Comparing efficacy, subject satisfaction, and safety of Food and Drug Administration–approved neuromodulators in facial aesthetics

Background: Neuromodulators are widely used in facial aesthetics, offering nonsurgical options for addressing wrinkles and rejuvenating the face. Currently, 6 FDA-approved botulinum toxin A (BoNTA) formulations are available: onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, prabotulinumtoxinA, daxibotulinumtoxinA, and letibotulinumtoxinA. However, no comprehensive analysis has directly compared their duration of efficacy, patient satisfaction, and safety profiles. Methods: A literature search of PubMed was conducted, identifying studies from the last 10 years evaluating neuromodulators in facial aesthetics. Inclusion criteria required studies to report on efficacy, duration of results, or safety profiles. Exclusion criteria included studies not focusing on facial aesthetic applications, those not differentiating between neuromodulators, meta-analyses, and studies combining BoNTA with other treatments. Data on investigator-determined responder rates at 30, 60, 90, and 120+ days, as well as subject satisfaction and adverse events, were extracted. Results: A total of 82 studies met the inclusion criteria. All neuromodulators demonstrated peak efficacy at 30 days, followed by a gradual decline. At day 30, mean responder rates ranged from 64.7% (letibotulinumtoxinA) to 95.6% (daxibotulinumtoxinA). At day 120, these ranged from 10.6% (letibotulinumtoxinA) to 65.2% (incobotulinumtoxinA). LetibotulinumtoxinA and prabotulinumtoxinA had the lowest responder rates, though limited study availability and differing methodology likely influenced these findings. Subject satisfaction showed a similar pattern, peaking at 30 days, though declining more slowly over time. At day 30, subject satisfaction rates ranged from 86.1% (onabotulinumtoxinA) to 97.4% (incobotulinumtoxinA). At day 120, these ranged from 74.2% (prabotulinumtoxinA) to 93% (incobotulinumtoxinA). There were no studies for daxibotulinumtoxinA or letibotulinumtoxinA that disclosed subject satisfaction rates, so they were excluded from this analysis. No serious treatment-related adverse events were reported. Mild, transient side effects were largely related to injection site reactions, such as bruising and erythema. Conclusion: All 6 FDA-approved neuromodulators are safe and effective for facial rejuvenation, with differences in responder rates and longevity potentially influenced by study methodologies. Injector skill, dosing, and patient-specific factors remain critical in optimizing outcomes. Further research is necessary to standardize assessment tools, conduct head-to-head trials, and evaluate long-term efficacy in diverse populations.