Periocular Applications of Botulinum Toxin 569

chains, whose molecular structure is connected with weak disulphide bonds, as a result of heat and agitation. Therefore, the toxin should be transported in a cold chain and without vibration. However, Trinidade et al reported in their controlled and double blinded studies that molecular structure of botulinum toxin A was resistant to foaming and cosmetic effect lasted for the same period.66

Studies by various authors showed that reconstitution of botulinum toxin 1 week67 2 weeks68-69 prior to injection did not decrease the efficacy of botulinum toxin.

Similarly Hexel et al reported that botulinum toxin molecule reserved its effectiveness after 6 weeks postconstitution.70

The botulinum toxin producer companies recommend, injection of botulinum toxin type A with the nonpreserved preparation. However, less painful injections were noted with the use of the preserved saline compared the nonpreserved preparation (P<0.0001). The preserved reconstitution appeared to have no effect on clinical outcome reports Kwait and coauthors.71 Studies by van Laborde et al72 and Alam, Dover and Arndt73 also proves that use of preservativecontaining saline to further dilute botulinum toxin type B and A, respectively can significantly decrease patient discomfort on injection. The effect does not change with the preservative content of the diluent.

Vadoud-Seyedi and Simonart reported that shortand long-term results show the equal effectiveness of botulinum toxin A, whether reconstituted in saline or in lidocaine. Injections of botulinum toxin A reconstituted in lidocaine are associated with significantly reduced pain, lidocainereconstituted botulinum toxin A may be preferable for treating axillary hyperhidrosis.74

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CONCLUSION AND FUTURE RESEARCH

The therapeutic and cosmetic use of botulinum toxin for periocular area pathologies are repeatable, safe and temporarily effective. Potential complications should be discussed with the patient before cosmetic procedure, patient should be selected carefully.

Determining optimum doses for certain anatomic areas, ideal concentrations, dose responses between different botulinum toxin serotypes, prevention of antigen formation , possible efficacy changes in long-term treatments, and longterm reliability are the areas that require more research.

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