Pricing Dysport, Xeomin, & Botox in the Aesthetics Market

Can you make money on Botox? Should you switch to Xeomin? The newest information shows that facial fillers and injectables will continue to be the primary physician-based cosmetic treatment (and a primary source of revenue and patient flow).

With Botox, Dysport and now Xeomin targeting wrinkles, and Juvederm, Radiesse, Kybella, Scupltra, and Belotero for volume/fullness, injection based treatments are the initial treatment point of contact for most cosmetic clinics, even those run by surgeons.

With the prevalence of these treatments we thought we'd take a look at the current state of care in the US (the largest single market) since there are a number of new players that are making inroads and taking some market share from the biggest players.

First up; Botox, Dysport and Xeomin.

Botox, Dysport, and Xeomin primarily treat glabellar Lines and lateral orbital rhytids (crow's feet) but they've seen increasing usage around the mouth in some practices. (We do not recommend this unless you're extremely skilled since this can cause some serious problems if you paralyze someone's mouth.)

These treatments are restricted by licence although there have been a number of unlicensed individuals (like this horror story) where individuals were treating patients.

Let's take a look at each.

BOTOX

The big boy in the market, Botox or onabotiliniumtoxinA was approved for cosmetic use in 2002. Approved treatment areas are as follows: hyperhidrosis, migraines, and the neck and chin. It is not limited to those areas as there are other FDA Approved uses in the body (Blepharophasm, Strabismus, and Overactive Bladder). It is used off-label by some physicians to treat other areas.

In 5 major US Cities, the average price of a Botox treatment for a patient is around $400. Botox (10mu) is selling around $400-$525 according to some US physicians and based on pharmacy price but it's much cheaper outside the US. Units used differ depending on the treated area, with a recommended 20 Units for the Glabellar Area, 6 to 20 Units for the Forehead, 4 to 12 for the Crow's Feet.

Many patients find Botox as the most effective in making wrinkles disappear, most are satisfied with their treatments over time, with a 95% Satisfaction Rate among patients. Not all however are mostly satisfied with their procedure, because some have complained making their appearance worse, probably do to the fact that every patient with a new treatment becomes hyper-focused on the mirror. Still, don't be to quick to discount patient reported effects of unevenness, ptosis, and sagging.

According to Mukherjee (2015), Botox is expected to grow to $2.9 Billion by 2018 with the facial aesthetic market to balloon to more than $4 Billion, with the US contributing half of it. (Nice!)

DYSPORT

The teenager Dysport (abobotiliniumtoxinA) entered the market in 2009 and has actually been giving Botox (Allergan) a respectable competitor. In its early release, many were skeptical about its efficacy, strengthening Botox' popularity among patients (possibly do to it's lower cost). However, many studies have shown that Dysport is a fast acting injectable as compared to Botox.

Why choose Dysport over Botox?

In a double-blind study conducted in 2011, Botox and Dysport were used to test ninety patients. Dysport was the better choice to treat crow's feet in the study. The dosage used in the study had 30 Units for Dysport, while 10 only for Botox.

On average, Dysport treatment costs $360 for some major US cities we looked at for Botox. As for the selling price of Dysport to physicians, it is at around $475-$800. According to some physicians, for treatment of crow's feet at least 30 units is used to treat one side, 20-80 for the forehead, and 40-80 units for the glabellar.

Dysport can be an alternative to those who do not find Botox effective. Some prefer Dysport as their neuromodulator of choice due to its longer efficacy. It has been said that due to lesser proteins, Dysport can easily be accepted by the body.

It has proven itself to be a worthy competitor against Botox with a 93% satisfaction rate by Dysport users. On the other hand, it is not all met with praise since it can cause the same side effects to patients that Botox can.

XEOMIN

The new kind on the block. Among the three neuromodulators, Xeomin contains only incobotulinumtoxin A, resulting in some calling Xeomin the 'Naked Botox'. It has no proteins which both the two prior injectables contain, and it requires no refrigeration. Many observe that Xeomin has the slowest onset among the toxins, with results appearing 3-4 days after treatment.

In administering Xeomin, the needle is smaller and the injections are a few centimeters away from each other (less pain?). It also uses only around 10-25 units for one side for crow's feet treatment, 10-15 for the forehead, and 20 for the glabellar. Merz retails a bottle of Xeomin at $466, with some pharmacies selling it at a lower cost around $260 - $300. On average, the treatment of Xeomin to patients is around $355.

Xeomin showed great results for frown lines for most patients, but it's often rated slightly lower by patients in terms of satisfaction. This may be due to actual results, but it's also likely that differing injection techniques by new clinicians who have previous experience with Botox and Dysport, as well as less patient name recognition could be the cause.

As part of this series we're going to do some internal surveys and research into pricing and satisfaction across physicians. If you'd like to be involved and/or have access when we release these results, please make sure that you sign up as a member.

Read the sister post to this on filler injections pricing and satisfaction for clinicians.

New Concierge Startups Could Devastate The Cosmetic Medicine Market

Futuristic new startups in concierge medicine could really put the screws to competitors as they expand their offering.

Silicon Valley is rife with startups looking to disrupt all aspects of healthcare, moving from traditional approaches to entirely new delivery systems and business models. The result is a number of new, well financed competitors that don't have the baggage of traditional methodologies and can easily adopt new methodologies and could bury existing competitors. Here are a couple of examples.

Forward is a new tech concierge medical start-up San Francisco that is focusing on reinventing the primary care clinic. With something of a clean look that founder Adrian Aoun describes as something aking to an Apple store crossed with Star Treks next generation sick bay. Physicians have access to some really cool gizmos, from a wall-sized screen to visualize and show patient data to automated speach recognition that transcribes converstaions in real time and adds them to patient records. Patients can get their prescritions filled in the on-site pharmacy and can text staff around the clock (with 30 second response times).

But the biggest value is not the glass and white walls, it's the removal of trivial tasks that prevent clinicians from operating at the top of their license. According to a 2016 study in the Annals of Internal Medicine, physicians spend more than half of their time on paperwork, compared to a measly 27% interacting with patients. (Read the study here)

Forward is using technology to ruthlessly elimiate waste and improve physician productivity while also delivering what patients are asking for with whiz-bang tools. They currently don't taken insurance - although they have plans to change that - and charge patients $149/month all in.

Of course Forward is joining a number of other primary care and concierge competitors.

One Medical is another that already has a number of locations. It's not quite as technically cool but it's also getting traction by delivering what patients want  - same day appointments, online access, and 24/7 virtual care - at the even more affordable price of $149 per year.

And that brings us to telemedicine and what's happening there.

Read the 2015 Telemedicine Report from Medical Spa MD

In a poll asking dermatologists if they were to use telemedicine in their practice, 41.84% were opposed to the idea of adopting it. Only 38.1% were in favor in using telemedicine, but that may be changing.

In a study by Wilson and Maeder (2015), teledermatology has produced positive outcomes with user satisfaction and uptake, and hopeful in the idea of improvements with healthcare. Another study mentions the benefits of using teledermatology, which could serve as an educational tool.

Despite study findings about telemedicine’s ability to diagnose illnesses, it is still met with resistance. In another study referenced by the authors, it seems that while it can screen and diagnose illnesses, it faced a challenge with an accuracy. Bashur et al., (2015) also suggest the same finding that inaccuracy could be a common challenge when using teledermatology.

According to the Wall Street Journal, the American Telemedicine Association expected the number of physicians using telemedicine to rise approximately 30% more. Healthmine has conducted a poll saying that out of 1500 physicians, only 15% employed telemedicine.

What does this mean for cosmetic / aestheitic practices?

These new startups are going to be under increasing pressure to find ways to generate revenue Forward, for example, has already raised $30m from venture capitalists and needs to get to a value of more than $100m to raise additional funding.

The likely result is that they, like others before them, will see that cosmetic medicine is primarily a cash fee-for-service business that will need little additional investment to add. Since these new competitors are built to deliver such extrodinalry patient satisfaction it will be more than just a little challenging for stand-alone clinics to compete.

Of course their success is not yet assured and they could implode if they can't meet their revenue needs.

If they can, there will be a period of adoption but they will be riding the wave of transformative care that is coming.

A Brief Overview on Cannulation Techniques For Fillers

Physicians have used cannulas to inject fillers as an alternative to needles.

Blunt-tip cannulas prevent the pricking on the veins. In addition, it is found that cannulas are more effective and safer for some patients. In one study, it is found that microcannulas lessened the incidence of tissue injury (Salti and Rauso, 2015). Dr. Sabine Zenker presents her techniques in using cannulas on the sagged lateral cheek areas and lips.

Many physicians have used the same method as cannulas have been seen as more effective and safer compared to needles. The author’s techniques are limited to the upper lateral and the lips.

Their technique for the lateral cheek is gentle molding, which would give an optimal result. The author recommends a linear threading method proceeding with a fan-shape that would help with cannulating from the entry point, the Zygomatic Arch.

As for the lips, the Zenker addresses it with “multiple boli” starting from the center eventually going laterally. In enhancing the lips, a lateral technique is also utilized. Thread volume is little, which allows correcting of the lips. The author reminds that there is a risk of overcorrection in this area.

So how else have authors used cannulas in their studies?

The authors have presented some cannulation techniques and recommendations on how to administer these injections. With cannulas, downtime has lessened significantly (Luthra, 2015). In addition, the author noted that patients returned for augmentation or enhancing procedures.

According to Arsiwala, when injecting with large-volume fillers, a cannula is more effective as opposed to the traditional needle. In Hedén’s (2016) study, which focuses on the nose, cannulas that are 25-G or wider lessens any risk to the vessel, in addition using thin cannulas reduces risk with intra-arterial injection. Montes, Wilson, Chang, and Percec (2016) recommend using a cannula for the upper eyelid to achieve ideal results.

Loghem, Yutskovskaya, and Werschler (2015) focuses on the danger zones and injection areas for cannulas. The authors suggest a multi-level approach (linear threading) when doing a brow lift and to avoid overcorrection to look masculine. In line with Zenker’s work, the researchers suggest to utilize a two-point cannula method when approaching the Zygomatic area.

To read more about the author’s techniques find out more about it here: https://www.prime-journal.com/indication-specific-cannula-treatment/

For the injection techniques by Loghem, Yutskovskaya, and Werschler, check it out here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295857/

Effective Medical Spa Platelet Rich Plasma Treatments?

PRP (Platlet Rich Plasma) treatments have become a staple for some clinics, so what's the deal?

Combining aesthetic techniques is probably the most popular 'cross-selling' technique and platlet rich plasma treatments are an easy add if you're set up for them. PRP serves mainly as regenerative, but it has branched out to anti-aging medicine. A number of clinics and physicians are using PRM an alternative to dermal fillers or adding them to filler treatments.

In a Medscape interview with Dr. Matarasso (plastic surgeon) last 2012 , he emphasizes that fillers and injectables break down over time, while using PRP would last longer—because it is natural and has no risk of rejection and allergy. Additionally, Puri (2015) suggests that given the natural treatment of PRP, it is considered an alternative to any synthetic filler—for patients who are unwilling to have them injected.

Most of the studies we've read have seen better results when adding PRP treatments into the mix, but there are any number of physicians who still have their doubts (perhaps they cynical group).

Using PRP with fat or Adipose tissue?

Sommeling et al. 2012 suggests that using a PRP and fat grafting technique for a treatment would enhance fat improvement. On the other hand, In Malekpour et al. (2014)’s study of the usage of PRP and fat grafting, patient satisfaction was reported despite lesser significant outcomes on the third and sixth month follow-up on the treatment.

Kumaran (2014) suggests that using PRP, mixed with fat grafts in treating scars, followed-up by a fractional laser treatment may yield good results. In the topic of lasers, PRP has also been treated alongside lasers and derma rollers or microneedling; studies focused on those modalities have resulted to patient satisfaction.

The usage of PRP and laser is deemed effective for some patients, reported better texture, elasticity, and lesser erythema (Shin et al. 2012).

In another study, conducted by Oyunsaikhan, Amarsaikhan, Batbyar, and Erdenetsogt (2017), dermarollers are another effective method as there have been improvements on the facial wrinkle grade and after six months, collagen and epidermal thickness had significantly improved.

Most study limitations focused on the ethical use of two materials for one treatment. Research on the treatment for aesthetic purposes is limited. In addition, most physicians noted that with PRP, one is "over-correcting" the treatment on the patient—which some claim that is how you get results. A select few also think that other treatments would be best suited for facial or skin rejuvenation or tightening.

 Most physicians already using PRP seem hopeful about the benefits and look to patient satisfaction as more of an indicator of efficacy .

Anyone having first hand experience is welcome to comment.

The State of Aesthetic IPLs & Lasers

In the last few years there's been an explosion of new IPLs and cosmetic lasers.

While that's generally good for clinics - inducing some competition and pricing/sales pressure - it can be a problem trying to find the right system to invest in.

READ: Cosmetic IPL & Laser Reviews & Comparisons Forums

In 2011, Dermatologist Dr. Goldman wrote a journal article about using what kind of laser should be used for the practice. In the present, there are devices that have multiple modalities and treatment options, you can have a single laser device instead of two or more. These devices are now made convenient for physicians and practitioners.

Lasers are steadily gaining traction in the aesthetic field. Many aesthetic devices have been launched, and various companies continue to upgrade their devices or create breakthroughs. Physicians are able to choose devices, which is suitable for their practice, as there are many ranging from skin rejuvenation to fat melting to even vaginal rejuvenation. At the same time, not everything has been met with praise, as lasers have its downsides for the patients or the physicians or practice itself. Thus, it is best that physicians and practitoners practice laser treatments with care.

Multiple treatments are common in many practices. More and more aesthetic companies are making more integrated systems with multiple modalities. Alma, Sciton, and Cutera are some of the aesthetic laser companies that have begun or launched a multiple modality device for one’s practice. No studies have been made about the efficacy of using multi-modality systems, but the technology is promising.

Having multiple modalities could mean multiple or combination treatment options. Effectiveness has been proven in several studies. Prior to multiple modality in a single device, physicians have been combining treatments.

Findings:

• In a dermatologic setting, treatment of non-melamona skin cancer with laser and photodynamic therapy was proven successful and effective. Er:YAG and ALA-PDT had the most efficacy rate with 98.97%
• Goldberg, 2012 suggests that IPL is better at removing hair considering it will be done with multiple sessions
• As for skin rejuvenation, an alternative to fillers would be repeated Erbium:YAG laser mini-peels (El-Domyati et al., 2013), leaving patients with an average of 88% satisfaction rate after the treatment.

Lasers remain to have some controversy over lawsuits filed by patients and complications brought about by its usage. One common issue faced by practices is negligence or mishandling by a non-physician administering the laser procedure. Several state laws allow non-physician practitioners, so long as the doctor is present in the practice. However, unhappy patients experieince some adverse side effects possibly due to poor handling and patient screening.

Training is important to avoid any of this concerns to rise and be the cause of lawsuits. According to E. Victor Ross, dermatologist, vigilance is key when administering laser treatment.

In 2016, a study was published by Dr. Gary Chuang, noting that fumes were present in a laser hair removal system. There are 13 carcinogenic compounds present in the laser hair removal plume. It is a cause for alarm as it could affect the respiratory systems of those performing the procedure and those receiving it. The researchers suggest that better ventilation systems and protection would help prevent any further issues.

Aside from this finding, Laser Service Solutions provides us with a list of common issues with laser devices. Technical issues like LCD screens and circuit boards should not be taken lightly. Other problems include: water issues, calibration, and handpieces.

It is expected that despite issues and problems, aesthetic laser procedures will still rise according to several market research reports.

REFERENCES:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390232/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3376014/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4632833/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100114/

http://dermatologytimes.modernmedicine.com/dermatology-times/news/laser-fundamentals?page=0%2C1

http://jamanetwork.com/journals/jamadermatology/article-abstract/2532614

https://www.laserservicesolutions.com/most-common-aesthetic-laser-issues/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3390232/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3376014/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4632833/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100114/http://dermatologytimes.modernmedicine.com/dermatology-times/news/laser-fundamentals?page=0%2C1http://jamanetwork.com/journals/jamadermatology/article-abstract/2532614https://www.laserservicesolutions.com/most-common-aesthetic-laser-issues/

Why You Should Review Injecting Techniques

Injectables are one of the many popular non-cosmetic procedures. Around 45% of the aesthetic/cosmetic procedures done in 2015 in the US was injectable procedures. It ranks high as an alternative to cosmetic surgery, and it is expected to rise in the coming years. These procedures have received praise by many patients. However, there is a constant need for reminder on injecting dermal fillers and botulinum toxin on patients. It is all in the [method of] injection, declares all practitioners. Additionally, some studies and researchers have emphasized the importance of administering procedures.

Some patients have reported that they have issues with fillers, which have caused adverse side effects like disfiguration of the face and vision loss. These side effects should serve as reminders to practitioners.

In the latest study by Scheuer, Sieber, Pezeshk, Campbell, Gassman, and Rohrich (2017) the authors present how to minimize problems in administering soft tissue filler injections. The authors suggest to inject slowly with small doses. In addition, a serial puncture technique is best in high risk areas. They cover six regions, which are considered danger zones.

Even with experience, physicians and certified injectors could still make mistakes in administering these injections. Thus, physicians must remember these safety concerns and administering of injections.

 Brow and Glabellar Region

• Digital injection must be applied.
• The authors recommend that intradermal injections must be done for this area.
• Blindness and tissue loss are common serious side effects in this region.

Temporal

• The measures of the danger zones in this area are 2.5 mm lateral and 3.0 mm superior to the peak of the brow (Scheuer, Sieber, Pezeshk, et al., 2017).
• Deep and superficial injections can be done in this area,
• The adverse side effect when injecting in this area is blindness.

Infraorbital

• Practitioners should refrain from injecting deeply
• Authors suggest to inject laterally and pushed medially
• Tissue necrosis is an adverse side effect in this region

Lips/Commissure

• On the commissure, the linear crosshatching method in injecting is safe.
• Injections done in either lips must be done superficially with around 3mm deep.
• Tissue necrosis is a serious side effect in these regions.

Nasolabial Fold

• Intradermal injections can be administered as well injected in the preperiosteal plane.
• Injections on the deep and superficial subcutaneous and dermal areas in the nasolabial fold are safe
• On the alar base, only intradermal injections should be administered.

Nose

• Fillers should be injected deeply and greater than 3mm.
• As suggested by the authors, any injections done on the tip and dorsum should be in the preperichondrial and preperiosteal planes.
• Tissue necrosis and visual loss are some of the adverse side effects.

To learn more about the injection techniques, you can watch the video provided by the authors here: http://journals.lww.com/plasreconsurg/Pages/videogallery.aspx?videoId=972&autoPlay=true

New Botulinum Toxin Undergoing Clinic Trials: Daxibotulinumtoxina

More competition might be coming for Botox, Dysport and Xeomin.

Three cosmetic injectables are currently available in the market (Botox, Dysport, and Xeomin). A fourth one is shaping up as the next competitor against the botulinum toxins. Revance Therapeutics Inc. is gearing up to produce the newest in the botulinum toxin market. The daxibotulinumtoxina is the newest to gain interest.

The neurotoxin is currently undergoing trials since early 2016. It claims that it will have a longer effect on the face against those available in the market. A 2011 study have found the effects of daxibotulinumtoxina for injection (RT002), which shows its efficacy and longevity.

How would this affect the three existing neurotoxins?

So far, Botox is the popular choice of neurotoxin, it being the first and proven effective for treatment of glabellar and lateral canthal lines. Xeomin and Dysport treats Cervical Dystonia and the glabellar lines. Many have expressed their concerns with the existing neurotoxins, most specifically with the possible side effects (e.g. ptosis).

Why does it matter?

Revance will include a peptide technology called: TRANSMTS in their (what they claim) a highly purified botulinum toxin to produce a longer-lasting effect. Aside from treating any aesthetic concern, daxibotulinumtoxina will also treat plantar fasciitis--- which is also undergoing study— and cervical dystonia. The neurotoxin will also come in a topical form.

Peptides have been used also for some cosmetics, with some calling it as an alternative to Botox having anti-aging effects for the face. Most studies regarding peptides are focused mostly on cosmetic products (i.e. make-up).

Botox, Dysport, and Xeomin have been met with their own criticisms from patients and physicians. The daxibotulinumtoxina could be a game changer in the market. Trials are underway for the daxibotulinumtoxina. Not much can be said about the trials but so far, the sample has not experienced any serious or adverse effects. According to clinicaltrials.gov, the study for the efficacy of daxibotulinumtoxina will be released on 2018 at the latest.

References:

http://www.revance.com/pdfs/diffusion-and-duration-of-new-type-a.pdf
https://clinicaltrials.gov/ct2/show/NCT03014622?term=DaxibotulinumtoxinA&rank=4
https://clinicaltrials.gov/ct2/show/NCT02973269?term=DaxibotulinumtoxinA&rank=2