Neuromodulators: Botox, Dysport, Xeomin
Botox, Dysport and Xeomin
Patients often seek treatments for facial aging that avoid surgery. In addition, patients who have had surgery seek methods to maintain their surgical result as long as possible while minimizing the effects of aging. Although the media often likes to link the now household terms Botox and various dermal fillers, it is important to note that these wonderful treatments are not similar at all. Botox is designed for the softening of dynamic lines (those that appear with facial movements such as smiling or frowning) and to soften static lines (those that are present at rest). During the aging process, the skin undergoes something called subdermal atrophy. This means essentially that skin becomes thinner and loses volume. Juvederm and other dermal fillers are designed to fill or plump the tissue of static lines caused by subdermal atrophy. One only needs to compare the hands of a 30 year old to that of a 70 year old to understand the problem with subdermal atrophy.
Injectable Therapy at Austin Cosmetic Surgery
BOTOX® injections soften the movement of the fine muscles around the eyes, forehead, lips, chin, and neck that cause creases in the skin called rhydids. By selectively weakening the proper muscles at key injection points, the provider can dramatically reduce wrinkles. In certain instances however, wrinkling may be too deep and either require surgical procedures or volume-enhancing procedures such as the placement of dermal fillers combined with Botox.
During treatment, very low doses of BOTOX Cosmetic are administered via a few tiny injections. “Frown lines” are caused by overactive facial muscles. BOTOX Cosmetic is intramuscular, blocking the chemicals that cause facial muscles to contract, thereby relaxing them. You can expect to see results within days after your treatment. The appearance of your “frown lines” may continue to improve for up to a week. Visible results can last up to 4 months. After that, you may be ready to return for a follow-up treatment. Your own results may vary, be sure to talk to our doctors about what you can expect.
While the treatment can be used alone, it is often used in conjunction with other cosmetic procedures such as soft tissue fillers (eg. Juvéderm®, Radiesse®). Botox® is often combined with surgical procedures such as face-lifts, blepharoplasty or laser resurfacing.
BOTOX has been used therapeutically for over 75 years to treat a variety of medical conditions. It is approved in more than 75 countries. Only licensed and trained healthcare professionals have the experience necessary to administer BOTOX Cosmetic. Allergan, Inc. is the only source for healthcare professionals to purchase the product, and each label has the “Allergan” hologram. Drs Carlotti have injected thousands of patients with BOTOX Cosmetic.
What Is a Neuromodulator?
Botulinum toxin (BoNTA) is a metabolic product of the Gram-positive, spore-forming bacterium Clostridium botulinum that was first isolated in 1946. It’s uses for medical intervention in blepharospasm and strabismus began in 1977, and the FDA approved treatment in these areas and for hemifacial spasm in 1989. Aesthetic trials began as cosmetic improvements were noted as a side effect of BoNTA for medical treatments. In 2003 the FDA approved BoNTA (Botox) for the treatment of frown lines (glabellar region), and then many off-label uses for facial wrinkle reduction emerged. Increased understanding of the mechanisms of action of this neurotoxin has led to the therapeutic use of botulinum toxin in modern medicine. Botulinum toxin can be divided into seven serological distinct forms, types A-G. The various serotypes differ in their duration of effect and potency, whereby type A has the most potent effect with the longest duration. Type A botulinum toxin is currently the main stereotype used in all commercially available neurotoxins on the market, especially with regard to the aesthetic indication.
Mechanism of Action
Botulinum toxin acts directly on the neuromuscular endplate and other cholinergic synapses, where it inhibits release (not the production) of the neurotransmitter acetylcholine, leading to temporary paralysis of the affected muscle fiber. The various serotypes of botulinum toxin all bind to the same receptor but exert their effect on different proteins within cholinergic nerve endings. Botulinum Type A cleaves the protein SNAP-25 involved with anchoring of acetylcholine to the plasma membrane. By inactivating the SNARE complex, the botulinum toxin prevents the release of acetylcholine into the synaptic cleft, stimulus conduction is thereby cut off. In striated muscle, this chemical enervation lads to flaccid paralysis, while in smooth muscle it produces atonia. The inhibition of sympathetic cholinergic nerve fibers also causes a reduction or loss of sweating, referred to as anhidrosis. This treatment is common for the palms of hands, feet, and underarm area. The botulinum toxin effect described above can be put to therapeutic use in a variety of cosmetic and medical disorders.
How Long Do the Results Last?
With the main serotype botulinum toxin, the initial effect sets in no earlier than 24 hours to 48 hours after the injection. Clinically relevant paralysis is observed after 2-10 days. The peak effect is then reached after about 2 weeks. New SNARE complexes are formed 10-12 weeks after the injection and the nerve ending start to regain their original function. Treatment with BoNTA typically lasts for approximately 3 months. However, clinical effect due to other factors including atrophy and behavior modification (not forcing muscle movement) may last considerably longer. Considerably longer efficacy period has been observed in the treatment of hyperhidrosis, up to 6-12 months of remission. Products and Dosage: Preparations of botulinum toxin A are offered under a variety of trade names on the European and American market. The manufacturer-specific preparations of BoNTA and key clinical differences are explained below:
- OnabotulinumtoxinA (Botox): Allergan, USA; FDA approved 2003; Onset 1-3 days; duration 3-4 months. It is supplied in 50-100 unit vials of vacuum dried powder neurotoxin complex, human albumin, and sodium chloride. Reconstitution is done with non preserved 0.9% saline solution. More biological activity per unit than Dysport and comparable to Xeomin. Great for treating small areas with precision or the dilution can be enhanced to treat larger areas. Most widely used BoNTA on the market.
- IncobotulinumtoxinA (Xeomin): Merz Pharmaceuticals, Germany; FDA approved 2011; Onset within 7 days; duration up to 3-4 months. Supplied in 50-100 unit vials of lyophilized powder neurotoxin complex, human albumin, and sucrose. It s reconstituted with 0.9% non preserved saline solution. It is free and separate from any accessory proteins or additives making it the only BoNTA that does not have to be refrigerated before use. Another benefit of this pure-form injectable is that the body is less likely to become resistant to it. A small percentage of patients have developed antibodies to Botox and Dysport which leads to treatment failure, especially when given high doses at too short of intervals. Biological activity and dosage are comparable to Botox, but Xeomin has the slowest onset of action of the 3 BoNTA’s.
- AbobotulinumtoxinA (Dysport): Galderma, Switzerland; FDA approved 2009; onset 1-2 days; duration up to 4 months. It is supplied in a 300 unit vial of freeze-dried neurotoxin complex, human albumin, and lactose that may contain trace amounts of cows milk proteins. It is reconstituted with 0.9% non preserved saline solution with 1.5-2.5ml per. Higher quantity needed in Dosage. The formula contains smaller molecules compared to Botox, which may be beneficial. Smaller molecules enable Dysport to work faster than Botox with some achieving onset results within 24 hours, and Botox taking up to 72 hours. A larger area of spreading can also be achieved that is great in some patients and in others could lead to droopy brows. Dysport is less effective in treating smaller areas where more precision is needed or areas with thicker muscles.
The relative potency of the three commercially available botulinum toxin A preparations is a subject of great debate and of countless articles in medical literature. Time to onset and maximal results vary among BoNTA products and may be dose-dependent. Most clinicians regard the preparation of Allergan (Botox) and Merz (Xeomin) as having similar potency while the preparation of Galderma (Dysport) being less potent per unit. As guidance, the approximate dosage equivalence relation between them is 1 unit of Botox: 1 unit of Xeomin: 2.5 units Dysport. This means that an injection of 2.5 units of Dysport and an injection of 1 unit of Botox or Xeomin leads to comparable results. Correct administration of the active substance is a prerequisite for a successful treatment.
It is important to give a full medical history to your provider so they can determine if there are any contraindications or precautions that need to be addressed such as:
- Allergy to the active substance or additives such as sodium chloride, human albumin, and cows milk (abo).
- Infection or lesions in the area being treated (herpes simplex)
- Neuromuscular disorders such as myasthenia graves
- Drugs such as aminoglycoside antibiotics (gentamicin, spectinomycin, tobramycin)
- Pregnancy or while actively breastfeeding, due to lack of adequate data.
Which Neuromodulator Should I Choose?
The choices between Neuromodulators may come down to a simple preference of both the injector and the patient. Some skilled injectors may even use a combination of treatment during the same visit to achieve the most desirable outcome. It is very important to go to a provider who has lots of experience, knowledge, and expertise in proper dosing and placement of all BoNTA.
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