# Botulinum Toxin Type A Reconstituted with Lidocaine: A Report of 1000 Consecutive Cases
###### Abstract  
(1) Background: There is an increasing demand for a reversal of the aging process and, nowadays, more patients are seeking minimally invasive methods instead of surgery to meet this goal. The purpose of this paper is to evaluate the predictability of the off-label aesthetic use of botulinum toxin type A (BoNTA) reconstituted with lidocaine. (2) Methods: One thousand treatments, between January 2010 and January 2020, with BoNTA reconstituted with lidocaine for the rejuvenation of the upper third of the face, were performed and retrospectively evaluated. (3) Results: A few seconds after the BoNTA injections, the effect of muscle paralysis was seen in all cases; this allowed providing an optimal symmetric result with no need for a touch-up procedure at the control after three weeks. A burning sensation during the injections was claimed by almost all patients. Major complications were not registered. No touch-up procedures were required. (4) Conclusions: The results of this study show how the reconstitution of BoNTA with lidocaine may avoid imperfect results after the injections; the immediate feedback on the extent of paralysis to be expected from the chemodeneration action of BoNTA allows the physician to have immediate control of the final result. botulinum toxin; facial aesthetics; minimally invasive; lidocaine +
Footnote †: journal: Medical-Surgical and Medical-Surgical and Medical-Surgical and Medical-Surgical and Medical-Surgical and Medical-Surgical and Medical-Surgical and Medical-Surgical and Medical-Surgical and Medical-Surgical and Medical  
To oppose the processes of natural aging due to a concatenation of exogenous and endogenous stressors, many organic and inorganic substances and various techniques have been developed and experienced, such as the intradermal microinjections of low molecular weight hyaluronic acid fragments mixed with amino acid (HAAM), which target fibroblast activity [7]. In the last 10 years, botulinum toxin has been the most-used drug in non-surgical aesthetic facial procedures [8]. The use of BoNTA is well-established in medical practice; its application extends over many indications and medical specialties such as hemi-facial spasm, strabismus, and others [9; 10]. BoNTA injections are the most common non-surgical cosmetic procedures performed in the United States of America [8]. Botulinum toxin type A (BoNTA) is a potent bacterial neurotoxin produced by anaerobic bacterium _Clostridium botulinum_, which produces muscle paralysis, atrophy, and weakness [11]. The first cosmetic indication for this drug was obtained by the FDA in 2002 for the treatment of glabellar lines; in 2013, it was also approved for periorbital lines (crow's feet); and in 2018, forehead line treatments were approved [12]. Once the toxin is injected into muscles at the presynaptic nerve terminal, the heavy chain binds synaptic vesicle glycoprotein 2, causing endocytosis of the toxin-glycoprotein complex and toxin light chain release into the neuronal cytosol [11]. Toxin light chains cleave syntaxin, either synaptosomal-associated protein 25 or vesicle-associated membrane protein (VAMP)/synaptobrevin, preventing the release of acetylcholine from the axon of peripheral motor nerves and causing subsequent temporary chemical denervation and muscle paralysis [9]. Several available BoNTA preparations exist, although only onabotulinum toxin A, abobotulinum toxin A, and incobotulinum toxin A are approved for use in medical cosmetic settings. Several papers have suggested that one toxin is superior to the others, although existing evidence suggests that experienced users should achieve equivalent results regardless of the BoNTA-A formulation [13; 14; 15]. BoNTA, before being administered, needs to be reconstituted with saline; once injected, it is necessary to wait for the onset of the drug's effect, which usually takes 21 days for a full effect, to evaluate the result and, in case of asymmetries, to perform a touch-up [11].