Painless Neurotoxin Injection Method? Join the Discussion!

What injection methods are most useful and reliable for neurotoxin injections: Botox & Dysport.

I have been in clinical private practice going on 14 years now and enjoy a busy and healthy cosmetic surgery practice.  Injectables, both fillers and neurotoxins, remain an integral part of my practice and I suppose that the loyalty my patients show by continuing to return to me as their injection provider is testament that my skills must be competitive with the many other local physicians who offer the same procedures.  I definitely do not price cut to keep the volume or attract new patients, and I believe I price fairly taking into consideration both my training and experience with typical pricing in my area by "mainstream" cosmetic providers.

I continue to strive to offer the least painful experience for my patients and have tried multiple different methods to decrease the degree of injection discomfort for my patients.  From topical anesthetics, icing, slow injection delivery, and currently vibration-distraction techniques, I have yet to find the WOW approach. I do use lidocaine-treated fillers and believe that these have advanced our patients' injection experience to an appreciable degree.

My intent for this entry is to stimulate a healthy community discussion on what methods the readers have found useful and reliable for neurotoxin injections (to keep this discussion focused I am not encouraging discourse on filler injections but perhaps this can be a future topic of discussion), in addition to disregarding any approach that they have found particularly not beneficial.  We all want to make our injections as easy as possible for our patients, so I am hopeful that this topic can generate healthy dialogue!

Xeomin vs. Botox vs. Dysport

Botox & Dysport now have a new contender in the cosmetic space... Xeomin.

About Xeomin: (pronouced ZEE-oh-min) from Merz Pharma GmbH & Co KGaA

Download the Xeomin Report PDF

Botox, Dysport and Xeomin have a lot in common, but they also have some important differences. Unlike both Botox and Dysport, Xeomin does not need to be refrigerated before it's reconstituted (see below). This should be an advantage during distribution. What's more, Xeomin has no additives — just botulinum toxin type A. This may lessen a patient's likelihood of developing antibodies.

Supposedly, Xeomin is more like Botox 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. Dysport, Xeomin and Botox should not be used interchangeably.

Also, since Xeomin is approved only for cervical dystonia and blepharospasm in adults who have had previous treatments with onabotulinumtoxinA (Botox), any use for wrinkles and crows feet is going to be off label. This, along with the fact that Botox pretty much owns this space will probably mean that Xeomin will have a hard slog finding a huge audience. It may be worth trying thought to see if you just like it that much better. (Anyone who's already tried it, please leave a comment and let us know what you think.)

Storage

Unopened vials of XEOMIN® (incobotulinumtoxinA) can be stored at room temperature 20 to 25°C (68 to 77° F), in a refrigerator at 2 to 8°C (36 to 46°F), or a freezer at -20 to -10°C ( 4 to 14°F) for up to 36 months. Do not use after the expiration date on the vial. Reconstituted XEOMIN® (incobotulinumtoxinA) should be stored in a refrigerator at 2 to 8°C (36 to 46°F) and administered within 24 hours.

Indications & Usage

Cervical Dystonia: XEOMIN (incobotulinumtoxinA) is indicated for the treatment of adults with cervical dystonia to decrease the severity of abnormal head position and neck pain in both botulinum toxin-naïve and previously treated patients.

Blepharospasm: XEOMIN (incobotulinumtoxinA) is indicated for the treatment of adults with blepharospasm who were previously treated with onabotulinumtoxinA (Botox).

Complications

Like other botulinum products, Xeomin must carry a black box warning regarding a rare risk for spreading outside of the injection site. If this occurs, life-threatening swallowing and breathing problems may result. This has not been seen in people receiving neurotoxins for cosmetic reasons or to treat blepharospams. It has mainly occurred among children treated off-label for cerebral palsy-related muscle spasms.

Adverse Reactions

Cervical Dystonia: The most commonly observed adverse reactions (incidence ≥10% of patients and twice the rate of placebo) for XEOMIN 120 Units and XEOMIN 240 Units, respectively, were: dysphagia (13%, 18%), neck pain (7%, 15%), muscle weakness (7%, 11%), and musculoskeletal pain (7%, 4%).

Blepharospasm: The most common adverse reactions (incidence ≥10% of patients and twice the rate of placebo) for XEOMIN were eyelid ptosis (19%), dry mouth (16%), visual impairment (12%), diarrhea (8%), and headache (7%).

Drug Interactions

Concomitant treatment of XEOMIN and aminoglycoside antibiotics, spectinomycin, or other agents that interfere with neuromuscular transmission (e.g., tubocurarine-like agents), or muscle relaxants, should be observed closely because the effect of XEOMIN may be potentiated.

Pregnancy

Pregnancy Category C: There are no adequate and well-controlled studies in pregnant women. XEOMIN should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Cost

The costs are expected to be similar to Botox. I checked over on Medical Spa RX and they don't seem to be carrying it as of now so you won't be able get a deal on it the way you can with Rx's Botox Group Buy Program.

Have you got any intention of trying something besides Botox or Dysport? Does Xeomin have a chance in your clinic? Would you try it on a few patients to see if you like it?

Botox: Allergans (Still) Big Seller

Every successful cosmetic clinic that I know of is a big consumer of Botox by necessity. Medspas, derms, clinics and in many places dentists offer Botox and move a lot of it.

Here's a really good artitlce on how Allergan has positioned Botox to be a really stable source of income over the long term.

Via CNN Money

Alergans Survival Strategy: Botox Everlasting

Most big, mainstream pharma companies are desperately working to develop new expensive drugs and filing lawsuits to extend patents on old ones. But to dodge that deadline, Allergan is using another strategy; let’s call it the “stay small and make weird products” approach.

The company behind Botox, the “face-lift in a bottle,” is itself aging rather gracefully. Net sales increased by 13.3%, to roughly $1.3 billion, in the first quarter of 2011 compared with the same period last year, and the company has given analysts no reason to think it won’t put together a string of good quarters.

That’s because Allergan’s product portfolio is looking first class: “We believe Allergan has one of the most compelling growth profiles in specialty pharma,” a May report by Piper Jaffray analysts David Amsellem and Michael Dinerman said. But pharma companies need more than a good growth strategy, says Ken Cacciatore, an analyst with Cowen Group. They should also develop new products and have plans to keep the patent rights for the ones that they already have. “That’s really the holy grail of pharmaceuticals,” he says, “and Allergan has it.”

The holy grail

A huge part of Allergan’s patent-cliff immunity is its blockbuster Botox, which has helped the company evade the patent problems facing others in the industry in two ways: First, Allergan has continued to discover new applications for it. “Really, Botox is a Russian doll,” says Allergan CEO David Pyott, because Allergan keeps discovering new uses stacked inside the original treatment.

Second, Botox is also a special pharmaceutical because of the way it’s made. “It’s going to be very difficult for anyone to get a truly substitutable product through the FDA,” says Cacciatore.

That’s because Botox is something called a biologic, which means it isn’t man-made. Instead, Botox is created by making a solution that contains trace concentrations of the deadly botulinum toxin. Botox works in both the medical and cosmetic arenas by temporarily paralyzing targeted muscles. For example, Botox injections into the eye muscles can help patients suffering from a condition called strabismus, in which their eyes are misaligned. In a more vain vein, cosmetic Botox reduces the appearance of wrinkles in the forehead by numbing facial muscles so that they can’t contract to form creases.

Allergan and doctors have found muscle paralysis can be useful in other places: Allergan plans on getting Botox approved to treat patients with neurogenic detrusor overactivity, or overactive bladders, this year. Last year Botox was approved to treat chronic migraines, which is one of Allergan’s most promising markets, according to Ben Andrew, an analyst from William Blair & Co. Botox has the potential to be the first treatment of its kind in that space, he says, because it’s preventive: “Every other FDA-approved product is used in response.”

Botox’s success as a treatment for chronic migraines could surprise the market, according to Gary Nachman, a senior analyst in specialty pharmaceuticals with Susquehanna Financial Group: “You’re looking at a potentially huge blockbuster that people are really not giving them full credit for.”

Product diversity

Allergan is unique, says Lavin, because it has positioned itself well in three distinct sectors: ophthalmology, obesity, and cosmetics, all of which target the aging, sedentary population of U.S. consumers. “I think of aging and obesity as two areas I’d like to invest in,” he says.

Allergan can develop in seemingly strange sectors because of its relatively small size. It has a market cap of about $25 billion, compared with, say, J&J (JNJ, Fortune 500) and Novartis (NVS), which have market caps of $183 billion and $145 billion, respectively. “A company like Allergan still has a small enough base revenue that incremental hundreds of millions matter,” says Cacciatore. “Large pharma companies have consolidated themselves into a box where they need incremental billions.”

Allergan’s growth strategy allows it to invest in niche markets heavily enough to be a persistent threat to much larger companies. It’s a phenomenon that CEO David Pyott enjoys: “I remember years ago when I was relatively new at this job, and people said, ‘Do you really think you can compete against Pfizer in ophthalmology?’ We’d just smile and say, ‘We love taking market share from those guys.’ ”

Method to the madness

Allergan’s portfolio looks bizarre at first glance, but there is a pattern to much of its drug development.

Take Latisse, for example. Allergan researchers noticed that patients using its glaucoma treatment Lumigan were also growing longer lashes. The company then conjured up a medical condition, hypotrichosis, or inadequate eyelashes, to pair with its newly made drug. Allergan essentially created the market for Latisse, which was approved by the FDA in 2008. The company expects to make over $500 million from Latisse — again, a drug it had already invented and released as Lumigan.

Latisse is just one example of how Allergan aims to keep improving its own technology to discover new drugs, renew patents for existing ones, and find new uses for both. Pyott says he has overseen the growth of the company’s research and development budget from $80 million when he joined 10 years ago to $800 million this year. That’s about 16% of total sales that Allergan plows back into R&D.

Dysport hasn't really made a huge difference and for most medspas or clinics it's certainly still playing second-fiddle. )I'd be interested if anyone has information they could add as a comment as to exactly where Dysport sits as a percentage of market share right now.)

Botox vs Dysport: A Comparison

By plastic surgeon, Marc Sheiner MD

What's the difference between Botox and Dysport?

The following discussion will explore Dysport and Botox Cosmetic in the United States, stressing the differences and the similarities between them. The discussion will begin with the similarities between Dysport and Botox.

Both of these roducts, Botox and Dysport, are neurotoxins. Specifically, they're type A Botulinum toxins that are Citicholine release inhibitors. Both therefore block the Citicholine release and prevent the communication between the nerve and the muscle, temporarily immobilizing muscles that produce wrinkles. Both are similarly FDA approved for the temporary improvement in the appearance of moderate to severe glabellar lines associated with Procerus and Corrugator muscle activity, i.e. the frown lines. Both are supplied in vials, and the fine powder requiring reconstitution with saline and both are injected in the facial muscles with a 30 gauge needle. In addition, both are also used off label to treat crow's feet and forehead lines or the lip line, essentially anywhere a rhytid or a wrinkle is present.

It has been reported that Dysport has a quicker onset, that is, people notice the effect of Dysport in 1-2 days as opposed to 4-7 days with Botox. Also, it is commonly reported that Dysport diffuses over a wider area than does Botox. This make some importance when treating areas around the eyes and that you can use a smaller amount of Dysport and alleviate potential complication such as ptosis (sagging or drooping of the eyelid). There are also some reports that people state that Dysport is less painful although this is not proven in any scientific literature. In addition, there are reports that Dysport may actually last a bit longer than Botox. Typically, Botox remains effective for 3-4 months and some reports say that Dysport may act a bit longer, 4-5 months.

Now for the differences among the 2 products. (Some of the differences are scientifically proven while others are anecdotal references.)

To begin with, Botox is supplied by the manufacturer Allergan in 150 unit vials. Typically the 100 unit vial is supplied for $525. Dysport is supplied by Medicis in 300 and 500 unit vials. The 300 unit vial typically goes for $475. So if the Botox and the Dysport vials are divided by units, one can see that 1 unit of Botox costs $5.25 with 1 unit of Dysport costs $1.50. However, the difference does not equate to a cheaper product if you will because you actually require more Dysport to obtain the same results with Botox. And we will discuss that in a moment.

The Botox is used in a fashion exactly the same as Dysport. However 1 unit of Botox does not equal 1 unit of Dysport. Typically, anywhere from 2.5-3 or even 4:1 ratios of Dysport to Botox is effective. So, that is to say that you may require 2.5 or 4 units of Dysport to obtain the same result as you would with 1 unit of Botox. For example, the glabella is typically treated with 5 injections of Botox, 4 units in each site and that's a total of 20 units. With Dysport, you actually use 10 units in 5 sites for a total of 50 units. Another difference is the reconstitution.

Reconstitution simply means the product needs to be dissolved in normal saline. There are many ways to do this. I typically apply 2.5 cc's of normal saline to a 100 unit vial of Botox, which will give you 4 units of Botox per 0.1 ml of fluid.

With Dysport, you place 1.5 cc's of normal saline into the 300 unit vial and that would equate to 10 units of Dysport per 0.05 mL or cc's of fluid.

Those are some of the similarities and differences. I would now like to discuss some of the questions that typically are asked by clients when they are deciding whether to use the Botox or Dysport.

One common thing that I hear often is one of the products is better than the other. I explain to them that basically both are the exact same product aside from some molecular differences. And I explain that some report subtle differences regarding quicker onset, but in my experience both products produce the same results and last essentially the same amount of time.

Another question I often hear is one of the products associate with more complications than the other product. And I tell them no, that both of the products are associated with the exact same side effects profile. You can obtain bruising, swelling, redness, ptosis from both of the products. However, Dysport is a relatively new product in the United States and Botox has been used for a greater length of time so the exact safety profile of Dysport has not been illustrated to date.

Another question I sometimes hear is why should I choose Botox over Dysport? If I'm asked that question, I don't make the decision for the person. I will occasionally help them along by explaining to them that I personally use on family members and what product most clients use. I tell them that they both predicatively improve wrinkles and in my office they're both the same price. You'll read a lot of information that Dysport is cheaper.  And of course if you do the math, 7:01 in the beginning you'll see cheaper per unit but you need to use more units. Still, when you do it that way, Dysport does come out to be more affordable. However, I offer them both at the same price after discussion, explaining to them that both of them have the same side effect profile and produce the same results.

And if you present them with that information and then say one is more expensive than the other, most people obviously choose the cheaper one so I just keep it in the office as an added product you know, cause some people  do actually prefer one product over the other, that's why I keep it in my office.

So, in conclusion, although there are subtle molecular differences between Botox and Dysport, both are injected exactly the same way, both have the exact same indications, that is the treatment of facial wrinkles or rhytids and both require reconstitution with normal saline. In addition, both have the similar side effect profiles and both, in my practice are similar in price. Although as mentioned, some practitioners will offer Dysport at a decreased cost. Also, some clinicians do report a quicker onset and a longer duration of action of Dysport but presently, this does not appear to be clinically significant.

In my opinion, again, I offer a choice because some people prefer it and other people actually like to try new products. My vote goes to Botox cause of it's long safety record and the fact that it's on the market for such a long time and I have predictable results with the product. However, I do think it's an added product for all aesthetic practices.

About: Marc Scheiner MD is the primary instructor for the online botox training course for clinicians at BotoxTrainingMD.com and is the owner of O'leigh Aesthetic Surgery Center in Elkton, Maryland.

Managing Patient Expectations Part 1 - Botox Training MD

Managing patient expectations are crucial to the success of any aesthetic practice.

If you are not 100 % on board with understanding and dealing with patient expectations, I believe it's going to be difficult to be successful with any aesthetic practice.

The way that I manage patient expectations starts from the initial correspondence with my clinic. My front desk staff typically will notify me if anything out of the ordinary is discussed on the phone at a new patient's consultation request. So, if for instance, they have a request that's perhaps out of the ordinary or they're perhaps not comfortable with the way the conversation went, they'll let me know so I'll have right off the bat, I'll have a little understanding that maybe it'll take a little bit more time with describing what can be done or perhaps the mode where I am not going to perform a procedure.

It's just as important and more difficult sometimes to actually refuse to perform a procedure than it is to do a procedure, have an unsatisfactory outcome, and recover from that. So I want to make that kind of clear again that if somebody presents to you that you do not feel comfortable treating, it may be more difficult to refuse that treatment than it is to actually deal with somebody who develops a complication or unsatisfactory result. However, interestingly enough, if you take the time to explain to a person why you don't feel you can't perform what they want, it can actually turn into a positive experience in the form of her/him recommending other patients to you. Or maybe that person selecting a different treatment that you offer. So, again, we start off right out of the bat, by making sure that our front desk is well aware that I need to be informed of anything out of the ordinary when a patient calls or comes in for the first time, not matter what it is.

There are two things I'm looking for. Out of the ordinary being number one, and number two would be behavior that is really not acceptable social behavior, like anger or overly demanding behavior. I like to know that too because if somebody is angry or demanding with the front desk in an unacceptable manner, then that is a clue that perhaps their behavior will be the same after I treat them.

If you're in this field long enough, you're going to hear some strange requests.

We get calls not too infrequently, once or twice a year from clients that are in the process of changing from a male to a female or a female to a male and they would like to have some, not only surgical procedures but some nonsurgical procedures like Botox or Dysport and a filler like Restylane or Juvederm. Typically, they are often required to have psychiatric evaluation before they undergo the actual transgender operation. So I've had a few instances where I had to contact their psychiatrist or actually put them in contact with a psychiatrist before treating them. So that's a little out of the ordinary.

And the other out of the ordinary are extremes of age. Teenagers calling for Restylane to augment their lips or Botox and knowing how to deal with that. And that would simply be... they have to be over 18. I mean you have to understand the..or appreciate the indications for Botox and it's right on the label.

Read: Managing Patient Expecations Part 2

About: Marc S Scheiner MD is a plastic surgeon who teaches Botox and filler injection technques to physicians and clinicians through Botox Training MD and his 14 credit CME two-day hand's on seminars.

Botox Of The Upper Face Tutorial

Botox Tutorial: Injecting crows feet, forehead and the upper face

This advanced Botox tutorial covers a number of Botox treatments around the forehead and around the eyes including injecting the Frontalis, Obicularis Oculi, Corrugator, Procerus muscles.

Botox Of The Lower Face Tutorial

Botox Tutorial: Injecting the lower face

This advanced Botox tutorial covers a number of Botox treatments around the lower face including injecting the DAO, Mentalis and DLI.

Botox vs Dysport: Which one is more effective?

Botox vs Dysport? Well, Dysport as another few arrows in the marketing quiver with a new study that says that Dysport is more effective than Botox in treating glabellar lines.

Here's a release from the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) that claims thta Dysport is actually more effetive than Botox.

The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) today announced positive clinical results demonstrating a significant efficacy advantage with Dysport™ (abobotulinumtoxinA) over Botox^® Cosmetic (onabotulinumtoxinA) for the treatment of Crow's feet. The data were presented Friday, September 24 at a scientific session at the AAFPRS 2010 Annual Fall Meeting, taking place September 23-26 in Boston.

Downloadable photos, fact sheets and other supporting materials available here: http://www.multimedianewscenter.com/aafprs/dysport-data-shows-superiority-versus-botox-cosmetic

The 90-subject study, titled "Internally Controlled Double-Blind Comparison of Onabotulinum and Abobotulinum Toxin Type A (Nettar, Kartik D., M.D., et. al)," met its primary endpoint (p=0.01) of greater efficacy of action with Dysport™ as defined by investigator assessment of maximum contraction at Day 30 post injection compared to Day 0. Additionally, a secondary endpoint -- subject assessment at maximum contraction at Day 30 compared to Day 0 -- also demonstrated statistical significance with Dysport™ (p=0.027).

"Botox has long been considered the gold standard of injectables, so this data showing Dysport's stronger efficacy is compelling," said Corey S. Maas, M.D., F.A.C.S., AAFPRS Group Vice President for Public and Regulatory Affairs. "Since injectables are the non-surgical cosmetic procedure rising fastest in popularity, it is important to continue honing new applications for existing treatments. Dysport's potential here is exciting as Crow's feet are a common concern for many men and women."

The study concluded that Dysport™ offers a quantifiable and demonstrable advantage in wrinkle effacement (shortening) and hyperfunctional frown lines compared to Botox^® Cosmetic in the treatment of Crow's feet. Study investigators recommend further studies in additional facial regions to confirm the data.

Both Botox^® Cosmetic and Dysport™ are FDA approved for treatment of moderate-to-severe glabellar lines (vertical lines between the eyebrows); neither product is presently indicated for treatment of Crow's feet. The study was funded by an educational grant from Medicis Aesthetics.

Additional Study Information: The randomized, double-blind, internally-controlled (split face) study was conducted at the Maas Clinic in California. Ninety subjects (75 females, 15 males) with moderate-to-severe lateral orbital rhytids (Crow's feet) were enrolled in the study. Participants received equivalent doses of both treatments: 10 units of Botox^® Cosmetic on one side of the face and 30 units of Dysport™ on the other side. Investigator and subject gradings of Crow's feet at relaxation and maximal contraction were obtained using the published validated dynamic and static Merz Crow's feet grading scale before injection (Day 0) and then two, four, six, and 30 days post injection. All patients were photographed in standard five-view series at rest and at maximal contraction in a dedicated photo lane recorded by Mirror software. Additional secondary endpoints not met in the study include investigator assessment at rest at Day 30 (p=0.41) and subject assessment at rest at Day 30 (p=0.28).