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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018



Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018



Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018



Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018



Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018



Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata



Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018



Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018



Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018



Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011



Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2024 | Month : June | Volume : 18 | Issue : 6 | Page : WC01 - WC03 Full Version

Clinical Profile and Outcome of Patients using Botulinum Toxin for Cosmetic Purposes: A Cross-sectional Study

Published: June 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/68224.19490

Reshmi Subramaniam, Vani Vasanth, BS Chandrasekhar, Asida Mohamed Ashraf, Ashwini Babu, Neetha Latha

1. Associate Professor, Department of Dermatology, Venereology and Leprosy, Sree Uthradom Thirunal Academy of Medical Sciences, Thiruvananthapuram, Kerala, India. 2. Senior Consultant, Department of Dermatology, Cutis Academy of Cutaneous Sciences, Bengaluru, Karnataka, India. 3. Director and Chief Consultant, Department of Dermatology, Cutis Academy of Cutaneous Sciences, Bengaluru, Karnataka, India. 4. Assistant Professor, Department of Pharmacology, Sree Uthradom Thirunal Academy of Medical Sciences, Thiruvananthapuram, Kerala, India. 5. Assistant Professor, Department of Dermatology, Venereology and Leprosy, Sree Uthradom Thirunal Academy of Medical Sciences, Thiruvananthapuram, Kerala, India. 6. Assistant Professor, Department of Dermatology, Venereology and Leprosy, Sree Uthradom Thirunal Academy of Medical Sciences, Thiruvananthapuram, Kerala, India.

Correspondence Address :
Dr. Ashwini Babu,
Assistant Professor, Department of Dermatology, Venereology and Leprosy, Sree Uthradom Thirunal Academy of Medical Sciences, Thiruvananthapuram-695028, Kerala, India.
E-mail: resh.sub@gmail.com; ashwinibabu@gmail.com

Abstract

Introduction: Botulinum toxin injection has become ubiquitous in the treatment of wrinkles. It is less invasive and easy to perform, with almost immediate effects. Although it is the most common non surgical cosmetic procedure performed in many parts of the world, accurate figures of its increasing trend in India need to be unraveled as well.

Aim: To analyse the clinical profile, outcomes, indications, and nature of revisits among patients seeking Botulinum toxin injections for cosmetic indications.

Materials and Methods: A cross-sectional observational study was conducted at a tertiary care centre, Department of Dermatology, Cutis Academy of Cutaneous Sciences, Bengaluru, Karnataka, India, for six months between November 2018 and April 2019 among 80 consecutive patients who received Botulinum toxin injection A for cosmetic purposes. The collected data included age, gender, indication, the number of units of Botulinum toxin used, and the profile of patients seeking revisits. The data was recorded and analysed using Statistical Product and Service Solutions (SPSS) version 23.0.

Results: The average age for treatment among females was 38 years, while among males, it was 35.5 years. Females, comprising 61 (76%), outnumbered men by a factor of three. The single most common indication for Botulinum toxin injection among females was Crow’s feet, accounting for 26 (43%), and among females below 40 years, it was Masseter hypertrophy in 13 (21%). The most common indication among men was Glabellar line correction in 10 (53%). Other indications included the Nefertiti lift, Marionette lines, Popply chin, Brow lift, and Gummy smile. Women revisited the clinic three times more often than men. Among women, Crow’s feet correction was the most common reason for revisits. The number of units of Botulinum toxin needed was found to be higher in males for Glabellar lines and in older individuals for Masseter Hypertrophy.

Conclusion: Women are more receptive to cosmetic facial Botulinum toxin injections and revisit more frequently than men. Adverse effects were mild and self-limiting. Upper-face Botulinum toxin injections appear to be the preferred indication in both genders. More epidemiological studies detailing the profile of patients seeking aesthetic Botulinum toxin injections are needed to better understand patients’ needs and concerns, offer preprocedure counselling, manage their expectations, and provide customised services.

Keywords

Aesthetics, Cosmetic techniques, Skin aging, Skin wrinkling

Introduction
From time immemorial, staying young has been an obsession among the aged and aging. The advent of Botulinum toxin has revolutionised this. Emile Van Ermengem (1851-1932) isolated the bacterium Clostridium botulinum from ham samples in 1895 and named the toxin “Bacillus Botulinus,” which means ‘sausage’ in Latin (1). Eight distinct serotypes (A, B, C1, C2, D, E, F, and G) of the neurotoxin have been identified so far. Types A and B of the neurotoxin, known to cause disease in humans, have been used medically and therapeutically. The toxin blocks presynaptic acetylcholine release, preventing nerve impulses responsible for muscle contraction. Recovery from the toxin’s effect occurs through the sprouting of nerve terminals and the formation of new synaptic clefts (1).

Botulinum toxin was first approved by the US Food and Drug Administration (FDA) in 1989 for treating blepharospasm and strabismus (1). However, it was only in 2002 that Botulinum toxin injections were approved by the FDA for correcting Glabellar lines (1) From being a dreaded and fatal poison found in raw sausages in the 1700s, Botulinum toxin, in its injection form, is now the most common non surgical cosmetic procedure in the USA. It is less invasive, easy, and quick to perform, with almost immediate results (1),(2). A recent review and survey have evaluated the efficacy and dosing patterns of cosmetic Botulinum toxin injections in young adults (3). Many consensus guidelines for injection strategies for the Asian face have also been developed (4),(5). While numerous papers discuss the use, common indications, and adverse effects of Botulinum toxin injections, accurate figures on the extent of its use for aesthetic purposes in India are scarce (6).

Therefore, the present study aimed to analyse the clinical profile, outcomes, indications, and nature of revisits among patients seeking Botulinum toxin injections for cosmetic reasons. The present study is one of the first to assess the patient profile of Botulinum toxin users in India and will further assist practitioners in addressing the needs and concerns of patients, deciding on the units’ dosing for the Indian context, and providing customised services.
Material and Methods
A cross-sectional observational study was conducted at a tertiary care centre, Department of Dermatology, Cutis Academy of Cutaneous Sciences, Bengaluru, Karnataka, India, over six months from November 2018 to April 2019. Ethical clearance was obtained from the Institutional Ethics Committee, Cutis Academy of Cutaneous Sciences, Bengaluru (letter No. 546 dated 16.10.2018). After obtaining written informed consent, patients were enrolled in the study. Consecutive patients seeking Botulinum toxin injections during the study period were as follows:

Inclusion criteria: Patients seeking Botulinum toxin for aesthetic purposes and giving consent to participate in the study were included.

Exclusion criteria: Patients seeking Botulinum toxin for non aesthetic indications were excluded. Six patients were excluded from the study.

Study Procedure

Clinical records of 80 patients were analysed for age, gender, indication for Botulinum toxin injection, dose of Botulinum toxin injected, and profile of revisits. Botulinum toxin is available in single-use 100- and 50-unit vials, which are reconstituted in 2.5 mL and 1.25 mL of 0.9% non preserved saline, respectively, to achieve resulting doses of four units per 0.1 mL. Botulinum toxin was injected using an Insulin syringe of 31 gauge and 6-8 mm length. Initially, patients were given several units of injection based on the indication, muscle mass, previous experience, and available literature. When the patient revisited after two weeks for a touch-up, more units were injected if the response was inadequate.

Statistical Analysis

The data was recorded in Microsoft excel and analysed using Statistical Product and Service Solutions (SPSS) version 23.0 for Windows. All variables were analysed using descriptive statistics. Quantitative variables such as age were expressed as the mean, and results of qualitative variables were expressed as percentages.
Results
Age-gender distribution: Out of the 80 patients, 61 (76.3%) were female. A female preponderance with a female-to-male ratio of 3.2:1 was observed. The youngest and oldest ages among males were 24 and 58 years, respectively, while females’ age ranged between 19 and 63 years. The average age for treatment among females was 38 years, while among males, it was 35.5 years. A total of 33 females (54%) were aged 40 years and below, compared to 14 males (74%) (Table/Fig 1).

Indication for Botulinum toxin injection: Among females, 40 (65%) underwent Botulinum toxin injection for more than one indication, compared to 11 (58%) among males. The single most common indication for Botulinum toxin injection among females was for Crow’s feet (43% of women), of which 17 (65%) were above 40 years of age. The second most common indication was the correction of forehead lines and Glabellar lines. Of the 13 patients concerned about Masseter hypertrophy, 12 were in the age group 21-30 years, making it the most sought-after indication for women below 40 years of age. The majority (77%) of women who sought the Nefertiti lift were below 40 years of age.

Other indications for Botulinum toxin injections in females were Marionette lines (8), Popply chin (5), Brow lift (4), and gummy smile (2). Seven women above 40 years of age sought Marionette line correction, as opposed to one woman below 40 years of age. The most common indication among men for Botulinum toxin injection was Glabellar complex correction in 10 (53%), followed by Crow’s feet 8 (42%). Men below 40 years of age were more concerned about Crow’s feet and forehead lines (6 each), compared to those above 40 years of age (2 for Crow’s feet, 1 for forehead lines). No such discrepancy was seen regarding Glabellar lines in men. Two male patients in the 31-40 years age group sought correction of Bunny lines and Under-eye wrinkles (Table/Fig 2).

Revisits: Out of the total patients, 30 patients (37.5%) revisited, 23 (77%) of whom were females. Among the 23 female patients who revisited, 14 did so for an indication different from the previous visit, often for more than one indication. Crow’s feet correction was the most common reason for revisit, made by 17 patients, most of whom (70%) were above 40 years of age. The next common reasons for revisit among women were Glabellar complex correction (12) and forehead lines (10). Only seven men revisited, five of whom revisited for Crow’s feet correction.

Units of Botulinum toxin: The number of units of Botulinum toxin needed was found to be higher in males than in females for the same indication. Additionally, it was noted that with increasing age, females required more units for Crow’s feet and Masseter Hypertrophy. Above 60 years of age, conservative doses were preferred (Table/Fig 3).

Adverse effects: The adverse effects of Botulinum toxin injection in the study were few and self-limited, such as headache and heaviness of eyelids observed in one patient each.
Discussion
In the study, more women sought cosmetic Botulinum toxin treatments than men. The most common indications for Botulinum toxin injection among women and men were Crow’s feet and Glabellar complex, respectively. Revisits for new indications were more common among women and increased with age. The number of units of Botulinum toxin needed was higher in males, as seen in a previous study (7). With increasing age, women required more units of Botulinum toxin for indications like Crow’s feet and Masseter hypertrophy, as observed in a previous study (7). The adverse effects of Botulinum toxin injection were mild and often self-limited, as in another study (8).

As mentioned earlier, detailed statistics on the epidemiological trends surrounding aesthetic Botulinum toxin injections in the Indian context are scarce. Women are known to be more concerned about body image than men (9). However, in Western society, more men are coming forward to undergo non invasive cosmetic treatments like Botulinum toxin injections in recent years, although this trend may take time to appear in India (10). Glabellar lines are the most common dynamic lines of the upper face for which Asian patients seek treatment (5). In the present study, more women 26 (42%) sought treatment for Crow’s feet, compared to 16 (26%) women seeking treatment for Glabellar complex, as seen in a previous study (11). However, among men, more than half sought Glabellar complex correction, making it the most common indication.

Botulinum toxin injections for facial contouring by injecting for Masseter hypertrophy were sought almost exclusively by the 21-30- year-old age group women in this study, as opposed to correction of Marionette lines, which was sought by older women. Facial contouring is a common concern among younger Asian women, unlike Caucasians, who naturally have a narrow face. A square-shaped face among younger Asians is often caused by symmetric or asymmetric increase in the masseter muscle (Masseter hypertrophy) (12). They prefer Botulinum toxin injection due to its non invasive nature and shorter downtime compared to mandibular resection surgery (13). Many studies have examined the efficacy of Botulinum toxin injection for this indication (14),(15). Marionette lines increase with age due to the effects of gravity, loss of volume, and repetitive facial expressions on inelastic aging skin, and are a common concern among older women (16).

More younger men sought upper face treatment with Botulinum toxin injections. Among women, the trend is reversed. No definitive conclusion can be drawn from this observation as the total number of patients is biased towards the female gender. Revisits for new indications are common among women and increase with age as they become more comfortable and satisfied with the procedure, and due to the co-existence of more than one type of facial lines with increasing age. The number and nature of revisits among Botulinum toxin injection-seeking patients have not been explored before.

Variations in Botulinum toxin requirements with age and gender help researchers counsel patients accordingly. Treatment indications, strategies, and dosages in Asians differ from those previously described for Caucasians due to distinctions in facial morphotypes, anatomy, and cultural expectations (4). To bridge this gap, consensus recommendations have been proposed to address the Botulinum toxin dose requirements among Asians (3),(9). Regarding efficacy, and based on limited available data, it is opined that Botulinum toxin is not as effective in individuals above 65 years of age (17).

Adverse effects reported in the literature include mild bruising (10- 25%), pain during injection, headache, and altered muscle response due to misplacement of the toxin (18),(19). The present study revealed that adverse events were confined to mild and transient effects.

Limitation(s)

The sample size was not calculated; further studies with a larger sample size can be conducted in the future.
Conclusion
Women were found to be more open to cosmetic facial Botulinum toxin injections. Upper-face Botulinum toxin injection seems to be the preferred indication in either gender. Masseter hypertrophy is a common indication among younger women. Revisits indicate the level of satisfaction and comfort with the procedure. Counselling about the transient and benign side-effects helps to encourage revisits.
Reference
1.
França K, Kumar A, Fioranelli M, Lotti T, Tirant M, Roccia MG. The history of Botulinum toxin: From poison to beauty. Wien Med Wochenschr. 2017;167(Suppl 1):46-48.   [CrossRef]  [PubMed]
2.
Whitcup SM. The history of botulinum toxins in medicine: A thousand year journey. Handb Exp Pharmacol. 2021;263:03-10.   [CrossRef]  [PubMed]
3.
Ahn BK, Kim YS, Kim HJ, Rho NK, Kim HS. Consensus recommendations on the aesthetic usage of botulinum toxin type A in Asians. Dermatol Surg. 2013;39(12):1843-60.   [CrossRef]  [PubMed]
4.
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DOI and Others
DOI: 10.7860/JCDR/2024/68224.19490

Date of Submission: Oct 22, 2023
Date of Peer Review: Dec 23, 2023
Date of Acceptance: Mar 30, 2024
Date of Publishing: Jun 01, 2024

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 23, 2023
• Manual Googling: Dec 29, 2023
• iThenticate Software: Mar 28, 2024 (13%)

Etymology: Author Origin

Emendations: 7
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