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Comparisons among Botulinum Toxins: An Evidence-Based Review

Klein, Arnold W. M.D.; Carruthers, Alastair F.R.C.P.C.; Fagien, Steven M.D.; Lowe, Nicholas J. M.D.

Plastic and Reconstructive Surgery: June 2008 - Volume 121 - Issue 6 - p 413e-422e
doi: 10.1097/PRS.0b013e318170813c
Cosmetic: Special Topic

Background: Botulinum neurotoxin treatment is the most common aesthetic procedure in the United States. A number of serotypes and formulations are available worldwide. Similarities and differences among these toxins were evaluated by reviewing the existing literature.

Methods: Reports of botulinum neurotoxin for aesthetic use, published in peer-reviewed literature or presented at recent professional congresses, were reviewed to summarize key features of different toxins. Data from therapeutic uses in comparable anatomical areas were included in the review when aesthetic literature was limited.

Results: Serotypes of neurotoxins share molecular structures and mechanisms of action but exhibit important differences between serotypes and between different formulations within the same serotype, including differences in distribution/diffusion patterns and risk/benefit profiles. The differences attributable to dissimilarities in bacterial strains, manufacturing techniques, and assays are likely to influence clinical performance.

Conclusions: Injection patterns, techniques, dilutions diffusion, and injection volumes established for a specific formulation of botulinum neurotoxin are not likely to be applicable to other formulations, and formulations are not interchangeable by any single conversion ratio. A large proportion of the clinical literature documents the aesthetic uses of the Allergan formulation of botulinum toxin type A. Additional studies are needed to establish optimal procedures for the Ipsen formulation and botulinum neurotoxin, and for diverse aesthetic uses.

Los Angeles, Calif.; Boca Raton, Fla.; and Vancouver, British Columbia, Canada

From the David Geffen School of Medicine, University of California, Los Angeles, and the Department of Dermatology, University of British Columbia.

Received for publication December 19, 2006; accepted July 19, 2007.

Disclosures: Alastair Carruthers, F.R.C.P.C., is a consultant to Allergan, Inc., Medicis, Inc., Solstice Neurosciences, Inc., and Merz GmbH; Steven Fagien, M.D., is a consultant to Allergan, Inc., and Medicis Inc.; Nicholas J. Lowe, M.D., is a consultant to and has received research and educational grants from Allergan, Inc., Medicis, Inc., and Mentor FzioMed, and is a stockholder in Allergan, Inc., and Medicis, Inc.; Dr. Arnold W. Klein, M.D., is a consultant to Ortho-Neutrogena. He serves as an investigator to Anika, and Medicis Inc., and is an investigator and shareholder for Skin Medica. He has received an educational grant from Allergan and Medicis Inc.

Arnold W. Klein, M.D., 435 North Roxbury Drive, Suite 204, Beverly Hills, Calif. 90210,

©2008American Society of Plastic Surgeons