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Dr. Christeen Youssef’s Pioneering Work in Botulinum Neurotoxin Research Now on PubMed

Consensus Statement on the Use of Botulinum Neurotoxin in the Middle East

Abstract

Background: Aesthetic minimally invasive procedures have become very popular and culturally acceptable among Middle Eastern populations. Botulinum neurotoxin type A (BoNTA) is a valuable treatment modality for many cosmetic as well as therapeutic indications. The presence of BoNTA in our toolkit has revolutionized the field of aesthetic medicine to the point where it is now one of the most commonly performed cosmetic procedures worldwide. This consensus considers popular on- and off-label BoNTA indications in the Middle East.

Methods: A multinational group of ten key opinion leaders, experts in facial plastic surgery and dermatology, convened the Middle East Aesthetics Consensus Group and reviewed the aesthetic applications of BoNTA. Recommendations and position statements were drafted based on the integration of the panel’s clinical experience with published data, targeted to the practices implemented in the Middle Eastern and the global population.

Results: Guidance statements are presented covering Middle Eastern facial characteristics and beauty ideals, BoNTA characteristics, pre-operative counselling, treatment indications and anatomical considerations, off-label and special uses including high-dose recommendations, and post-treatment advice. Throughout, an evidence-based approach to selection of products and injection techniques is provided, supplemented by the experts’ advice on injections dosages and placement.

Conclusion: This consensus reflects the knowledge and expertise of physicians practicing in the Middle East. The panel acknowledged the use of on-label indications and variability in the toxin formulations and immunogenicity and agreed upon a wide use of “off-label” indications.

Keywords: Middle East; aesthetic use; botulinum neurotoxin type A; consensus.

Conflict of interest statement

The authors report no conflicts of interest in this work.

References

  1. International Society of Aesthetic Plastic Surgery (ISAPS). ISAPS international survey on aesthetic/cosmetic procedures performed in 2019. Available from:https://www.isaps.org/wp-content/uploads/2020/12/Global-Survey-2019.pdf  Accessed January 8, 2023.
  2. The middle east population; 2022. Available from: https://worldpopulationreview.com/continents/the-middle-east-population. Accessed June 16, 2022.
  3. Kashmar M, Alsufyani MA, Ghalamkarpour F, et al. Consensus opinions on facial beauty and implications for aesthetic treatment in Middle Eastern women. Plast Reconstr Surg Glob Open. 2019;7(4):e2220. doi:10.1097/GOX.0000000000002220 – DOI – PMC – PubMed
  4. Yutskovskaya Y, Gubanova E, Khrustaleva I, et al. IncobotulinumtoxinA in aesthetics: Russian multidisciplinary expert consensus recommendations. Clin Cosmet Investig Dermatol. 2015;8:297–306. doi:10.2147/CCID.S72301 – DOI – PMC – PubMed
  5. Sundaram H, Huang PH, Hsu NJ, et al; Pan-Asian Aesthetics Toxin Consensus Group. Aesthetic applications of botulinum toxin A in Asians: an international, multidisciplinary, pan-asian consensus. Plast Reconstr Surg Glob Open. 2016;4(12):e872. doi:10.1097/GOX.0000000000000507 – DOI – PMC – PubMed
  6. Sundaram H, Signorini M, Liew S, et al.; Global Aesthetics Consensus Group. Global aesthetics consensus: botulinum toxin type a–evidence-based review, emerging concepts, and consensus recommendations for aesthetic use, including updates on complications. Plast Reconstr Surg. 2016;137(3):518e–529e. doi:10.1097/01.prs.0000475758.63709.23 – DOI – PMC – PubMed
  7. Farkas LG, Katic MJ, Forrest CR, et al. International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg. 2005;16(4):615–646. doi:10.1097/01.scs.0000171847.58031.9e – DOI – PubMed
  8. Al-Sebaei MO. The validity of three neo-classical facial canons in young adults originating from the Arabian Peninsula. Head Face Med. 2015;11(1):4. doi:10.1186/s13005-015-0064-y – DOI – PMC – PubMed
  9. El Minawi H, El Saloussy Y, Sabry M, Wahdan W, El Sharkawy O. Facial anthropometry and analysis in Egyptian women. Plast Reconstr Surg Glob Open. 2022;10(5):e4333. doi:10.1097/GOX.0000000000004333 – DOI – PMC – PubMed
  10. Samizadeh S, De Boulle K. Botulinum neurotoxin formulations: overcoming the confusion. Clin Cosmet Investig Dermatol. 2018;11:273–287. doi:10.2147/CCID.S156851 – DOI – PMC – PubMed
  11. Kerscher M, Roll S, Becker A, Wigger-Alberti W. Comparison of the spread of three botulinum toxin type A preparations. Arch Dermatol Res. 2012;304(2):155–161. doi:10.1007/s00403-011-1179-z – DOI – PubMed
  12. Grein S, Mander GJ, Fink K. Stability of botulinum neurotoxin type A, devoid of complexing proteins. Botulinum J. 2011;2(1):49–58. doi:10.1504/TBJ.2011.041815 – DOI
  13. Carr WW, Jain N, Sublett JW. Immunogenicity of botulinum toxin formulations: potential therapeutic implications. Adv Ther. 2021;38(10):5046–5064. doi:10.1007/s12325-021-01882-9 – DOI – PMC – PubMed
  14. Fathallah AM, Bankert RB, Balu-Iyer SV. Immunogenicity of subcutaneously administered therapeutic proteins–a mechanistic perspective. AAPS J. 2013;15(4):897–900. doi:10.1208/s12248-013-9510-6 – DOI – PMC – PubMed
  15. Bellows S, Jankovic J. Immunogenicity associated with botulinum toxin treatment. Toxins. 2019;11(9):491. doi:10.3390/toxins11090491 – DOI – PMC – PubMed
  16. Kerscher M, Wanitphakdeedecha R, Trindade de Almeida A, Maas C, Frevert J. IncobotulinumtoxinA: a highly purified and precisely manufactured botulinum neurotoxin type A. J Drugs Dermatol. 2019;18(1):52–57. – PubMed
  17. Carey WD. Incorrect reconstitution of incobotulinumtoxinA leads to loss of neurotoxin. J Drugs Dermatol. 2014;13(6):735–738. – PubMed
  18. Niamtu J. Neurotoxin waste from drawing product through the vial stopper. J Clin Aesthet Dermatol. 2014;7(6):33–37. – PMC – PubMed
  19. Thomas JP, Siupsinskiene N. Frozen versus fresh reconstituted botox for laryngeal dystonia. Otolaryngol Head Neck Surg. 2006;135(2):204–208. doi:10.1016/j.otohns.2006.04.001 – DOI – PubMed
  20. Soares DJ, Dejoseph LM, Zuliani GF, Liebertz DJ, Patel VS. Impact of postreconstitution room temperature storage on the efficacy of incobotulinumtoxinA treatment of dynamic lateral canthus lines. Dermatol Surg. 2015;41(6):712–717. doi:10.1097/DSS.0000000000000365 – DOI – PubMed
  21. Wright G, Lax A, Mehta SB. A review of the longevity of effect of botulinum toxin in wrinkle treatments. Br Dent J. 2018;224(4):255–260. doi:10.1038/sj.bdj.2018.126 – DOI – PubMed
  22. Frevert J. Pharmaceutical, biological, and clinical properties of botulinum neurotoxin type A products. Drugs R D. 2015;15(1):1–9. doi:10.1007/s40268-014-0077-1 – DOI – PMC – PubMed
  23. Car H, Bogucki A, Bonikowski M, et al. Botulinum toxin type-A preparations are not the same medications — basic science (Part 1). Neurol Neurochir Pol. 2021;55(2):133–140. doi:10.5603/PJNNS.a2021.0027 – DOI – PubMed
  24. DYSPORT® Prescribing Information. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/125274s107lbl.pdf. Accessed October 3, 2023.
  25. BOTOX© Prescribing Information. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/103000s5232lbl…. Accessed October 3, 2023.
  26. XEOMIN© Prescribing Information. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/125360s078lbl.pdf. Accessed October 3, 2023.
  27. Carruthers A, Carruthers J, Cohen JL. Dilution volume of botulinum toxin type A for the treatment of glabellar rhytides: does it matter? Dermatol Surg. 2007;33(1):S97–S104. doi:10.1111/j.1524-4725.2006.32339.x – DOI – PubMed
  28. Trindade De Almeida AR, Secco LC, Carruthers A. Higher dilution associated with higher diffusion and less efficacy. Handling botulinum toxins: an updated literature review. Dermatol Surg. 2011;37(H):1553–1565. doi:10.1111/j.1524-4725.2011.02087.x – DOI – PubMed
  29. Cohen JL, Ozog DM, Editors. Botulinum Toxins: Cosmetic and Clinical Applications. First ed. JohnWiley & Sons Ltd; 2017. Available from: www.wiley.com/go/cohen/botulinum. Accessed October 3, 2023.
  30. Kaidbey KH, Agin PP, Sayre RM, Kligman AM. Photoprotection by melanin, a comparison of black and Caucasian skin. J Am Acad Dermatol. 1979;1(3):249–260. doi:10.1016/S0190-9622(79)70018-1 – DOI – PubMed
  31. Hexsel DM, Hexsel CL, Brunetto LI. Botulinum toxin. In: Grimes PE, editor. Aesthetic and Cosmetic Surgery for Darker Skin Types. Philadelphia, PA: Lippincott Williams and Wilkins; 2008:211–224.
  32. Montagna W, Prota G, Kenney J. The structure of black skin. In: Montagna W, Prota G, Kenney J, editors. Black Skin Structure and Function. Gulf Professional Publishing; 1993.
  33. Sugino K, Imokawa G, Maibach H. Ethnic differences in stratum corneum lipid in relation to stratum corneum function. J Invest Dermatol. 1993;100:594.
  34. Yi KH, Lee JH, Hu HW, Kim HJ. Anatomical proposal for botulinum neurotoxin injection for glabellar frown lines. Toxins. 2022;14(4):268. doi:10.3390/toxins14040268 – DOI – PMC – PubMed
  35. Yi KH, Lee JH, Kim GY, Yoon SW, Oh W, Kim HJ. Novel anatomical proposal for botulinum neurotoxin injection targeting lateral canthal rhytids. Toxins. 2022;14(7):462. doi:10.3390/toxins14070462 – DOI – PMC – PubMed
  36. Amiri L, Galadari H, Al Mugaddam F, Souid AK, Stip E, Javaid SF. Perception of cosmetic procedures among Middle Eastern Youth. J Clin Aesthet Dermatol. 2021;14(12):E74–E83. – PMC – PubMed
  37. Yi KH, Lee JH, Lee K, Hu HW, Lee HJ, Kim HJ. Anatomical proposal for botulinum neurotoxin injection targeting the platysma muscle for treating platysmal band and jawline lifting: a review. Toxins. 2022;14(12):868. doi:10.3390/toxins14120868 – DOI – PMC – PubMed
  38. Phan K, Younessi S, Dubin D, Lin MJ, Khorasani H. Emerging off-label esthetic uses of botulinum toxin in dermatology. Dermatol Ther. 2022;35(1):e15205. doi:10.1111/dth.15205 – DOI – PubMed
  39. Baker A. Off-label cosmetic use of botulinum toxin in the lower face. Pmfa News|February/March 2016|Vol 3 No 3; 2016.
  40. Munavalli GS, Benedetto AV, Biesman BS, Cutler Peck CM. Treatment of the periocular area – crow’s feet, brow, and bunny lines. In: Cohen JL, Ozog DM, editors. Botulinum Toxins: Cosmetic and Clinical Applications. Wiley Online Library;2017. doi:10.1002/9781118661833.ch12 – DOI
  41. Shirshakova M, Morozova E, Sokolova D, Pervykh S, Smirnova L. The effectiveness of botulinum toxin type A (BTX-A) in the treatment of facial skin oily seborrhea, enlarged pores, and symptom complex of post-acne. Int J Dermatol. 2021;60(10):1232–1241. doi:10.1111/ijd.15574 – DOI – PubMed
  42. Allen S, Sengelmann R, Simmons R. Treatment of the perioral area. In: Cohen JL, Ozog DM, editors. Botulinum Toxins: Cosmetic and Clinical Applications. Wiley Online Library;2017. doi:10.1002/9781118661833.ch14 – DOI
  43. Yi KY, Lee JH, Hu HW, Kim HJ. Novel anatomical guidelines on botulinum neurotoxin injection for wrinkles in the nose region. Toxins. 2022;14(5):342. doi:10.3390/toxins14050342 – DOI – PMC – PubMed
  44. Hur MS, Lee S, Jung HS, Schneider RA, Cray JJ. Anatomical connections among the depressor supercilii, levator labii superioris alaeque nasi, and inferior fibers of orbicularis oculi: implications for variation in human facial expressions. PLoS One. 2022;17(3):e0264148. doi:10.1371/journal.pone.0264148 – DOI – PMC – PubMed
  45. Yi KH, Lee JH, Hu HW, et al. Novel anatomical guidelines for botulinum neurotoxin injection in the mentalis muscle: a review. Anat Cell Biol. 2023;56(3):293–298. doi:10.5115/acb.22.266 – DOI – PMC – PubMed
  46. Choi DY, Bae H, Bae JH, Kim HJ, Hu KS. Effective locations for injecting botulinum toxin into the mentalis muscle; cadaveric and ultrasonographic study. Toxins. 2021;13(2):96. doi:10.3390/toxins13020096 – DOI – PMC – PubMed
  47. Yi KH, Lee JH, Hu HW, et al. Novel anatomical proposal for botulinum neurotoxin injection targeting depressor anguli oris for treating drooping mouth corner. Anat Cell Biol. 2023;56(2):161–165. doi:10.5115/acb.22.258 – DOI – PMC – PubMed
  48. Kaufman-Janette J, Cox SE, Dayan S, Joseph J. Botulinum toxin type a for glabellar frown lines: what impact of higher doses on outcomes? Toxins. 2021;13(7):494. doi:10.3390/toxins13070494 – DOI – PMC – PubMed
  49. Dayan S, Joseph J, Moradi A, et al. Subject satisfaction and psychological well-being with escalating abobotulinumtoxinA injection dose for the treatment of moderate to severe glabellar lines. J Cosmet Dermatol. 2022;21(6):2407–2416. doi:10.1111/jocd.14906 – DOI – PMC – PubMed
  50. Fabi SG, Carruthers J, Joseph J, et al. High-dose neuromodulators: a roundtable on making sense of the data in real-world clinical practice. Aesthet Surg J Open Forum. 2021;3(4):ojab036. doi:10.1093/asjof/ojab036 – DOI – PMC – PubMed

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