LetibotulinumtoxinA Attenuates the Psychological Burden of Glabellar Lines and Is Associated With High Subject Satisfaction in Phase 3 Clinical Trials.

BACKGROUND: Hyperfunctional glabellar frown lines can transmit facial miscues that adversely affect emotional communication, increase perceptions of age, and diminish self-esteem. OBJECTIVE: To evaluate the efficacy of letibotulinumtoxinA in mitigating the negative psychological impact associated with moderate to severe glabellar lines and to assess subject satisfaction with treatment outcome in the BLESS phase 3 clinical trials. MATERIALS AND METHODS: Baseline and posttreatment assessments were made using validated subject-administered instruments: Modified Skindex-16 Glabellar Line Quality of Life (GL-QoL) Scale, Facial Assessment and Cosmetic Evaluation Questionnaire (FACE-Q) Appraisal of Lines Between Eyebrows Scale, FACE-Q Age Appraisal Visual Analog Scale, and FACE-Q Satisfaction with Outcome Scale. An integrated analysis using pooled BLESS data was conducted on these secondary end points. RESULTS: Among enrolled and treated subjects ( N = 1,272), 85.5% had moderate to severe psychological impact at baseline. LetibotulinumtoxinA subjects experienced significant improvements compared with placebo on all measures. Mean improvement to Week 4 for the Modified Skindex-16 GL-QoL Scale overall score was -33.84 for letibotulinumtoxinA subjects compared with -1.37 for placebo subjects ( p < .001). Attenuation of psychological burden was highly correlated with improvement in glabellar line severity ( p < .0001). CONCLUSION: LetibotulinumtoxinA significantly improved the psychosocial burden associated with glabellar lines across all trials. Treated subjects experienced improved quality of life, younger perceived age, and satisfaction with treatment outcome.

Efficacy and Safety of Letibotulinumtoxin A in the Treatment of Glabellar Lines: A Randomized, Double-Blind, Multicenter, Placebo-Controlled Phase 3 Study.

BACKGROUND: Letibotulinumtoxin A (Hugel, Inc., Chuncheon, Republic of Korea and CROMA Pharma, Leobendorf, Austria) is a newly manufactured neurotoxin derived from Clostridium botulinum strain CBFC26. OBJECTIVES: The aim of this study was to assess the efficacy and safety of letibotulinumtoxin A in reducing glabellar line severity (GLS) and to evaluate long-term safety and efficacy following repeated injections. METHODS: In this prospective, randomized, parallel-group, double-blind, multicentre, placebo-controlled Phase III clinical trial, 355 subjects with moderate to severe glabella frown lines received injections of 20 U of letibotulinumtoxin A or placebo. GLS, onset and duration of effect, time to retreatment, and adverse events were evaluated. Response to treatment was defined as a GLS score of 0 or 1 (assessed by the subject and the investigator) and an improvement at Week 4 of ≥2 points in GLS score relative to baseline. RESULTS: At 4 weeks, 78.6% of the active treatment subjects were responders based on the investigator's assessment and 68.8% based on the subject's assessment, resulting in a composite responder rate of 64.7% for the active treatment group, whereas the corresponding rate was 0.0% in the placebo group (P < 0.001). Subjects noted a substantial improvement in GL severity as early as Day 2, with the median time to onset of effect being 3 days. The mean [standard deviation] time until first retreatment for the letibotulinumtoxin A group was 127.26 [65.6] days. Letibotulinumtoxin A was well tolerated. CONCLUSIONS: Letibotulinumtoxin A demonstrates high efficacy and a convincing safety profile in the treatment of glabellar lines.

A Randomized, Double-Blind, Active- and Placebo-Controlled Trial Evaluating a Novel Topical Treatment for Keloid Scars.

Keloid and hypertrophic scars are fibroproliferative disorders resulting from abnormal wound healing in genetically susceptible individuals. Current therapies are often ineffective. Kynurenine shows promise as a topical treatment for keloids and hypertrophic scars. In this study, healthy adult male and female subjects seeking treatment for mature keloid scars were enrolled. Subjects were randomized in double-blind fashion to receive kynurenic acid 0.5% (FS2) cream (Group 1), an active onion extract comparator treatment (Group 2), or the inactive vehicle (Group 3). Each treatment was applied twice-daily. Qualitative assessments were made using the Vancouver Scar Scale (VSS), as well as the Patient and Observer Scar Assessment Scales (POSAS). Among subjects in Group 1, there was a substantial decrease in mean PGSS scores after 30 days of treatment that continued to trend downward, becoming significant versus Group 2 at days 90 and 180 (P<0.05) and versus Group 3 at day 180 (P<0.01). Based on mean VSS scores, subjects in Group 1 achieved beneficial effects that became significant versus Group 2 at day 90 (P<0.01), day 120 (P<0.05), and day 180 (P<0.001) and versus Group 3 at day 180 (P<0.05). There were no significant improvements in Groups 2 or 3. There were no adverse events or local skin reactions. The twice-daily application of FS2 Cream represents a potentially new and effective treatment for mature keloid scars. J Drugs Dermatol. 2021;20(9):964-968. doi:10.36849/JDD.6197.

A Supersaturated Oxygen Emulsion for Wound Care and Skin Rejuvenation.

Although oxygen is essential for proper wound healing, wounds are often hypoxic with diminished oxygen delivery to the healing tissue. Since oxygenation of the outer layers of skin is almost exclusively provided by the atmosphere, increasing the presence of external oxygen enhances the healing process. Hyperbaric oxygen therapy is beneficial for treating nonhealing wounds, such as diabetic ulcers, and has been used to speed post-treatment recovery following aesthetic procedures; however, it is not suitable for home use. Recently, perfluorocarbon emulsions have been developed that can absorb large amount of oxygen. Preparations containing 2% of these compounds can absorb up to seven-times more oxygen than water at 37°C. A topical perfluorocarbon emulsion consisting of perfluorodecalin, water, plant derived emulsifiers, and a preservative, has been developed for use in dermatology (Cutagenix™ & Cutavive™ Professional Skin Care Emulsion; Cutagenesis, Niwot, CO). Designed to be applied 2 to 4 times daily following skin rejuvenation procedures, this topical oxygen emulsion reduces the incidence of post-procedure complications. The application of a topical emulsion is well-suited for patient application to enhance recovery following energy-based aesthetic procedures. J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.4728.

Randomized, Investigator-Blinded Study to Compare the Efficacy and Tolerance of a 650-microsecond, 1064-nm YAG Laser to a 308-nm Excimer Laser for the Treatment of Mild to Moderate Psoriasis Vulgaris

Background: Phototherapy is a safe and effective modality for the treatment of mild to moderate psoriasis. Objectives: To compare the efficacy and safety of the 650-microsecond, 1064-nm pulsed YAG laser with the excimer laser for the treatment of mild to moderate psoriasis vulgaris of the arms and legs. Methods: Eligible subjects (n=15) aged 54.3 ± 11.7 years enrolled in a randomized, investigator-blinded study. Psoriatic plaques on one side of the body were treated with the 650-microsecond laser and plaques on the other side were treated with the 308-nm excimer laser. Subjects made up to 15 visits, twice weekly, or fewer if full clearance was achieved. Efficacy and tolerance were evaluated by the mPASI scores and local skin reactions, respectively. Results: Both devices showed efficacy in treating psoriatic plaques. Differences between the two devices were not significant for redness, thickness, scaliness, mPASI scores for arms and legs, and overall mPASI scores for the treated psoriatic plaques on each side of the body. The investigator-assessed scores for erosion/ulceration, vesicles, erythema, scaling, edema, and atrophy were low and identical for both sides of the body. Conclusion: The efficacy and tolerance of the 650-microsecond laser is equivalent to that of the excimer laser for the treatment of mild to moderate psoriasis vulgaris of the arms and legs. J Drugs Dermatol. 2020;19(2)176-183. doi:10.36849/JDD.2020.4769

A Cohort Study Using a Facial Cleansing Brush With Acne Cleansing Brush Head and a Gel Cleanser in Subjects With Mild-to-Moderate Acne and Acne-Prone Skin

Introduction: Acne vulgaris is a highly prevalent skin condition that can adversely affect the quality of life. Acne-predisposed skin is in a state of subclinical inflammation leading to skin barrier dysfunction. A multi-center cohort study was designed to evaluate clinical efficacy and safety of twice daily facial cleansing using an oscillatory sonic brush, acne brush head, and cleansing gel for 4 weeks. Methods: Subjects with mild-to-moderate acne and acne-prone skin used the cleansing regime after which they applied the skin care products they routinely used. Physician-assessed skin condition comparing baseline versus week 4 using the FDA/IGA scale and subject satisfaction with cleansing efficacy and handling properties of the regime were scored during the last visit. Results: Forty-six subjects completed the study. Physician-scored skin condition showed a statistically significant improvement in FDA/IGA scores and a significant reduction of inflammatory and non-inflammatory lesions comparing baseline versus 4 weeks. Thirty-five (76.0%) subjects had cleared or almost cleared. Subjects similarly assessed their skin to be improved. Conclusion: Both the physician and subject scores revealed the gentle cleansing routine using the sonic brush to be effective reducing the number of acne lesions, improving skin condition. No adverse events were reported during the study period. The cleansing regime may offer an attractive, safe option for maintenance and treatment of subjects with mild-to-moderate acne and acne-prone skin. J Drugs Dermatol. 2019;18(11):1140-1145.

Expert Consensus on Achieving Optimal Outcomes With Absorbable Suspension Suture Technology for Tissue Repositioning and Facial Recontouring.

A complete approach to facial rejuvenation includes restoration of the skin's surface, relaxation of muscles that contribute to hyperkinetic movement, revolumization, and repositioning/recontouring of descended tissues and fat pads. After receiving 510(k) clearance from the US Food and Drug Administration (FDA) in 2015, the Silhouette InstaLift™ absorbable suspension suture became the only available non-surgical technique for repositioning of facial tissue. In January 2017, a consensus paper presented a review of the literature on the efficacy and safety of absorbable suspension sutures and provided information on treatment procedures. Since that time, the clinical experience of the authors has further shaped their treatment practices, highlighting the need for additional guidelines to support an optimal treatment approach. This update will expand upon the 2017 consensus paper on the safety and efficacy of absorbable suspension sutures and provide guidance for obtaining consistently high patient satisfaction with the procedure. Recommendations are based on the extensive clinical experience of expert physicians with absorbable suspension sutures over the past 2.5 years. Here, the authors provide guidance on full face assessment and treatment to support maximum benefit and provide patient selection and procedural recommendations. In addition, the authors stress the benefits of the dual mechanisms of action within the absorbable suspension suture: the immediate lift and volumizing over time that together lead to the outcome of recontouring. J Drugs Dermatol. 2018;17(6):647-655.

The Use of Botulinum Neurotoxin Type A in Aesthetics: Key Clinical Postulates.

BACKGROUND: The most common aesthetic procedure performed worldwide is the injection of botulinum neurotoxin Type A (BoNT-A). Aesthetic providers must fully comprehend the objective scientific data, theoretical mechanisms of action, and differences between brands of BoNT-A. OBJECTIVE: To determine and review the relevant clinical postulates for the use of botulinum toxin in aesthetics. MATERIALS AND METHODS: The BoNT-A clinical postulates presented here discuss how each brand of BoNT-A acts identically, how the molecular potency may vary between the different products, how patient age, gender, genetics, and muscle mass cause variation in toxin receptor number and density, and how both practitioner and patient can affect toxin distribution. RESULTS: A total of 8 clinical postulates have been identified that are key to understanding the use of botulinum toxin in aesthetics and to obtaining the best clinical results. CONCLUSION: All of these factors affect the potential efficacy of the injected toxin and hence the aesthetic results obtained.

Expert Consensus on Absorbable Advanced Suspension Technology for Facial Tissue Repositioning and Volume Enhancement.

BACKGROUND: Signs of facial aging include wrinkles, loss of subcutaneous volume, decreased tone, texture, and sagging of the skin. The objective of this review is to determine whether facial suspension absorbable sutures are a safe and effective modality for facial rejuvenation.

METHOD: A group of US plastic surgeons and dermatologists who practice medical aesthetics convened to review evidence obtained from literature searches and to reach a consensus on clinical practice guidelines for the use of facial absorbable suspension sutures.

RESULTS: Currently, there are different types of lifting sutures available. Absorbable, facial suspension sutures allow for superior repositioning of tissue along a vector line together with the added benefit of volumization of the area. These benefits are for patients who have moderate facial aging and require treatment beyond the use of injectable products only.

CONCLUSIONS: Treatment with absorbable facial suspension sutures, when performed properly, is associated with minor and infrequent complications and offers a beneficial clinical alternative to traditional facial rejuvenation techniques.

J Drugs Dermatol. 2017;16(7):661-666.

Expert Consensus on Cosmetic Outcomes After Treatment of Actinic Keratosis.

Dermatologists treat actinic keratosis (AK) primarily because these lesions have the potential to progress to invasive squamous cell carcinoma. Patients, on the other hand, generally seek treatment to remove the lesions and achieve an improved appearance of their skin following treatment. In selecting a treatment option for AK, dermatologists should consider post-treatment cosmesis, because cosmetic outcomes differ across AK treatments. To obtain expert opinion on the cosmetic sequelae related to chronically photodamaged skin and the treatment of AK, an expert panel meeting among dermatologists was conducted in February 2016. These experts reviewed current treatment options for photodamage, including AK, and discussed the relative merits of the various cosmetic assessments commonly used by investigators and patients in both clinical trial and dermatology practice settings. A main goal of the expert panel meeting was to propose assessment tools that could be specifically designed to characterize cosmesis results after treatment of AK. The panel agreed that existing tools for measurement of cosmetic outcomes following treatment of photodamage could also be used to evaluate cosmesis after treatment of AK. Digital photography is probably the best method used for this, with validation by other technologies. Better measurement tools specifically for assessing cosmesis after AK treatment are needed. Once they are developed and validated, regulatory agencies should be educated about the importance of including cosmetic outcomes as a component of product labeling.

J Drugs Dermatol. 2017;16(3):260-265.

Treatment of Hyaluronic Acid Filler-Induced Impending Necrosis With Hyaluronidase: Consensus Recommendations.

Injection-induced necrosis is a rare but dreaded consequence of soft tissue augmentation with filler agents. It usually occurs as a result of injection of filler directly into an artery, but can also result from compression or injury. We provide recommendations on the use of hyaluronidase when vascular compromise is suspected. Consensus recommendations were developed by thorough discussion and debate amongst the authors at a roundtable meeting on Wednesday June 18, 2014 in Las Vegas, NV as well as significant ongoing written and verbal communications amongst the authors in the months prior to journal submission. All authors are experienced tertiary care providers. A prompt diagnosis and immediate treatment with high doses of hyaluronidase (at least 200 U) are critically important. It is not felt necessary to do a skin test in cases of impending necrosis. Some experts recommend dilution with saline to increase dispersion or lidocaine to aid vasodilation. Additional hyaluronidase should be injected if improvement is not seen within 60 minutes. A warm compress also aids vasodilation, and massage has been shown to help. Some experts advocate the use of nitroglycerin paste, although this area is controversial. Introducing an oral aspirin regimen should help prevent further clot formation due to vascular compromise. In our experience, patients who are diagnosed promptly and treated within 24 hours will usually have the best outcomes.

Treatment of facial actinic keratoses with aminolevulinic acid photodynamic therapy (ALA-PDT) or ingenol mebutate 0.015% gel with and without prior treatment with ALA-PDT.

OBJECTIVE: This randomized, 3-group study compared the efficacy and tolerability of 3 treatment modalities for facial actinic keratoses. METHODS: Twenty-four healthy adult male and female subjects who had 4 to 8 clinically visible and discrete actinic keratoses on the face in a contiguous 25cm2 treatment area. Subjects were randomized into one of three treatment groups: 2 treatments with 5-aminolevulinic acid (ALA) and photodynamic therapy (PDT), 1 ALA-PDT treatment and 1 course of ingenol mebutate (ingenol mebutate) 0.015% gel daily for 3 consecutive days, or 1 course of ingenol mebutate gel alone. Actinic keratoses in the treatment field were counted at the baseline visit, and at the completion of the study (day 57 or day 71). At the site of application, local site reactions were graded at each visit. RESULTS: Subjects in the two ALA-PDT treatment group had a 97.5% mean reduction (P<0.00001) from the number of baseline actinic keratosis; ALA-PDT plus ingenol mebutate gel group had an 86.7% mean reduction (P<0.00001); while subjects in the ingenol mebutate gel alone group had a 91.7% mean reduction from the number of baseline actinic keratoses. The peak composite LSR score was 4.625 for the ALA-PDT group, 10.375 for the ALA-PDT followed by ingenol mebutate gel group, and 12.625 for the ingenol mebutate gel alone group (P=0.0004 and 0.001, respectively). CONCLUSION: ALA-PDT, ingenol mebutate gel, and a combination of the two treatment modalities are successful topical therapies for the reduction of actinic keratoses on the face. The group of subjects receiving 2 consecutive treatments with ALA-PDT, compared to treatment with ingenol mebutate gel alone or sequentially after one course of ALA-PDT had a significantly lower mean composite LSR score and a non-significant trend for greater efficacy.

A cross-sectional content quality analysis of information in TikTok videos on "Dermarolling (Roller Microneedling)".

BACKGROUND: TikTok is one of the fastest-growing social media platform, and its short-form videos have become a widely used source of health information. "Dermarolling" is a form of roller microneedling often practiced at home, and patients may be using TikTok to inform their decision to pursue this treatment and their practice of it. AIMS: This study assessed the informational content quality, source, and engagement of TikTok dermarolling videos to highlight potentially harmful social media trends. METHODS: On a predetermined date, "dermarolling" was searched on TikTok. The top 75 results were screened. Number of views, creator type, type of video, and whether risks were discussed were recorded. Information quality was assessed using the DISCERN tool. The data were stratified by creator type, and statistical analysis was performed using R version 4.3.2. Median viewership and DISCERN scores were compared using Kruskal-Wallis tests with post hoc pairwise Wilcoxon tests. Fisher's exact test was used to compare rates of risk discussion between groups. RESULTS: Sixty-one of the reviewed videos met the inclusion criteria. Influencer videos engaged the largest overall audience and had higher median viewership than other creators. Physicians, primarily dermatologists, created exclusively educational content and influencers created mostly experience-based content. Overall content quality was generally low-moderate, with a median (IQR) DISCERN score of 30.5 (26.5-33.5). Physician content had higher median DISCERN scores than influencers (p = 0.004) and others (p = 0.004). Physicians were more likely to discuss risks compared to influencers (p = 0.02). CONCLUSIONS: TikTok content on "dermarolling" was of relatively low quality, and nonphysicians command a large viewership. Physician-created content is often of higher informational quality, and dermatologists should escalate their efforts to engage patients in this space to mitigate the effects of potential misinformation.

Stasis Dermatitis: Pathophysiology, Current Treatment Paradigms, and the Use of the Flavonoid Diosmin.

Objective: We sought to examine the role of flavonoids, particularly diosmin, as a therapeutic agent for stasis dermatitis (SD) through discussion of pathophysiology, current treatment paradigms, potential mechanisms of action, and a systematic review of evidence on clinical efficacy. Methods: In addition to articles on pathophysiology and standard treatment, a search of PubMed was conducted using the following query: ("Diosmin" OR "MPFF" OR "Micronized Purified Flavonoid Fraction" OR "Flavonoid") AND ("Stasis Dermatitis" OR "Venous Ulcer" OR "Lipodermatosclerosis"). Emphasis was placed on studies that were randomized controlled trials examining an oral flavonoid against a placebo or standard of care. Results: Diosmin is effective at improving stasis changes, increasing ulcer healing frequency, decreasing the time to ulcer healing, and reducing tissue edema. They also cause significant improvement in patient quality of life and reduction of venous symptoms. Diosmin has been shown to have a favorable safety profile with very few mild adverse events which did not differ significantly from placebo. Flavonoids also appear to be effective for other dermatologic conditions, including rosacea and senile purpura. Conclusion: There is a growing body of evidence indicating that diosmin has therapeutic efficacy in managing stasis dermatitis. Data from studies in diseases with pathogenic similarities suggests the potential for even broader dermatologic applications.

A review of nonsurgical facial rejuvenation and the role of oxymetazoline hydrochloride ophthalmic solution, 0.1% in periorbital revitalization.

BACKGROUND: The demand for nonsurgical facial rejuvenation options is growing, yet the periorbital region remains an area of relative unmet need. This review explores nonsurgical options for facial rejuvenation and the role of oxymetazoline hydrochloride ophthalmic solution, 0.1%, in treating age-related blepharoptosis as part of periorbital rejuvenation. METHODS: Advisors experienced in facial rejuvenation met to discuss existing literature on the upper face and periorbital rejuvenation and the role of oxymetazoline hydrochloride ophthalmic solution, 0.1%, in treating facial aging. RESULTS: An array of nonsurgical options exist to address the signs of aging, including minimally invasive treatments, such as botulinum toxin injections and dermal fillers, and noninvasive therapy, such as lasers, chemical peels, and microdermabrasion. However, treating age-related ptosis in periorbital rejuvenation is mainly addressed surgically. The newly approved α-adrenergic receptor agonist oxymetazoline hydrochloride ophthalmic solution, 0.1%, provides a novel non-interventional approach to blepharoptosis. CONCLUSIONS: Facial rejuvenation is highly sought-after in this post-pandemic era. Each nonsurgical treatment option has its advantages and drawbacks. A patient-centered approach is necessary to select the appropriate procedure considering the patient's concerns and aesthetic sensibilities. The eyes are an area of primary concern for patients, yet surgery is the gold standard for treating ptosis. Oxymetazoline hydrochloride ophthalmic solution, 0.1%, is a safe and effective nonsurgical treatment for blepharoptosis.

Body contouring using 635-nm low level laser therapy.

Noninvasive body contouring has become one of the fastest-growing areas of esthetic medicine. Many patients appear to prefer nonsurgical less-invasive procedures owing to the benefits of fewer side effects and shorter recovery times. Increasingly, 635-nm low-level laser therapy (LLLT) has been used in the treatment of a variety of medical conditions and has been shown to improve wound healing, reduce edema, and relieve acute pain. Within the past decade, LLLT has also emerged as a new modality for noninvasive body contouring. Research has shown that LLLT is effective in reducing overall body circumference measurements of specifically treated regions, including the hips, waist, thighs, and upper arms, with recent studies demonstrating the long-term effectiveness of results. The treatment is painless, and there appears to be no adverse events associated with LLLT. The mechanism of action of LLLT in body contouring is believed to stem from photoactivation of cytochrome c oxidase within hypertrophic adipocytes, which, in turn, affects intracellular secondary cascades, resulting in the formation of transitory pores within the adipocytes' membrane. The secondary cascades involved may include, but are not limited to, activation of cytosolic lipase and nitric oxide. Newly formed pores release intracellular lipids, which are further metabolized. Future studies need to fully outline the cellular and systemic effects of LLLT as well as determine optimal treatment protocols.

A review of AbobotulinumtoxinA (Dysport).

AbobotulinumtoxinA was approved by the US Food and Drug Administration in 2009 as the second botulinum neurotoxin type A (BoNTA) for use in facial aesthetics. This article provides an overview of abobotulinumtoxinA's applications and indications as well as safety and efficacy data. AbobotulinumtoxinA is generally well tolerated. Adverse events from abobotulinumtoxinA are similar to those reported with other BoNTA products. Clinical applications of the product are also discussed in this article. Information on handling, storage, and dosing is provided.

IncobotulinumtoxinA (Xeomin): background, mechanism of action, and manufacturing.

IncobotulinumtoxinA is the third botulinum neurotoxin type A (BoNTA) to be approved for aesthetic use in the United States. This article introduces the new product with an overview of clinical applications and a discussion of the neurotoxin's molecular structure. The role and clinical relevance of complexing proteins in BoNTA products are discussed. Finally, incobotulinumtoxinA's mechanism of action is described.

IncobotulinumtoxinA in clinical literature.

IncobotulinumtoxinA is the third neurotoxin type A to be approved for aesthetic use in the United States. Because incobotulinumtoxinA has been in use in Europe for some time, the clinical literature is fairly replete with references to its properties and characteristics, as well as its safety and efficacy. In North America, 2 pivotal trials, referred to as GL-1 and GL-2, investigated the safety and efficacy of incobotulinumtoxinA in the glabellar region; both are currently in press with another journal. Other published studies of incobotulinumtoxinA are also described in depth in this article, including reports on aesthetic indications, diffusion, therapeutic indications, and studies pertaining to the preclinical and clinical pharmacology of incobotulinumtoxinA. Topics addressed include potency variability, mean concentration, stability and dissociation, and endopeptide immunoassay.

Consensus panel's assessment and recommendations on the use of 3 botulinum toxin type A products in facial aesthetics.

In this summary article, the authors discuss the characteristics of abobotulinumtoxinA, incobotulinumtoxinA, and onabotulinumtoxinA. With 3 neuromodulators available in the US market, comparisons between and among products will invariably be made, so arguments for the most effective facial aesthetic uses of each neuromodulator are presented. Topics addressed in this article include patient expectations, toxin reconstitution and preparation, patient positioning, differences among products, the role of complexing proteins, and dosing and injection strategies. Recommendations are also provided by treatment area.