Aesthetic neuromuscular modulators, known more commonly as Botox, Dysport and now Xeomin, has been a decades old concept from an FDA standpoint….and twice that long as an off-label use for the treatment of unwanted facial expressions and wrinkles. Because the dose of each of these injectates will vary between each patient, it has become clear that their use is as much art as it is a science. While manuals exist as guidelines for where to inject and doses to use, each patient must still be treated individually.

The dosing issue has become more complicated now that there is more than just Botox available. Most physicians feel that there is a 3:1 unit comparison between Dysport and Botox and the jury is still out on where Xeomin will compare. I generally use 24 to 30 units of Botox for the glabella, frontalis and crow’s feet areas, the most common area for neurotoxin use. This works well for most patients and is a good value point for a cosmetic treatment that will last around four months. By comparison, the comparative dose of Dysport would be 70 to 90 units for the same areas.

There remains some controversy about whether Botox or Dysport is ‘better’. There is tremendous brand loyalty amongst providers to Botox and the company certainly does a lot of marketing and promotions to maintain it. I think Dysport has done a relatively poor job of how it markets and promotes its equivalent and, as a result, it continues to be occupy a relatively small piece of the injectable neurotoxin market in the United States. Whether that will change depends ultimately on how well it works in the years ahead.

It appears fairly clear that Dysport does have a few days of earlier onset and a greater zone of diffusion than Botox. This makes it preferable to those who want to have a quick onset of action and may be better in the crow’s feet area where the orbicularis muscles are broad. Because of this greater diffusion, some feel that it has a higher risk of unintended effect in areas where numerous muscles have opposing actions such as around the mouth. I have heard and read that Dysport lasts longer and is more cost-effective but these claims are not substantiated by any clinical study.

Unlike ten years ago, the one area that Botox and its competitive analogues have had increasing use is as an adjunct and sometimes a replacement for surgery. For many patients, reducing muscle action in the forehead can delay or eliminate the need for a surgical browlift. While this so-called chemical or pharmacologic browlift is very useful in the forehead, it is ineffective for the mid- or lower face as a lifting technique. For those patients actually undergoing a browlift, injecting Botox either before or after the procedure can enhance the results. I find it particularly useful in my Indianapolis browlift patients for injecting during surgery to get the best lift possible in the tail of the eyebrow. This is an area that can be the most difficult to surgically lift as opposed to the central brow.

Another area that injectable neuromuscular modulators are very helpful is in laser skin resurfacing. By injecting at least a week before surgery, the muscles are relaxed so there is not as much pull on the healing skin as it is healing. That does provide some better comfort although touting it as promoting better healing is not based on any science. A good protocol that I use is to inject Botox two weeks prior to laser resurfacing and then again at three or four months afterwards to maintain a good smooth result. Keeping the muscles relaxed will also prolong the results of many non-surgical treatments besides laser resurfacing such as injectable fillers, chemical peels, and skin tightening devices. (Skin Tyte, Thermage, Ulthera)

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Cankle Lipo

Liposuction can be performed almost anywhere there is some thickness of subcutaneous fat. The thick leg, between the knee and the ankle, represents differing thicknesses of subcutaneous fat which yield an amorphous lower leg that has a straight line shape. Creating an improved shape comes by creating a thinner profile, or inward indentation, from the lower end of the calf down to just above the ankle bone. (particularly above the inside of the ankle) Discrete small-cannula liposuction can be safely done to reduce the appearance of a chubby ankle.

The key is to not overdo the liposuction area and focus on a limited treatment area that will make the most difference. Because of the elevated venous and lymphatic pressures, the ankle swelling after surgery is more prolonged than liposuction does in almost any other area of the body. But the results can be very visible later and a modest shape improvement is definitely achievable.

Earlobe Lift

Even though the earlobe is small, it is extremely visible. Its appearance can definitely create an impression as to one’s age. (much like one’s hands) An abnormal earlobe, like the ‘pixie earlobe’ deformity after a facelift, is particularly unflattering and a well-known sign of a ‘bad facelift.’

As we age, the earlobe for some people actually deflates losing some of its fat volume.  It may also get elongated, particularly in women, due to decades of ear ring wear. The deflated or stretched out earlobe can be rejuvenated. Injectable fillers are an easy and immediate fix to the wrinkled and delated earlobe. A few tenths of a cc of Juvaderm (or amost any filler) provides an instant plumping. Fillers in the earlobe seem to last longer than almost anywhere else in the face, perhaps due to its slow lymphatic clearance. This is a not uncommon request after someone has had a facelift. The floppy thin earlobe looks out of place after.

In the elongated earlobe, a simple earlobe lift can be done by removing a full-thickness wedge of tissue. Done under local anesthesia, a shorter and fuller earlobe is the result.

Dimpled Chin

Neuromuscular injections have found a low of uses but no matter where it is placed on the face it is for muscle weakening or paralysis of an area of hyperactivity. One of the uncommon but very effective uses for this treatment is in the softening of chin fasciculations. Some patients will experience excessive muscle activity of the mentalis muscle. This is a small but thick muscle that envelopes the bony chin with attachments into the overlying skin. When this muscle becomes stressed, through habit or from straining in a short chin, the chin skin will develop irregular dimples and assume an almost golfball shape. In the extreme, it can be quite noticeable and peculiar-looking.

Muscle weakening injections, like Botox and Dysport, can lessen these chin skin irregularities. While not permanent, repeat injections over time make allow for some expression re-education.

Knee Liposuction

When looking at the legs, it is important to look at the entire legline particularly its inner aspect. The inside of the knee is one small area that can stick out and breakup a smooth transition from the inner thigh down to the calf. It is one of the most bothersome leg areas for many women. It is an easy area in which to do liposuction from a small incision located in the backside of the knee. A surprising amount of fat can be quickly removed and it is important to blend the fat removal down into the upper calf and upward into the knee and lower inner thigh so a smooth flow of the inner leg line is obtained.

It is uncommon to just do knee liposuction alone. It is almost always done as part of inner and outer thigh reshaping. One important patient consideration is that the knee will be sore for some time, often longer than any other liposuction area. Because the knee is a moveable joint, there is a lot of continuous motion across the area leading to prolonged swelling and discomfort. I advise my patient to wear an elastic athletic knee strap afterwards for several weeks. Not only does it stay on but the contiunous support helps reduce discomfort.

Neckline Botox

Even after a good facelift, low neck lines (necklace lines) may still be present. No form of  a necklift can produce  as much improvement way down in the neck below the adam’s apple as it does above it. These low horizontal lines across your neck are a telltale sign of aging. One of the only methods to treat it are Botox or Dysport injections.

While claimed to produce a bit of a neck lift, some go as far as calling it a “Nefertiti lift.”  While there are no other options to treat these neck lines, I have never been impressed that a true neck elongation actually occurs. But a slight softening effect can be seen and it is quick and easy to do.  Whether injections into this neck area is beneficial is ultimately based on whether one feels that the cost is worth its temporary effect.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

1.      How soon will I see the results of my Botox treatment? And how long will it last?

Unlike injectable fillers, the effects of Botox are not seen immediately. It takes several days for Botox to begin to ‘kick-in’and a full week for its maximal muscle-weakening effects to be seen. Clinical studies show that the average length of time that Botox works is between 100 to 130 days. (three to four months)

2.      What is the difference between Botox and Dysport injections?

Botox was FDA approved for cosmetic use in 2002 and was the only injectable facial wrinkle reducer until recently. In the summer of 2009, Dysport became available as a competitive drug to Botox by a different manufacturer. It s a botulinum toxin with a slightly different molecular structure . While Dysport was released with much hype about its potential for lasting longer and being less expensive, my experience in my Indianapolis plastic surgery practice shows that much about it is comparable to Botox. If Dysport has any advantages over Botox, they are not yet apparent.

3.      Will my face be frozen afterwards? Will I look unnatural?

A common patient concern and misconception about Botox is that one’s face will look unnatural afterwards…and be like some Hollywood faces. While this can certainly be achieved with Botox, it takes a lot of injections (high doses) and cost to create this unnatural look. And this is usually beyond the budget and desires of most patients. Judicious use of Botox in a few select facial areas produces a relaxed and natural facial look. Botox is primarily used to reduce furrowing betweens the eyebrows, lessen horizontal forehead wrinkles, and make wrinkles around the eyes less noticeable.

4.      Does the regular use of Botox keep my wrinkles from getting deeper and keep me looking young?

Because Botox temporarily reduces wrinkling caused by continuous facial muscle activity, its regular use has long-term anti-aging facial benefits. Regular Botox use over years does result in less facial wrinkles because the cause of them has been reduced. I have seen this particularly illustrated in a set of identical twins where one has had Botox for over seven years and the other has not. The amount of facial wrinkles is significantly reduced in the Botox user.

5.      Are Botox treatments the same no matter where I go?

In theory, the results of Botox injections should be the same no matter where you go. But there are a variety of factors that affect how well Botox works and what results are obtained. Injector experience, how Botox is prepared, where on the face injections are given, and how many units are administered all affect what results are seen.

6.      Can one become immune to the effects of Botox?

Developing a resistance to a drug is always possible. Most patients never develop a tolerance or an immunity, but reported cases do exist. A minority of treated patients will develop a perception that Botox isn’t working as well as it used to. Whether this is because one has become accustomed to the results or whether it really is less effective is not clear. In these cases, one may try Dysport instead which has a slightly different formulation to which the body may be more susceptible.

7.      What other cosmetic and medical conditions is Botox useful?

Botox has been around for over twenty years and has a variety of approved uses. Most of these are for muscular conditions such as spasms in cases of paralysis and for strabismus. (continuous eye muscle twitching) Botox has been approved during this past decade for hyperhidrosis (excessive sweating) of the armpits, hands, and feet. Encouraging results are being seen in off-label applications of the face such as in the treatment of certain migraine headaches and TMJ and jaw muscle disorders.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarain West Medical Center, Avon, Indiana

Indianapolis 

Dysport, with its recent FDA approval, offers a competitive product to Botox. Another neurotoxin for aesthetic use is highly welcomed by many as some are frustrated by the service and price that comes from a monopolistic manufacturer. As Dysport has become commercially available, rumors abound that it lasts longer than Botox and its price will be less.

To date, no large scale studies have been published that can support or refute these supposed properties that Dysport provides. In the November 2009 issue of Plastic and Reconstructive Surgery, Kane and colleagues have published results from the clinical trial that evaluated the effectiveness of Dysport for glabellar lines. I presume that this information is what made up most, if not all, of the manufacturer’s submitted clinical data to the FDA for consideration for approval.

This was a phase III, double-blind, placebo-controlled study that was conducted in 27 centers and involved 816 patients. Patients were stratified by race and received a single treatment with Dysport or a placebo based on a variable dose that differed for women and men. They were evaluated up to 150 days after treatment. In essence, this was a very well designed and conducted clinical study.

In reading the results, one can draw the following conclusions of  clinical relevance. First, onset of the effects of Dysport were seen as early as 24 hours with a mean onset of 4 days. This does seem earlier than that of Botox and so the rumor that Dysport has an earlier onset of action does seem to be true. But it is not always within the first 24 hours but rather days. This means that it kicks in a few days earlier than Botox on average. The mean duration of effect for Dysport averaged slightly less than 110 days. When compared to Botox, this is a very comparable length of active time. The rumor that Dysport lasts longer than Botox appears to be just that…a rumor not fact. What is very interesting in the study is that the response and duration of action was slightly higher in African American patients. They do not speculate as to why.

A cost analysis was not done as part of this clinical study nor would it be appropriate for a clinical investigation. The study shows that there is not a dose comparison between Dysport and Botox as everyone knows. Given that the ‘average’ dose of Botox for the glabella is around 20 units, Dysport doses ranged from 50 to 80 units based on muscle mass and sex of the patient. That equals roughly 2.5 to 3 units of Dysport to 1 unit of Botox in dose administration. Knowing that ratio should help physicians and patients determine if they are getting a Dysport treatment that is equal to or less in cost than that of Botox.

The rumors that Dysport is ‘better’ than Botox are not substantiated in this large clinical study. It does show that it is just as effective and does offer a true competitive analogue. Whether it will cost less is determined completely by the pricing and incentives that your local provider may or may not give.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Botox and Dysport are the single most effective non-surgical treatment of the face for wrinkle reduction and an overall anti-aging effect. It is fairly simple to inject and the large numbers of patients who are successfully and happily treated, by practitioners of a wide variety of educational backgrounds, is a testament to its effectiveness and excellent margin of safety.

But adverse effects with Botox and Dysport do occur and they are exclusively of the aesthetic type. True medical complications have not been reported with the doses used in the facial cosmetic patient. One of the potential negative effects of Botox is that it doesn’t work well or at all which may be a reflection of its age or dilution. But its potential for lack of effectiveness is not what I want to cover here.

The most dreaded and well known complication of injectable neuromuscular facial treatments is upper eyelid drooping, known as ptosis. This occurs when the toxin diffuses or migrates from an injection site in or around the eyebrows down into the upper eyelid. The position of the upper eyelid margin drops down, covering some portion of the iris.  This is easily seen by all and no patient wants to walk around for months with an eyelid at ‘half-mast’. This results from injecting too close to the eyebrow or putting in large volume in an injection site near the eyebrow. Fortunately, eyelid ptosis is very uncommon as there is no known reversal or antidote to this problem other than letting it wear off.

One of the more frequently seen adverse effects is an unusual or unnatural looking forehead movements. When the area between the eyebrows (glabella) is treated, those pesky vertical lines  and furrows will go away but the rest of the forehead is unaffected. For those with very active forehead movements, this can result in a central zone of paralysis amidst a sea of moving forehead areas. This may also make the eyebrows lift up in its mid- to lateral parts but not in the brow area closest to the nose. (known as a ‘Spock’ brow) These abnormal forehead movements can be easily managed by the judicious placement of injections in other areas of the forehead to soften those movements and create a less active but more symmetric movement of the forehead and brows.

The last adverse forehead effect is an undesired lowering of the eyebrows, also known as ptosis. When too many injections are done above the brow and across the forehead, the eyebrow may feel heavy and actually drop a little bit. The arch of the eyebrow may change as well. In some cases, placing injections high up along the scalp line may cause the eyebrow to raise although this is not always successful.

Botox and Dysport have a very profound reducing effect on facial muscle movements where they are injected. But forehead movements, eyebrow and eyelid positions all may be adversely effected by these injections and sometimes it is possible to have too much of a good thing. In somes cases, additional ‘balancing’ injections can be done to counteract how the muscle movements have been affected. When in doubt as to whether more injections can be effective, I prefer in my Indianapolis plastic surgery practice to first use a local anesthetic that lasts for 24 hours or so and see if the patient finds it helpful…before proceeding with the longer acting injections.  Upper eyelid ptosis, however, is largely irreversible and must await the tincture of time.   

Barry L. Eppley, M.D., D.M.D.

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The wrinkle wars are beginning to heat up. After decades of a monopoly, there is finally a competitor to Botox for the treatment of facial wrinkles, Dysport. The introduction of Dysport now allows doctors to offer an alternative neurotoxin for facial cosmetic applications. Although Botox and Dysport  are both botulinum toxin type A molecules, they are manufactured somewhat differently. As a result, they have some subtle differences in their clinical effects.

Some of the reported differences with Dysport is that it has a faster onset of action than Botox. Rather than waiting for a week to work with Botox, Dysport begins to work in just a day or so. Another important difference is that the effect of Dysport is reported to last longer than Botox, sometimes by a month or longer. Although it should be pointed out that no studies have ever been done yet that compares Dysport to Botox in a head-to-head comparison. So the longer lasting benefits of Dysport are largely anectodal but may well be real.

Dysport also has a wider area of effect, known as spread. This suggests that injections may be spaced further apart, resulting in fewer needle sticks to get a good effect. Because of the spread difference, there will be instances when a patient could be injected with both Dysport and Botox in the same treatment session. For example, Dysport may be used in the forehead while Botox is injected into the crow’s feet area.

Although the marketing for both Botox and Dysport will become spirited, it remains to be seen which product patients will find more appealing. Some patients will undoubtably keep using Botox because of its familiarity and successful use. Others will become new adopters since some patients are always looking for new treatment options and want to use the latest available  technology. In my Indianapolis plastic surgery practice, I think patients who are very happy with Botox will continue to request it. However, there are definitely patients who were never completely satisfied with their Botox results or who feel that its effects are ‘weakening’or developing resistance.

One of the potential benefits of Dyport may be its pricing. It is being touted that the purchase price is 10% to 20% less than Botox which may allow for some pricing flexibility. It is believed that Dysport will have to be offered at a lower price to gain any traction in the marketplace. Whether Dysport will ultimately be lower in price than Botox at the patient level remains to be seen. As a treatment provider, there is more to pricing than just the raw purchase price of the bottle. If widespread clinical practice does show that Dysport lasts longer, it is unlikely than a lower price will persist for long.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Look out Botox, a new kid is on the block! Dysport is the newest wrinkle-reducing injection treatment in the United States. While widely used around the world, it was formally approved by the Food and Drug Administration in April of this year and is now becoming available in the local Indianapolis market. Just like Botox, it treats deep lines and wrinkles of the forehead by weakening or paralyzing the muscles that move it.

As the two prepare to go head to head in the battle for the cosmetic patient, how does one compare Dysport vs. Botox? Some doctors are saying Dysport works faster, lasts a little longer and is less expensive. It also might work on people for whom Botox has stopped working, because the body has built up a resistance to it over time after many injections. Other doctors are saying there is very little difference and they are really fairly comparable, but Dysport will definitely cause the price of Botox to drop.

According to one doctor who participated in the U.S. clinical trials on a large number of patients (1500 patients over 5 years), his experience was that it does last longer. In those patients who had tried both, his patients ‘loved’ Dysport and had great results with it. However, his experience is that Dysport is bit trickier to use which will have an impact on how good the results will be. It is not clear what makes it trickier. Most likely this means how it is injected and in what dose for any given area.  Whether one will have the same results as this physician, who has developed a very learned skill at using Dysport, remains to be seen.

There are some differences in the size of the toxin molecule which may account for the reported larger zone of diffusion from the injection site with Dysport. It is hard to know if this will be an advantage or disadvantage yet. The dosages between Dysport and Botox  with a bottle of botox being 100 units and a bottle of Dysport at 300 units. Clearly there will be a learning curve for the first few months of use to figure out how to optimally dose patients.

I can’t honestly say at this point, based on all that I have read, that the differences between Dysport and Botox are significantly different. Unless one has done a direct head-head comparison between the two in the same patient, one can only conjecture and believe whatever authority one chooses. Ultimately I will have to make these determinations based on my own patient experiences.

But what I can for sure is…the competition brought by Dysport will affect Botox usage and company behavior. Since Botox has had a monopoly on these treatments for many years, there is definitely a subculture of physicians who do not care for the service of Botox’s parent company and its pricing. Some of these will use Dysport out of spite or use it to market the newest beauty treatment on the block.  This will likely drive down the price of Botox as a result of the competition. While doctors may have a spurious debate over which one is better, the real winner will be the patients who will be able to get their ‘facial fix’ at lower pricing amidst the upcoming ‘toxin war’. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

It has finally happened….a competitive alternative to Botox for cosmetic facial wrinkle reduction has been approved by the FDA. Last week, The FDA put its stamp of approval on the boulinum toxin A drug Dysport. (had been known as Reloxin) This was anticipated since January when an FDA panel gave it a preliminary nod. Dysport has been used for some time in Europe and other countries so its formulation is not new. Actual distribution will begin in 30 days or so. Because of training requirements and a pent up demand, Dysport vials probably won’t start to flow and become widely available until mid-summer.

As the first (and surely not the last) major competitor to Botox, how does Dysport compare in clinical performance? The information from pre-approval clinical trials indicates that it is just as effective as Botox in facial muscle reduction and lasts the same month of time, around 4 months. Its one advantage is that its onset is quicker, occurring within a day or two rather than a week. This buys the patient an extra week of results for the same price so to speak. Unit dosages are different between the two so they cannot be compared by what we know now as a ‘Botox unit’.

In a 2006 Dermatology journal report, a clinical study compared Botox and Dysport. At a 2.5:1.0 unit Dysport:Botox ratio, Botox was more effective for wrinkle treatment. In a previous study cited by the same authors, a 4:1 ratio produced similar results, but the patients receiving Dysport had more adverse effects. To me this means that the proper use of Dysport will involve a learning curve even for experienced Botox injectors, which will slow its wide acceptance unless the cost difference significantly favors Dysport.

 

Dysport’s biggest advantage, therefore, will likely be its price. I am assuming that the quickest way to take a significant share of Botox’s market is to undercut it in price. Botox, because of its long-term monopoly on the market, has had ongoing price increases over the years and is not known for its service in many geographic regions. There are definitely significant numbers of physicians as a result that can’t wait to jump ship and use a competitor. Botox will undoubtably respond quickly by lowering its price. Where the price points and treatment costs will settle out for both is unknown at this point. But the patient is likely to be a winner in this scenario because of the stiff competition that will ensue.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis