# BOTME Study: A National e‐Delphi Study on the Use of Botulinum Toxin for Aesthetic Treatment of Middle Easterners

## TL;DR

This study provides standardized guidelines for using botulinum toxin in cosmetic treatments for people with skin of color, focusing on Middle Eastern populations.

## Contribution

The study offers the first consensus-based clinical recommendations for BTX-A use in skin of color patients using a modified e-Delphi method.

## Key findings

- Consensus was reached on 22 out of 29 evidence-based statements regarding BTX-A treatment practices.
- Key recommendations include age of initiation, dosing, reconstitution, and injection techniques for safe and effective treatments.
- Topical EMLA was agreed upon for pain control, though some technical aspects like injection depth remained inconclusive.

## Abstract

The demand for botulinum toxin A (BTX‐A) cosmetic treatments is growing among individuals with skin of color, primarily due to increased cultural acceptance, social media influence, and patient awareness. However, there remains a lack of standardized, evidence‐based guidance on the use of BTX‐A in these populations.

To develop consensus‐based clinical recommendations on aesthetic botulinum toxin injection practices in patients with skin of color.

A modified e‐Delphi method was conducted with 10 board‐certified dermatologists specializing in cosmetic dermatology. Inclusion criteria required ≥ 5 years of experience and publications, or teaching activity in BTX‐A use. Two e‐Delphi rounds evaluated 29 evidence‐based statements. Consensus was defined as ≥ 70% agreement.

Consensus was achieved on 22 statements. Key recommendations included initiating BTX‐A treatments at ages 30–35, dosing 40–60 IU for the upper face, with 16–20 week intervals, using 2 mL of saline reconstitution per 100 IU, and employing 30‐gauge insulin syringes. Topical EMLA was collectively agreed upon for pain control. While several technical aspects, such as injection depth and under‐eye applications, remained inconclusive, participants decided on key practical precautions, including posttreatment activity restrictions.

These consensus‐based recommendations can standardize, make BTX‐A injections safe and effective for skin of color patients, supporting more uniform and comparable treatment results.