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Nonsurgical cosmetic procedures, including injection procedures, are among the fastest growing medical procedures. In 2018, botulinum toxin and hyaluronic acid injections were the two most common nonsurgical cosmetic procedures performed in the United States. Botulinum toxin is a neuromodulator with seven serotypes, but only serotypes A and B are in clinical use. The facial areas in which botulinum toxin is used most commonly include the forehead, glabella, and lateral canthal lines (ie, crow’s feet). Adverse effects are transient. Several types of injectable dermal fillers are available. Hyaluronic acid is the most commonly used filler and is hypoallergenic. Others include calcium hydroxylapatite, poly l-lactic acid, and polymethylmethacrylate. The characteristics of fillers, including their elasticity and viscosity, are used to determine which should be used for specific applications. Potential serious complications include vascular occlusion leading to tissue necrosis or blindness. Immediate recognition and management of complications are needed to prevent long-term sequelae. With appropriate training, physicians and other clinicians can perform these injections safely in the office setting.

Case 1. Sarah is a 55-year-old woman who comes to your office for follow-up of hypertension. At the check-in desk, she notices a sign that your office offers botulinum toxin injections. She asks whether she might be a candidate for botulinum toxin injections for the wrinkles in her lower forehead area and crow’s feet. She asks if her health insurance will cover the injections, and if not, how much will the procedure cost.

Nonsurgical cosmetic procedures, including injection procedures, are among the fastest growing medical procedures. According to the American Society for Aesthetic Plastic Surgery (ASAPS), in 2018 botulinum toxin and hyaluronic acid injections were the two most common nonsurgical cosmetic procedures performed in the United States.1 Between 2014 and 2018, the number of injection procedures performed increased by more than 35%.

Women represent the majority of patients who receive injection procedures, but the percentage of men receiving these procedures is increasing.1 In 2018, men accounted for approximately 8% of injection procedures.

Botulinum Toxin

Botulinum toxin is a neuromodulator with seven serotypes (ie, A, B, C, D, E, F, G).2 Only serotypes A and B are in clinical use. The Food and Drug Administration (FDA) has approved four types of serotype A botulinum toxin, including onabotulinumtoxinA (Botox), abobotulinumtoxinA (Dysport), incobotulinumtoxinA (Xeomin), and prabotulinumtoxinA (Jeuveau).3,4,5,6 The only serotype B that currently is FDA-approved is rimabotulinumtoxinB (Myobloc), but it is not approved for cosmetic uses (Table 1).7 The remainder of this section refers to cosmetic use of botulinum toxin serotype A.

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