Botulinum Toxin is Effective in Treating Facial Synkinesis

Two new studies from the JAMA Plastic Surgery studied neuromodulators in treating facial synkinesis, With one of them comparing incobotulinumtoxinA (Xeomin), abobotulinumtoxinA (Dysport), and onabotulinumtoxinA (Botox) among one another (Thomas et al., 2017).

To determine its efficacy, the researchers depended on the Synkinesis Assessment Questionnaire (SAQ).

Read More

Nurse Practitioner Pay In New "Medical" Spas

Nurse Practitioner Medical Spa Pay

What's a good Nurse Practitioner pay in a new 'medical spa' that wants to offer Botox?

I get lots of individual emails looking for information about pay for PAs, NPs and MDs who are being recruited by a local medical spa. Some of these are just entering aesthetics and others are old hands.

Here's an example email that's typical from a NP who's being solicited by a day spa who's wanting to offer Botox and fillers:

Hello, I am a Nurse Practitioner from Wyoming and I am going to start doing some medical aesthetics for an established spa that up to this point has offered everything except medical aesthetics. The owner of the spa and I are having trouble figuring out a fair pay for me. The products are being ordered under my license and I will also be doing all the injections. Right now we are just starting out with Botox and Fillers. She pays her staff an hourly wage plus commission, but I have also talked with other spas that pay straight commission. Both of us are new to this and we are having a hard time finding out what other medical spas pay. Any insight on this would be helpful.



Ok, so here's where we're going to drop some knowledge-bombs on you. (For this post I'm not going to go too deep on whether these types of setups are good ideas on their own.)

First, think about what you're asking and how you're thinking about this new business. You're counting your eggs a little before you've got any eggs.

The fact that you're asking how much you should be paid reveals a number of problems with your understaning of how this is going to work and who's going to be responsible. (This isn't uncommon at all and we're going to disucss business models at lenght in future posts.) Since you're the clinician, you're going to be responsible for everthing to do with this business with the probable exceptions of: #1, paying for stuff and #2 supplying the 'patients'.  So let's look at what you're going to be responsible for:

Since you're going to be practicing medicine, the fulcrum in this relationship is you as the clinician. It's going to be your reputation, medical licence, malpractice insurance, and your ass on the line.

I'm reminded from a line from the science fiction novel Dune in which goes something like, "He who has the ability to destroy a thing, controls that thing." Meaning, that this is effectively going to be your business, not the spas. (Note, I'm not denying that the spa could probably find someone else to do this same deal, just that it's never going to be the spas business.)

The spa will invariably take the tact that this will be an add-on to their existing business and that the 'patients' are their customers etc. This is both wrong in practice and illegal. This will be the practice of medicine and that's pretty cut and dried. You're still going to regulated, HIPPA compliant, etc. and that's it.

You're also going to need to set this up legally in your state. In most states you can't become an employee of or partner directly with a non-physician. (Not sure about how this applies to NPs so if anyone knows, please leave a comment.)

The patients are going to be yours, the responsiblity will be yours, the insurance will be yours etc., and you can't just be paid for performing medical treatments by a non-physician. All that being said, there are ways that this can be done if you're smart, and the spa owner is reasonable.

  1. Set up a legal entity for yourself. (Have a real lawyer do this who has knowledge with clinicians.)
  2. Make sure that the spa has a legal entity. (Different lawyer there.)
  3. The agreement will be between these two entities. (There are different ways to set this up depending on state. In some cases it might be the NP's entity that is 'renting' space from the spa but there are other options. Read through the forum threads on this site for those.) The agreement should also clearly define scopes and responsibilities and what will happen if the business fails. In cases like this, the spa is often 'paid' for rent and/or 'marketing' expenses, not fee splits or referrals. A technicality maybe but an important one.

People always try to overlook the 'business fails' part of the equation but it's a necessity to outline this up front since this business will end at some point in the future, even if both parties are happy.

Since it's illegal in most states to be a clinician who is an employee of a non-physician, that becomes somewhat problematic since you can't be 'paid' in the normal way. I would also suggest that all monies go though your legal entity before being distributed. In effect, you take all payments, not the spa. Headache yes but medicine in the US is the most highly regulated and litigious market there is. Don't sit around on your thumbs with this.

If you look at what you're going to be required to do, the conversation with the spa should be much clearer and should help the negotiations. If the spa owner refuses to understand how this should be set up, don't do any deal. You can't negotiate in good faith with someone who is willing to put you at risk right at the start.

About your Pay?

The real question is, "how much money are you going to make?". 

Business 'partners' always run into personal conflict when; they don't make any money, or.. they make a lot of money. I would suggest that you make sure that you go into this with your eyes open and the spa owner does the same. If you can't resolve the above issues then the money won't matter.

Comments welcome.

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!

Dr. Roy Kim - Plastic Surgeon In San Francisco

Dr. Roy Kim San Francisco,Board Certified Plastic Surgeon

Dr. Roy Kim shares his thoughs on social media, marketing, technologies and treatments including the Iguide neck lift system.

Name: Roy Kim, MD
Location: San Francisco, CA

That's interesting: Dr. Kim has gone to Guatemala several times, and he has operated on patients from Rwanda as well. 

Dr. Kim is also an investigator in several elite clinical trials regarding facial fillers, the Iguide system, and cohesive or “gummy bear” implants and is a member of Operation Access, a way for local San Franciscans to get free health care.

You've got a blog on your site, you're on Facebook, Google +, LinkedIn and Twitter. You seem to be comfortable with social media and reaching out to patients online. How much of your marketing efforts are now online and are they working?

Most of my marketing efforts are concentrated on

Read More

Botox, Dysport, Xeomin: How Many Neuromodulators Should Your Practice Offer?

Botox, Dysport, XeominWith Botox, Dysport, and Xeomin available and being marketed directly to your patients by thier manufacturers, how many — and which ones — do you need?

In the United States, we currently have three neuromodulator products (Botox - Allergan, Dysport - Medicis and Xeomin - Merz) approved by the FDA for treatment of the glabella complex.

These products are also frequently used “off-label” for treatment of the upper-, mid- and lower-face. Botox has over a ten year-track record of safe and effective use and is the best-selling neuromodulator worldwide. Dysport was similarly approved as a cosmetic treatment in 2009. Of note, a recent injunction against Merz unrelated to safety or efficacy has delayed the nationwide rollout of Xeomin.

Given that we have multiple agents to choose from, there are a number of issues to consider when choosing which neuromodulator(s) to offer to your patients. I’ll focus on Botox and Dysport as Xeomin is currently unavailable and has yet to receive its nationwide rollout pending the legal controversy.

Read More

Interview: Stephen Weber MD, PhD of Lone Tree Plastic Surgery

Sitting down with Dr. Stephen Weber of Lone Tree Facial Plastic & Cosmetic Surgery Center outside of Denver, Colorado.

Physician: Stephen Weber MD, PhD
Location: Lone Tree, CO

That's interesting: Dr. Weber has participated in the "Face to Face" program where local plastic surgeons donate their services to the victims of domestic violence and has participated in the annual humanitarian mission surgical trips providing free care to medically isolated, indigent patients.

Profile: I am a double board-certified Facial Plastic and Reconstructive Surgeon practicing at Lone Tree Facial Plastic & Cosmetic Surgery Center in the Denver metro area. My practice involves all aspects of facial cosmetic surgery including facelift, browlift, blepharoplasty, rhinoplasty, otoplasty, facial implants, facial resurfacing and scar revision. Our office also provides comprehensive treatments for facial aging including Botox and Dysport to reduce facial wrinkles, dermal fillers to minimize facial lines and folds as well as fractional laser (Fraxel and MiXto) resurfacing.

Can you tell us a little bit about you and how you got started in cosmetic medicine?

I became a Facial Plastic & Reconstructive Surgeon by a very circuitous route. In medical school, I planned to become an Infectious Disease specialist and even obtained a Ph.D. in Immunology and Microbiology in pursuit of that goal. However, my first rotation after successfully defending my thesis was in head and neck surgery. I knew that first day that I wanted to become an Otolaryngologist (Head & Neck Surgeon, ENT). During my residency training in Otolaryngology and Head & Neck Surgery I realized that my goals of performing a diversity of procedures in a technically demanding sub-specialty made Facial Plastic Surgery a very well suited specialty. I trained as Dr. Shan Baker’s fellow in Facial Plastic Surgery at the University of Michigan and then entered practice.

Can you tell us more about your clinic and the services available? 

My practice is a single specialty clinic. We have two plastic surgeons here at the practice, myself and Dr. Rick Schaler who is my partner and practice owner. We have eight other staff including one nurse, five estheticians, one front desk staff member and a billing manager. We offer the full range of facial reconstructive and cosmetic surgery. Our office has a fully functional operating room in which we perform all of our cosmetic procedures under IV sedation. On the medical spa side, we offer all of the available injectable treatments including Botox, Dysport, Xeomin, Restylane, Perlane, Juvederm, Radiesse and Sculptra. We perform laser services including Fraxel and MiXto (fractional CO2) resurfacing, vascular laser and laser hair removal treatments. We also perform a full complement of facial peels and facial treatments. Our patient population comes from the surrounding suburbs of Lone Tree, Highlands Ranch, Littleton, Parker as well as Denver proper.

How are you dealing with staff in your clinic?

Fortunately, we have not had the need to fire staff. The reason for this is that we’re very careful with the hiring process. The communication between members of our office is very clear. When we set out to hire a new member of the office we have a clear, articulated goal regarding our needs and the type of person we want to hire. Everybody in the office has a chance to veto a potential new member of the office staff. Each member of the office also has the opportunity to veto that potential candidate. We tend to hire from a pool of people already familiar to the office or from strong referrals from friends of the practice. We have avoided print advertising of open positions of late as this always leads to a huge response with relatively low yield of the type of candidate that we need.

For the front desk staff, compensation is hourly. For procedure or treatment oriented members of the office, including physicians, compensation is heavily weighted toward production. This is the most fair compensation method and encourages productivity. The formula is simple, clearly articulated and fair. Employees are paid a percentage of net collections. An employee can review their production at the end of each month, if requested. I review my own production at the end of every pay period and encourage the rest of our staff to do the same.

What laser technologies are you using now? How do you decide on new purchases?

We perform laser treatments including Fraxel and MiXto (fractional CO2) resurfacing, vascular laser and laser hair removal treatment. In terms of new purchases, laser companies really need to show us a substantial improvement in results before we will purchase new technology. We are marketed to by phone, mail, email and at conferences. I am interested in new radiofrequency technologies but I think the jury is still out and we’re holding out on making that purchase.

How do you market your clinic?

In terms of social media, we market on Facebook , Twitter, as well as LinkedIn. We’re trying to determine whether Pinterest can be leveraged with pre- and post-op photos and other images. We use social media to communicate with current and prospective patients with informational posts and product samples/ give-aways. Our email list of current patients is our most valuable marketing tool. Providing current patients with updates that they can forward to friends is invaluable. We also put on open houses and seminars that allow us to provide education, meet new patients and learn more about our current clients.

In the pay-per-click arena, we use Google AdWords with a relatively conservative budget. That has drawn a lot of traffic to our website and helped generate surgical cases. We have been testing the waters of direct mail and print advertising. Direct mail has had moderate result. Print advertising has been disappointing. We do not currently take part in Groupon, Living Social or any other daily deal sites. The main reason for this is cost and questionable ability to develop lasting relationships with users of these services.

What are the most coveted treatments/services in your practice? Have you tried removing some of your services?

The sun and dry air in Denver are the reason why people flock to this area. However, they wreak havoc on facial skin. As a result the demand for lasers and peels here is tremendous. On a volume basis, Fraxel skin resurfacing and Botox are the most common services in our office. However, the fixed cost associated with these services is significant. From a revenue perspective, surgery provides the greatest revenue and greatest profit for the practice. About 75% of our cases are elective in nature. We have not dropped any procedures recently. When I joined the practice, I introduced Sculptra facial injections and Radiesse hand rejuvenation and we’ve seen high demand for these treatments. 

What have you learned about practicing cosmetic medicine?

I’ve developed a thicker skin and learned not to take things personally. In the past, when a patient booked surgery with a competitor I assumed that I had erred in some way or not provided excellent photos of patient results or …. I’m noticing today more and more patients that will meet multiple surgeons and come back to book surgery with me. When I’ve asked why, the answers that patients provide are incredibly vague. It really is a gut feeling that people have that you are or are not the surgeon that will provide what they’re looking for. All we can do is provide as much information and education, quality photos of surgery results, a top notch facility and a warm, caring environment to convince patients that we’re the right team for them.

Any last thoughts on advice for your physician colleagues in the cosmetic industry?

I would urge physicians, especially in the plastic surgery realm, to compete by providing exceptional service. With Groupon and other daily deal sites, there is increasing pressure to compete on cost. Some of these deals will temporarily drive patients into the practice. However, few are likely to be loyal patients when the practice down the road runs an even cheaper deal. The daily deal trend has provided consumers with cheap (not necessarily quality) services. However, this has come at the expense of sustainability for practices that jumped in without doing enough research. The bottom line is that daily deals will lead to a spike in volume composed of largely price-oriented patients. Further, the deal seeking crowd is unlikely to see the value in your services. Continuing to drive down prices when our costs are fixed is not only unsustainable but diverts your attention from providing services, such as surgery, that are the profit engine for the practice. When you offer services at cost, you CANNOT "make it up on volume."

This interview is part of a series of interviews of physicians running medical spas, laser clinics and cosmetic surgery centers. If you'd like to be interviewed, just contact us.

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 and is the owner of O'leigh Aesthetic Surgery Center in Elkton, Maryland.

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:

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).

Botox and the 80/20 rule

Are you happy with your Botox Rep?

I posted a while ago about  our dissapearing Botox sales rep.

Someone who appears to be an Allergan rep responded with the following:

Maybe your practices were not bringing in a large amount compared to the rep's quotas. We rate offices from A-Z and if you are C and below...I don't bother call on that office. 80/20 rule and so far it's been working. President's club 3 out of the past 5 years and great bonuses. Don't take it personal, but it makes sense to serve the offices who have the greatest potential in serving us. If my quota is 100 and your potential is only 5, I'm skipping you to talk to the next 5 doctors who have a potential to do 100 on their own and blow out my quotas.

So take no offense. These guys have Botox quotas of their own and I'm guessing that commission is a prime motivator. If you're not ranked as an A or B by Allergan (and I guess it goes all the way down to Z), you might just be on your own.

Anyone switching to Dysport?

The Price Of Fake Botox

Are price increases in Botox motivating some physicians as well as non-physicians to sell fake Botox to their patients?

A Houston physician, Gayle Rothenberg was sentenced to 5 ½ months in Federal prison last Friday for injecting patients with a fake Botox product not approved by the Food and Drug Administration for human use. Apparently Dr. Rothenberg injected at least 170 patients with an unapproved botulism chemical. According to testimony, Rothenberg stopped using Botox after a price increase in January 2004 and began ordering the unapproved drug, which was half the price, despite knowing it was not for human use and labeled only for research purposes. In 2004, when fpur people became paralyzed from the counterfeit Botox, the FDA’s involvement has led to 31 arrests and 29 convictions of individuals selling the fake Botox. In addition to a jail sentence, Dr. Rothenberg must pay more than $98,000 in restitution to her patients and cannot reinstate her suspended Texas medical license.

The case of Dr.Rothenberg is no different than the case of Laurie D’Alleva, another fine citizen of my home state of Texas charged with selling counterfeit Botox. So far D’Alleva’s case has yet to be prosecuted as evidence is still being gathered. The common similarities between the two are that both individuals were motivated by greed to jeopardize patient safety ahead of financial gain.  Laurie’s case is especially intriguing to me based on public opinion. Here is someone who seems to be viewed by her customers as a “business woman” who was doing a “good service” for those individuals who felt that Botox cosmetic was too expensive because the “greedy” doctors were charging too much for the filler. While Laurie seems to be viewed by many as a caring individual, making Botulism more affordable to the masses, public commentary on Dr. Rothenberg is quite the opposite. Comments such as “5-1/2 months? Justice is not only blind, it's stupid. (and maybe corrupt) “ and “That sentence is not even one day of confinement for every defrauded patient!.” I feel the same way as the above two comments, but why is the public sentiment different with these two con-artists? Is it because one is a doctor and one is not?

Personally, I find it very frustrating that the price of Botox has doubled in since its introduction. I remember being excited when Dysport came out because I thought this product would be half the price and would drive the price of Botox down so more patients could afford the price. Sadly, this was not the case. As physicians have to pay more money for Botox, so do their patients. These increasing prices enable individuals such as Ms. D’alleva and Dr. Rothenberg to find counterfeit Botox they can buy at a cheaper price to make a greater profit, while sacrificing patient safety. Laurie d’Alleva’s “Botox” price was probably pennies on the dollar, whereas a physician’s cost for Botox is now at $600 per bottle. Hopefully another pharmaceutical company peddling botulism toxin will come along, get FDA approval and drive the price of Botox down to a more reasonable price for physicians to purchase for their patients. Until then, brace yourself for more Laurie d’Allevas and Dr. Rothenberg’s to come along. Thank heavens for the invention of ventilators!

Guest post by Wendy Hovorka, Valley Laser Surgical Solutions Vein Center,  McAllen, Texas

Submit a guest post and be heard.

Restylane Big Lips Overdose

If you're looking to see what a Restylane or Juvederm lip filler overdose looks like... well, then look no further.

This collection of lip augmentation overdoses is brought to you from Russia, where it looks like you can buy your Juvederm or Restylane wholesale and it's sold in 2-liter bottles.

Plastic surgery is booming thru Russia and it appears from these lip augmentation photos that the natural look isn't really in. There are enthusiasts in Russia tracking down Russian ladies with poor results on social networks and publishing them in special communities, sometimes making fun of them, but sometimes admiring their marvelous lips.

Read More