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Using Digital Image Speckle Correlation to Optimize Botox Injection Sites: A Prospective Crossover Trial
Gabriel M. Klein, MD1, Richa Verma, MD1, Yan Xu, PhD2, Miriam Rafaelovich, PhD2, Sami U. Khan, MD1, Duc T. Bui, MD1, Alexander B. Dagum, MD1.
1Stony Brook University Hospital, Stony Brook, NY, USA, 2Stony Brook University, Stony Brook, NY, USA.

PURPOSE: Physicians have historically relied upon their judgment when determining the site and dosage of injection of Botulinum Toxin (BT) in the treatment of facial rhytids. Although these clinical decisions may take into account the muscle mass and degree of wrinkle formation, this method is inherently subjective and operator dependent. Digital Image Speckle Correlation (DISC) is a technology that tracks pore movement from rest to maximal exertion, thus allowing for the objective determination of the optimal sites of injection. DISC also provides the ability to track the degree of paralysis following BT injection. In this prospective crossover trial, we compare the efficacy of utilizing DISC compared to physician assessment in determining BT injection sites.
METHODS: 10 female patients aged 32-59 (mean 46.8) were enrolled in our study. Subjects were randomized to one of two arms. Group I received BT injections based on DISC analysis first, and Group II received BT injections based on the 2004 "Consensus Recommendations on the Use of Botulinum toxin Type A in Facial Aesthetics". Subjects were blinded as to which method was used. All patients received 20 units of BT in the glabellar region (Botox, Allergan, Irvine, CA). Follow-up photographs and DISC analysis were completed weekly for the first month, then monthly up to six months post-injection. The Facial Lines Outcome 11-item survey (FLO-11) survey was also administered at each follow-up. After 6 months, subjects were crossed over and were re-injected utilizing the other method. Follow-up for the second injection was the same as the first. Statistical comparison was completed via matched sample T-test.
RESULTS: Six subjects (Group I) were injected utilizing DISC for the first arm of the crossover while the remaining four were in Group II. On average, the DISC analysis provided 4.8 (range 4-6) injection sites, while the practitioner chose 5 (range 4-7) injections sites. When matched by week, the mean FLO-11 score was better in patients injected via DISC (p=0.0003). The degree of paralysis was also greater in these patients (p=0.003). Furthermore, DISC directed injection maintained paralysis for a longer period of time (20 versus 18 weeks) and patients were less likely to return to their baseline movement within the six month follow up period (p=0.03)
CONCLUSION: Due to a lack of standardized practice, there is often significant variability in the site of injection and number of units injected between different practitioners. Currently, there exists no evidence-based tool that adequately addresses this issue. This study demonstrates the improved benefits of utilizing DISC in determining the optimal site of BT injection. Utilizing DISC may lead to a greater degree of paralysis, longer duration of effect, and increased patient satisfaction.


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