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Neuromodulators – Dysport and Botox
The most popular cosmetic procedure in the world is wrinkle reducing injections with neurotoxins or the friendlier term, neuromodulators. The injections work by reducing the activity of the muscles they are injected to, thereby resulting in less movement and less dynamic wrinkles.
The history of neuromodulators dates to the isolation of the botulinum toxin, the cause of botulism, in the 1928. It was later refined and made commercially available for injections in the 1989 and initially FDA approved for strabismus, lazy eye. Soon thereafter, blepharospasm, spasm of the muscles around the eye, treatments were approved. The team of Carruthers and Carruthers observed that during blepharospasm treatments, the wrinkles around the eye, crows feet, were also improved. Studies were later performed on the frown lines, and FDA approval for cosmetic use was achieved in 2002.
The current areas most often treated with neuromodulators are:
- Frown lines – glabella
- Crows feet
- Forehead lines
- Bunny lines
- Brow lift
- Smokers lines
- Enlarged masseters for TMJ and facial slimming
- Depressor Angularis Oris – DAO to upturn the mouth corners
- Platysma bands
- Gummy smile
- Walnut or hyperdynamic chin
- Undereye for wrinkles or opening the eye
Other treatments neuromodulators are used for:
- Hyperhidrosis of axilla, hands, feet, face, scalp
- Reducing scarring by decreasing movement around incisions
Duration of neuromodulators is highly variable among individuals and location. Typical durations quoted are 3-4 months. It takes 2-5 days (Dysport sooner than Botox) for the initial onset of the neuromodulator to appear, and it peak effects in 2-3 weeks. Starting about 2 months after injection, the muscles gradually start to gain more activity. In other words, the relaxing effect of neuromodulators isn’t equal throughout the treatment, with the last 4 weeks showing increasing muscle activity. While studies show that there is still a small effect on the muscle at 5 months, it is generally recommended to get re-injections at 3-4 months. Waiting too long for follow up injections allows the muscles to regain their full strength and the wrinkles reestablish. In areas such as the forehead, dosing is usually less to allow movement and a more natural appearance. When dosing does not completely immobilize an area, the duration will be less. Lip injections with neuromodulators last only 4-6 weeks because too high a dosing leads to problems with drinking or pronunciation. There should be no difference between the brands of neuromodulators if equivalent doses are used. (see below for further explanation). There are some patients who will get more or less duration and that’s a function of:
- Body’s metabolism
- Activity of the muscle
There is a grading system for the strength of glabella frown lines: 0-4. During FDA trials, a success is when the strength is changed 2 grades. For patients with a grade 4 glabella, it is nearly impossible for them to go all the way to a grade 0. If the treatments are performed regularly, there should be gradual improvement as the muscle atrophies, and it could be possible to achieve a grade 1.
Wrinkles that appear without movement are static wrinkles. These are distinct from dynamic wrinkles which appear with movement. Static wrinkles do not respond well to neuromodulators and often need other treatments such as lasers or fillers. This is especially true for forehead lines and glabellar creases.
There are currently 4 FDA approved neuromodulators of botulinum toxin A for cosmetic use: Botox, Dysport, Jeuveau, and Xeomin. They all work similarly by blocking the acetylcholine release at the neuromuscular junction. Each brand has their own definition of what a unit dose is, so this can be confusing to both the practitioner and the patients. The differences between the 3 is the associated inactive protein, or absence of this protein in the case of Xeomin. Studies have shown that once the drug powder is mixed with water or saline in the provider’s office, the inactive protein disassociates almost immediately. Why then, are there differences in clinical outcomes between the 3 neuromodulators?
There is a recent comparison of the active protein molecule in the 3 products dosing in the glabella. The study looked at the FDA approved doses for frown lines – glabella. A very interesting finding was that there was 0.27ng in Dysport using the 50u dose vs 0.18ng in Botox’s. Xeomin was a distant 3rd coming in at 0.08ng with their 20u dose. In essence, patients are receiving a stronger dose when using Dysport when compared to Botox or Xeomin.
It’s long been established that Dysport seems to be effective (in 1-2 days) sooner than Botox (3-4 days) but the reason was never clearly elucidated. It’s also well known that higher dosing of any of the neuromodulators will lead to longer durations of action. This higher level of active protein with Dysport can explain the clinical phenomenon of quicker onset and longer duration.
One other topic needing addressing is the myth of higher diffusion with Dysport vs Botox. Diffusion or spread, is a result of dosing, volume, speed of injection and not a function of the neuromodulator. As stated before, when reconstituted, all the products are free of their associated proteins and only consist of free, active protein. We now know that Dysport has more active protein in their approved dosing, so to compensate, lower volumes must be used for reconstitution. The author’s recommended reconstitution for Botox is 2cc and for Dysport is 1.5cc for the glabellar injections. When diffusion or spread is desired, larger volumes can be used.
With the recent comparison study of active protein in the dosing schemes of the 3 commercially available neuromodulators, it is easy to see why Dysport should be the standout choice. Dysport gives more effective treatments because of the higher active protein, leading to quicker onset and longer duration (up to 5 months) than Botox and Xeomin. Pricing is usually less with Dysport, so it becomes a “no brainer” 1st choice for Dr. Weiner’s practice.
For those patients who desire Botox over Dysport, The Aesthetic Clinique will gladly perform Botox treatments. Dr. Weiner’s experience with Botox dates to 1994. At that time, Botox was used for therapeutic treatments only – neck and facial spasms, TMJ, and spasmodic dysphonia. He started cosmetic Botox injections long before the FDA approval for frown line injections in 2002.
Xeomin is not routinely administered at The Aesthetic Clinique.
Jeuveau is currently being evaluated by Dr. Weiner and it will be determined if it will become part of our regularly offered neuromodulators.