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Practice Gaps |

Dilution, Reconstitution, and Complexity:  Comment on “A Small Study of the Relationship Between Abobotulinum Toxin A Concentration and Forehead Wrinkle Reduction ”

Murad Alam, MD, MSCI
Arch Dermatol. 2012;148(1):121-122. doi:10.1001/archderm.148.1.121.
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The treatment of dynamic upper facial creases with botulinum toxin type A is sometimes characterized as a trivial procedure, one equally successful in the hands of anyone capable of holding a syringe and depressing a plunger. In fact, this procedure is surprisingly complex and replete with nuance. With this study, Abbasi et al further define the properties of different dilutions of botulinum toxin.

The specific practice gap addressed is how dilution affects effectiveness, and whether effectiveness and safety can be improved by using more dilute botulinum toxin preparations. However, in a larger context, the practice gap is not merely uncertainty about dilution, but more generally, how botulinum toxin should be deployed for cosmetic treatments. When botulinum toxin was classified by the US Food and Drug Administration as a drug, the subtleties of its use were not yet very well understood, and official guidance about dosage and administration on the package insert is consequently sparse. In practice, botulinum toxin operates with the site-specific concentration and means of delivery more important than total dose. Furthermore, as the number of routine off-label indications like forehead, crow's feet, and lower face wrinkles has grown, the question of where, what, and how to inject has only become more convoluted.

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Figure. Assuming that each of the known variables that may affect botulinum toxin effectiveness for facial wrinkles has just 2 possible values, there are at least 26, or 64, permutations.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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