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Background:. As long-term, regular aesthetic botulinum neurotoxin A (BoNT-A) use becomes more commonplace, it is vital to understand real-world risk factors and impact of BoNT-A immunoresistance. The first Aesthetic Council on Ethical Use of Neurotoxin Delivery panel discussed issues relating to BoNT-A immunoresistance from the health care professionals’ (HCPs’) perspective. Understanding the implications of BoNT-A immunoresistance from the aesthetic patient’s viewpoint allows HCPs to better support patients throughout their aesthetic treatment journey. Methods:. A real-world consumer study surveyed 363 experienced aesthetic BoNT-A recipients across six Asia-Pacific territories. The survey mapped participants’ BoNT-A aesthetic treatment journey and characterized awareness and attitudes relating to BoNT-A immunoresistance and treatment implications. At the second Aesthetic Council on Ethical use of Neurotoxin Delivery meeting, panelists discussed survey findings and developed consensus statements relating to the impact of BoNT-A immunoresistance on the aesthetic treatment journey. Results:. Aesthetic BoNT-A patients’ depth of knowledge about BoNT-A immunoresistance remains low, and risk/benefit communications need to be more lay-friendly. The initial consultation is the most important touchpoint for HCPs to raise awareness of BoNT-A immunoresistance as a potential side effect considering increased risk with repeated high-dose treatments. HCPs should be cognizant of differences across BoNT-A formulations due to the presence of certain excipients and pharmacologically unnecessary components that can increase immunogenicity. Standardized screening for clinical signs of secondary nonresponse and a framework for diagnosing and managing immunoresistance-related secondary nonresponse were proposed. Conclusion:. These insights can help patients and HCPs make informed treatment decisions to achieve desired aesthetic outcomes while preserving future treatment options with BoNT-A.

Background:. Microfocused ultrasound with visualization (MFU-V) is used for lifting and tightening of facial tissues. Standard protocols are completed in a single session. Despite excellent outcomes, we identified several barriers of entry for a significant number of patients. Therefore, we devised an individualized pan-facial protocol that is delivered as a series of short, intense treatments to address these issues. Methods:. We enrolled 12 participants with mild-to-moderate skin and fibromuscular laxity to receive one superficial and one deep pass per visit (average 280 lines). Qualitative improvements were rated by both patients and physicians at 6 or 10 months due to COVID-19 delays. Changes in the submentum and eyebrow heights were quantified. Results:. Ten patients (age range: 31–61 years) underwent an average of four MFU-V treatments. Two patients were excluded after massive weight gain. Skin and fibromuscular ptosis and overall soft tissue laxity improved in all patients. Mean brow height increased by 1.7 mm, whereas the mean submental lift was 78.7 mm2. All patients and treating physicians rated an improvement in appearance, whereas independent physicians rated improvements in 87% of cases. Four patients self-rated as “markedly improved.” Pain was rated at up to 6.2 (out of 10). Although mask-wearing was mandatory, loss of elasticity, wrinkles, and skin roughness all improved. Superficial welts (n = 5), erythema (n = 3), tenderness (n = 3), and mild bruising (n = 2) occurred, but all resolved within a few days and no severe or permanent adverse events occurred. Conclusion:. The Hi5 protocol was noninferior to standard single-session protocols and improved brow heights and submental lifting.

Background:. A retrospective review of patients who switched from onabotulinumtoxinA (onaA) and/or abobotulinumtoxinA (aboA) to incobotulinumtoxinA (incoA) found anecdotal reports of differences in “feel,” including a “lighter” feel or treatment-associated tightness. We surveyed the frequency of these sensations as an initial proof of concept of toxin proprioception among our patients who switched toxins. Methods:. Seventy-nine patients who had past facial aesthetic treatments with more than one botulinum toxin A (BoNT/A) formulation completed a questionnaire on their experience of treatment-associated sensations, including stiffness or a frozen feeling. Results:. Treatment-associated sensations of tightness (47.3%), headache (41.8%), heaviness (38.2%), feeling frozen (29.1%), stiffness (20.0%), and weakness (20.0%) were reported by 55 of 79 patients. Furthermore, 78.2% of 55 patients noted an interformulation sensory difference. Of 79 patients surveyed, 68.4% of onaA-treated patients associated sensations with onaA, 39.1% of aboA-treated patients associated sensations with aboA, and 12.2% of incoA-treated patients associated sensations with incoA. Conclusions:. Some patients reported a different feel between toxins, and the difference in frequency of treatment-associated sensation varies between the different formulations used. Given the fine coordination of facial expressive muscles, we suspect that associated proprioceptive afferents are involved. Our findings confirm that post-toxin treatment-associated sensations can be detected by some patients, and this is likely due to the variations between the formulations. Failing to advise patients of this before switching formulations may cause a misperception that the treatment is not working well or that its effect has worn off prematurely, and some patients may consider switching formulations to reduce these conscious proprioceptive sensations.

Background:. Botulinum neurotoxin A (BoNT-A) injection is the most widely performed aesthetic procedure and a first-line therapeutic option for various medical conditions. The potential for BoNT-A immunoresistance and secondary nonresponse related to neutralizing antibody (NAb) formation warrants attention as the range of BoNT-A aesthetic applications continues to expand. Methods:. An international multidisciplinary panel reviewed published evidence on BoNT-A immunoresistance in aesthetic and therapeutic applications and discussed best practices integrating clinical, ethical, and aesthetic considerations. Consensus statements relating to awareness, assessment, and management of the risk of NAb-related secondary nonresponse in aesthetic practice were developed. Results:. There was a consensus that, as doses used in aesthetic practice become like those in therapeutics, rates of NAb formation may be expected to increase. However, the true extent of NAb formation in aesthetics is likely underestimated due to limitations of published evidence and variability in treatment patterns of aesthetic patients. Since BoNT-A therapy is often lifelong, practitioners need to recognize immunogenicity as a potential complication that might affect future therapeutic use and strive to minimize modifiable risk factors. The selection and use of a BoNT-A product with the least immunogenic potential from the beginning may thus be advantageous, especially when treatment with high doses is planned. Conclusions:. In view of current trends in BoNT-A aesthetic use, it is essential for practitioners to conduct thorough clinical assessments, inform patients of treatment risks, and develop BoNT-A treatment plans to minimize immunogenicity. This can help preserve the option of continued or future BoNT-A treatment with satisfactory outcomes.

Summary:. Physicians using neuromodulators need to develop an in-depth and holistic understanding of the facial musculature as a single, large, functional structure that does not work in isolation. In this Special Topic, I review the anatomy of the continuous fibromuscular layer of the face, discuss how certain age-related indications develop as a consequence of imbalances to this unified structure, and propose considerations for neuromodulator-based interventions of the upper, mid, and lower face. I provide evidence-supported recommendations on the most optimal applications of neuromodulators to help rebalance the musculoaponeurotic layer for more natural outcomes. Through outcomes of my patients, I show how the facial mimetic muscles can be modulated with careful placement of botulinum toxin, without causing unnatural facial expressions, to achieve an expressive, well-balanced face that reflects health, vitality and happiness.