in conjunction with surgical correction. Appropriate facial volumization is dependent on patient characteristics, consistent longitudinal anatomical changes, and qualities of fillers available. In this article, anatomical changes seen with aging are illustrated, appropriate techniques for facial volumization are described in the setting of correct filler selection, and potential complications are addressed.

Patient Perceived Benefit in Facial Aesthetic Procedures: FACE-Q as a Tool to Study Botulinum Toxin Injection Outcomes.

BACKGROUND: There are numerous methods of assessing patient satisfaction with botulinum toxin type A neuromodulation of the glabellar rhytids. As the use of aesthetic neuromodulation increases both in breadth and number of procedures, there is a need for more comprehensive tools to evaluate patient-reported outcomes. The FACE-Q is a recently validated patient-reported outcome instrument that can be used to measure patient perceptions of botulinum toxin type A neuromodulation. OBJECTIVES: This study used the FACE-Q to assess patient satisfaction following botulinum toxin type A neuromodulation of the glabellar rhytids. METHODS: 57 female patients completed the FACE-Q, a survey that evaluates patients' satisfaction with their facial appearance. After this baseline survey, the patients received injections of one of onabotulinumtoxinA (Botox, Allergan, Dublin, Ireland), abobotulinumtoxinA (Dysport, Galderma, Lausanne, Switzerland), or incobotulinumtoxinA (Xeomin, Merz Pharmaceuticals, Frankfurt am Main, Germany) in the glabella. Two weeks post-injection, the patients completed the FACE-Q again. The percentage changes in patient responses were tabulated to determine how neuromodulation affects patient satisfaction with their facial appearance. The percentage changes for each of the neurotoxin groups were compared to determine if patient satisfaction with neuromodulation varies with the type of neurotoxin. RESULTS: Patient satisfaction with their overall facial appearance increased by 28% following neuromodulation. Patients stated that they believe they look an average of 5.6 years younger post-neuromodulation. There were no significant differences among the treatment groups. CONCLUSIONS: The FACE-Q demonstrates that patients are more satisfied by their overall facial appearance and age appearance following neuromodulation of their glabellar rhytids. Patients are equally satisfied with the improvement of their facial appearance regardless of which neurotoxin they received. LEVEL OF EVIDENCE 2: Therapeutic.

Analysis of Cosmetic Topics on the Plastic Surgery In-Service Training Exam.

BACKGROUND: The Plastic Surgery In-Service Training Exam (PSITE) is a multiple-choice examination taken by plastic surgery trainees to provide an assessment of plastic surgery knowledge. OBJECTIVE: The purpose of this study was to evaluate cosmetic questions and determine overlap with national procedural data. METHODS: Digital syllabi of six consecutive PSITE administrations (2008-2013) were analyzed for cosmetic surgery topics. Questions were classified by taxonomy, focus, anatomy, and procedure. Answer references were tabulated by source. Relationships between tested material and national procedural volume were assessed via Pearson correlation. RESULTS: 301 questions addressed cosmetic topics (26% of all questions) and 20 required image interpretations (7%). Question-stem taxonomy favored decision-making (40%) and recall (37%) skills over interpretation (23%, P < .001). Answers focused on treatments/outcomes (67%) over pathology/anatomy (20%) and diagnoses (13%, P < .001). Tested procedures were largely surgical (85%) and focused on the breast (25%), body (18%), nose (13%), and eye (10%). The most common surgeries were breast augmentation (12%), rhinoplasty (11%), blepharoplasty (10%), and body contouring (6%). Minimally invasive procedures were lasers (5%), neuromodulators (4%), and fillers (3%). Plastic and Reconstructive Surgery (58%), Clinics in Plastic Surgery (7%), and Aesthetic Surgery Journal (6%) were the most cited journals, with a median 5-year publication lag. There was poor correlation between PSITE content and procedural volume data (r(2) = 0.138, P = .539). CONCLUSIONS: Plastic surgeons receive routine evaluation of cosmetic surgery knowledge. These data may help optimize clinical and didactic experiences for training in cosmetic surgery.

Motivations for seeking minimally invasive cosmetic procedures in an academic outpatient setting.

BACKGROUND: The demand for minimally invasive cosmetic procedures has continued to rise, yet few studies have examined this patient population. OBJECTIVES: This study sought to define the demographics, social characteristics, and motivations of patients seeking minimally invasive facial cosmetic procedures. METHODS: A prospective, single-institution cohort study of 72 patients was conducted from 2011 through 2014 at an urban academic medical center. Patients were aged 25 through 70 years; presented for botulinum toxin or soft tissue filler injections; and completed demographic, informational, and psychometric questionnaires before treatment. Descriptive statistics were conducted using Stata statistical software. RESULTS: The average patient was 47.8 years old, was married, had children, was employed, possessed a college or advanced degree, and reported an above-average income. Most patients felt that the first signs of aging occurred around their eyes (74.6%), and a similar percentage expressed this area was the site most desired for rejuvenation. Almost one-third of patients experienced a "major life event" within the preceding year, nearly half had sought prior counseling from a mental health specialist, and 23.6% were being actively prescribed psychiatric medication at the time of treatment. CONCLUSIONS: Patients undergoing injectable aesthetic treatments in an urban outpatient academic center were mostly employed, highly educated, affluent women who believed that their procedure would positively impact their appearance. A significant minority experienced a major life event within the past year, which an astute clinician should address during the initial patient consultation. This study helps to better understand the psychosocial factors characterizing this patient population. LEVEL OF EVIDENCE: 4 Therapeutic.