Which is better botox or dysport 1

Botulinum toxin A in wrinkle treatment: overview and delimitation to alternative methods

MEDICINE

Summary
Botulinum toxin A is increasingly used in dermatology for wrinkle treatment. Botulinum toxin A prevents acetylcholine exocytosis for three to twelve months, depending on the target tissue. Low-dose botulinum toxin A is suitable for treating facial wrinkles. Contraindications are diseases of neuromuscular signal transduction, allergies to components of the solution, taking antibiotics and acetylsalicylic acid before treatment, infections in the area of ​​the injection sites and pregnancy and lactation. Alternative procedures for wrinkle treatment use erbium-YAG or CO2 lasers, augmentation procedures and operations.

Key words: botulinum toxin, facial wrinkles, wrinkle treatment

Summary
Botulinum Toxin A for the Treatment of Wrinkles
The use of botulinum toxin A is increasingly common in dermatological treatment of wrinkles. Depending on the tissue botulinum toxin A inhibits the exocytosis of acetylcholine for three to twelve months. Low dose botulinum toxin A can improve hypercinetic facial lines. Contraindications are diseases that affect the neuromuscular signal transduction, allergic
Reactions against components of the solution, use of antibiotics or acetylsalicylic acid prior to treatment, infections in the injection areas, pregnancy and nursing period. Erbium-YAG- or CO2-laser as well as augmentation procedures or facelifting are alternative treatment options.

Key words: botulinum toxin A, hypercinetic facial lines, treatment of wrinkles


The first therapeutic applications of botulinum toxin A took place in 1980 by the ophthalmologist A. Scott for the treatment of Strabis
mus in children. Since 1983, the substance has been increasingly used in ophthalmology (e.g. blepharospasm), in the neurological field (e.g. for the treatment of blepharospasm, spastic torticollis or dystonia) (1), in urology (e.g. in detrusor-sphincter dyssynergy) and in in gastroenterology (for example, for achalasia or increased activity of the upper esophageal sphincter) (21). In dermatology, botulinum toxin A has been used in the treatment of hyperhidrosis (11, 12, 17) and for wrinkle correction for several years. Another therapeutic indication is the treatment of anal fissures (21). Botulinum toxin is produced by anaerobic bacteria of the genus Clostridium botulinum in seven different serotypes A to G.
Mechanism of action, safety and contraindications
The mechanism of action takes place on the terminal axon of cholinergic neurons. The onset of action usually occurs after two to seven days, with a maximum after 15 days (1). Here, by preventing the fusion of acetylcholine-filled vesicles with the plasma membrane, the release of the transmitter into the synaptic gap is prevented (20). The duration of action varies greatly from person to person. The information in the literature ranges from three to nine months. Compared to the effect on the muscles (three to six months), the duration of the effect on the sweat glands is significantly longer (six to twelve months) (3, 14, 20, 21).
During this period of time, the toxin is split intraneuronally by the cell's own proteases and the nerve endings regain their original function (21). The use of botulinum toxin A is relatively safe due to its wide therapeutic range in both products currently available in Germany.
For Botox, the LD50 is used for an i. m. injection in monkeys given as 40 units / kg body weight, this would correspond to a lethal dose of 2,800 units for a body weight of 70 kg. Based on reports on individual cases of poisoning, the orally lethal dose for humans is in the range of 3,000 to 30,000 units (specialist information on Botox). After intramuscular injection of Dysport into the eye muscle in monkeys, the LD50 values ​​were 28 ng / kg body weight. Based on this result, the lethal intramuscular dose for a person weighing 70 kg is calculated to be 39,200 to 78,400 units (Dysport specialist information).
Greene et al. (9) give the lethal dose of botulinum toxin A for a person weighing 70 kg as 3,000 units. For wrinkle correction, dosages of up to 100 units of Botox (4) and 230 units of Dysport (20) are used per session. The average doses are 20 to 40 units of Botox and 100 units of Dysport, so that if the substance is handled properly and the injection is carried out correctly, no serious side effects are to be expected (8). In the case of botulinum toxin A units, the product specification is required because the units for Botox and Dysport are not identical. One unit of Botox corresponds to 3 to 5 units of Dysport (8).
General contraindications to treatment with botulinum toxin A are diseases of neuromuscular transmission (e.g. myasthenia gravis or myasthenic Lambert-Eaton syndrome), pronounced myopathies, motor neuron diseases, pregnancy, breastfeeding, allergies to components of the solution (e.g. albumin), local infections, Ingestion of aminoglycosides or spectinomycin as well as an increased tendency to bleed (21).
Indications in cosmetic dermatology
Botulinum toxin A is particularly suitable for correcting dynamic facial wrinkles in the upper third of the face and neck, which are caused by the activity of the facial muscles (Figures 1 and 2).
They have been present since early childhood and hyperactivity can lead to persistence of these wrinkles in early adulthood. (22) In particular, the deep, dynamic facial wrinkles in the upper half of the face, such as forehead wrinkles, glabellar lines, transverse wrinkles in the area of ​​the root of the nose, radial wrinkles in the area of ​​the lateral corner of the eyelid (“crow's feet”) and infraorbital wrinkles can be suitable for botulinum toxin A therapy. Indications, contraindications and practical information are explained in text box 1.
Use and differentiation from available alternatives
For the treatment of these deep wrinkles, for example on the forehead or glabella, surgical procedures (lifting operations) are most likely to be used, which, apart from complications from anesthesia, hematoma, edema and scarring, may and may not result in a permanent reduction in expression if overcorrected offer as many modification options as the use of botulinum toxin A (1). Augmentation procedures with hyaluronic acid, collagen and autologous fat are more suitable for superficial to medium-deep wrinkles, such as perioral wrinkles and nasolabial folds. However, these methods can be combined well with the use of botulinum toxin A, whereby, according to the authors' experience, an injection interval of 8 to 14 days should be observed and therapy with botulinum toxin A should precede tissue augmentation.
In our experience and based on an evaluation of the literature, peeling procedures, as well as an erbium-YAG laser therapy, are better suited for superficial to medium-deep wrinkles so-called "creases" and for the treatment of solar elastoses such as elastosis actinica or Favre's disease. Racouchot. However, these procedures can be combined well with the use of botulinum toxin (19).
The CO2 laser is suitable for treating more pronounced wrinkles. However, the depth of the thermally induced necrosis zone is two to four times the visible penetration depth of the laser (13).
In addition to mechanical abrasion, the heat-induced contraction of the collagen fibrils ("collagen shrinking") and thus skin tightening (13). However, the CO2 laser is used more for extensive wrinkle therapy in cases of pronounced elastosis. Compared to the use of botulinum toxin A, it shows a significantly higher rate of complications and the patient is restricted in carrying out his normal lifestyle for weeks after the procedure (13).
Another advantage of wrinkle treatment with botulinum toxin compared to peeling and laser procedures is the independence of the skin type. With dark skin types (from skin type 3 according to Fitzpatrick), pigmentation disorders often occur with both peeling and laser applications, while the intramuscular injection of botulinum toxin A does not lead to any manipulation in the epidermis area. A summary of other methods of wrinkle treatment is given in text box 2.
Side effects and problems
Local side effects of the use of botulinum toxin consist in the appearance of small hematomas after the injection, which, depending on the localization, are reported with a frequency of two to 20 percent. Immediately following compression with ice-cold compresses has proven its worth here (22). In rare cases, depending on the location, the product-dependent diffusion can lead to paralysis of neighboring muscle groups that is reversible after three to six months. For example, ptosis can occur during treatments in the forehead area (3, 4).
This complication rate could possibly be reduced even further by adding adrenaline, as Le-Louharn et al. were able to show in a study (16). The frequency of this complication is given as one to two percent (4, 20).
Another complication that can be avoided by choosing the right injection site, namely lateral to the outer canthus with a minimum distance of 1 cm from the eyelid, is the occurrence of an ectropion after treatment of the lateral eye folds (14).
In addition, an injection below the zygomatic arch should be avoided, as otherwise an affection of the major zygomaticus would be feared, and this could lead to an asymmetrical smile.
However, apraclonidine eye drops can be used for ptosis. This is an alpha-2 agonist that acts directly on the tarsalis muscle when applied to the eye (22).
Song et al. (23) were able to show through muscle biopsies in patients who had been treated with botulinum toxin for seven years that no signs of permanent muscle degeneration could be detected. Furthermore, no antibodies against botulinum toxin could be detected in these patients.
If the desired cosmetic result does not occur in individual patients, according to the experience of Klein et al. the electromyographically controlled injection may improve the result (15).
In summary, it can currently be stated that with experienced users, critical indications, professional education and application, the use of botulinum toxin A is an effective and safe method in the treatment of dynamic wrinkles, especially in the area of ​​the upper half of the face (3, 13) that it can be seen both as a monotherapy with timely indication and as a supplement to the therapeutic alternatives presented for very deep, long-standing, dynamic wrinkles.

How this article is cited:
Dt Ärztebl 2001; 98: A 1758-1760 [issue 26]

The numbers in brackets refer to the bibliography, which is available from the author in an offprint and on the Internet (www.aerzteblatt.de).

Address for the authors:
Dr. med. Michael Weidmann
Department of Dermatology
Ulm University Hospital
Upper Eselsberg 40
89081 Ulm


Department of Dermatology (Head: Prof. Dr. med. Ralf Uwe Peter), Ulm University Hospital



Indications:
- Horizontal forehead wrinkles, glabellar wrinkles "frown lines", lateral eye wrinkles "crow's feet", nasal dorsal lines, platysma lines

Contraindications:
- Diseases of the neuromuscular transmission (e.g. myasthenia gravis, Lambert-Eaton syndrome)
- Allergies to components of the solution (e.g. albumin)
- taking antibiotics shortly before or after treatment (aminoglycosides increase the effect)
- Taking ASA up to 14 days before treatment
- Infections around the injection sites
- pregnancy and breastfeeding period

Making the finished solution:
- Material: Botox dry substance from the freezer (-4ºC) or Dysport dry substance, dilution of 1 ampoule of Botox at 100 U corresponds to Dysport at 500 U with 5 ml NaCl (stock solution), distribution of the stock solution over five 1 ml insulin syringes, CAVE: Denaturation of botulinum toxin by shaking or blistering

Wrinkle treatment with botulinum toxin: practical implementation
- Written information for the patient, photo documentation before treatment, application of ice-cold saline compresses; If necessary, use EMLA ointment, disinfect the injection sites with alcohol-free antiseptic, draw the injection points with a washable pen (e.g. kohl pencil) during muscle contraction, advance the injection needle until you hit the periosteum, withdraw minimally and inject, injection amount per injection: horizontal forehead wrinkles : 1-4 U Botox / 5-20 U Dysport; Nasal folds: 1–2 U Botox / 5–10 U Dysport; Lateral eye wrinkles (“crow's feet”): 2–5 U Botox / 5–15 U Dysport; Platysma folds: 1–7 U Botox / 3–35 U Dysport, recommended maximum dose per session: 100 U Botox / 500 U Dysport, re-application of ice-cold compresses after injection, upright posture for four hours, no massaging the injection site, a lot of facial expressions 14 days of renewed photo documentation and, if necessary, post-correction

Side effects:
- Hematoma (2–20 percent), local injection pain, headache, paralysis of neighboring muscle groups, drooping of the eyebrows (1–2 percent), non-responders, numbness




Application of botulinum toxin in
Differentiation from alternative methods of wrinkle treatment

Botulinum toxin:
- Horizontal forehead wrinkles, glabellar wrinkles "frown lines", lateral eye wrinkles "crow's feet", nasal dorsal folds, platysma lines
Advantages: low complication rate, low material expenditure, easy repeatability
Disadvantages: effect only for 3 to 9 months

Peeling procedure / erbium-YAG laser:
- Superficial to medium deep wrinkles
- Treatment of solar elastoses
Advantages: long-lasting effect, extensive use
Disadvantages: cost of materials, higher complication rate (post-therapeutic erythema phase), pigmentation disorders

CO2 laser:
- Extensive wrinkle therapy for pronounced solar elastosis
Advantages: long-lasting effect, extensive use
Disadvantages: long post-therapeutic erythema phase, pigmentation disorders, scarring

Augmentation procedure: (hyaluronic acid, autologous fat or collagen injection)
- Superficial to medium deep wrinkles
Advantages: Therapy also possible in regions that are a contraindication for botulinum toxin
Disadvantages: effect only 6 to 24 months, possible foreign body granulomas (with collagen), uneven correction of wrinkles

Operative procedures: ("Facelifting")
- Correction of deep, dynamic facial wrinkles (largely the same indication areas as botulinum toxin)
Advantages: long-lasting, far-reaching effect
Disadvantages: risk of anesthesia, hematoma and scarring, fewer modification options compared to botulinum toxin, risk of permanent reduced facial expression
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Botulinum toxin A in wrinkle treatment: overview and delimitation to alternative methods

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