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Posted 7/31/2013


Do you ever treat the same patient with more than 1 approved neurotoxin simultaneously?

Response From Hema Sundaram, MD

Founder and Director, Dermatology, Cosmetic & Laser Surgery, Rockville Maryland, and Fairfax, Virginia

Currently, 3 botulinum neurotoxin type A (BoNTA) products are approved by the US Food and Drug Administration (FDA) for aesthetic use: onabotulinumtoxinA (BoNTA-ONA; Botox® Cosmetic; Allergan Inc.), abobotulinumtoxinA (BoNTA-ABO; Dysport®; Medicis Aesthetics, Inc.), and incobotulinumtoxinA (BoNTA-INCO; Xeomin®; Merz Aesthetics). All are approved for the temporary improvement of glabellar lines in adults; thus, treatment of other facial areas is considered off-label use.

In the majority (over 90%) of my patients, I select 1 of these neurotoxin products for use pan-facially. In practice, I have found all 3 BoNTA products to be equally safe and efficacious and to produce excellent and comparable results when treating the upper face, lower face, and neck. These observations are reflected by the results of controlled studies of BoNTA-ONA, BoNTA-ABO, and BoNTA-INCO (evidence level II) that demonstrate excellent safety and efficacy with each product when used for glabellar treatment.[1-3] It should also be noted that the incidence of adverse events, including upper eyelid ptosis, is low and comparable across these studies.

Although all FDA-approved BoNTA products are largely similar and can be used with exactly the same pattern and number of injection points, BoNTA-ABO does appear to be associated with a somewhat greater spread, or "field of effect," than that seen with BoNTA-ONA or BoNTA-INCO.[4] Thus, BoNTA-ABO may produce a somewhat larger zone of muscular paresis around each injection point than BoNTA-ONA or BoNTA-INCO; this may produce more focal zones of muscular paresis.

On occasion, I may leverage these different fields of effect by using different BoNTA products to target specific facial muscles. For example, I have found that I can often reduce the number of injection sites needed for treatment of the forehead, crow's feet, or neck (via targeting of the frontalis, orbicularis oculi, and platysma muscles, respectively) when using BoNTA-ABO due to its greater spread. By the same token, treatment of the perioral rhytides (via targeting of the orbicularis oris muscle) with BoNTA-ONA or BoNTA-INCO can produce a more discrete effect that may benefit some patients.

It is important for the clinician to understand that any of the 3 currently approved BoNTA products can be employed for successful pan-facial rejuvenation and that treatment of the same patient with more than 1 product simultaneously will tend to be the exception rather than the norm. Because this treatment paradigm has not been formally evaluated with controlled studies, it must be considered anecdotal (evidence level V).

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