Which wrinkle reducing agent is right for you?

By Mathew T. Epps CONTRIBUTOR

Botulinum toxin type A (BoNT-A), historically referred to as Botox, remains the No. 1 nonsurgical facial rejuvenation treatment. Botox is one of many botulinum neurotoxins that act to temporarily weaken facial muscles to smooth or soften dynamic fine lines and wrinkles.

Treatments should be tailored to the individual in what is known as a particular individual’s “pattern.” Botox is not alone though – currently there are four other major formulations of Botulinum toxin.

To some, the most familiar neurotoxin brand name is Botox (an Allergan product). There are several other FDA approved BoNT-A toxins including Xeomin (by Merz), Dysport (Galderma), and Jeuveau (Evolus). While the active component of each of these agents is

BoNT-A toxin, they vary markedly in formulation including a “protein blend” that can affect injection efficacy, duration of effect, and diffusion.

Dysport has the diffusion size of roughly a quarter, Botox a nickel, and Xeomin a dime. Diffusion of the injections can greatly alter the predictability of a treatment, or likewise, can create a smoother look on large surface areas such as the forehead or a more precise treatment around the eyes.

Some BoNT-A toxins contain carrier proteins that can infer a progressive immunity that may limit duration of effect over the course of several treatments. Purer product formulation such as the affordably priced Xeomin may be helpful in patients who have developed an immunity to Botox.

Of the four major wrinkle-smoothing agents, Xeomin and Dysport begin to have an effect within three to five days, as opposed to Botox which routinely takes effect in seven to 10 days. Generally, Botox, Xeomin and Dysport have a duration of four to six months.

As such, the caveat with all these current treatment options is that regardless of the formulation, they are dose dependent and vary in price. In other words, less is not more, and markedly more is not necessarily better.

For Botox, the average dose currently ranges from 40 to 64 units. Under-treatment or skimping on the dose results in under treatment and commonly results in under-satisfaction. Conversely, over treatment can result in a “frozen” look and brow-drop.

BoNt-A toxins are very safe, relatively temporary, and can be quite predictable in well-trained hands. The most important factor in satisfaction following anti-wrinkle treatments is having a qualified injector who is competent and confident in using the neurotoxin of choice. Likewise, bargain Botox can be costly to fix.

Treatments can be tailored to treat the glabellar area between the eyebrows and above the nose where the “11” lines form, the forehead, crow’s feet, muscles that contribute to a gummy smile, chin pitting, jawline, neck bands, and even large, full-appearing cheek masseter muscles. Rare side effects include bruising and headaches.

The takeaway is that Botulinum toxin in the right hands can be a fun, refreshing zero-downtime experience that is performed safely and reliably millions of times a year.

Mathew T. Epps, MD, MS, DABS is a plastic surgeon, triple- fellowship trained in facial, eyelid, and breast surgery. matheweppsmd.com or info@dreppsmd. com