Conditions: Cosmetic Techniques
Keywords: minimally invasive procedures neurotoxins cosmetic Botox eyebrow area glabella Dysport Jeuveau Xeomin forehead cosmetic injections facial rejuvenation wrinkle reduction
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 143
Healthy volunteers: no

Brief summary:
The purpose of the study is to use 3D imaging to evaluate the effects of four FDA approved neuromodulators on facial lines, wrinkles and animation. Participation is available to women who have never had a cosmetic procedure above the malar region nor a treatment with a neuromodulator within 12 months. All subjects will undergo 3D imaging using the VECTRA M3 (Canfield Scientific, Inc, Fairfield, NJ) prior to treatment with a neuromodulator in order to determine their baseline dimensions. Imaging will be repeated post injection to determine change over time.

Detailed description:
This study is a randomized controlled trial in which patients will be randomly assigned into one of four groups: those receiving onabotulinumtoxinA (Botox, Allergan, Irvine, California), abobotulinumtoxinA (Dysport, Ispen Biopharmacueticals Inc.Cambridge, MA), incobotulinumtoxinA (Xeomin, Raleigh, NC) or prabotulinumtoxinA (Jeuveau, Evolus, Newport Beach, California). Each patient will receive FDA approved dosages in which they are assigned in to treat rhytids within the glabella, as per FDA approved indications. All injections will be performed by a blinded single trained physician according to a preset injection plan per FDA approved administration guidelines. Prior to injection patients will be imaged with 3-dimensional photogrammetry. All pre-procedure images will be evaluated for absolute strain performing two types of facial animation: 1) relaxed, and 2) frowning. Subjects will return Day 3, 30, 90, and 180, post intervention for re-imaging with the same expressions. Strain will be calculated using the same metrics.

Arms:
arm 1: Botox arm 2: Dysport arm 3: Xeomin arm 4: Jeuveau

Interventions: intervention 1: Onabotulinumtoxina for Injection intervention 2: Abobotulinumtoxina for Injection intervention 3: IncobotulinumtoxinA for Injection intervention 4: PrabotulinumtoxinA for Injection
Intervention descriptions: intervention 1: cosmetic injection into the glabella area (eyebrow area) intervention 2: cosmetic injection into the glabella area (eyebrow area) intervention 3: cosmetic injection into the glabella area (eyebrow area) intervention 4: cosmetic injection into the glabella area (eyebrow area)

Protocol document:
Prot_SAP_000.pdf: 
Glabella 4 Toxin Study 
 
Page 1 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
 
 
A Randomized Prospective Evaluation of Four Injectable Neuromodulators in 
the Glabella Area 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol Number IRB Number 
849045 
 
 
Clinicaltrials.gov 
NCT05167864 
 
 
 
 
 
 
 
 
Initial version [08.27.2020] 
Amended 
[Date] 
Amended 
[Date] 


Glabella 4 Toxin Study 
 
Page 2 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
Table of Contents 
BACKGROUND AND STUDY RATIONALE ......................................................................................... 5 
1 
INTRODUCTION ................................................................................................................................ 5 
1.1 
BACKGROUND AND RELEVANT LITERATURE .................................................................................. 5 
2 
STUDY OBJECTIVES ........................................................................................................................ 6 
2.1 
PRIMARY OBJECTIVE ....................................................................................................................... 6 
3 
INVESTIGATIONAL PLAN .............................................................................................................. 6 
3.1 
GENERAL DESIGN ........................................................................................................................... 6 
3.2 
ALLOCATION TO INTERVENTIONAL GROUP ..................................................................................... 6 
3.3 
STUDY MEASURES .......................................................................................................................... 6 
3.4 
STUDY ENDPOINTS .......................................................................................................................... 7 
3.4.1 Primary Study Endpoint ............................................................................................................. 7 
3.4.2 Secondary Study Endpoints ........................................................................................................ 7 
1) 
Quantify the change in the dynamic strain of the glabella area after injection between the four 
neuromodulators .................................................................................................................................... 7 
2) 
Quantify the change of dynamic strain measurements of each facial animation over time. ......... 7 
4 
STUDY POPULATION AND DURATION OF PARTICIPATION .............................................. 7 
4.1 
DURATION OF STUDY PARTICIPATION ............................................................................................. 7 
4.2 
TOTAL NUMBER OF SUBJECTS AND SITES ....................................................................................... 7 
4.3 
INCLUSION CRITERIA ...................................................................................................................... 7 
4.4 
EXCLUSION CRITERIA ..................................................................................................................... 7 
4.5 
SUBJECT RECRUITMENT .................................................................................................................. 8 
4.6 
VULNERABLE POPULATIONS: .......................................................................................................... 8 
5 
STUDY PROCEDURES ...................................................................................................................... 8 
5.1 
SCREENING ..................................................................................................................................... 8 
5.2 
STUDY INTERVENTION OR OBSERVATIONAL PHASE ........................................................................ 8 
RANDOMIZED CONTROLLED SINGLE BLINDED STUDY ................................................................................ 8 
5.2.1 Visit 1 (sometimes referred to as the baseline visit) .................................................................. 8 
5.2.2 Visit 2 ......................................................................................................................................... 9 
5.2.3 Visit 3 ......................................................................................................................................... 9 
5.2.4 Visit 4 ....................................................................................................................................... 10 
5.2.5 End of Study Visit 5 .................................................................................................................. 10 
TABLE 1  SCHEDULE OF STUDY PROCEDURES ........................................................................... 10 
5.3 
UNSCHEDULED VISITS .................................................................................................................. 10 
5.4 
SUBJECT WITHDRAWAL ................................................................................................................ 10 
5.4.1 Data Collection and Follow-up for Withdrawn Subjects ......................................................... 11 
5.5 
EARLY TERMINATION VISITS ........................................................................................................ 11 
6 
STATISTICAL PLAN ....................................................................................................................... 11 
6.1 
SAMPLE SIZE AND POWER DETERMINATION ................................................................................. 11 
6.2 
STATISTICAL METHODS ................................................................................................................ 11 


Glabella 4 Toxin Study 
 
Page 3 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
6.3 
CONTROL OF BIAS AND CONFOUNDING ......................................................................................... 11 
6.3.1 Baseline Data ........................................................................................................................... 11 
6.3.2 Analysis of Primary Outcome of Interest ................................................................................. 11 
7 
SAFETY AND ADVERSE EVENTS ............................................................................................... 12 
7.1 
DEFINITIONS ................................................................................................................................. 12 
7.1.1 Adverse Event ........................................................................................................................... 12 
7.1.2 Serious Adverse Event .............................................................................................................. 12 
7.2 
RECORDING OF ADVERSE EVENTS ................................................................................................ 12 
7.3 
RELATIONSHIP OF AE TO STUDY ................................................................................................... 13 
7.4 
REPORTING OF ADVERSE EVENTS, ADVERSE DEVICE EFFECTS AND UNANTICIPATED PROBLEMS 13 
7.4.1 Follow-up report ...................................................................................................................... 13 
7.4.2 Investigator reporting: notifying the study sponsor ................................................................. 14 
7.4.3 Investigator reporting: notifying the Penn IRB ....................................................................... 14 
7.4.4 Sponsor reporting: Notifying Participating Investigators ....................................................... 14 
7.5 
MEDICAL MONITORING ................................................................................................................. 14 
7.6 
CONFIDENTIALITY ......................................................................................................................... 14 
7.7 
DATA COLLECTION AND MANAGEMENT ....................................................................................... 15 
7.8 
RECORDS RETENTION ..................................................................................................................... 15 
8 
STUDY MONITORING, AUDITING, AND INSPECTING ......................................................... 15 
8.1 
STUDY MONITORING PLAN ........................................................................................................... 15 
8.2 
AUDITING AND INSPECTING .......................................................................................................... 15 
9 
ETHICAL CONSIDERATIONS ...................................................................................................... 16 
9.1 
RISKS ............................................................................................................................................ 16 
9.2 
BENEFITS ...................................................................................................................................... 17 
9.3 
RISK BENEFIT ASSESSMENT .......................................................................................................... 17 
9.4 
INFORMED CONSENT PROCESS / HIPAA AUTHORIZATION ............................................................ 17 
10 STUDY FINANCES ........................................................................................................................... 17 
10.1 
FUNDING SOURCE ......................................................................................................................... 17 
10.2 
CONFLICT OF INTEREST ................................................................................................................. 17 
10.3 
SUBJECT STIPENDS OR PAYMENTS ................................................................................................ 17 
11 PUBLICATION PLAN ...................................................................................................................... 17 
12 REFERENCES ................................................................................................................................... 18 
13 ATTACHMENTS .............................................................................................................................. 18 
 


Glabella 4 Toxin Study 
 
Page 4 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
Study Summary 
 
Title 
A Randomized Prospective Evaluation of Four Injectable 
Neuromodulators in the Glabella Area: Randomized Controlled 
Trial 
Short Title 
Glabella 4 Toxin Study 
IRB Number 
849045 
Protocol Number 
NCT05167864 
Methodology 
Randomized Control Trial  
Study Duration 
18 months  
Study Center(s) 
Single-center. 
Objectives 
To quantify the dynamic strain of four commonly available 
neuromodulators injected in the glabellar area over time as well as 
correlate patient satisfaction to the change in dynamic strain over time.    
Number of Subjects Approximately 140  
Main Inclusion and 
Exclusion Criteria 
Inclusion criteria:  
1) Women ages 30-65  
2) No neuromodulator treatment within 12 months 
3) Have not undergone cosmetic procedures to the upper face 
above the malar region (cheekbone area).   
 
Exclusion:  
1) Men 
2) Patients who have previously been treated with a 
neuromodulator<12 months  
3) Over 65 or under 30 years of age 
4) Those with a prior known condition that affects facial animation 
(such as stroke, palsy),  
5) Cannot be actively taking blood thinners,  
6) Presence of eye ptosis 
7) Autoimmune disease 
  


Glabella 4 Toxin Study 
 
Page 5 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
Intervention  
 
Randomization to one of four neuromodulator glabellar injections: 
1) onabotulinumtoxinA  
2) abobotulinumtoxinA  
3) incobotulinumtoxinA 
4) PrabotulinumtoxinA   
Statistical 
Methodology 
Descriptive statistics will be used to describe variables of interest. 
Fischer’s exact test and Chi-square will be used to compare categorical 
variables, and linear regression will be used for continuous variables.  
Data and Safety 
Monitoring Plan  
PI will oversee the study, protocol, and data monitoring and storage.  
 
Background and Study Rationale 
1 
Introduction 
 
This study will be conducted in full accordance with all applicable University of Pennsylvania Research 
Policies and Procedures and all applicable Federal and state laws and regulations including [as applicable 
include the following regulations as they apply 45 CFR 46, 21 CFR Parts 50, 54, 56 All episodes of 
noncompliance will be documented.] 
 
The purpose of the study is to use 3D imaging to evaluate the effects of four FDA approved 
neuromodulators on facial lines, wrinkles and animation. Participation is available to women who have 
never had a cosmetic procedure above the malar region nor a treatment with a neuromodulator within 12 
months. All subjects will undergo 3D imaging using the VECTRA M3 (Canfield Scientific, Inc, Fairfield, 
NJ) prior to treatment with a neuromodulator in order to determine their baseline dimensions. Imaging 
will be repeated post injection to determine change over time. 
 
1.1 
Background and Relevant Literature  
 
With an annual rise and over 845% increase since the year 2000, botulinum toxin neuromodulation is the 
most commonly performed minimally invasive technique in cosmetic surgery [1]. In accordance, much 
research has been produced evaluating the characteristics and efficacy of the various toxin-strain 
modalities currently available for use [2-4].  
 
One such method for evaluation involves 3D photogrammetry. This technology involves for high level 
feature enhancement and microscopic anatomical evaluation that was not previously possible [5]. 3D 
photogrammetry has been used for a range of studies in cosmetic and reconstructive medicine and 
surgery, including its use in evaluating minimally invasive injection efficacy [6-8]. 
 


Glabella 4 Toxin Study 
 
Page 6 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
In spite of the research, there are few FDA approved neuromodulators for the treatment of dynamic 
ryhtids, most of which have been available for a period of time and have been clinically described [8]. 
More recently, a newer neuromodulator, PrabotulinumtoxinA, has received FDA approval, although few 
studies have captured its onset and effect compared to currently available neuromodulators [9]. We aim to 
assess onset and quantify the efficacy of four neuromodulators to help determine appropriate treatment 
selection. 
 
2 
Study Objectives 
The overall study object is to quantify the dynamic strain of four commonly available neuromodulators 
using 3D imaging as well as other potential physical measurements differences over time.  
 
2.1 
Primary Objective 
To compare the efficacy of four commonly available neuromodulators using 3D imaging to quantify 
dynamic strain measurements  
3 
Investigational Plan  
3.1 
General Design 
 
This study is a randomized controlled trial in which patients will be randomly assigned into one of four 
groups: those receiving onabotulinumtoxinA (Botox, Allergan, Irvine, California), abobotulinumtoxinA 
(Dysport, Ispen Biopharmacueticals Inc.Cambridge, MA), incobotulinumtoxinA (Xeomin, Raleigh, NC) 
or prabotulinumtoxinA (Jeuveau, Evolus, Newport Beach, California).  Each patient will receive FDA 
approved dosages in which they are assigned in to treat rhytids within the glabella, as per FDA approved 
indications. All injections will be performed by a blinded single trained physician (Ivona Percec) 
according to a preset injection plan per FDA approved administration guidelines. Prior to injection 
patients will be imaged with 3-dimensional photogrammetry. All pre-procedure images will be evaluated 
for absolute strain performing two types of facial animation: 1) relaxed, and 2) frowning. Subjects will 
return Day 3, 30, 90, and 180, post intervention for re-imaging with the same expressions. Strain will be 
calculated using the same metrics. 
 
3.2 
Allocation to Interventional Group 
 
Subjects will be randomized to either the prabotulinumtoxinA abobotulinumtoxinA, incobotulinumtoxinA or 
onabotulinumtoxinA groups. Subjects will be randomized in a one to one fashion using block 
randomization.   
3.3 
Study Measures 
 
3D photogrammetry imaging of each subject at the pre-determined time points will be obtained using the 
VECTRA M3 (Canfield Scientific, Inc., Fairfield, NJ), This allows for dynamic measurements of facial 
strain. Each subject's face will be measured along lines of tension when the face is in the relaxed and then 
frowning. Each facial animation will be recorded as an image. Three-dimensional coordinates will be 


Glabella 4 Toxin Study 
 
Page 7 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
calculated to generate each subject’s topographic configuration, displacement, and surface strain of each 
detected point on the surface of the face relative to its original reference image.  
 
3.4 
Study Endpoints  
3.4.1 
Primary Study Endpoint 
The primary endpoint is to quantify the change in dynamic strain of the glabella area after injection of 
four neuromodulators using 3D facial imaging measurements over time.  
3.4.2 
Secondary Study Endpoints 
1) Quantify the change in the dynamic strain of the glabella area after injection between the four 
neuromodulators  
2) Quantify the change of dynamic strain measurements of each facial animation over time. 
 
3) Correlation of satisfaction as determined by the FACE-Q to the degree of dynamic strain 
overtime  
4 
Study Population and Duration of Participation  
Adult subjects, ages 30-65, who are interested in rhytid treatment of the glabella with a neuromodulator 
under FDA approved use. Each participant will participate for 180 days.   
4.1 
Duration of Study Participation  
 
The duration of study participation is a minimum of 180 days. Subjects will receive injections on day-1, 
and follow up imaging and analysis occurs on day 3, 30, 90 and 180 post intervention.  
 
The overall study duration is estimated 12- 18 months. It may take approximately 6 months to enroll all 
subjects and complete initial imaging and procedures, 7 months for follow up imaging, and 4-5 months 
for data analysis. Each individual subject’s participation time in the study will consist of the duration of 
the initial imaging session (approximately 20 minutes), procedure (15 minutes), follow up imaging (20 
min). 
4.2 
Total Number of Subjects and Sites  
 
140 patients will be enrolled from at a single location, the Hospital of the University of Pennsylvania.  
4.3 
Inclusion Criteria 
• Female 
• 30-65 years of age 
• Interested in glabellar injections to reduce rhytids and facial strain 
• Participants must sign the informed consent form  
4.4 Exclusion Criteria 
• Females under 30 or above 65 years of age 
• Males 


Glabella 4 Toxin Study 
 
Page 8 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
• Those who have received glabellar injections for rhytids <12 months 
• Underwent cosmetic surgical procedure above the malar region 
• Those with a condition that affects facial expression, such as prior stroke 
4.5 
Subject Recruitment  
 
Patients will be recruited through the plastic surgery clinic, which is a high-volume practice for those who 
may be interested in cosmetic injections. Additionally, we plan to use of a flyer posted throughout the 
health system and campus. Injections to the glabellar region to reduce rhytids are a popular procedure and 
we do not anticipate significant difficulty in recruiting willing participants.  
4.6 
Vulnerable Populations:  
Children, pregnant women, fetuses, neonates, or prisoners are not included in this research study. 
 
5 
Study Procedures  
This section should list the procedures, observations, measures, etc. that will take place at each of the 
study visits. Every measure, procedure, observation, etc. that was listed in Section in Section 3.3 should 
be included in the study procedures section. A table can supplement this section. An example procedures 
table is included below in Appendix 15.1.  
5.1 
Screening  
The screening visit involves patient evaluation of inclusion and exclusion criteria. This information is 
readily available on the intake visit and does not deviate from standard of care for a clinic visit, including 
age and past medical history. Once patients are deemed eligible, the process of informed consent will 
begin. Informed consent will take place. 
  
5.2 
Study Intervention or Observational Phase  
Randomized Controlled Single Blinded Study 
5.2.1 
Visit 1 (sometimes referred to as the baseline visit)  
 
Visit 1 involves screening, consent, baseline imaging to measure dynamic strain, randomization, 
intervention. The subject will be photographed using 3D imaging with multiple facial animations. All pre-
procedure images will be evaluated for absolute strain performing two types of facial animation: 1) 
relaxed, 2) frowning. Following the baseline images, subjects will complete a FACE-Q questionnaire and 
then randomized to one of the four neuromodulators onabotulinumtoxinA (Botox, Allergan, Irvine, 
California), abobotulinumtoxinA (Dysport, Ispen Biopharmacueticals Inc.Cambridge, MA), 
incobotulinumtoxinA (Xeomin, Raleigh, NC) or PrabotulinumtoxinA (Jeuveau, Evolus, Newport Beach, 
California) according to a preset injection plan per FDA approved administration guidelines. The injector 
will be blinded to the neuromodulator assigned to the subject via randomization at the time of injection in 
order to decrease any underlying bias during drug administration. The syringes will be documented and 
prepared by appropriately trained staff.   
 


Glabella 4 Toxin Study 
 
Page 9 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
Intervention Preparation as described on the FDA approved medication guide 
 
PrabotulinumtoxinA (Jeuveau)  
Reconstitute 100 unit vials with 2.5 mL preservative-free 0.9% sodium chloride injection, USF.  Load 
0.5mL in a single syringe with a 30-gauge needle. Each of the five FDA approved injection points will 
receive 0.1 mL of the reconstituted solution (4 unit of toxin) intramuscularly for a total of 20 units in 
0.5mL. 
 
OnabotulinumtoxinA (Botox) and IncobotulinumtoxinA (Xeomin) 
Reconstitute 50 unit vials with 1.25 mL preservative-free 0.9% sodium chloride injection, USF.  Load 0.5mL in a 
single syringe with a 30-gauge needle. Each of the five FDA approved injection points will receive 0.1 mL of the 
reconstituted solution (4 unit of toxin) intramuscularly for a total of 20 units in 0.5mL 
 
AbobotulinumtoxinA (Dysport) 
Reconstitute 300 unit vials with 3.0 mL preservative-free 0.9% sodium chloride injection, USP.  Load 
0.5mL in a single syringe with a 30-gauge needle.  Each of the five FDA approved glabella injection points 
will receive 0.1mL of the reconstituted solution (10 units of toxin) intramuscularly for a total of 50 units 
in 0.5mL.  
 
 
 
Once reconstituted, unused toxin may be stored in the original container in a refrigerator at 2-8ºC or 36-
46ºF.  Do NOT freeze.  All toxin must be discarded within 24 hours after reconstitution. All reconstituted 
vials should be single-use for one subject only.  
5.2.2 
Visit 2  
Visit 2 which will occur 3-days post-injection, will consist of a repeat of the above measurements using 
3D imaging with facial animations of 1) relaxed and 2) frowning. Subjects will also complete the FACE-
Q via electronic REDCap survey and communicate any questions or concerns. 
5.2.3 
Visit 3  
Visit 3 which will occur 30-days post-injection, will consist of a repeat of the above measurements using 
3D imaging with facial animations of 1) relaxed and 2) frowning. Subjects will also complete the FACE-
Q via electronic REDCap survey and communicate any questions or concerns. 


Glabella 4 Toxin Study 
 
Page 10 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
5.2.4 
Visit 4  
Visit 4 which will occur 90-days post-injection, will consist of a repeat of the above measurements using 
3D imaging with facial animations of 1) relaxed and 2) frowning. Subjects will also complete the FACE-
Q via electronic REDCap survey and communicate any questions or concerns. 
5.2.5 
End of Study Visit 5  
Visit 5 which will occur 180-days post-injection, will consist of a repeat of the above measurements using 
3D imaging with facial animations of 1) relaxed and 2) frowning. Subjects will also complete the FACE-
Q via electronic REDCap survey and communicate any questions or concerns. 
 
 
TABLE 1  SCHEDULE OF STUDY PROCEDURES  
 
Baseline 
Visit 1 
Intervention 
 
Follow-up Visit  2 
Day 3 
Follow-up Visit  3 
Day 30 
Follow-up Visit 4 
Day 90 
Follow-up Visit 5 
Day 180 
Visit Window 
Day 1 
Day 1 
Day 3 ±1 
Day 30  ± 5 
Day 90 ±7 
Day 180 ±10 
Eligibility 
X 
 
 
 
 
 
Informed Consent 
X 
 
 
 
 
 
Demographic 
X 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
Consultation 
X 
 
 
 
 
 
Vectra Photography 
 
X 
X 
X 
X 
X 
FACE-Q 
 
X 
X 
X 
X 
X 
Adverse Events 
X 
X 
X 
X 
X 
X 
 
5.3 
Unscheduled Visits 
Unscheduled visits will be handled on a case by case basis dependent upon the reasoning for the patients’ 
visit. If subjects are displaying signs of immediate danger or instability, they will be referred to 
emergency department or directly admitted. However, unscheduled visits are rare for this type of 
procedure.  
5.4 
Subject Withdrawal  
 
Subjects may withdraw from the study at any time without impact to their care.  They may also be 
discontinued from the study at the discretion of the Investigator.  Subjects may also be withdrawn 
following an adverse event that does not allow them to continue with the study. It will be documented 


Glabella 4 Toxin Study 
 
Page 11 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
whether or not each subject completes the study. Subjects who withdraw early will have one final 
communication to collect final evaluations and assess for adverse events.   
5.4.1 Data Collection and Follow-up for Withdrawn Subjects 
Patients must document in a letter asking not to use the data collected and formalize the withdrawal.  
Otherwise, data up until withdrawal will be available for analysis.   
5.5 
Early Termination Visits   
This may be due to the subjects’ own choice or the investigator’s decision. If the investigator makes the 
decision, subjects will be contacted and reasons for study termination will be thoroughly explained.  
6 
Statistical Plan 
6.1 
Sample Size and Power Determination 
The sample size is based on a previously successful study with the same purpose [1], and an anticipated 
15% drop-out/withdrawal rate. Significant decrease in the dynamic strain in OnabotulinumtoxinA and 
AbobotulinumtoxinA were determined at day 4, 14, and 90 post intervention compared to baseline.  We 
are increasing the patient population to account for a potential increase drop out due to the number of 
follow-up visits.    
 
1. Wilson AJ, Chang B, Taglienti AJ, et al. A Quantitative Analysis of OnabotulinumtoxinA, 
AbobotulinumtoxinA, and IncobotulinumtoxinA: A Randomized, Double-Blind, Prospective 
Clinical Trial of Comparative Dynamic Strain Reduction. Plast Reconstr Surg. 
2016;137(5):1424–1433. 
  
6.2 
Statistical Methods 
The primary analysis will be done using chi-squared testing and Fischer’s exact test for categorical 
variables, where applicable, and the paired t-test for continuous variables. Analysis is preformed blinded 
at the end of the study. There is no interim analysis.  
6.3 
Control of Bias and Confounding  
 
Block randomization will be employed to assign subjects into each study arm. 40 blocks consisting of 4 
assignments per block will be used in sequence until study enrollment is complete. The injecting 
physician will be blinded to which neuromodulator is assigned at the time of injections prevent any 
underlying bias.   
6.3.1 
Baseline Data 
Baseline and demographic characteristics will be summarized by standard descriptive statistics (including 
mean and standard deviation for continuous variables such as age and standard percentages for categorical 
variables such as race). 
6.3.2 
Analysis of Primary Outcome of Interest 
The primary analysis will be done using chi-squared testing and Fischer’s exact test for categorical 
variables, where applicable, and the paired t-test for continuous variables.    


Glabella 4 Toxin Study 
 
Page 12 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
7 
Safety and Adverse Events 
7.1 
Definitions 
7.1.1 
Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens in severity 
during the course of the study.  Intercurrent illnesses or injuries should be regarded as adverse events.  
Abnormal results of diagnostic procedures are considered to be adverse events if the abnormality: 
• results in study withdrawal 
• is associated with a serious adverse event 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 
• is considered by the investigator to be of clinical significance 
 
For FDA regulated studies the FDA defines an adverse event as the following:  
 
Adverse event means any untoward medical occurrence associated with the use if a drug in humans 
whether or not considered drug related.  
7.1.2 
Serious Adverse Event 
Adverse events are classified as serious or non-serious.  A serious adverse event is any AE that is:  
• fatal 
• life-threatening 
• requires or prolongs hospital stay 
• results in persistent or significant disability or incapacity 
• a congenital anomaly or birth defect 
• an important medical event 
 
Important medical events are those that may not be immediately life threatening, but are clearly of major 
clinical significance.   They may jeopardize the subject, and may require intervention to prevent one of 
the other serious outcomes noted above.  For example, drug overdose or abuse, a seizure that did not 
result in in-patient hospitalization or intensive treatment of bronchospasm in an emergency department 
would typically be considered serious.  
 
All adverse events that do not meet any of the criteria for serious should be regarded as non-serious 
adverse events.  
7.2 
Recording of Adverse Events 
At each contact with the subject, the investigator will seek information on adverse events by specific 
questioning and, as appropriate, by examination.  Information on all adverse events will be recorded 
immediately in the source document, and also in the appropriate adverse event module of the case report 
form (CRF).  All clearly related signs, symptoms, and abnormal diagnostic procedures results should be 
recorded in the source document, though should be grouped under one diagnosis. 
 
All adverse events occurring during the study period will be recorded.  The clinical course of each event 
will be followed until resolution, stabilization, or until it has been determined that the study intervention 


Glabella 4 Toxin Study 
 
Page 13 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
or participation is not the cause.  Serious adverse events that are still ongoing at the end of the study 
period will be followed up to determine the final outcome.  Any serious adverse event that occurs after the 
study period and is considered to be possibly related to the study intervention or study participation will 
be recorded and reported immediately. 
7.3 
Relationship of AE to Study  
The relationship of each adverse event to the study procedures should be characterized. The PI or medical 
monitor will determine how the relationship of the AE will be classified as: 
• likely related – a well-known effect of the device or clearly not related to the subject or environmental 
factors 
• probably related – is known or suspected effect of device or cannot be readily explained by subject or 
study procedures  
• possibly related – is a possible effect of the device or can be explained by the subject or study 
procedures 
• unlikely related – is not a suspected effect of the device or can readily be explained by the subject or 
environmental factors  
• unrelated – is not a known effect of the device and can readily be readily and easily explained by the 
subject or environmental factors 
7.4 
Reporting of Adverse Events, Adverse Device Effects and Unanticipated Problems 
Investigators and the protocol sponsor (which may or may not be a Penn Investigator) must conform to 
the adverse event reporting timelines, formats and requirements of the various entities to which they are 
responsible,  
 
If the report is supplied as a narrative, the minimum necessary information to be provided at the time of 
the initial report includes: 
 
• Study identifier 
• Study Center 
• Subject number 
• A description of the event 
• Date of onset 
• Current status 
• Whether study intervention was discontinued 
• The reason why the event is classified as 
serious 
• Investigator assessment of the association 
between the event and study intervention 
 
 
Additionally, all other events (unanticipated problems, adverse reactions, unanticipated adverse device 
effects and subject complaints will be recorded and reported with respect to institutional and federal 
policies.  
 
7.4.1 Follow-up report 
If an SAE has not resolved at the time of the initial report and new information arises that changes the 
investigator’s assessment of the event, a follow-up report including all relevant new or reassessed 
information (e.g., concomitant medication, medical history) should be submitted to the IRB. The 
investigator is responsible for ensuring that all SAE are followed until either resolved or stable.  


Glabella 4 Toxin Study 
 
Page 14 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
7.4.2 
Investigator reporting: notifying the study sponsor 
Investigators from all participating sites should report all unexpected and related adverse events, 
regardless of whether they are serious or not, and all unanticipated problems to the sponsor. 
 
Any study-related unanticipated problem posing risk to subjects or others, and any type of serious adverse 
event, will be reported to the study sponsor by telephone within 24 hours of the event.  To report such 
events, a Serious Adverse Event (SAE) form will be completed by the investigator and emailed to the 
study sponsor within 24 hours.  The investigator will keep a copy of this SAE form on file at the study 
site.  Report serious adverse events by sending via email to: [Evolus., Company Call Center:  1-877-
EVOLUS1 (1-877-386-5871), Company Email:  EvolusMI@druginfo.com] 
 
Within the following 48 hours, the investigator will provide further information on the serious adverse 
event or the unanticipated problem in the form of a written narrative.  This should include a copy of the 
completed Serious Adverse Event form, and any other diagnostic information that will assist the 
understanding of the event.  Significant new information on ongoing serious adverse events should be 
provided promptly to the study sponsor. 
7.4.3 
Investigator reporting: notifying the Penn IRB 
For single and multi-site studies each site PI will need to follow their local IRB reporting requirements in addition to 
the protocol outlined reporting.  
7.4.4 
Sponsor reporting: Notifying Participating Investigators  
For clinical trials, in addition to reporting certain unanticipated problems and adverse events noted above 
to the FDA, it is the responsibility of the study sponsor to report those same adverse events or findings to 
participating investigators. 
7.5 
Medical Monitoring 
It is the responsibility of the site Principal Investigator to oversee the safety of the study at his/her site.  
This safety monitoring will include careful assessment and appropriate reporting of adverse events as 
noted above. The lead PI will monitor all AEs reported.   
7.6 
Confidentiality 
Information about study subjects will be kept confidential and managed according to the requirements of 
the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Those regulations require a 
signed subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by regulation, 
retains the ability to use all information collected prior to the revocation of subject authorization.  For 
subjects that have revoked authorization to collect or use PHI, attempts should be made to obtain 
permission to collect at least vital status (i.e. that the subject is alive) at the end of their scheduled study 
period. 


Glabella 4 Toxin Study 
 
Page 15 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
7.7 
Data Collection and Management  
REDCap will be used to store and maintain the primary study records. The data entered into REDCap will 
be obtained from the study-relevant patient EMRs.  Study personnel will be granted access to this project 
created in REDCap with each user obtaining individual access authenticated by a login system.  Minimal 
patient identifiers will be collected and stored in the REDCap database. Patient name and date of birth 
will be collected in REDCap.   
 
Source data will mainly be from the patient’s EMR. When the study requires data not normally collected 
in the patient’s EMR, the case report forms will also be the source document. Data from source 
documents (Appendix15.4, case report forms (case report forms definition- Appendix 15.5), will be 
entered into an electronic data capturing system. All source documents should be secure in private spaces 
with restricted access.  After Visit 1 the FACE-Q will be sent electronically to the subject for each follow-
up visit via a REDCap survey.   
 
During procurement of data charts will be reviewed in private spaces to ensure the confidentiality of 
acquired data. Data will be stored for up to 7 years after completion of the last follow-up visit of the last 
patient randomized.  Data may be collected for up to two years following the treatment.     
7.8 
Records Retention  
The Principal Investigator at each site is responsible for storing regulatory documents, subject files and 
financial records for the period specified by law.  The time period for maintaining research records is 
defined first by HIPAA regulations that require any HIPAA-regulated information, authorizations, 
waivers, etc. must be maintained for at least 6 years subsequent to the Institutional Review Board (IRB) 
acknowledgement of the termination of the research project and secondly by DHHS regulations (45 CFR 
46.115) and FDA regulations (21 CFR 56.115) state that IRB records relating to research shall be retained 
for at least 3 years after completion of the research.   
8 
Study Monitoring, Auditing, and Inspecting 
8.1 
Study Monitoring Plan 
This study will be closely monitored by the PI and the project manager.  The PI will be participating and 
the data will be collected by the PI and one other study steam member from the patient’s EMR.  The study 
team member will enter the data into the REDCap and the project manager will monitor the entry to verify 
the compliance with respect to the protocol, data collection and source documents.     
8.2 
Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the EC/IRB, the sponsor, 
government regulatory bodies, and University compliance and quality assurance groups of all study 
related documents (e.g. source documents, regulatory documents, data collection instruments, study data 
etc.).  The investigator will ensure the capability for inspections of applicable study-related facilities (e.g. 
pharmacy, diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by government 
regulatory authorities and applicable University compliance and quality assurance offices. 


Glabella 4 Toxin Study 
 
Page 16 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
9 
Ethical Considerations 
This study is to be conducted in accordance with applicable US government regulations and international 
standards of Good Clinical Practice, and applicable institutional research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted independent Ethics 
Committee (EC) or Institutional Review Board (IRB), in agreement with local legal prescriptions, for 
formal approval of the study conduct.  The decision of the EC/IRB concerning the conduct of the study 
will be made in writing to the investigator and a copy of this decision will be provided to the sponsor 
before commencement of this study.  
 
All subjects for this study will be provided a consent form describing this study and providing sufficient 
information for subjects to make an informed decision about their participation in this study.  This consent 
form will be submitted with the protocol for review and approval by the EC/IRB for the study.  The 
formal consent of a subject, using the EC/IRB-approved consent form, must be obtained before that 
subject undergoes any study procedure.  The consent form must be signed by the subject or legally 
acceptable surrogate, and the investigator-designated research professional obtaining the consent. 
9.1 
Risks 
All treatments used in this protocol will be used according to the FDA approved intended use.  No 
unexpected risks should occur.  Risks that may be experienced from any injection are swelling bruising, 
redness, itching, infection, or pain.   
 
There is minimal risk to this study. This study is a prospective observational study of an FDA approved 
cosmetic drugs used as approved.  The study protocol only adds 3D imaging required to make the 
observational measurements.  The images will be identifying as they are of the face.  All identifying 
images will be stored on a database or computer behind the firewall and a password. 
 
Potential risks of the neuromodulators are:  
• dry mouth 
• discomfort or pain at the injection site 
• tiredness 
• headache 
• neck pain 
• eye problems: double vision, blurred vision, decreased eyesight, drooping eyelids, swelling of your 
eyelids, and dry eyes. 
• drooping eyebrows 
• allergic reactions. Symptoms of an allergic reaction may include: itching, rash, red itchy welts, 
wheezing, asthma symptoms, or dizziness or feeling faint.  
• upper respiratory tract infection 
 
Reproductive risks: If patient is of child-bearing potential, a urine pregnancy test may be administered 
prior to injection to confirm negative pregnancy status.  The effects of this drug/device, there could be 
serious harm to unborn children or children who are breast-feeding. These effects could also harm the 
mother.   


Glabella 4 Toxin Study 
 
Page 17 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
9.2 
Benefits 
Subjects participating in this trial may gain insight into the potential benefit of wrinkle reduction in the 
glabella area from participating in this study.  The risks of this study are the same as those that would 
apply to any injection procedure, such as swelling and low-levels of pain. Additionally, a breach of 
confidentiality is a possibility although we have created measures to mitigate this risk. Although the 
benefits may not be readily apparent on an individual basis, the advancement of knowledge gained will 
serve the medical society and community 
 
There is financial compensation for participation in this study. Subjects will be compensated $15 for each follow-up 
visit and questionnaire completed. The payment will be administered after completion of the fourth and final 
follow-up visit for a maximum total of $60. The subjects will receive the neuromodulators for no charge.  
 
9.3 
Risk Benefit Assessment 
Subjects participating in this trial will unlikely experience an increase in risk as this is an observational 
study of FDA approved neuromodulators. No change in patient care will happen if the subject is 
consented.  All subjects will be asked to return for four follow-up visits for observation and surveys.  
9.4 
Informed Consent Process / HIPAA Authorization  
 
All subjects for this study will be provided a consent form describing this study providing sufficient 
information for subjects to make an informed decision about their participation in this study.  This consent 
form will be submitted with the protocol for review and approval by the IRB for the study.  The formal 
consent of a subject, using the IRB-approved consent form, must be obtained before that subject 
undergoes any study procedure.  The subject, or legally acceptable surrogate, must sign the consent form, 
and the investigator-designated research professional obtaining the consent. Subjects will be consented by 
the study Principal Investigator, or appropriate designee, in a room we have selected in which to perform 
consent, which is located outside of the clinic. Potential subjects will review the consent form in detail 
with the person designated to consent (either PI or CRC) and have the ability to take the consent home for 
further review.  
10 Study Finances 
10.1 
Funding Source 
Funding Sources pending  
10.2 
Conflict of Interest 
None 
10.3 
Subject Stipends or Payments 
There are no subject payments or stipends. 
11 Publication Plan 
Following data analysis and summary, data will may be presented to relevant conferences and submitted 
for publication. Once published, data is destroyed.  


Glabella 4 Toxin Study 
 
Page 18 
Version: 27 AUG 2020 
 
CONFIDENTIAL 
 
This material is the property of the University of Pennsylvania.   
 
12 References 
 
1. https://www.plasticsurgery.org/documents/News/Statistics/2018/cosmetic-procedure-trends-
2018.pdf 
2. Field M, Splevins A, Picaut P, et al. AbobotulinumtoxinA (Dysport®), OnabotulinumtoxinA 
(Botox®), and IncobotulinumtoxinA (Xeomin®) Neuromodulator Content and Potential 
Implications for Duration of Response in Patients [published correction appears in Toxins 
(Basel). 2019 Feb 13;11(2):]. Toxins (Basel). 2018;10(12):535.  
3. Carruthers A., Carruthers J., Cohen J. A prospective, double-blind, randomized, parallel-
group, dose-ranging study of botulinum toxin type a in female subjects with horizontal 
forehead rhytides. Dermatol. Surg. 2003;29:461–467. 
4. Grosset DG, Tyrrell EG, Grosset KA. Switch from abobotulinumtoxinA (Dysport®) to 
incobotulinumtoxinA (Xeomin®) botulinum toxin formulation: a review of 257 cases. J 
Rehabil Med. 2015;47(2):183–186. 
5. Ho OA, Saber N, Stephens D, et al. Comparing the Use of 3D Photogrammetry and Computed 
Tomography in Assessing the Severity of Single-Suture Nonsyndromic 
Craniosynostosis. Plast Surg (Oakv). 2017;25(2):78–83. doi:10.1177/2292550317694845 
6. Mathys A, Semal P, Brecko J, Van den Spiegel D. Improving 3D photogrammetry models 
through spectral imaging: Tooth enamel as a case study. PLoS One. 2019;14(8):e0220949. 
Published 2019 Aug 13. doi:10.1371/journal.pone.0220949 
7. Schendel SA. Enriched autologous facial fat grafts in aesthetic surgery: 3D volumetric 
results. Aesthet Surg J. 2015;35(8):913–919. 
8. Wilson AJ, Chang B, Taglienti AJ, et al. A Quantitative Analysis of OnabotulinumtoxinA, 
AbobotulinumtoxinA, and IncobotulinumtoxinA: A Randomized, Double-Blind, Prospective 
Clinical Trial of Comparative Dynamic Strain Reduction. Plast Reconstr Surg. 
2016;137(5):1424–1433. 
9. Beer KR, Shamban AT, Avelar RL, Gross JE, Jonker A. Efficacy and Safety of 
PrabotulinumtoxinA for the Treatment of Glabellar Lines in Adult Subjects: Results From 2 
Identical Phase III Studies. Dermatol Surg. 2019;45(11):1381–1393. 
 
13 Attachments