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Neurotoxin and filler injections continue to top the list of most in-demand treatments for aesthetic patients. With many safe and effective options available, new and emerging products are also showing promise. Nashville, TN-based Dermatologist Michael H. Gold, MD shares his insights about trends, what’s new, and what potential developments he’s excited about.

What neuromodulator treatment trends have you been seeing and/or do you expect to see in 2023?

Michael Gold, MD: The biggest trend today is that we have a new toxin becoming available in 2023, with the concept that it lasts longer. We know the study results for Revance Therapeutics, Inc.’s Daxxify (daxibotulinumtoxinA-lanm) which showed nice 6-month results. In addition, several other companies have started to investigate different dilutions to extend the results of their toxins already on the market. We have data from Allergan, Galderma, and Merz showing that, if you change the formulation through dilution, you can get very nice long-term results.

I think Daxxify is really good, and it’s going to make a splash in the marketplace.

Additionally, beginning mid-second quarter 2023, we’re expecting another toxin from Hugel, which will also add to the choices that we have. Hugel’s Letybo was approved in Europe in 2021 and quickly gained market share there. Once FDA approved, it will also be called Letybo in the US. Interestingly, in their studies, they included a psychological aspect. One of the things that we’ve learned over time is, obviously, that people who get toxins have a better self-image, self-worth, self-confidence, whatever the self is that they’re thinking about. Mark Nestor, MD even recently published a paper discussing this in detail. And it’s very true. People feel more confident.

Galderma’s investigational RelabotulinumtoxinA is also expected to be approved this year. This is a ready-to-use liquid botulinum toxin A with a proprietary strain. Topline results from two Phase 3 clinical studies show it improves both glabellar and lateral canthal lines with a rapid onset of action and a long duration of up to 6 months.

There is a liquid toxin available now in Europe that is part of Galderma’s Ipsen collaboration. It’s called Alluzience—it’s already available, and the clinical studies they did on it in Europe are really well done. It has a fast onset, it is long lasting, and it’s off the shelf. You don’t have to think about how many ccs you need; it takes the guesswork out of mixing stuff, which may be seen as a big benefit for some. I think having a liquid toxin in the US with approved indications is going to be a big win.

There has also been talk about the potential for biosimilar toxins, but they have to undergo the same kind of rigorous studies that everything else goes through before we know if they will become prevalent.

Is there room in the market for new toxins?

Dr. Gold: I think that having yet another toxin is very interesting. And there are several more coming down the pike probably in the next few years, which is only adding options for the clinician.

It gives us choices for the patient. I think overall, the more products are available in the toxin market, the more opportunity there is to get patients in for injections. The reality is we still don’t see everybody who wants these treatments done.

There are a lot of patients still on the fence. There are a lot of people who just haven’t come in to get their toxin injections if they need them and want them. I think the more products in the market, the better for patient awareness, helping drive patients into our clinics. That’s exciting, and I think that’s going to only benefit all of us and benefit our patients as well. It’s still a skilled procedure that should be done by very qualified individuals.

In addition to longer-lasting results, what other trends have you noticed?

Dr. Gold: I think the other thing that’s becoming more prevalent is the concept of microtoxin injections—injecting very small amounts into areas of the face to treat a variety of different things, including oily skin, large pores, rosacea, the redness of rosacea, even acne. These treatments may attract a whole different patient, but it’s a need that, again, is starting to be looked at and starting to be addressed by the companies.

It will take a while to make it through the clinical world, but many of us are doing microtoxin injections already and starting to define them and getting a better understanding of how they work and best practices. We have learned a lot about microtoxin injecting from our Asian colleagues who have been doing them for years.

I think we’re going to see more microtoxin injections over the next few years. There are clinical studies that are ongoing for a variety of new indications.

What trends are you seeing in the filler market?

Dr. Gold: The filler world is interesting. Every company has come out with a variety of different fillers. They all are good; they all work. I think the exciting thing that’s going on is that we will have more fillers in the US soon. There are clinical trials with new companies. And again, it’ll be nice to have new options. It adds to the market. Most of these fillers are from Europe, so they have already been around for a long time, and they’re now in partnership with companies in the US. It’s similar to when Revance launched RHA; it’s a great filler line, but it had been available outside of the US. It wasn’t new to a lot of us, but it’s nice to have the US approval. So we may have some new-to-the-US fillers in 2023. Additional fillers improve patient awareness. Patient education through direct-to-consumer advertising and social media increases the visibility of all the options out there, and that’s good. It doesn’t mean companies like Allergan, Galderma, and Merz are sitting down. Obviously, we have a lot of fillers already available from them that work and that we utilize all the time.

In the filler world, I’m also really excited about the emergence of combination fillers, like hyaluronic acid with calcium hydroxylapatite. There are two available in Europe, and once studies get underway, it is to be hoped that products will eventually come to the US. I’m excited about that because you get that immediate response from HA, and then you get the long-term effect from the calcium hydroxylapatite.

The biostimulatory category is also very important. Some are looking for label extensions on what we have now for products like Radiesse and Sculptra and being able to hyper dilute. This offers a great option for our patients, but the problem is that, if it’s done by providers who don’t know what they’re doing, you’re putting a longer-acting filler into or in places that we didn’t inject in before. It’s essential to have skilled providers who know what they’re doing. You have to make sure that you learn the techniques, learn from the experts how to do this, where to inject, and how you dilute these products.

These are exciting potential development in the filler world. We’ll see how all of it plays out as clinical trials eventually get underway for these indications.

Are you seeing a trend with patients looking to achieve a more natural look with fillers?

Dr. Gold: When we do clinical trials, especially volumization studies, we’re given a range. You can inject up to X amount of filler in each cheek at the beginning, and then you get a touch-up 2 to 4 weeks later. With one of the original volumization studies, they were injecting about 7ccs in cheeks. And that’s when we saw some nodule formation and just not natural results. I always sit down with my patients and explain to them that I’m going to put in what I think they need to not look unnatural. And if we need more, it’s okay to come back and put a little more in.

I’d rather give a little less than a little more because you don’t need to plump patients up to look weird. You also don’t want to risk nodules and other things with poor technique. I want people to leave my office, come back, and say people noticed their skin looked so much better but did not comment that they look like they had a lot of work done. There’s a difference in how that is projected when you talk about it. I think that being natural, giving less, sometimes is better.

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