Botulinum Toxins: Getting Acquainted

For years, Botox has been the exclusive product for botulinum toxin procedures, but the introduction of Dysport has given patients and physicians more choices.

By Joel Schlessinger, MD
 

The question that presents itself during every encounter with a patient interested in botulinum toxin procedures is whether to use Dysport (abobotulinum toxin A, Medicis) or Botox (onabotulinum toxin A, Allergan). Most patients want to know if Dypsort, the newer and less recognizable product, is the same, better, or worse than Botox. In addition, they want to weigh the costs and potential benefit of each product. It is therefore important for physicians to recognize the opportunities presented by having two botulinum products in a clinical sense and also the effects on marketing services and generating interest in botulinum toxin procedures.

Discussing the relative merits of each product with his/her physician allows the patient to think about procedures in a new way by recognizing levels of variation in treatment. Since the patient may have more options and flexibility with two botulinum toxin products, physicians have new opportunities to introduce or re-introduce the cosmetic procedure to patients who may have dismissed it in the past.

Sales, Staff, and Promotion
Every time that we encounter a patient seeking botulinum toxin therapy in my practice—whether that patient is new to the procedure or has had it before— we discuss both options. This is because we recognize that (s)he may want to try something new, or after listening to their options, may choose to stay with what they have had previously. It is critical that your staff be knowledgeable about the full range of procedures available in order to facilitate interest in procedures and maximize opportunities to sell services. Never underestimate the value of a good staff that can explain the various details of the products to patients and answer their questions. It is important that, when going over options with patients, the staff discuss any potential discounts, programs, or incentives for the different products. This helps the patient to realize that there are new alternatives and potential cost savings available, even though they may have been happy with previous treatments with one product. For example, the Dysport challenge, which offers a $75 discount for the first treatment and $75 for either Dysport or Botox following that, may be of interest to a previous patient. There are also opportunities for cost savings when botulinum toxin procedures are packaged with other products, such as Latisse (bimatoprost 0.03%, Allergan) or Juvéderm (hyaluronic acid, Allergan). Therefore, the staff should be aware that there is more choice for patients and increased options for physicians and practices to sell products and services to satisfied as well as reluctant patients.

Dosage and Techniques
In addition to the considerations of marketing and sales, the choice between Dysport and Botox also depends upon subtle differences between the two products. It's worth noting that there are many ways dermatologists may prepare and administer Dysport compared to how they prepare and administer Botox.

Dilution. While most physicians are comfortable with the set way that they prepare Botox with respect to dilution, the issue of dilution of Dysport can be the subject of disagreement and even controversy. Since a vial of Botox contains 100 units, while a vial of Dysport contains 300 units, there is an inherent question as to how many patients can be injected per vial and what the 'equivalency' is vial-to-vial in practice. There are no hard and fast rules to this, but generally speaking, one vial of Dysport in my practice treats slightly more patients than a vial of Botox.

I currently use 3cc of saline to reconstitute a vial of Dysport and 2.5cc of saline for each vial of Botox. This translates to a ratio of 2.5:1, Dysport to Botox. Some dermatologists use the same dilution (2.5ccs or other equivalents) when reconstituting each product, which would then work out to a ratio of 3:1 Dysport to Botox units. Calculating the relative ratio allows physicians to judge the exact amount going into the patient without calculating different volumes for each treatment. Therefore, in my constitution ratio, were I to use 20 units of Botox for the glabellar areas, the relative amount for Dysport would be 50 units. By no means is this dilution scheme the only one to consider, but it is slightly safer in my opinion, as Dysport tends to work a little more aggressively, and therefore this leads to less overtreatment than in a 3:1 ratio of dilution.

The fact remains that many excellent cosmetic surgeons choose to use different amounts for volume administration or simply due to preference. While there is no right way of determining dilution amounts, most often dilution patterns for Dysport will be to some degree similar to Botox, allowing physicians some 'built-in' familiarity with the subject.

Constitution. We currently use a non-preserved saline preparation for both Botox and Dysport, based on our perception that results have been better and longer lasting. There has been some conjecture that preserved saline potentially stings less, but I have always felt that the benefits of non-preserved saline outweigh the benefits of any other preparation type.

Injection patterns. I generally use the same basic injection patterns for both Dysport and Botox. However, with Dysport I adhere to a slightly tighter injection pattern where the eyebrow and the glabella conjoin because I feel that if there is any spread, it can affect eyebrows more if Dysport is injected too far laterally on the median glabelar injection point (or the “11”). On the “11” area, there are two points, one on either side of the “11.” Migrating laterally to that, further out near or by the eyebrow area, can cause ptosis.

While I use the same injection patterns for Dysport as for Botox in most other injection points, it is important to note that I do not use the same injection pattern in any two people. I have recognized that injection pattern will differ based on the curvature of the face, the placement of eyebrows, the extent of one's wrinkles, how the person frowns, etc. Understanding these aspects of the face is essential to determine the appropriate injection technique, so no physician should have one 'fixed' set of injection patterns. Indeed, it is somewhat misleading to answer the question, “Where does one inject?” for botulinum toxin procedures or fillers, too specifically. Instead, it is more helpful to discuss approximate areas of injection and decide upon more intricate details of injection techniques based on the details of each patient's face.

Expert Tips
The differences between Botox and Dysport can be very subtle, but it is important to understand the individual components of each drug and understand that they offer different benefits that may clue the physician as to which patients might be encouraged to try one or the other. Following is a list of several tips I have compiled based on my experience with both products (during the Dysport clinical trials I personally injected over 1,500 sessions, which translates to the largest Dysport experience of any US investigator).

Crows feet. The crows feet area tends to have a bit more possibility of unintentional zygomaticus muscle involvement when using Dysport as opposed to Botox. In particular, some people may have slight involvement of zygomaticus muscle if Dysport is used too far inferiorly in this area. Therefore, I recommend using the same pattern, but with a slightly superior injection pattern as compared to Botox in the crows feet.

Forehead area. Patients sometimes complain that their upper forehead may still have wrinkles despite seemingly adequate amounts of Botox. These cases present opportunities to transition patients to Dysport, which can be very effective in the forehead area. Dysport can also be more effective in individuals whose glabellar frown lines are extraordinarily strong.

Brows and lips. For patients who want to retain the ability to lift brows or have some movement on the forehead, Botox may be a better choice. We use Dysport almost exclusively for women and men who want little or no activity after their procedure, while some individuals who want a slight effect, but not too much, such as actors and actresses, often opt for Botox. As for lips, I generally tend to use whichever product the patient has chosen for the forehead or eyes. Lips are not the determinant of use, but I feel it is probably better to remain consistent if a patient would like to have the lips injected as well.

Potency. In our practice, we have a preponderance of women who undergo botulinum toxin procedures (about five percent of our botulinum toxin patients are men). I have observed generally that Dysport is wellreceived because it is a bit more potent than Botox. On the other hand, everyone has a preference it seems, and those women who wish to “hide” their treatments from husbands or the public but retain subtle benefits often opt for Botox.

Onset and duration. For a patient who needs a quick onset of botulinum toxin, I generally recommend Dysport. It usually takes effect in one to two days vs. three to four days for Botox. This can be especially helpful if the patient has an engagement within the next couple of days. As for longevity, the results of Dysport tend to last longer than those of Botox. In my practice, I would estimate that Dysport generally lasts anywhere from 3.5 to four months, as compared to approximately 2.75 to three months for Botox. This is not always the case, but in general, Dysport’s potential longer duration of effect can be promoted as a potential benefit to the patient. As with all treatments, patients can have different results, so it is best to not overpromise until there is experience one way or another with the particular patient.

Making the switch. If a patient has had a bad experience with one of the products, I usually encourage her or him to try the other product, if anything for the sake of completeness. I have had cases in which one product works dramatically better than the other, although, theoretically, the two should work similarly. Some of this may be due to the fact that all patients are different and evaluate results differently. In any case, it is important that a patient be made aware that switching products doesn't guarantee improvement. Still, it is important that patients who are happy with the results of previous procedures with a given product know of the other product and the range of benefits each may provide. Ultimately, patients will decide which product fits their styles and preferences, but physicians should always emphasize the positive side of a new foray into the world of cosmetic surgery.

Greater Choice, Greater Opportunity
Overall, the addition of Dysport to the market has dramatically improved physicians’ options regarding botulinum toxin procedures and continues to increase the numbers of such procedures performed in my practice. From a scientific standpoint, as well as from a marketing/business standpoint, having two products available has opened up many new avenues of discussion and exploration. With two products in the pipeline— PurTox (Mentor) and Xeomin (Merz; approved this month by the FDA for neurologic indications)— patients will be confronted with new choices. As patients become more inquisitive and demanding of outstanding results, it is incumbent upon cosmetic dermatologists to learn as much as possible about these products, explore the many available options, and present them to patients where they are appropriate. It is especially important to be attuned to the small details and understand how the subtle differences in the products will offer benefits in particular cases.

Dr. Schlessinger has served as a researcher and consultant for Allergan, Medicis, Mentor, and Obagi, and as a researcher for Merz.

 

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About Practical Dermatology

Practical Dermatology is the monthly publication that provides coverage of medical care, cosmetic advancements, and practice management for clinicians in the field. With straight-forward, how-to advice from experts in various fields, we strive to enhance quality of care and improve the daily operation of dermatology practices.