Dr. Ronald Moy provides an update in botulinum toxins, including dosing and dilution and how to differentiate your practice by minimizing pain and bruising.
Ronald Moy, MD, Past President, American Academy of Dermatology, American Society for Dermatologic Surgery, and American Board of Facial Cosmetic Surgery and a practicing dermatologist and facial plastic surgeon in Beverly Hills, California.
“The first question was, ‘Which is the best [botulinum toxin] product for patients?’” said Ronald Moy, MD, who presented “Update on Botulinum Toxins,” at the 4th Annual San Diego Dermatology Symposium.
Dr. Moy, who said he has no ties to the companies behind today’s neurotoxins, reviewed the available products: Botox (onabotulinumtoxinA, AbbVie), Xeomin (incobotulinumtoxinA, Merz), Dysport (abobotulinumtoxinA, Galderma), and Jeuveau (prabotulinumtoxinA-xvfs, Evolus). He also mentioned one new and one investigational option.
“The answer to the question is, I don’t think there’s a big difference between them. I think that it really is dependent on dose.”
DaxibotulinumtoxinA (Daxxify, Revance), a marketplace newcomer, claims a mean duration of about 24 weeks, said Dr. Moy.
“You could argue that if we gave higher dosages of the four existing products, they would last up to five months. The differences may be fairly insignificant. But I think there are patients who would say give me the longest lasting product, and it probably will be this product called Daxxify.”
The neurotoxin BoNT/E (Abbvie) is not yet approved but promises a faster onset and a shorter duration of two to four weeks. Practices might use BoNT/E for last minute demand or to introduce patients to the effects of neurotoxins, said Dr. Moy.
Truly comparative trials on the efficacy and duration of available neurotoxins are lacking, he said.
“There’s really only one study that I saw that was done by Nicolas Lowe.1 He compared Botox to Dysport. But the study, at least in my mind, wasn’t really conducted at equivalent dosages, and … I would argue if you dosed Dysport higher you would see equivalent results.”
So, How Do You Differentiate?
According to Dr. Moy, based on the experience at his practice on Rodeo Drive in Beverly Hills, in a highly competitive market, there are several ways in which dermatology practices can differentiate themselves.
“My first tip is to do painless or pain-free injections successfully.”
There are many ways to increase patient comfort when injecting neurotoxins. Among those, according to Dr. Moy:
- Use preserved saline containing benzyl alcohol, which is less painful than the unpreserved normal saline.
- Dilute your product with lidocaine or Ringer’s lactate, which also is less painful than unpreserved saline and doesn’t interfere with neurotoxin activity or efficacy.
- Use the smallest needle possible, which is the 32-gauge Tuberculin needle or syringe. It also helps to avoid product waste.
- Chill the skin before injecting. Dr. Moy said his practice uses the Zimmer cold air blower.
- Create a relaxing environment and do things to distract the patient, including conversation.
- Consider a topical anesthetic.
- Use fewer injection sites than the classic five-injection method in the glabella.
“It’s not really necessary because we know all the injections diffuse about 1.5 cm. I think the best method and the one I use in Beverly Hills is to do ONE injection over each glabella. We try to pinch muscle, and we try not to put the needle on bone or the periosteum. An accurate injection into the muscle allows for less injections.”
- When treating the glabella, inject the neurotoxin into a follicular orifice to significantly reduce pain.2
“The other discussion point is dosing and dilution of any of these products. As it turns out, I think we’re all using higher dosages for longer lasting results. Physicians treating the glabellar area inject an average 20 units. For crow’s feet lines, 12 units or more does block these crow’s feet lines, although results don’t tend to be as good as in the glabella. So, I think the dosages have gone up and that helps for efficacy.”
However, there are downsides of injecting too many areas and higher volumes of neurotoxins, especially in the forehead area, said Dr. Moy.
“If you give the injections too low on the forehead, you will get dropping of the brows. And if you give too much, there’s no movement. Generally, …I will compromise. I won’t inject within a centimeter of the brow and usually inject above the mid forehead.”
Another tip for success is to avoid bruising, said Dr. Moy.
“It’s easy to get bruising, especially around the eyes. So, you want to inject very superficially. It’s not like the glabellar area where you want to be in the muscle. The orbicularis muscle around the eye is superficial. It’s almost a tuberculin type of injection where you’re just getting almost just below the dermis.”
References:
1. Lowe PL, Patnaik R, Lowe NJ. A comparison of two botulinum type a toxin preparations for the treatment of glabellar lines: double-blind, randomized, pilot study. Dermatol Surg. 2005 Dec;31(12):1651-4. doi: 10.2310/6350.2005.31303.
2. Lewis T, Jacobsen G, Ozog D. Intrafollicular orifice injection technique for botulinum toxin type A. Arch Dermatol. 2008 Dec;144(12):1657-8. doi: 10.1001/archderm.144.12.1657.