[LITERATURE REVIEW]

Comparison and Overview of Currently

Available Neurotoxins
THOMAS J. WALKER, MD; STEVEN H. DAYAN, MD
Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery,
University of Illinois at Chicago, Chicago, Illinois

ABSTRACT
Background: Botulinum toxin has been in use since the 1970s. Over the last few years, the indications for botulinum
toxin use have extended for cosmetic and noncosmetic applications. Three preparations of botulinum toxin type A and
one preparation of botulinum toxin type B are commercially available and approved for use in the United States by the
United States Food and Drug Administration. Objective: To review the most recent literature on all commercially
available botulinum toxins in the United States, their indications, Food and Drug Administration approvals, and handling
(reconstitution, storage, and dilution). Methods: A literature review (not Cochrane type analysis) using several
databases (PubMed, MEDLINE, textbooks, Food and Drug Administration homepage, and manufacturer information)
was performed. Conclusion: Several different preparations of botulinum toxins exist worldwide, none of which are
identical or interchangeable. Manufacturer recommendations on all available botulinum neurotoxins advise the use of
unpreserved saline for reconstitution. Side effects are mostly mild and always self-limited. More serious complications
are associated with higher doses, improper injection techniques, and occur in patients with underlying comorbidities.
(J Clin Aesthet Dermatol. 2014;7(2):31–39.)

C
lostridium botulinum is a Gram-positive bacterium crow’s feet. In the lower face, the use of botulinum toxin was
first identified more than 100 years ago. It produces initially controversial because results were considered
a neurotoxin that has been studied extensively since unpredictable. While the demarcation between the upper
its discovery. Today, seven antigenically different serotypes and lower face is somewhat arbitrary, the utility of
have been identified, two of which are used clinically: botulinum toxin in the lower face is becoming increasingly
serotypes A and B. Serotype A (BTX-A) appears to be the apparent. However, the medical literature on use of
most potent subtype among them.1 botulinum toxin in the lower face and neck is sparse with
In 1980, Scott published the landmark paper describing most publications limited to clinician experiences only.4
the clinical use of botulinum toxin type A for the treatment
of strabismus.2 In 1987, Carruthers and Carruthers noticed MECHANISM OF ACTION/PHARMACOLOGY/
that patients treated with botulinum toxin for STRUCTURE
blepharospasm experienced improvement in glabellar lines.3 Botulinum neurotoxin (BTX) is a safe and attractive
Since then, BTX-A has been approved by the United States therapeutic treatment modality for several clinical
Food and Drug Administration (FDA) for a variety of conditions. The clinical effect of BTX is a highly specific, but
cosmetic and noncosmetic applications, including reversible, inhibition of presynaptic neurotransmitter
strabismus, blepharospasm, cervical dystonia, (acetylcholine) release. Botulinum toxins inhibit the
hyperhidrosis, glabellar rhytides, and, most recently, urinary exocytotic mechanisms within neurons, resulting in
incontinence from detrusor overactivity. temporary inhibition of neurotransmitter release at the
Botulinum toxin’s most common cosmetic application is neuromuscular junction or in other tissues.
in the treatment of upper facial rhytides and dynamic lines, Botulinum toxins are synthesized by a variety of
namely glabellar lines, horizontal forehead wrinkles, and Clostridial species, most commonly Clostridium

DISCLOSURE: Dr. Walker reports no relevant conflicts of interest. Dr. Dayan participates in clinical research and acts as a speaker and consultant to
Allergan, Medicis, and Merz.
ADDRESS CORRESPONDENCE TO: Thomas J. Walker, MD; E-mail: [email protected]

[February 2014 • Volume 7 • Number 2] 31

botulinum, but also C. baratii or C. butyricum.5 These is reversible, which has clinical advantages and
bacteria synthesize seven different neurotoxin strains disadvantages. Benefits include the flexibility to inject a
classified as serotypes A through G. In nature, a single core given muscle based on its activity level, which may fluctuate
neurotoxin (150-kD) is contained within a molecular over time; the avoidance of irreversible and more invasive
complex that varies in size based on nontoxic, clinically interventions, such as surgery; and the resolution of possibly
inactive proteins classified as hemagglutinins or unintended effects after a period of time. The main
nonhemagglutinins.6 These associated proteins serve as limitation of the reversibility of BTX injections is the need
stabilizers to protect the neurotoxin molecule from pH, for repeat injections. However, repeat treatments may yield
thermal stress, and enzymatic degradation.7 sustained efficacy.
For biological activity, the core neurotoxin requires Even though the main effect of BTX-A is on alpha motor
enzymatic cleavage by proteases to exert its activity.8 neurons inhibiting their acetylcholine release, BTX-A also
Cleavage produces a molecule consisting of a heavy chain inhibits neurotransmitter release from gamma motor
and light chain held together by a disulfide bond. The neurons innervating muscle spindles.16 Gamma motor
activated di-chain has the following three functional neurons are known to play a critical role in maintenance of
terminals: 1) the C-terminal (heavy chain) contains the hyperactive muscle contractions, such as spasticity and
binding domain that docks to the neuron; 2) the N-terminal dystonias.
(heavy chain) contains the translocation domain; and 3) the SNARE proteins also appear to play a role in C-fiber
light chain contains the catalytic portion responsible for nocioceptive neurons that are known to release glutamate
cleavage of the intracellular BTX target. All Clostridial and substance P. Those two substances result in vasodilation
neurotoxins consist of the same tertiary protein structure, and the release of pro-inflammatory mediators, such as
but differ in protein sequences among the serotypes, which bradykinin, prostaglandins, histamine, and serotonin.17 BTX-
accounts for their different affinities, antigenicities, and A is thought to involve inhibition of these factors, which may
intracellular targets.9 account for its treatment possibilities in chronic pain
In order to exert clinical activity, the BTX has to gain disorders, such as migraine headaches or neuralgias.
entry into the neuronal end terminal via its translocation
domain. Under physiological conditions, the core 150-kD INDICATIONS
protein dissociates from the toxin complex, binds to Botulinum neurotoxin is an effective treatment in
synaptic vesicle protein 2 using its heavy chain, and enters managing strabismus, hemifacial spasm, blepharospasm,
the presynaptic neuronal cell by endocytosis.10 Cell surface cervical dystonia, spasmodic dysphonia, hyperhidrosis,
receptors at the neuronal endplate that facilitate BTX entry sialorrhea, gustatory sweating (Frey’s syndrome), and facial
are over-expressed in neurons that actively secrete rejuvenation.18 The effects suggest that BTX injections also
neurotransmitters.11 The acidic pH within the endocytotic affect postganglionic neurons of the parasympathetic
vesicle cleaves the disulfide bond freeing the light chain and nervous system, which use acetylcholine as their
enabling it to traverse into the neuronal cytosol where it neurotransmitter.19,20
disrupts one or more SNARE (soluble N-ethyl-maleimide- Beyond the effects on muscle and secretions, BTX-A has
sensitive factor attachment protein receptor) proteins on been reported to reduce pain associated with cervical
the presynaptic vesicle.12 Without an active SNARE protein, dystonia, temporomandibular disorders, post-herpetic and
the vesicle containing the neurotransmitter can no longer trigeminal neuralgias, and chronic migraine headaches.
fuse with the cell membrane, thereby preventing its Although the exact mechanism of action in those conditions
exocytotic release. Type A botulinum toxin binds to and is unclear, it has been hypothesized that it occurs through
cleaves the 25-kD SNARE protein “SNAP-25” inhibition of afferent neuronal neurotransmitter release.21
(synaptosomal-associated protein), whereas botulinum Facial rejuvenation. In the upper face, botulinum toxin
toxin type B (BTX-B) binds to and cleaves “VAMP” (vesicle is most commonly used to eliminate or diminish glabellar
associated membrane protein).13 lines (procerus and corrugator muscles), forehead rhytides
The duration of action or rather inhibition of (frontalis muscle), and crow’s feet (lateral orbicularis oculi
neurotransmitter release varies among the serotypes based muscle).
on the half-life of the light chain and the time of the neuron In the lower face, botulinum toxin may be used to treat
to restore SNARE proteins. Studies suggest that botulinum perioral lip lines (orbicularis oris, depressor anguli oris, and
toxin type A has the longest half-life, followed by types C1, mentalis muscles). In most cases, botulinum toxin is
B, F, and E.14 administered to this area in conjunction with dermal fillers.
The recovery of neuronal activity has been attributed to Injections are given in small amounts (1 U Botox® or 3 U
two phenomena: First, axonal sprout development in Dysport® per site, 4–5 sites each in the upper and lower lips)
response to growth factor secretion from denervated while staying in close proximity (within 5mm) to the
muscle. These sprouts are active and produce temporary re- vermilion border. Results are generally not as dramatic as
innervation in the early recovery phase. Second, during the those in the upper face and last approximately 10 weeks.
later phase of recovery, vesicular neurotransmitter release The risk of dysarthria and oral incompetence should be
has been found to return in the original nerve terminal.15 discussed with the patient prior to administration.4 Due to
The BTX-mediated inhibition of neurotransmitter release the risk of oral incompetence, BTX-A should not be used in

32 [February 2014 • Volume 7 • Number 2] 32

the perioral region in singers, musicians, or scuba divers. the frontalis muscle.26 In the lower face, BTX-A may be
The oral commissures (depressor anguli oris muscles) are injected into the masseter muscle to alter the shape of the
another popular area for BTX administration in the lower jawline, a particularly popular application in Eastern Asian
face. As with perioral lip lines, oral commissure rhytides countries, most commonly in South Korea. Ten to 25 U
should not be treated in patients where oral incompetence Botox® or 30 to 75 U Dysport® are typically used on each side
would have a significant impact on the patient (singers, administered in one to three injection sites. The patient is
musicians, scuba divers, etc.). One injection (2–4 U Botox® asked to bite down while the practitioner holds the anterior
or 6–12 U Dysport®) is given on each side directly into the and posterior border of the masseter muscle. The thickest
depressor anguli oris muscle overlying the mandibular body. portion of the muscle is injected over the “buckled” area.4 Up
Injections in the midline, directly into the mental fold, or in to 50-percent reduction of muscle bulk has been reported
close proximity to the mouth should be avoided.4 through atrophy.27 It is important to keep in mind that the full
While nasolabial folds are best treated with dermal fillers, treatment effect requires multiple sessions with the full
some practitioners have successfully used botulinum toxin benefit not being evident for three to four treatment cycles
preparations in select patients including those with short (usually 1 year).4 Adverse effects include mastication
upper lips or those who have a “canine” smile (strong raising difficulty, muscle pain, dysarthria, and awkwardness with
of the medial upper lip upon smile). Nonetheless, patients smiling.
must be advised that their smile pattern may be altered Adjunctive botulinum toxin A. BTX-A is increasingly
secondary to the BTX administration. Only small doses (1 U used in surgical and nonsurgical cosmetic procedures to
Botox® or 3 U Dysport® per side) should be used for prolong or enhance cosmetic results. BTX-A may be
treatment of nasolabial folds injected just below the nose synergistically used in combination with soft tissue
into the lip elevator complex and the levator labii superioris augmentation to achieve improved longevity of results by
alaeque nasi muscle.4 Good candidates have deep nasolabial reducing the dynamic component of wrinkles.28 Laser
folds with “gummy smiles” where all incisors and some of the resurfacing results may be optimized by pretreatment with
gingivae show upon smiling.22 BTX-A, leading to longer-lasting and superior results.29
The dimpled chin may be successfully treated with BTX Studies of intense pulsed dye laser showed that BTX-A
administration directly into the mentalis muscle. The most treatment improves cosmetic outcomes and skin texture in
commonly used dosage ranges between 5 to 10 U Botox® or treatment of cutaneous telangiectasias.30 In surgical
15 to 30 U Dysport® total given into two injection sites in a interventions, such as browlifts, many surgeons use BTX-A as
paramedian position (5mm lateral to the midline) overlying an adjunctive procedure to increase longevity of the surgical
the inferior mandibular border. Injections administered too intervention. BTX-A also reduces contractile forces on the
far laterally (depressor anguli oris muscle) should be surgical site diminishing the risk of wound dehiscence or
avoided, as should injections too far superiorly (orbicularis scarring by reducing tension on wound edges. For instance,
oris muscle leading to oral incompetence and drooping BTX-A treatment of the underlying musculature (especially
mouth). Some practitioners advocate for only one injection the lateral orbicularis oculi muscle) 5 to 10 days prior to
site midline.4 surgical browlifts diminishes the opposing brow depressor
In the neck, BTX preparations may be used to treat forces, allowing better suture suspension with less “cheese-
platysmal bands, particularly in older patients who are not wiring” effects. Overall, longer-lasting and improved cosmetic
good candidates for surgery, in those who do not want results are achieved with more rapid wound healing.31
surgery, or in younger patients who are not candidates for
cervicofacial rhytidectomies yet.23,24 Other good candidates DURATION OF ACTION
are patients who have retained their skin elasticity with Botulinum toxins appear to have a significantly longer
minimal descent of submental adipose tissue. Patients to effect on autonomic neurons (6–9 months), such as
avoid are those with jowl formation or bone resorption.25 It is hyperhidrosis or overactive bladders vis-à-vis to the 3 to 4
important to keep in mind that BTX has no effect on skin months observed for striated muscle (facial rhytides). This
redundancy, laxity, or fat deposits. Neck treatment with BTX finding suggests that neuronal sprouting does not occur to
appears to require higher dosages than the lower face. A the same degree in the autonomic nervous system as it does
total of 10 U Botox® or 30 U Dysport® per platysmal band is in striated muscle.
typically used. Some practitioners inject the neurotoxin in
three to five sites per band from the mandible to the lower FORMULATIONS
neck in 1cm intervals. Others inject only the central portion Botulinum toxin formulations are neither identical nor
of the band at the cervicomental angle trying to recreate it. interchangeable. They possess individual potencies and
Injection into the strap muscles must be avoided as different, although sometimes overlapping, indications.
dysphagia, dysphonia, and neck weakness may ensue.4 Attention to different preparations to ensure proper
Facial sculpting. In the upper face, BTX-A is used for application is required for safe use to avoid errors. In April
chemical brow elevation and widening of the eyes. Injections 2009, the FDA established drug names to help the provider
into the glabella have been reported to lead to medial, in differentiating several preparations and to prevent
central, and lateral brow elevation secondary to partial potentially serious adverse effects.32 paragraph: For an
inhibition of brow depressors and increased resting tone of overview and comparison of currently available botulinum

[February 2014 • Volume 7 • Number 2] 33

toxins, see Table 1. its efficacy has yet to be determined.
Botox®/Botox Cosmetic®. Botox® (Allergan, Inc., Neuronox®. Neuronox® (Medy-Tox Inc., South Korea) is
Irvine, California) is the trade name for onabotulinumtoxinA a botulinum toxin type A complex widely used in South
and is approved for over 20 indications in more than 75 Korea and Southeast Asia.33 While limited literature is
countries.33 It is the original botulinum toxin type A product, available on the efficacy and safety of Neuronox®, it appears
which was initially purified by Shantz and later used to be effective.
clinically by Scott in San Francisco. In 1997, there was a CBTX-A/Prosigne®/Lantox®. CBTX-A (Lanzhou
formulation change to reduce the amount of immunogenic Institute of Biological Products, China) is Chinese botulinum
protein content. The active neurotoxin is botulinum toxin toxin A and the only BTX-A approved in China. The
type A. This neurotoxin comprises 85 percent of the formulation contains bovine gelatin protein to prevent the
worldwide Botox® market, and most scientific articles on neurotoxin from adhering to the wall of the vial or syringe.
botulinum toxins are about Botox®.33 In the United States, Most other botulinum preparations utilize human serum
Botox® is FDA approved for the treatment of cervical albumin instead, but in the case of CBTX-A, the gelatin used
dystonia, severe primary axillary hyperhidrosis, is bovine in nature, which has the potential to trigger an
blepharospasm, neurogenic detrusor overactivity (urinary immunological response and allergic reactions. In the worst-
incontinence), chronic migraine, upper limb spasticity, and case scenario, bovine spongiform encephalopathy (i.e., “mad
moderate-to-severe glabellar lines.32 OnabotulinumtoxinA is cow disease”) may be transmitted. CBTX-A is marketed as
also known as Vistabel® in Europe and Vistabex® in Italy.34 Prosigne® in Brazil, but is not available in the United States.
Dysport®/Reloxin®/Azzalure®. Dysport® (Medicis A double-blind, randomized, crossover study of Prosigne®
Pharmaceutical Corp., Scottsdale, Arizona) is the trade versus Botox® in patients with blepharospasm and
name for abobotulinumtoxinA. It was approved by the FDA hemifacial spasm showed similar efficacy and safety profiles
in 2009 for the treatment of cervical dystonia and for between Prosigne® and Botox®.37
temporary improvement in the appearance to moderate-to- CNBTX-A. CNBTX-A (Nanfeng Medical Science and
severe glabellar lines.32 The active neurotoxin is botulinum Technology Development Co. Ltd., China) is a botulinum
toxin type A. The difference between Botox® and Dysport® toxin type A preparation that is neither approved nor
lies in the purification procedure. Botox® is purified by licensed in any country. It should not be confused with
repeated precipitation and re-dissolution, whereas Dysport® CBTX A/Prosigne®/Lantox®/Redux. CNBTX-A was found to
is purified by a column separation method.33 After injection, contain much higher levels of neurotoxin than listed on the
Dysport® appears to have a greater spread effect clinically package insert, which could potentially lead to severe health
leading to a more diffuse distribution of clinical effects. Dose risks to patients.38
ratios between Dysport® and Botox® have been debated in MyoBloc®/NeuroBloc®. MyoBloc® (Solstice Neurosciences,
the past and likely vary greatly based on dosage. However, in Inc., Louisville, Kentucky) is the trade name for
a cosmetic clinical practice, a dose ratio of approximately 3:1 rimabotulinumtoxinB. It is the only botulinum toxin type B
is most commonly agreed upon.35 commercially available in the United States. Its sole
Xeomin®/Bocoture®. Xeomin® (Merz Pharmaceuticals, indication lies in the treatment of adults with cervical
Frankfurt, Germany), the trade name for incobotulinum- dystonia to reduce the severity of abnormal head position
toxinA, is licensed in Germany. The active neurotoxin is and neck pain associated with this condition. In fact,
botulinum toxin type A stripped from any complexing MyoBloc® was the first FDA-approved treatment for cervical
proteins. It is mainly used in Europe, Mexico, and Argentina dystonia in the United States. Today, MyoBloc®/NeuroBloc®
for the treatment of blepharospasm and cervical dystonia. In is approved in the United States, Canada, and Europe for the
the United States, Xeomin® was FDA approved in 2011 for treatment of cervical dystonia. MyoBloc® injections for
temporary improvement in the appearance of moderate-to- cosmetic applications have a more rapid onset of action and
severe glabellar lines in adults. Xeomin® appears to exhibit a greater area of diffusion at the expense of more painful
dose ratio with Botox® of 1:1.33 No significant differences in injections and shorter duration of effects.39 MyoBloc® is
safety and efficacy have been found in studies comparing available as a liquid with an acidic pH (5.5–6.5), which
Botox® and Xeomin®. In fact, as Xeomin® is free of explains the increased discomfort associated with its
therapeutically superfluous complexing proteins, its purer injections. Furthermore, the units appear to be significantly
formulation has been suggested to lead to greater efficacy less effective when compared with BTX-A units. In cervical
with reduced risk of sensitization or antibody formation.36 dystonia, the ratio is approximately 50:1, whereas for
However, the clinical relevance of this has yet to be glabellar frown lines, the ratio appears to be 100:1.39,40
determined. NeuroBloc® (Eisai Co., Ltd, United Kingdom) is the
PurTox®. PurTox® (Mentor Worldwide LLC, Santa European equivalent to MyoBloc®.
Barbara, California) is a new, purified botulinum type A
neurotoxin. It has completed stage III clinical trials for FDA RECONSTITUTION
approval in the United States. PurTox® resembles Xeomin® Unpreserved saline. OnabotulinumtoxinA (Botox®) is
(free of therapeutically superfluous complexing proteins) the most studied botulinum neurotoxin. Initially, it was
and aims to improve the appearance of glabellar frown lines thought to be a fragile substance.41 However, later studies
and forehead rhytides. However, any conclusive evidence on have relativized this initial belief and confirmed persistence

34 [February 2014 • Volume 7 • Number 2] 34

TABLE 1. Comparison of botulinum toxin preparations5

ONABOTULINUMTOXINA ABOBOTULINUMTOXINA CBTX-A BONTA

Botox®, Botox Cosmetic®,

COMMERCIAL NAMES Dysport®, Reloxin®, Azzalure® Prosigne®, Lantox® Neuronox®
Vistabel®, Vistabex®

Lanzhou Institute of
Medy-Tox Inc., South
COMPANY Allergan Inc. Medicis Pharmaceutical Corp. Biological Products,
Korea
China

TYPE A A A A

> 10 countries including South Korea, India, South

Worldwide, including United > 65 countries, including
COUNTRIES China, not in the United America, not in the United
States and Canada United States and Canada
States or Canada States or Canada

ACTIVE SUBSTANCE BTX-A complex (900 kD) BTX-A complex (500–900 kD) BTX-A (900 kD) BTX-A (940 kD)
(MOLECULAR WEIGHT)
STRENGTH 1:1 1:2–1:4
(BTX-A: PRODUCT)

Blepharospasm, cervical
dystonia, glabellar lines, Blepharospasm, cervical
Blepharospasm, cervical
INDICATIONS hyperhidrosis, chronic dystonia, glabellar lines, Blepharospam
dystonia, glabellar lines
migraine, urinary hyperhidrosis
incontinence, etc.

Botox®: cervical dystonia,

severe primary axillary
hyperhidrosis, blepharo-
spasm, neurogenic detrusor
overactivity (urinary Cervical dystonia, glabellar
FDA APPROVAL None None
incontinence), chronic lines (moderate to severe)
migraine, upper limb
spasticity
Botox Cosmetic®: glabellar
lines (moderate to severe)

MODE OF ACTION SNAP-25 SNAP-25 SNAP-25 SNAP-25

PHARMACEUTICAL FORM Powder Powder Powder Powder

UNITS/VIAL 100 or 200 300 or 500 50 or 100 100

VOLUME 1.25 or 2.5mL, 10mL max 2.5mL to 5mL max

RECONSTITUTION 0.9% NaCl 0.9% NaCl

Human serum albumin, lac- Human serum albumin,

EXCIPIENTS Human serum albumin, NaCl Gelatin, dextran, sucrose
tose NaCl

STORAGE BEFORE DILUTION 2–8°C or < -5°C 2–8°C 2–8°C 2–8°C

STORAGE AFTER DILUTION 24 hours/2–8°C 4 hours/2–8°C 4 hours/2–8°C 4 hours/2–8°C

[February 2014 • Volume 7 • Number 2] 35

TABLE 1 continued. Comparison of botulinum toxin preparations5

INCOBOTULINUMTOXINA TBD RIMABOTULINUMTOXINB

COMMERCIAL NAMES Xeomin® PurTox® MyoBloc®, NeuroBloc®

COMPANY Merz Pharmaceuticals Mentor Worldwide LLC Solstice Neurosciences Inc.

TYPE A A B

United States since 2011, Germany,

Pending in the United States United States, some European
COUNTRIES other European countries, Mexico,
(Phase 3 trials completed) countries
Argentina, Brazil

ACTIVE SUBSTANCE BTX-A complex (150 kD); NO BTX-A complex (150 kD); NO
BTX-B complex (700 kD)
(MOLECULAR WEIGHT) complexing proteins complexing proteins

STRENGTH 1:1 1:1.5 1:50–1:100

(BTX-A:PRODUCT)

Blepharospasm, cervical dystonia,

cosmetic use in some countries
INDICATIONS TBD; currently in Phase 3 trials Cervical dystonia
including glabellar lines in the
United States

FDA APPROVAL Cervical dystonia, blepharospasm Pending Cervical dystonia

MODE OF ACTION SNAP-25 SNAP-25 SNAP-25

PHARMACEUTICAL FORM Powder Powder

UNITS/VIAL 50 or 100 2,500; 5,000; 10,000

VOLUME 8mL 0.5mL; 1mL; 2mL

RECONSTITUTION 0.9% NaCl 0.9% NaCl Not necessary

Human serum albumin, NaCl,

EXCIPIENTS Human serum albumin, sucrose
disodium succinate, water

STORAGE BEFORE DILUTION 2–8°C < 25°C

STORAGE AFTER DILUTION 24 hours/2–8°C 4 hours (if diluted)/2–8°C

36 [February 2014 • Volume 7 • Number 2] 36

of activity of BTX-A preparations in different situations. Most IMMUNOGENICITY/ALLERGY/RESISTANCE
manufacturers recommend that botulinum toxins be Antibody formation may occur in response to botulinum
reconstituted with unpreserved saline. RimabotulinumtoxinB toxin injections. As the protein load in current preparations
(MyoBloc®/NeuroBloc®) does not require reconstitution as is lower than in earlier formulations (prior to 1998),
the manufacturer provides it as a ready-to-use liquid. immunological responses with antibody formation have
Preserved saline. Multiple studies have shown that decreased. Nonetheless, immunogenic responses may still
reconstitution of onabotulinumtoxinA (Botox®) with occur in the modern formulations, particularly when large
preserved saline (containing benzyl alcohol) does not affect doses of botulinum toxin are utilized (most frequently in
the potency of the neurotoxin.42,43 In fact, the injections were therapeutic, noncosmetic applications).54 The overall risk of
less painful.44 A consensus panel in 2004 stated that antibody formation may be minimized by using low doses
preserved saline is the preferred method of reconstitution with the longest feasible interval between injections.
for Botox®.25 A separate panel recognized that benzyl alcohol Allergic reactions, while possible, are exceedingly rare but
acts as a local anesthetic, albeit negligibly, at low volumes.45 have been reported in the literature. Allergies may range from
Lidocaine with epinephrine. Multiple studies have non-serious skin rashes over more serious skin rashes and
shown that Botox® reconstituted with lidocaine containing granuloma formation to localized or even systemic anaphylactic
epinephrine (lidocaine 1% or 2% and epinephrine 1:100,000 reactions. Whether the anaphylactic reaction is from the
or 1:200,000) retained its function without a compromise in neurotoxin itself or its reconstitution solvent is unknown.50,55,56
efficacy or safety.46–49 However, there is a case report in the
literature of a fatal anaphylactic reaction in a patient treated SAFETY/COMPLICATIONS
with Botox® for chronic neck and back pain reconstituted in Upper face. Most adverse effects of cosmetic applications
lidocaine containing epinephrine.50 Even though the exact of botulinum toxin are mild and transient. The majority of
cause of anaphylaxis remains unknown to date, caution adverse effects include bruising, edema, or pain at the
should be exercised when reconstituting in lidocaine as injection site, and possibly flu-like symptoms. More serious
some patients may exhibit a type-1 immediate adverse effects include brow or eyelid ptosis and diplopia
hypersensitivity reaction to this substance. The advantage of from extraocular muscle weakness. Those more serious side
using lidocaine with epinephrine for reconstitution of effects are secondary to poor injection technique, improper
botulinum toxin lies in enhancing its short-term efficacy, needle placement, and lack of experience and/or
accelerating the rate of onset, and reducing patient understanding of the underlying anatomy and physiology,
discomfort associated with injections. thus allowing the neurotoxin to either diffuse or be
Bupivacaine. Reconstitution of Botox® with bupivacaine inadvertently injected into adjacent musculature.57,58
reduces injection pain without compromising its efficacy and As botulinum toxin works through temporary
safety. Yen et al51 conducted a randomized, double-blind chemodenervation of muscles, complications may be
study where Botox® reconstituted with 0.75% bupivacaine diminished by using more concentrated doses, which allow
was injected into one corrugator muscle, where the for more precise placement of toxin through less diffusion
contralateral corrugator was treated using Botox® with a greater duration of effect.
reconstituted with unpreserved saline. At one week, the side Brow and eyelid ptosis through spread of neurotoxin into
treated with bupivacaine-reconstituted Botox® showed adjacent musculature are the most troublesome
greater muscle weakness than the control side. However, at complications in the upper face and may last up to three
one and three months follow-ups, no differences were noted months. The risk of brow ptosis (through diffusion into the
between the two sides. The faster onset of action may be frontalis muscle) may be reduced by avoiding treating
attributed to a synergistic effect between Botox® and patients with preexisting brow ptosis or using a very
bupivacaine-induced myotoxicity.51 conservative dose in the frontalis muscle.
Sterile water. Limited literature is available on Botox® Eyelid ptosis may occur when the neurotoxin is injected
reconstitution with sterile water. Moore and Naumann52 into the glabella (procerus and corrugator muscles) with
report that Botox® is effective when reconstituted in sterile inadvertent diffusion into the levator orbicularis muscle.
water, but associated with short-lived, intense pain at the However, it is more likely from unmasking of a preexisting
injection site.52 ptosis that becomes increasingly more evident following
relaxation of the brow elevators. Higher concentrations,
DILUTION careful toxin placement (1cm above the superior orbital rim
The package insert of onabotulinumtoxinA (Botox®) and 1.5cm lateral to the lateral canthus), and advising the
recommends dilution of 100 units in 1 to 8mL of saline (12.5 patient to refrain from manipulating the treated area for a
to 100 U/mL). Three hundred units of abobotulinumtoxinA few hours after treatment help diminish the risk of eyelid
(Dysport®) may be diluted in 0.6 to 2.5mL of saline (120 to 500 ptosis.33 Additionally, a thorough exam with particular
U/mL). Many physicians believe that the higher the dilution of attention to the eyelid position and function may prevent a
botulinum toxin, the greater the chance of diffusion to dissatisfying outcome.
unwanted sites and the shorter the duration of effects, thereby Other complications include headache, infection, cocked
leading to suboptimal results.34 Large volume injections result eyebrow, diplopia, ectropion, decreased strength of eye
in greater diffusion and larger affected areas.53 closure, and xerophthalmia.58

[February 2014 • Volume 7 • Number 2] 37

 Aesth Plast Surg. 2007;31:188–191.
Lower face and neck. In the lower face and neck, adverse
2. Scott AB. Botulinum toxin injection into extraocular muscles as
effects are usually from overzealous delivery of large an alternative to strabismus surgery. Ophthalmology.
neurotoxin doses. Dysphagia, dysarthria, inability to purse 1980;87(10):1044–1049.
lips, oral incompetence, and smile asymmetry may ensue.58 3. Carruthers J, Carruthers A. Botulinum toxin in facial
Small doses of BTX-A injected superficially and symmetrically rejuvenation: an update. Dermatol Clin. 2009;27(4):417–425.
may decrease the risk and visibility of the aforementioned 4. Dayan SH, Maas CS. Botulinum toxins for facial wrinkles: beyond
complications. Neurotoxin injections too close to the mouth, glabellar lines. Facial Plast Surg Clin North Am. 2007;15(1):
directly into the mental crease, or into the orbicularis oris 31–39, vi.
muscle are more likely to yield adverse effects. In contrast to 5. Hatheway CL. Clostridium botulinum: ecology and control in
BTX-A use in the upper face, administration in the lower face foods. In: Hauschild AHW, Dodds KL, eds. Food Science and
and neck is less forgiving of imprecise technique and dosing Technology, vol. 54. New York: Marcel Dekker; 1993:3–20.
that may lead to adverse effects. The lower face cannot 6. Popoff MR, Marvaud C-C. Structural and genomic features of
tolerate even a few misplaced units, which most commonly clostridial neurotoxins. In: Alouf JE, Freer J-H, eds. The
affect the smile pattern in an undesirable way.4 Fortunately, all Comprehensive Sourcebook of Bacterial Protein Toxins, 2nd
these side effects are reversible once the neurotoxin wears off ed. London: Elsevier; 1999:174–201.
after several months. 7. Kukreja RV, Singh BR. Comparative role of neurotoxin-associated
proteins in the structural stability and endopeptidase activity of
SUMMARY botulinum neurotoxin complex A and E. Biochemistry.
Botulinum toxins have been used therapeutically for 2007;46:14316–14324.
more than 30 years with very few adverse effects when used 8. DasGupta BR. Botulinum neurotoxin: studies on the structure
and structure-biological activity relation. Toxicon. 1979;17:
appropriately and with proper training. There are many
41–101.
different preparations of botulinum toxins worldwide, which
9. Smith TJ, Lou J, Geren IN, et al. Sequence variation within
are neither identical nor interchangeable. Results with one
botulinum neurotoxin serotypes impacts antibody binding and
product cannot be extrapolated to another. Manufacturer
neutralization. Infect Immun. 2005;73:5450–5457.
recommendations on all available botulinum neurotoxins 10. Sattler G. Current and future botulinum neurotoxin type A
advise the use of unpreserved saline for reconstitution. preparations in aesthetics: a literature review. J Drugs Dermatol.
However, literature reports show that preserved saline or 2010;9:1065–1071.
anesthetics (bupivacaine or lidocaine with epinephrine) may 11. Simpson LL. Ammonium chloride and methylamine
be used safely instead. hydrochloride antagonize clostridial neurotoxins. J Pharmacol
Botox® (onabotulinumtoxinA) is the most commonly Exp Ther. 1983;225:546–552.
used botulinum toxin. It appears to be less fragile and more 12. Fischer A, Montal M. Crucial role of the disulfide bridge between
stable than initially thought. While it is wise to follow the botulinum neurotoxin light and heavy chains in protease
manufacturers’ recommendations, some of them seem translocation across membranes. J Biol Chem. 2007;282:
somewhat excessive. In cosmetic applications, BTX-A was 29604–29611.
initially used for treatment of upper facial rhytides, but is 13. Binz T, Rummel A. Cell entry strategy of clostridial neurotoxins.
now considered a key component of facial rejuvenation J Neurochem. 2009;109:1584–1595.
procedures as an adjunct to either nonsurgical or surgical 14. Elopra R, Tugnoli V, Quatrale R, et al. Different types of
interventions, including in the lower face and neck. Smaller botulinum toxin in humans. Mov Disord. 2004;19(Suppl
doses for perioral treatment than for upper facial 8):S53–S59.
applications are used as the oral musculature responds more 15. Meunier FA, Schiavo G, Molgo J. Botulinum neurotoxins: from
strongly to the same BTX-A dosing. Only one preparation of paralysis to recovery of functional neuromuscular transmission. J
botulinum toxin type B (MyoBloc®/NeuroBloc®) exists. Its Physiol Paris. 2002;96:105–113.
sole indication and FDA approval lies in treatments of 16. Rosales RL, Arimura K, Takenaga S, Osame M. Extrafusal and
intrafusal muscle effects in experimental botulinum toxin-A
cervical dystonia.
injection. Muscle Nerve. 1996;19:488–496.
Side effects are mostly mild and always self-limited. More
17. McMahon SB, Bennett DLH, Bevan S. Inflammatory mediators
serious complications are associated with higher doses,
and modulators of pain. In: McMahon SB, Koltzenberg M, eds.
improper injection techniques, and occur in patients with
Wall and Melzack’s Textbook of Pain, 5th ed. Philadelphia:
underlying (mostly cardiovascular or neurological) Churchill Livingstone; 2005.
comorbidities. Complications may be minimized by site- and 18. Carruthers A, Carruthers J. Botulinum toxin products overview.
patient-specific dosing. Skin Therapy Lett. 2008;13:1–4.
An understanding of functional facial anatomy, the 19. Lagalla G, Millevolte M, Capecci M, et al. Botulinum toxin type A
importance of precise injections, correct dosing, and for drooling in Parkinson’s disease: a double-blind, randomized,
familiarity with the neurotoxin and its indications are critical placebo-controlled study. Mod Disord. 2006;21:704–707.
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