Use of Incobotulinum Toxin A (Xeomin) for Cosmetic Facial Rejuvination

Abstract

Botulinum toxin therapy is commonly used for cosmetic treatment of glabellar, forehead, lateral periocular, and other facial rhytids. Many providers have familiarity with onobotulinum toxin A (Botox®) and are accustomed to the dosing, diffusion, onset, and duration of action. Patients also commonly refer to all botulinum toxins as “Botulinum toxin” and are not familiar with other variations of the toxin. While some patients are loyal to Botulinum toxin either from past use, patient recommendation, or even media, many patients would like to try other similar medications including incobotulinum toxin A (Xeomin®) and abobotulinum toxin A (Dysport®); this chapter will focus on the former.

Botulinum toxin therapy is commonly used for cosmetic treatment of glabellar, forehead, lateral periocular, and other facial rhytids. Many providers have familiarity with onobotulinum toxin A (Botox^®) and are accustomed to the dosing, diffusion, onset, and duration of action. Patients also commonly refer to all botulinum toxins as “Botulinum toxin” and are not familiar with other variations of the toxin. While some patients are loyal to Botulinum toxin either from past use, patient recommendation, or even media, many patients would like to try other similar medications including incobotulinum toxin A (Xeomin^®) and abobotulinum toxin A (Dysport^®); this chapter will focus on the former.

Xeomin is a highly purified protein without the complexing proteins seen in the Botulinum toxin molecule. Xeomin been shown in study to be equivalent in safety and efficacy in patients treated for benign essential blepharospasm (Jankovic et al. 2011; Dressler et al. 2008). Cosmetic use of Xeomin is becoming more common in aesthetic practices because of its price point, ease of use/transition from Botulinum toxin, and potential for patient preference. Another practical advantage to Xeomin is that the package does not require refrigerated storage prior to reconstitution. Patients may prefer Xeomin to Botulinum toxin because of rapidity of onset, perceived efficacy of treatment, or social stigma of Botulinum toxin therapy (Chundury et al. 2013).

Common aesthetic patterns of treatment for Xeomin in the upper face:

• 1. Glabella (corrugator/procerus) – 15–25 units, divided in 3–5 injections. Total dose depends on span and force of muscular contraction.

• 2. Frontalis – 10–20 units, divided in 5–8 injections. Ensure lateral frontalis is paralyzed as abnormal brow contour may result if not treated properly.

• 3. Orbicularis oculi:

  • (a) Lateral orbicularis rhytids – 5–7.5 units per side, divided into 2–3 injections on each side.

  • (b) Superolateral orbicularis/inferior brow – 2–4 units per side, divided into 1–2 injections on each side may allow for lateral brow elevation.

  • (c) Lower eyelid orbicularis roll – 1–2 units per side, divided into 1–2 injection sites per side; care is taken to not overtreat as eyelid malposition may develop.

• 4. Nasalis – 1–4 units on each side, divided into 1–2 injection sites per side.

Helpful hints for the use of Xeomin for cosmetic facial rejuvenation:

• 1. Like Botulinum toxin, topical anesthesia may reduce epidermal sensation of needle entry.

• 2. Reconstitution of Xeomin with bacteriostatic saline may reduce discomfort with infiltration.

• 3. Like other botulinum toxins, the diffusion of spread depends not only on the drug utilized but also the concentration of the reconstituted toxin. Spread of diffusion is similar to Botulinum toxin.

• 4. For treatment-naïve patients, doses similar to Botulinum toxin may be appropriate as an initial regimen.

• 5. In patients previously treated with Botulinum toxin, it may be wise to use similar, if not less, doses as an initial treatment.

• 6. A practitioner may choose to use Xeomin over Botulinum toxin in patients who required a quicker onset of action, patients desiring a treatment other than Botulinum toxin, and those who demonstrate resistance to Botulinum toxin.