FAQ's On BTXA Drugs

 - Dr. Liz Kelleher, drliz@lkaesthetics.com, (021) 484-3444

FAQ's on Botox® Cosmetic, Dysport®, Xeomin® Injections.

 

What is Botox and how does it correct wrinkles?

 

Not long ago, the so-called "dynamic" wrinkles; wrinkles caused by facial expressions, such as crow's feet, glabellar or frown lines, and forehead lines were the source of much consternation for patients and doctors alike because they were difficult to treat even with surgery. These wrinkles do not also respond well to laser resurfacing or dermal fillers, such as Juvederm and Radiesse (non-surgical methods). Currently, botulinum toxin type A, commonly known as Botox, is the most commonly injectable used in the management of these wrinkles. A tiny amount of Botox when injected into tense facial muscles inhibits contraction of the targeted muscle, causing it to relax. With less muscle movement, wrinkles on the overlying skin begin to soften. The cosmetic outcome of Botox injections is typically visible within 3-7 days and lasts for 3-6 months, depending on the brand and the dose of the product, the type and size of the muscle that is injected, and the quality and the age of the skin overlying the muscle.

The word Botulinum in Botulinum toxin, the neuromuscular blocking toxin in Botox, comes from the Latin word botulus, meaning sausage. A widespread illness during Napoleonic wars, now known as botulism, was then found to be associated with the ingestion of a toxin, now known as Botulinum toxin, secreted by the bacteria present in spoiled sausages.

Botulinum toxin type A found in Botox is one of the 7 distinct toxins lettered A through G, produced by Clostridium botulinum bacterium. Botox Cosmetic was the first commercially available diluted and purified botulinum toxin type A product that had received the approval of Food and Drug Administration (FDA) for cosmetic use. BOTOX Cosmetic is produced by Allergan, Inc., of Irvine, California. It is the most studied brand of botulinum toxin type A in the world.

What is the difference between Botox Cosmetic and facial fillers?

While Botox Cosmetic temporarily corrects or eliminates dynamic wrinkles by blocking the chemicals that cause the underlying muscles to contract; dermal fillers smooth out wrinkles that exist in the absence of any facial expression; that is, "static" wrinkles. Moreover, dermal fillers can plump up hollows and depressions, such as under eye hollows and sunken cheeks, caused by aging and dieting. There are several available fillers. They include Restylane, Sculptra, Radiesse, Juvederm, and Perlane.

Can Botox injections be combined with dermal fillers?

In cases where untreated wrinkles have become permanently etched in and appear even at rest, or when wrinkles are caused by the looseness of the skin, Botox injections can be administered in conjunction with other treatments, such as dermal fillers, or fractional laser resurfacing.

Botox, Dysport, and Now Xeomin - are they all approved by the FDA?

Despite the fact that Botulinum toxin was known for over a century, and was used for medical purposes for more than 50 years, it was only in 2002 that the FDA approved its use, as Botox Cosmetic, for temporary improvement in the appearance of moderate to severe glabellar lines--the vertical "11" lines that crease their way between the brows. In 2004, the FDA approved Botox for the excessive sweating of the underarms (axillary hyperhidrosis). The other botulinum toxin product in this class, marketed as Dysport from Medicis, was approved on April 29, 2009 for the same purpose. Xeomin, manufactured by Merz Pharmaceuticals, was the latest contender in the growing list of botulinum toxin products intended for the correction of glabellar lines. The FDA approved Xeomin in July 2011.

Which product is the best - Botox, Dysport or Xeomin?

While the active ingredient in Botox, Dysport, and Xeomin is the same Botulinum toxin, the preparations differ in the way they are manufactured and purified. As a consequence, concentrations and units of administration doses are different, Dysport diffuses better than Botox, and unlike Botox and Dysport, Xeomin does not need to be refrigerated and has a longer shelf life.

As to the effectiveness of the three products in cosmetic surgery, some researchers have reported that clinical results with Dysport last longer than Botox (4-7 months as compared with 3-6 months) and that results with Dysport are often noticed a day or two earlier than with its competitor Botox (2-4 days as compared with 3--8 days). There are also reports documenting that Dysport improves the appearance of crow's feet significantly better than Botox. This is ascribed to the property of Dysport to diffuse better. Xeomin seems to act more like Botox than Dysport. It is observed that it takes about one week for the full effects of Xeomin injections to be realized, and once this occurs, the results seem to last from 3-6 months.

In practice, the vast majority of clients have experienced similar results in terms of effectiveness of the three products and their clinical duration. The differences likely mean more to the physician than the consumer (longer shelf life and no need for refrigeration).

How to get prepared for Dysport, or Xeomin injections?

During your initial consultation, be sure to mention all of the medications, vitamins, and herbal remedies that you are taking. In addition describe any complications you have experienced during previous neuromuscular blocking toxin injections. To minimize the chance of bruising it is important to avoid consuming alcohol, ingesting anti-inflammatory medications like Aspirin or Ibuprofen (i.e. NSAIDS) as well as certain herbal preparations and vitamins like Vitamin E, Ginkgo Biloba etc. known to increase bruisability.

What to expect during Botox, Dysport, or Xeomin injection sessions?

You will be asked to remove any makeup before Dr. Kelleher starts injecting Botox, Dysport, or Xeomin. This will help Dr. Kelleher identify and avoid the veins at injection sites that are prone to bruising, like the crow's feet area.

During the actual procedure, you will be placed in a sitting position. The areas to be treated will be cleansed and topical ice applied to help shrink the blood vessels and desensitize the skin. Just before the injections, Dr. Kelleher will ask you to repeatedly contract and relax your problematic muscles. Dr. Kelleher will then assess the thickness and quality of your skin, the thickness and size of the underlying muscles, and determine the most appropriate dose and point suitable for the injections. Finally, Dr. Kelleher injects the targeted muscles with the finest possible needle, thus minimizing discomfort and bruising. In the unlikely event that skin bleeding occurs, you will be asked to apply manual point pressure. This helps minimize the extent of bruising. Makeup may be applied as soon as the bleeding stops.

Botox, Dysport, and Xeomin - what is the aftercare like?

For most practical purposes Botox, Dysport, and Xeomin injections are considered lunchtime procedures, whereby people can return to normal activities immediately after the treatment. However, it is advisable for patients to avoid lying down for 2-4 hours after a treatment, as well as avoiding vigorous exercise, hot showers, sauna and bathtub. These activities may lead to excess blood congestion in injected areas and wash out the medication before it has a chance to interact with the targeted muscles. Furthermore, manual pressure should not be applied on certain injection sites, like the frown line (glabella), in order to avoid diffusion of the injected medication toward the upper eyelid area which may consequently lead to droopy eyelids. Currently, most physicians do not consider exercising the injected muscles after a treatment to be necessary to achieve the desired effect.

When are results seen and how long do they last?

Patients usually notice the clinical effect 1-3 days following botulinum toxin injections, and the effect is maximal by 1-2 weeks. The clinical results can vary depending on the skill of the practitioner, the nature, dose and concentration of the product, the frequency of the injections, the nature of the injected muscle, as well as the quality of the skin. For instance, a higher dose for a particular area might be needed if the interval between treatments is much longer than recommended.

The benefits of Botox, Dysport, and Xeomin treatments typically last 3-6 months, except when used for jaw reduction. Surprisingly, jaw line reduction results are slow to show, but usually last more than a year. Younger patients may also experience longer lasting benefits due to the better quality of their skin. Treatments can be repeated as the effects of botulinum toxin wear off. Deeper wrinkles may require 1 to 2 additional sequential sessions before the best results are seen. In select cases, it may be necessary for the patient to have additional procedures, such filler injections, for optimal results.

Who can administer Botox injections?

The manufacturers of BOTOX Cosmetic recommend that Doctors or Dentists inject the medication only. Accordingly, it is very important to have the treatment at a Clinic where a doctor performs the procedure.

What are the conditions that can be treated with Botox, Dysport, and Xeomin?

Despite the fact that cosmetic injections of Botox, Dysport, or Xeomin in any site other than the glabella constitute an off-label indication in the United States, the scope of botulinum toxin applications in cosmetic surgery is increasing every year.  Botox, Dysport, or Xeomin are commonly used to correct the following:

  • frown lines
  • forehead lines
  • crow's feet
  • bunny lines
  • corners of the mouth
  • brow lift or brow balance
  • smokers lines
  • wide jawline and square face
  • gummy smile
  • teeth grinding
  • wrinkled and dimpled chin
  • nasal flare
  • excessive sweating
  • chest rejuvenation

 

What are the contraindications and complications associated with Botox, Dysport, and Xeomin?

Although Botulinum, the neuromuscular blocking toxin in Botox is associated with botulism, there is no danger of botulism from BOTOX, because botulism is caused by very large amounts of the toxin in the system, usually from eating contaminated food. Very high doses, often 100 times more than would normally be used, would have to be injected to cause harm and botulism.

In fact, risks are very minor when Botox is used for cosmetic purposes. As of today, no serious issues have been reported among adults who have received botulinum products, such as Botox, Dysport or Xeomin, for cosmetic uses. Adverse effects are usually mild and transient. The most common substantive complication is excessive weakness of the treated muscles, and this resolves as the action of the toxin wears off. Complications such as brow ptosis, eyelid ptosis (Eyelid sagging), neck weakness are usually due to injector error or lack of injector experience. All of these effects are reversible, and fade with time. If you have eyelid drooping after a Botox procedure, it is a good idea to let the cosmetic surgeon know because there are medicines available that may alleviate this condition. Ptosis can be treated with apraclonidine 0.5% eyedrops. Phenylephrine (Neo-Synephrine) 2.5% can be used when apraclonidine is not available. Note that Neo-Synephrine is contraindicated in patients with narrow-angle glaucoma and in patients with aneurysms. Any other difficulties, such as difficulty breathing or rashes, should be reported to the doctor.

The most common side effects of botulinum toxin used in cosmetic surgery are temporary soreness or mild bruising around the injection sites. Bruising can occur, particularly if a small vein is lacerated or a patient has taken aspirin, vitamin E, or NSAIDs, or has consumed alcohol on the day of injections or the few days preceding the treatment. Ideally, patients should stop taking these products 1 week before the procedure. Applying ice to the injection sites before and after treatment may decrease the pain and the risk of swelling and bruising. Some people may experience a slight headache that lasts for several hours after treatment.

Contraindications include prior allergic reaction and injection into areas of infection or inflammation. Botox injections are contraindicated for patients with allergic history to egg albumin. Botox injections are not recommended in pregnant or breastfeeding women. However, many patients have been unknowingly injected during pregnancy and to date no fetal injury or birth defects have been reported in these cases. Nonetheless, to be on the safe side, delay of injections is recommended until pregnancy is complete and breastfeeding has ended.

Botulinum toxins should be used with caution by patients taking certain medications that decrease neuromuscular transmission, such as aminoglycosides, penicillamine, quinine, and calcium channel blockers. Ask your doctor about possible interaction with these medications before a treatment. Patients with certain neurological disorders, such as myasthenia gravis, ALS, or LAMBERT-EATON syndrome could be at an increased risk of side effects.