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Archive for the ‘Botox’ Category

A Clinical Study of the Nefertiti Lift

Monday, July 10th, 2017

Botox injections are the most common form of chemical neuromodulation of the face. Decreasing undesired facial expressions has become a mainstay of modern aesthetic facial management. Every conceivable undesired facial expression can be treated with usually satisfying effects.

But decreasing adverse muscle activity can also extend down into the neck. The hyperactive platysma muscle that results in vertical muscle bands and resultant horizontal neck wrinkles can also be treated by Botox injections. Known as the ‘Nefertiti Lift’, the platysmal bands and the lower border of the jaw are injected. While this use of Botox is widely practiced and marketed, no clinical study has ever evaluated its effectiveness.

In the July 2017 issue of the journal of Plastic and Reconstructive Surgery, an articlee was published entitled ‘Botulinum Toxin for Neck Rejuvenation: Assessing Efficacy ands Redefining Patient Selection’.  In this clinical study the authors injected thirty (30) patients along the jawline and into the platysmas bands. An average of 125 units was used per patient. Results were assessed by static and dynamic pictures. Their findings showed that platysmas bands at rest and with maximal tension were significantly improved. Over 90% of investigators and patients alike rated their results as improved and satisfying. The patients who had the best results were younger patients with good skin elasticity.

While there is only one known image of the Egyptian Queen  Nefertiti, her beauty is defined by her distinct jawline and facial proportion. The use of the term ‘Nefertiti Lift’ is a marketing name and is not a surgical lift but an injectable approach to contouring the jawline and neck. By precisely placing Botox injections along the jawline and neck, the platysmas muscles are weakened that pull down on the jawline. This allows the tissues to redraw up tighter along the jawline. The effectiveness of this muscle release works best in thinner and younger patients where the definition of the jawline can be better appreciated and revealed. By combining many other facial techniques (injectable fillers, laser resurfacing, chemical peels etc) enhanced versions of the Nefertiti Lift have been touted.

Marketing issues aside, the Nefertiti Lift is based on sound anatomic principles of chemodenervation of sections of the platysma muscle. It is no surprise that is most effective in thinner patients with good skin elasticity. Thus, patient selection is critical. I have found that it works best when combined with other skin tightening procedures such as laser resurfacing and chemical peels of the rest of the face.

Dr. Barry Eppley

Indianapolis, Indiana

Botox Injections Using Ultra Small Needles

Wednesday, September 16th, 2015

Botox Injections Dr Barry Eppley IndianapolisBotox injections into various areas of the face are tremendously effective at reducing specific wrinkle areas, particularly around the eyes and forehead. While effective they are not necessarily pain-free. Despite using a very small 30 gauge size needle, some discomfort still exists with Botox injections. This has led to a variety of pain management strategies from ice to topical anesthetics to help make the injections as comfortable as possible.

In the September 2015 issue of the JAMA Dermatology journal, an article appeared entitled ‘Pain Perception with Botulinum Toxin Type A Injections’. In this study the authors compared differences in the perception of pain with Botox injections using 30 vs 32 gauge needles. Twenty (20) patients were studied using a blinded randomized clinical trial approach for their glabellar and forehead wrinkles with one side of the forehead injected with a 30-gauge needle and the other side with a 32 gauge needle. Similar injections were also done in the arms. For facial injections, more pain was seen with the  30-gauge needles which were associated with more pain in 8 patients (40%) compared with the 32-gauge needles, which were associated with more pain in 3 patients (15%) Mean injection pain scores for the face were somewhat lower with the 32-gauge needle (3.4/10) than with the 30-gauge needle (4.15/10). The mean pain scores were lower for the arm injections (1.2 with the 32-gauge needle and 1.66 with the 30-gauge needle).

The study found that significant pain was almost 4X times more likely with facial injections with 30-gauge needles than with 32-gauge needles. This was different in the arms where there was very little if any differences in pain associated with the two needle sizes.

small needles for injectionWhile this study is far from conclusive, it is logical to assume that the smaller the injection needle the less pain that may likely result from its use. While no injection can be absolutely pain free, use of 32-gauge needles may be as close as one can get. Because they are more expensive, however, many practices are likely to not routinuely use them and save them for the most pain-sensitive injection patients.

Dr. Barry Eppley

Indianapolis, Indiana

Botox for Glabellar Lines

Monday, September 14th, 2015


glabellar wrinkle lines for Botox Dr Barry Eppley IndianapolisThe glabellar frown lines (between the eyebrows) are a top target for Botox injections. They are what the initial studies for FDA approval was based on and continue to be the number one wrinkle area treated by injection. Other than an occasional bruise or temporary soreness in the injected area there are few other adverse problems that happen with injections in this part of the face. The typical effective dose of Botox is in the range of 16 to 24 units by most injectors.

In the September issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Efficacy and Safety of Botulinum Toxin Type A in the Treatment of Glabellar Lines: A Meta-Analysis of Randomized, Placebo-Controlled, Double Blind Trials’. In this paper the authors looked at seven studies comprising nearly 1500 patients to assess the safety and effective endpoint (dose) of botulinum toxin type A for treating glabellar lines. The seven studies included were all randomized, placebo-controlled and double blind trials that used an injection dose of 20 units. Their findings show the the botulinum toxin injected patients had much better improvement in their glabellar wrinkles than the placebo group but, interestingly, the same rate of adverse events.

The incredible popularity and use of neuromuscular modulators in the face using botulinum toxin injections over the past nearly two decades is a statement in and out itself. It is a testament alone that they must be fairly effective and incredibly safe. This study, which amassed well conducted other studies supports what widespread clinical use has shown.

Dr. Barry Eppley

Indianapolis, Indiana

Xeomin vs. Botox Neurotoxin Injections

Sunday, September 6th, 2015


Botox is the undisputed king of aesthetic neurotoxins since it was officially FDA approved in 2002. While newer neurotoxins from different manufacturers have since emerged (Dysport, Xeomin), they have not and likely never will topple the market share that Botox currently has. Most likely it will waver with modest changes back and forth very similar to what goes on the soda market battle of Coke vs. Pepsi.

But just because these other neurotoxins have a much smaller piece of aesthetic neurotoxin pie, does that mean they are inferior products? It is generally believed that all three neurotoxins are equivalent in terms of effectiveness and in how long they last. Botox is much better known, not only because they were the first neurotoxin FDA-approved and revolutionized the aesthetic facial industry, but because its manufacturer Allergan has done an outstanding job with its branding efforts.

Xeomin Injections Indianapolis Dr Barry EppleyAs the last of the neurotoxin three to enter the market, the comparative effectiveness of Xeomin has not been backed up by any good comparative science. A recent study, however, may finally put that issue to rest. In a recently reported prospective double-blinded study Xeomin and Botox went head to-head in the treatment of glabellar frown lines in several hundred women using 20 units of each drug. The study showed equivalence in terms of time of onset, peak effect, number of complications and patient satisfaction levels. Such study information is critical as doctors had to rely on their own experience and word of mouth as to the merits of Xeomin.

Despite its equivalence to Botox, the use of Xeomin is going to be highly influenced by the practice behavior of the injector. Some practices use all three neurotoxins while others may only use one exclusively. Personal preference, brand familiarity, practice behavior and cost all lead to preferences of neurotoxin use. The cost issue is what aspect where Xeomin excels over Botox. It comes at a lower acquisition cost and these savings can be passed onto the patient.

Change is difficult and for this reason many patients may not be willing to leave Botox for a different neurotoxin. But because of clinical equivalency neurotoxin experimentation is possible with no downside.

Dr. Barry Eppley

Indianapolis, Indiana

The Liquid Facelift – What It Is and Isn’t

Sunday, September 6th, 2015

The well known procedures of anti-aging facial plastic surgery continue to be debated as to which techniques are best. (e.g., facelift)  And those debates will undoubtably continue for decades to come as the differences in them are often subtle and no matter how it is done it is still a surgical procedure. In contrast, the number of options of non-surgical facial rejuvenation procedures continues with growing numbers of injectable fillers, neuromodulators and skin tightening devices.

liquid facelift indianapolisOne of the most well known but least understood injectable facial rejuvenation procedure is that of the Liquid Facelift. This office-based procedure is an amalgamation of neurotoxins (like Botox, Dysport and Xeomin) combined with a variety of different injectable fillers. (e.g., Juvederm, Voluma) These are often combined with some skin resurfacing tightening procedure like a chemical peel, fractional laser resurfacing or pulsed light therapies. Because it is non-surgical, a Liquid Facelift has next to no downtime, requires no anesthesia and its full effects are evident within days to a week after it is done.

It is touted as a procedure that can take years off the face and can maintain or restore a youthful glow without surgery. While all three techniques (wrinkle weakening, adding facial volume and skin tightening/resurfacing) work synergetically, the back bone of the procedure as the name implies is the injectable filler part. Fillers add volume and with today’s number of injectable filler options exceeding a dozen, the choices are numerous most of which are hyaluronic-acid based. But almost no matter which FDA-approved injectable filler is used, they are all temporary with the exception of one. (Bellacol which contains small plastic non-resorbable beads) It is only question of how long they will last.

The volume effect of the injectable fillers is designed for the midface to add fullness and help create more of a V effect. Whether it really does much lifting can be debated but what it can do is increase cheek and midfacial contours. This can counteract the geometric effect when facial tissues fall (inverted V) and can correct cheek hollows from fat loss. The intent of creating this midfacial effect has led to the Liquid Facelift also being called the Liquid V-Lift.

While the Liquid Facelift has its place in facial rejuvenation, it should not be confused with what a surgical facelift can accomplish. These differences make it critical for patient selection and expectations. While age along is not the only factor, a Liquid Facelift is really for younger patients with early signs of facial aging that do not have a lot of loose skin. Significant jowls and turkey waddles are not going to get improved by an amount of volume addition or superficial skin tightening.

Dr. Barry Eppley

Indianapolis, Indiana

Botox vs. Xeomin for Upper Facial Wrinkles

Wednesday, May 27th, 2015


Aesthetic facial neuromodulation, aka ‘Botoxing one’s face’, is a long proven method for reducing the development of certain facial wrinkles and unwanted facial expressions. It has been done for so long and with such success that the original facial neurotoxin and still the most popular, Botox, has worked its way into the cosmetic procedure lexicon as a verb.

Botox Facial Wrinkle Injections Dr Barry Eppley IndianapolisBut Botox is not the only player in the injectable neurotoxin market as two ‘younger’ products have appeared in the scene in the last five years, that being Xeomin and Dysport. While all three advertise, promote whatever subtle differences that may exist between them and physicians have their preferences between them for their own reasons, but it is not really clear whether one is more or less effective than the other.

In the May 2015 issue of Plastic and Reconstructive Surgery journal, the article entitled ‘A Prospective Split-Face, Randomized, Double-Blind Study Comparing OnubotulinumtoxinA to IncobotulinumtoxinA for Upper Facial Wrinkles’ was published . In this paper a clinical study was published on 45 patients (41 women and 5 men) who had three types of facial wrinkles treated  using a 1:1 dose ratio of Botox and Xeomin. A total of 50 units of each drug was administered to the upper face in three areas. (glabella, forehead and crow’s feet) and evaluated over a four month period. The effect on the wrinkles was assessed by a scale amongst blinded physicians. For toxin comparison, the researchers calculated differences in the degree of wrinkle scale at each period compared with pre-treatment and performed statistical analyses. They analyzed wrinkle types both individually and combined.

Xeomin Indianapolis Dr Barry Eppley IndianapolisTheir results showed that at identical doses, both Botox and Xeomin are safe and effective in the treatment of upper facial wrinkles. However, Botox  had statistically greater effectiveness in dynamic wrinkle reduction at each point in the study out to four months. This would suggest. although does not prove, that Xeomin may need higher doses to be equally effective.

Dr. Barry Eppley

Indianapolis, Indiana

Counterfeit Botox in the U.S. Alert

Saturday, April 18th, 2015


Botox injection therapy is the single greatest pharmacologic agent in use today for non-surgical facial rejuvenation. It has been become so popular and used that patients talk about getting ‘Botoxed’…reminiscent of days when copying was known as ‘Xeroxing’. That is how you know your product has worked its way into the national lexicon when its name becomes used as a verb.

Fake BotoxWith such treatment popularity, competition is inevitable (which is good) but imitators may also emerge. (which for a drug can be very bad) Known as ‘Black Market Botox’ drugs that appears as the real Botox or try to be passed off as such have been known to occur. The FDA reports today that such compounds have been found in the U.S. and may be being used in some doctor’s office and clinics. This occurs when an unlicensed supplier who is not permitted by FDA regulations to ship or distribute products into the U.S. does so.  Offering seemingly similar effectiveness but at lower prices is the inducement for physicians to purchase and use it. Patients would have no idea that an unlicensed drug may be given to them during their treatments.

Botox Injections Indianapolis Dr Barry Eppley IndianapolisSince these compounds have not been manufactured according to FDA standards, there is no assurance that they are safe or effective. How can one tell if their ‘Botox’ is real? For physicians it can be determined by the packaging and the actual vial that contains the compound. On real Botox as manufactured by Allergan the active ingredient known as  onabotulinum toxin A is listed on the outer carton as well as on the glass bottle. With the fake compound, the active ingredient is listed as botulinum toxin type A is listed on the outer carton and glass bottle. Also on the fake product the glass bottle may be missing any lot numbers.

For patients determining that they be given a counterfeit product may be impossible to tell. Very low advertised prices per unit or extraordinary specials may be a clue. Injections done in non-medical settings by dubiously qualified injectors may be another tip off. Any change in the effectiveness of one’s ‘traditional’  Botox treatment may also raise some suspicion.

Dr. Barry Eppley

Indianapolis, Indiana

An Anatomic Study of Botox Injections For Drooping Mouth Corners

Thursday, November 6th, 2014


Botox can be used for a wide variety of facial deanimation purposes that has aesthetic benefits. By far the most common facial area that is treated by Botox injections because of its undesireable wrinkles and furrows created by excessive muscle activity is the forehead. A far less common area is that on the south side of the face around the mouth.\

Depressor Anguli Oris Muscle Botox for Drooping Mouth Corners Dr Barry Eppley IndianapolisOne of the features that makes for an aged or unhappy appearance is that of drooping or downturned corners of the mouth. This is partially contributed to by the weight of falling midfacial tissues, but an overactive depressor anguli oris (DAO) muscle can also play a major role. This muscle originates from the lower jawline and comes upward and inserts into the modiolus muscle as well as interconnects with other adjacent facial muscles as well. (risorius, zygomaticus and depressor labii inferiorus) The action of the DAO muscle pulls the corner of the downward.

Botox injections into the DAO muscle can help lift and level out a downturned corner of the mouth. But to be effective, its injection must be precise due to numerous muscular interconnections. In the November 2014 issue of the journal Plastic and Reconstructive Surgery, on this topic entitled ‘Anatomical Considerations Regarding  the Location an Boundary of the Depressor Anguli Oris Muscle with Reference to Botulinum Toxin Injection’ was published. Using cadavers for study, they found that the modiolus was located about 1 cm to the side of the mouth corner and slightly less than 1 cm below this lateral point. The DAO muscle fans oout below the modiolus and is located less than 45 degrees lateral and less than 30 degrees medial to the modiolus down to the jawline. The authors suggest that this fan-shaped area is the safest and most effective Botox injection site.

The modiolus is the intersection of all muscles that act on the corner of the mouth. Since the DAO muscle pulls down on the modiolus, its hyperactivity can lead to drooping of the corner of the mouth. Injection of Botox into the DAO will allow for its weakening and allow its antagonists (levator anguli oris and zygomaticus major muscles) to lift up the mouth corner.

Dr. Barry Eppley

Indianapolis, Indiana

Botox Injections for Lower Facial Contouring (Masseter Muscle Reduction)

Monday, August 11th, 2014


The large masseter muscle (masseteric hypertrophy), unlike the prominent bony jaw angle, does not have a surgical solution. Surgical muscular reduction is associated with a high rate of complications and potental disability. As a result, the use of botulinum toxin type A injections (most commonly Botox) has become the standard of treatment to improve lower facial contour due to large masseter muscles.

There is little question that Botox into the masseter muscles can be effective but there is little standardization in dose and injection points of treatment. Dosage amounts vary amongst practitioners as well as treatment schedules. Long-term outcomes of a sustained effect remain wanting.

In the August 2014 issue of Plastic and Reconstructive Surgery, a paper on this topic was published entitled ‘Classification of Masseter Hypertrophy for Tailored Botulinum Toxin Type A Treatment’. In this  paper over 500 masseter muscles were classified into bulging types with three degrees of thickness. Over 200 patients were treated with Botox injections of 20 to 40 units per side with one to three injection sites per muscle. After injection, masseter muscle thickness decreased by an average of roughly 33% (13mms to 9mms approximately) as measured three months later. There was a corresponding improvement in the width of the lower face to the upper facial intercanthal distance. Overall patient satisfaction was 96% without any serious complications.

This study provides evidence in a large series of patients that an injectable approach to massteric muscle reduction is effective. Its maximum effect occurs by three months after treatment with a visible reduction is lower facial width. Dosages in units should be increased based on the muscle characteristics anywhere from 20 to 40 units per side. It is important to keep the injections into the bulk of the muscle closer to the jaw angle area to avoid a temporary weakening effect on the buccal branches of the facial nerve.

What this study does not address is how long this muscular facial thinning effect lasts and how many treatments it takes to achieve its maximal effects. It is still unclear as to whether Botox causes a permanent muscle atrophic result in the muscles of mastication.

Dr. Barry Eppley

Indianapolis, Indiana

Comparing Botox, Dysport and Xeomin Injectable Facial Neuromuscular Modulators

Sunday, April 20th, 2014


The announcement this month that Johnson & Johnson (J & J) has pulled any further development of their aesthetic neuromuscular modulator PurTox was a surprise. It was certain several years ago that a fourth injectable drug would soon be on the market to compete with the big three, Botox, Dysport and Xeomin. But it now appears that these three cosmetic drugs will only have only to compete amongst themselves for some time into the foreseeable future.

Botox Facial Wrinkle Injections Dr Barry Eppley IndianapolisIt has now been three years since the last of the big three (Xeomin) was approved. And while there has been some minor new FDA approvals for indications that were already widely done off-label anyway (crow’s feet), the number of men and women seeking this injectable cosmetic treatment continues to grow. Having multiple products to treat unwanted facial lines and wrinkles has helped create awareness and grow the market. These drugs today are as accepted as capuccinos and are done almost just as much. To some degree, Botox and his competitors have very much become commodities where the lowest cost per unit often sways what provider/location that a patient will go to.

This raises the question of how do these drugs differ and, what advantages if any, do any of them offer over the others? What all three drugs share is that they are FDA-approved Type A botulinum toxins. They work exactly the same through the same mechanism of molecular action and all have the same type of heavy chain receptor. While Dysport and Xeomin have a little shorter onset (1 to 2 days), they last the same amount of time as Botox having a duration of action of between 3 and 4 months after injection.

Dysport Indianapolis Dr Barry EppleyThey do differ significantly, however, in their dosing and methods of storage. The dosing of Dysport is very different from that of Botox or Xeomin. This makes it difficult to compare Dysport to the other two in clinical studies. While the biologic activity is the same for Botox and Xeomin, it is quite different for Dysport and there is no standard dose conversion. While all three must be reconstituted on the day of administration, Xeomin does not require refrigeration which makes it more portable and not prone to be accidentally left out of cold storage after a treatment.

From a marketing and public awareness standpoint, Botox is the dominant force occupying close to 80% of the market. It is the ‘Coke’ of the injectable neuromuscular modulators, the most studied and also the most expensive. Dysport and Xeomin are the ‘Pepsi’ and ‘Seven-Up’ by comparison and are still trying to gain market share. As a result they are priced under that of Botox and is there only real method of improving their small market share given that they have no other advantages.

Xeomin Indianapolis Dr Barry Eppley IndianapolisSome small claimed advantages over Botox for Dysport is that it has wider zone of diffusion from the injection site. This may be an advantage in the bigger muscles areas of the frontalis muscle of the forehead and the orbicularis muscle of the crow’s feet area. But would be a disadvantage in a discrete muscular area like the glabella which is also the number one area for all aesthetic neuromuscular injections. Xeomin claims a less risk of allergic reaction than with Botox because it does not contain hemagglutin and non-hemagglutin complexing proteins. While this may be theoretically true, the incidence of allergic reactions to Botox is so insignificant after over twenty years of clinical use that this advantage is meaningless.

While there are other aesthetic injectable neuromuscular drugs under development, none of them seem to have any major advantages over the big three that are available now. Every patient would like them to last longer (or be permanent) and cost less but that does not appear to be likely for as far as one can see into the future. The one promising approach is that of a topical botulinum type A gel of which several companies have ongoing clinical trials. Avoiding needle sticks could be the one advantage a new product could have that would help shakeup the market as we know it now.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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