Not long ago, the so-called “dynamic” wrinkles; wrinkles caused by facial expressions, such as crow’s feet, glabellar lines (the vertical lines between the eyebrows) 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 other non-surgical procedures, such as laser resurfacing or dermal fillers.
Currently, botulinum toxin type A, commercially available as Botox® Cosmetic, Dysport®, and Xeomin® are the most commonly used injectables in the management of dynamic wrinkles. When injected into a tense facial muscle, botulinum toxin inhibits its contraction causing it to relax. With less muscle movement, wrinkles on the overlying skin begin to soften. In practice, one 10-minute treatment, a few tiny injections, and within days there’s a noticeable improvement in furrowed brows and moderate to severe glabellar lines, crow’s feet, and the frontalis.
Botulinum toxin type A used in cosmetic surgery is one of the 7 distinct toxins lettered A through G, produced by Clostridium botulinum bacterium. The word Botulinum 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. Bacteria present in the spoiled sausages, was found to produce the toxin.
Although considered off-label use, Botox® Cosmetic , Dysport®, and Xeomin® are nowadays being used for many other aesthetic enhancement purposes. Please go to applications of Botox® in cosmetic surgery to read about the conditions that are conveniently treated with the product, or go to Botox® FAQ to read the answers related to frequently asked questions about Botox® Cosmetic, Dysport®, and Xeomin® FAQs.
Dr. Dishakjian, the cosmetic surgeon of the Medical Spa, has worked with all the three products and is fully comfortable using them to his patient’s benefit. Having alternative products to choose from is always beneficial for patients, as it enables the physician to choose the best treatment according to each patient’s individual needs, previous responses to treatment, and patient expectations.
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.
The cosmetic outcome of Botox® injections is typically visible within 3-7 days and lasts for 3-6 months, depending on 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. In general, fewer injections are needed after the second or third year.
BOTOX® FOR CROW’S FEET
BOTOX® FOR JAW LINE REDUCTION
Although Dysport® has been successfully used in Europe and the Americas for over 17 years, and has a proven track record of safety and success in the United Kingdom, Germany, and many other European countries, the U.S. FDA approved Dysport® for cosmetic use only on May 2009.
Dysport®, manufactured by Medicis, is made from the same active ingredient as Botox® Cosmetic (made by Allergan), botulinum toxin type A, however, the manufacturing process of Dysport® is slightly different, resulting in slight differences in its clinical use for cosmetic purposes. For instance, Dysport® may provide a little faster onset of action and has a greater ‘spread’ (giving a more ‘natural’ look) compared to Botox® Cosmetic . Botox®, on the other hand, tends to remain more localized, allowing for greater precision in the treatment area, but possibly requiring more injections in the course of a treatment. There are also claims and suggestions that Dysport® results might last up to a month or even two beyond that of Botox®. The unit dosage of each product is also different and accordingly different number of units have to be used to achieve comparable results.
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 Food and Drug Administration (FDA) approved Xeomin® in July 2011 for the treatment of severe frown lines or “11’s” between the eyes. Like Botox® and Dysport®, Xeomin® is a Botulinum type A formulation, but with a longer shelf-life without refrigeration. This is accomplished by the removal of complexing proteins present in Botox® and Dysport® during the manufacturing process. Xeomin® is more like Botox® Cosmetic than Dysport®. It takes about one week for the full effects of Xeomin® injections to be realized, and once this occurs, the results last from three to six months.
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 Advil or Motrin (i.e. NSAIDS) as well as certain herbal preparations and vitamins like Vitamin E, Ginkgo Biloba etc. known to increase bruising.
You will be asked to remove any makeup before your doctor starts injecting Botox® Cosmetic, Dysport®, or Xeomin®. This will help your doctor identify and avoid the veins at injection sites that are prone to bruising, like the crow’s feet area.
During the 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. Dishakjian, the cosmetic surgeon at the Center, will ask you to repeatedly contract and relax your problematic muscles. Dr. Dishakjian 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. Dishakjian will inject 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.
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.