UPPER FACE AND
BOTOX® FOR FACIAL WRINKLES
BLEPHAROPLASTY FOR SAGGING/PUFFY EYELIDS
BROW AND FOREHEAD LIFT FOR SAGGING BROWLINE
LATISSE FOR LONGER LASHES
Beauty and the upper facial areas
The upper face with the nose, eyes, and brows is the area of the face that is most important to facial beauty, at least at first look. It is the first place people look, they "look you in the eye". The eyebrows and eyes have a strong social significance. Treating these areas can have a dramatic effect on your appearance.
Here are your options...
REDUCE YOUR WRINKLES AROUND THE EYES “CROW’S FEET”, FOREHEAD, AND BETWEEN THE EYEBROWS
Neuromodulators, the most widely known being Botox® Cosmetic, are used to temporarily weaken the muscles in the forehead, around the eyes, and between the eyebrows. The name given to this type of products is “neuromodulators” because they regulate muscle activity by blocking the release of acetylcholine, the signal that activates muscle fibers to contract. By weakening weaken muscles they relax the skin and reduce visible wrinkles! That is, until the process of activation can be renewed in the affected areas, after around 3-4 months. The “active ingredient” contains tiny amounts of a highly purified botulinum toxin which occurs naturally from a bacteria but is refined or purified so that it can be injected safely with minimal risk of side effects other than the desired reduction in muscle activity.
IS BOTOX® SAFE?
Botox® Cosmetic is the only FDA approved treatment to temporarily improve the appearance of those moderate to severe frown lines between the eyebrows, forehead, and crow’s feet lines in adults. Since its discovery in the 1970s usage has grown exponentially as it has been applied to cosmetic indications. Botox® Cosmetic is one of the most extensively studied medical aesthetic treatments and is approved for cosmetic use in 78 countries. It has been evaluated in both Allergan sponsored clinical trials and over 400 peer-reviewed articles in scientific and medical journals. Although no treatment is completely risk-free, it has a very low risk of undesired side effects. Over 10 million vials have been sold in the United States alone since 2002.
ARE THERE ALTERNATIVES?
Since the introduction of Botox® Cosmetic, other products with a similar effect on muscle activity and wrinkles have been introduced by other companies. There are currently four FDA-approved versions of botulinum toxin: Allergan's Botox®, Galderma's Dysport®, Evolus Newtox/Juveau® and Merz Xeomin®. The biggest difference is that Xeomin® does not have accessory proteins that can destabilize with temperature changes and so it does not need to be refrigerated.
In some cases wrinkles may be so deep that neuromodulators alone may not be satisfactory and other options are available. Fillers can be used in some areas for deep wrinkles, microneedling, facials, and chemical peels will help treat skin irregularities and smooth/brighten the skin surface.
WHEN IS SURGERY NEEDED?
Surgeries reduce the amounts of excess skin and fat. For example blepharoplasty includes small incisions along the eyelid creases or behind the eyelid to remove excess bulging fatty tissue or remove excess skin of the eyelid. No topical treatment or neuromodulator will fix these problems. Dr. Wenzel can help you decide when the time is best for surgery in order for you to meet your aestetic goals.
WHAT ABOUT MY LASHES?
Latisse® is a special product which lengthens, thickens, and darkens eyelashes. Latisse® contains a prostaglandin analog which was used in Lumigan, a drug used to treat glaucoma. It was discovered that some patients treated for glaucoma with Lumigan had increased thickness and darker color to their eyelashes. The active ingredient is now used in Latisse®.
BOTOX® Cosmetic (onabotulinumtoxinA) Important Information
BOTOX® Cosmetic (onabotulinumtoxinA) is indicated in adult patients for the temporary improvement in the appearance of:
- moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity
- moderate to severe lateral canthal lines associated with orbicularis oculi activity
- moderate to severe forehead lines associated with frontalis activity
IMPORTANT SAFETY INFORMATION, INCLUDING BOXED WARNING
WARNING: DISTANT SPREAD OF TOXIN EFFECT
Postmarketing reports indicate that the effects of BOTOX® Cosmetic and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults treated for spasticity and other conditions, particularly in those patients who have an underlying condition that would predispose them to these symptoms. In unapproved uses, including spasticity in children, and in approved indications, cases of spread of effect have been reported at doses comparable to those used to treat cervical dystonia and spasticity and at lower doses.
BOTOX® Cosmetic is contraindicated in the presence of infection at the proposed injection site(s) and in individuals with known hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation.
WARNINGS AND PRECAUTIONS
Lack of Interchangeability between Botulinum Toxin Products
The potency Units of BOTOX® Cosmetic are specific to the preparation and assay method utilized. They are not interchangeable with other preparations of botulinum toxin products and, therefore, units of biological activity of BOTOX® Cosmetic cannot be compared to nor converted into units of any other botulinum toxin products assessed with any other specific assay method.
Spread of Toxin Effect
Please refer to Boxed Warning for Distant Spread of Toxin Effect.
No definitive serious adverse event reports of distant spread of toxin effect associated with dermatologic use of BOTOX® Cosmetic at the labeled dose of 20 Units (for glabellar lines), 24 Units (for lateral canthal lines), 40 Units (for forehead lines with glabellar lines), 44 Units (for simultaneous treatment of lateral canthal lines and glabellar lines), and 64 Units (for simultaneous treatment of lateral canthal lines, glabellar lines, and forehead lines) have been reported.
Serious Adverse Reactions With Unapproved Use
Serious adverse reactions, including excessive weakness, dysphagia, and aspiration pneumonia, with some adverse reactions associated with fatal outcomes, have been reported in patients who received BOTOX® injections for unapproved uses. In these cases, the adverse reactions were not necessarily related to distant spread of toxin, but may have resulted from the administration of BOTOX® to the site of injection and/or adjacent structures. In several of the cases, patients had pre-existing dysphagia or other significant disabilities. There is insufficient information to identify factors associated with an increased risk for adverse reactions associated with the unapproved uses of BOTOX®. The safety and effectiveness of BOTOX® for unapproved uses have not been established.
Serious and/or immediate hypersensitivity reactions have been reported. These reactions include anaphylaxis, serum sickness, urticaria, soft-tissue edema, and dyspnea. If such reactions occur, further injection of BOTOX® Cosmetic should be discontinued and appropriate medical therapy immediately instituted. One fatal case of anaphylaxis has been reported in which lidocaine was used as the diluent and, consequently, the causal agent cannot be reliably determined.
There have been reports following administration of BOTOX® of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. Some of these patients had risk factors including pre-existing cardiovascular disease. Use caution when administering to patients with pre-existing cardiovascular disease.
Increased Risk of Clinically Significant Effects with Pre-existing Neuromuscular Disorders
Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis, or neuromuscular junction disorders (eg, myasthenia gravis or Lambert-Eaton syndrome) should be monitored when given botulinum toxin. Patients with neuromuscular disorders may be at increased risk of clinically significant effects including generalized muscle weakness, diplopia, ptosis, dysphonia, dysarthria, severe dysphagia, and respiratory compromise from onabotulinumtoxinA (see Warnings and Precautions).
Dysphagia and Breathing Difficulties
Treatment with BOTOX® and other botulinum toxin products can result in swallowing or breathing difficulties. Patients with pre-existing swallowing or breathing difficulties may be more susceptible to these complications. In most cases, this is a consequence of weakening of muscles in the area of injection that are involved in breathing or oropharyngeal muscles that control swallowing or breathing (see Boxed Warning).
Pre-existing Conditions at the Injection Site
Caution should be used when BOTOX® Cosmetic treatment is used in the presence of inflammation at the proposed injection site(s) or when excessive weakness or atrophy is present in the target muscle(s).
Human Albumin and Transmission of Viral Diseases
This product contains albumin, a derivative of human blood. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral diseases and variant Creutzfeldt-Jakob disease (vCJD). There is a theoretical risk for transmission of Creutzfeldt-Jakob disease (CJD), but if that risk actually exists, the risk of transmission would also be considered extremely remote. No cases of transmission of viral diseases, CJD or vCJD have ever been identified for licensed albumin or albumin contained in other licensed products.
The most frequently reported adverse reaction following injection of BOTOX® Cosmetic for glabellar lines was eyelid ptosis (3%).
The most frequently reported adverse reaction following injection of BOTOX® Cosmetic for lateral canthal lines was eyelid edema (1%).
The most frequently reported adverse reactions following injection of BOTOX® Cosmetic for forehead lines with glabellar lines were headache (9%), brow ptosis (2%) and eyelid ptosis (2%).
Co-administration of BOTOX® Cosmetic and aminoglycosides or other agents interfering with neuromuscular transmission (eg, curare-like compounds) should only be performed with caution as the effect of the toxin may be potentiated. Use of anticholinergic drugs after administration of BOTOX® Cosmetic may potentiate systemic anticholinergic effects.
The effect of administering different botulinum neurotoxin products at the same time or within several months of each other is unknown. Excessive neuromuscular weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin.
Excessive weakness may also be exaggerated by administration of a muscle relaxant before or after administration of BOTOX® Cosmetic.
USE IN SPECIFIC POPULATIONS
There are no studies or adequate data from postmarketing surveillance on the developmental risk associated with use of BOTOX® Cosmetic in pregnant women. There are no data on the presence of BOTOX® Cosmetic in human or animal milk, the effects on the breastfed child, or the effects on milk production.
JEUVEAU CONSUMER Important Safety Information
IMPORTANT SAFETY INFORMATION FOR JEUVEAU™ (prabotulinumtoxinA-xvfs) JEUVEAU may cause serious side effects that can be life threatening. Get medical help right away if you have any of these problems any time (hours to weeks) after injection of JEUVEAU: • Problems swallowing, speaking, or breathing, due to weakening of associated muscles, can be severe and result in loss of life. You are at the highest risk if these problems are pre-existing before injection. Swallowing problems may last for several months. • Spread of toxin effects. The effect of botulinum toxin may affect areas away from the injection site and cause serious symptoms including: loss of strength and all-over muscle weakness, double vision, blurred vision and drooping eyelids, hoarseness or change or loss of voice, trouble saying words clearly, loss of bladder control, trouble breathing, trouble swallowing. Do not use JEUVEAU if you: are allergic to any of the ingredients in JEUVEAU (see Medication Guide for ingredients); had an allergic reaction to any other botulinum toxin product such as rimabotulinumtoxinB (MYOBLOC®), onabotulinumtoxinA (BOTOX®/BOTOX® Cosmetic), abobotulinumtoxinA (DYSPORT®), or incobotulinumtoxinA (XEOMIN®); have a skin infection at the planned injection site; or are a child. JEUVEAU dosing units are not the same as, or comparable to, any other botulinum. Tell your healthcare provider about all your muscle or nerve conditions, such as ALS or Lou Gehrig’s disease, Myasthenia gravis, or Lambert-Eaton syndrome, as you may be at increased risk of serious side effects including difficulty swallowing and difficulty breathing from typical doses of JEUVEAU. Tell your healthcare provider about all your medical conditions, including: any side effects from botulinum toxin products, including dry eye; breathing, swallowing, bleeding, or heart problems; plans to have surgery; weakness of forehead muscles; drooping eyelids; had surgery on your face; are pregnant or breastfeeding or plan to become pregnant or breastfeed (it is not known if JEUVEAU can harm your unborn baby or passes into breast milk). Tell your healthcare provider about all the medicines you take, including prescription and over-thecounter medicines, vitamins, and herbal supplements. Using JEUVEAU with certain other medicines may cause serious side effects. Do not start any new medicines until you have told your healthcare provider that you have received JEUVEAU in the past. Especially tell your healthcare provider if you: have received any other botulinum toxin product in the past and the last 4 months, and exactly which product you received (such as BOTOX, BOTOX Cosmetic, MYOBLOC, DYSPORT, or XEOMIN). JEUVEAU may cause loss of strength or general muscle weakness, vision problems, or dizziness within hours to weeks of treatment with JEUVEAU. If this happens, do not drive a car, operate machinery, or do other dangerous activities. JEUVEAU can cause other serious side effects including: allergic reactions (such as itching, rash, red itchy welts, wheezing, asthma symptoms, or dizziness or feeling faint), heart problems (such as irregular heartbeat and heart attack), and eye problems (including dry eye, reduced blinking, and corneal problems). Tell your healthcare provider or get medical emergency help right away if you experience a serious side effect. The most common side effects include: headache; eyelid drooping, upper respiratory tract infection, and increased white blood cell count in your blood.
JEUVEAU CONSUMER Important Safety Information
APPROVED USE JEUVEAU is a prescription medicine that is injected into muscles and used in adults for a short period of time (temporary) to improve the look of moderate to severe frown lines between the eyebrows (glabellar lines). The risk information provided here is not complete. For more information about JEUVEAU, see the full Prescribing Information including BOXED WARNING, and Medication Guide, visit evolus.com or talk to your healthcare provider. To report side effects associated with use of JEUVEAU, please call 1-877-EVOLUS1/1-877-386-5871. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit or call 1-800-FDA-1088.
Manufactured by: Evolus, Inc., 1027 Garden St., Santa Barbara, CA 93101 ©2019 Evolus, Inc. All rights reserved. JEUVEAU is a trademark of Evolus, Inc. All other trademarks are the property of their respective owners.
HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use XEOMIN® safely and effectively. See full prescribing information for XEOMIN.
XEOMIN (incobotulinumtoxinA) for injection, for intramuscular or intraglandular use Initial U.S. Approval: 2010
----------------------------RECENT MAJOR CHANGES-------------------------- Indications and Usage (1.1, 1.4) 5/2019 Dosage and Administration (2.1, 2.2, 2.5, 2.8) 5/2019
----------------------------INDICATIONS AND USAGE--------------------------- XEOMIN is an acetylcholine release inhibitor and neuromuscular blocking agent indicated for the treatment or improvement of adult patients with: chronic sialorrhea (1.1) upper limb spasticity (1.2) cervical dystonia (1.3) blepharospasm (1.4) temporary improvement in the appearance of moderate to severe glabellar lines with corrugator and/or procerus muscle activity (1.5)
----------------------DOSAGE AND ADMINISTRATION----------------------- Chronic Sialorrhea: the recommended total dose is 100 Units per treatment session consisting of 30 Units per parotid gland and 20 Units per submandibular gland, no sooner than every 16 weeks (2.2)
Upper limb spasticity, cervical dystonia, and blepharospasm: the optimum dose, frequency, and number of injection sites in the treated muscle(s) should be based on severity and prior treatment response; individualize dosing for each patient: Upper Limb Spasticity in Adults: the recommended total dose is up to 400 Units no sooner than every 12 weeks (2.3) Cervical Dystonia: the recommended initial total dose is 120 Units per treatment session (2.4) Blepharospasm: the recommended initial total dose is 50 Units (25 Units per eye) (2.5)
Glabellar Lines: the recommended dose is 20 Units per treatment session divided into five equal intramuscular injections of 4 Units each (two injections in each corrugator muscle and one injection in the procerus muscle; wait a minimum of three months before retreatment (2.6)
Reconstituted XEOMIN: is intended for intramuscular or intraglandular injection in the parotid and submandibular glands only (2.7) use for only one injection session and for only one patient (2.7) instructions are specific for 50 Unit, 100 Unit, and 200 Unit vials (2.7) store in a refrigerator (2°C to 8°C) and use within 24 hours (2.7)
---------------------DOSAGE FORMS AND STRENGTHS---------------------- For injection: 50 Units, 100 Units, or 200 Units lyophilized powder in a single-dose vial (3)
-------------------------------CONTRAINDICATIONS------------------------------ Known hypersensitivity to the active substance botulinum neurotoxin type A or to any of the excipients (4, 5.3) Infection at the proposed injection sites (4)
-----------------------WARNINGS AND PRECAUTIONS------------------------ Respiratory, speech, or swallowing difficulties: Increased risk if bilateral neck muscle injections are needed or with pre-existing muscular disorders; immediate medical attention may be required (5.1, 5.4) The potency Units of XEOMIN are not interchangeable with other preparations of botulinum toxin products (5.2) Corneal exposure and ulceration: protective measures may be required (5.5) Risk of ptosis: follow dosage recommendations (5.6)
------------------------------ADVERSE REACTIONS------------------------------- The most commonly observed adverse reactions at rates specified below and greater than placebo are: Chronic Sialorrhea: (≥4% of patients) tooth extraction, dry mouth, diarrhea, and hypertension (6.1) Upper Limb Spasticity: (≥2% of patients) seizure, nasopharyngitis, dry mouth, upper respiratory tract infection (6.1) Cervical Dystonia: (≥5% of patients) dysphagia, neck pain, muscle weakness, injection site pain, and musculoskeletal pain (6.1) Blepharospasm: (≥10% of patients) eyelid ptosis, dry eye, visual impairment, and dry mouth (6.1) Glabellar Lines: (>1% of patients) headache (6.1)
To report SUSPECTED ADVERSE REACTIONS, contact Merz Pharmaceuticals, LLC at 888-493-6646 or FDA at 1-800-FDA-1088 or
------------------------------DRUG INTERACTIONS------------------------------- Aminoglycosides or other agents that interfere with neuromuscular transmission may potentiate the effect of XEOMIN; co-administer only with caution and close observation (7)
----------------------USE IN SPECIFIC POPULATIONS------------------- Pregnancy: based on animal data, may cause fetal harm (8.1)
See 17 for PATIENT COUNSELING INFORMATION and Medication Guide. Revised: 5/2019
Distant Spread of Toxin Effect
Postmarketing reports indicate that the effects of Dysport and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity but symptoms can also occur in adults treated for spasticity and other conditions, particularly in those patients who have underlying conditions that would predispose them to these symptoms. In unapproved uses, including spasticity in children and adults, and in approved indications, cases of spread of effect have been reported at doses comparable to those used to treat cervical dystonia and at lower doses.
Dysport is contraindicated in patients with known hypersensitivity to any botulinum toxin preparation or to any of the components in the formulation.
This product may contain trace amounts of cow’s milk protein. Patients known to be allergic to cow’s milk protein should not be treated with Dysport
Dysport is contraindicated for use in patients with infection at the proposed injection site(s).
DOSAGE AND ADMINISTRATION
The potency Units of Dysport are specific to the preparation and assay method utilized. They are not interchangeable with other preparations of botulinum toxin products and, therefore, units of biological activity of Dysport cannot be compared to or converted into units of any other botulinum toxin products assessed with any other specific assay method.
WARNINGS AND PRECAUTIONS
Facial Anatomy in the Treatment of Glabellar Lines
Caution should be exercised when administering Dysport to patients with surgical alterations to the facial anatomy, excessive weakness or atrophy in the target muscle(s), marked facial asymmetry, inflammation at the injection site(s), ptosis, excessive dermatochalasis, deep dermal scarring, thick sebaceous skin or the inability to substantially lessen glabellar lines by physically spreading them apart.
Do not exceed the recommended dosage and frequency of administration of Dysport. In clinical trials, subjects who received a higher dose of Dysport had an increased incidence of eyelid ptosis.
Pre-existing Neuromuscular Disorders
Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis or neuromuscular junction disorders (e.g., myasthenia gravis or Lambert-Eaton syndrome) should be monitored particularly closely when given botulinum toxin.
Patients with neuromuscular disorders may be at increased risk of clinically significant effects including severe dysphagia and respiratory compromise from typical doses of Dysport.
This product contains albumin, a derivative of human blood. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral diseases.
A theoretical risk for transmission of Creutzfeldt-Jakob disease (CJD) is also considered extremely remote. No cases of transmission of viral diseases or CJD have ever been reported for albumin.
Intradermal Immune Reaction
The possibility of an immune reaction when injected intradermally is unknown.
The safety of Dysport for the treatment of hyperhidrosis has not been established.
In clinical studies, the most frequently reported adverse events (≥2%) were nasopharyngitis, headache, injection site pain, injection site reaction, upper respiratory tract infection, eyelid edema, eyelid ptosis, sinusitis and nausea.
Patients treated concomitantly with botulinum toxins and aminoglycosides or other agents interfering with neuromuscular transmission (e.g., curare-like agents) should be observed closely because the effect of the botulinum toxin may be potentiated. Use of anticholinergic drugs after administration of Dysport may potentiate systemic anticholinergic effects such as blurred vision.
The effect of administering different botulinum neurotoxin products at the same time or within several months of each other is unknown. Excessive weakness may be exacerbated by another administration of botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin.
Excessive weakness may also be exaggerated by administration of a muscle relaxant before or after administration of Dysport.
USE IN SPECIFIC POPULATIONS
Dysport is not recommended for use in children or pregnant women.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
Please see Dysport Full Prescribing Information including Medication Guide.
Patient Safety Information by product