A newly published stepwise approach for using onabotulinumtoxinA, abobotulinumtoxinA and incobotulinumtoxinA to treat dynamic facial wrinkles differentiates among the three FDA-approved neurotoxins and gives practitioners a template for achieving optimal results, while avoiding complications.
The paper in the October 2016 issue of Plastic and Reconstructive Surgery makes several key points:
- Physicians treating patients with neuromodulators should understand facial anatomy and know how to accurately analyze the face, examining wrinkles using a top-down approach and including facial animation.
- They should also be familiar with how Botox (Allergan), Dysport (Ipsen) and Xeomin (Merz) differ, realizing that dosages and effects of these products are not interchangeable.
- And don’t forget the importance of a thorough medical history, inquiring about supplement and medicine, allergies, previous surgical and nonsurgical facial procedures and more, prior to injecting patients.
While today’s neuromodulators have equivalent potential for success, each has specifications for use. In general, the authors write, 2.5 U of Dysport (which has been shown to diffuse more than other products) is comparable to 1 U of Botox, and 1 U of Xeomin is comparable to 1 U of Botox.
Reconstitution is necessary for Botox, Dysport and Xeomin, and the authors suggest that reconstitution with preserved isotonic saline, versus non-preserved isotonic saline, might result in less pain.
Again, in general, a 100-U vial of Botox can be diluted in 2.5 mL of diluent for a final concentration of 4 U/0.1 mL.
While Botox and Dysport need to be refrigerated, Xeomin only needs refrigeration after it has been reconstituted.
Injection Tips
The authors recommend injecting the frontalis in several sporadic, horizontal rows, superficially, with about 6 to 15 U. Stay one fingerbreadth or more above the brow to avoid brow ptosis. And inject an added 2 U in the mid forehead superior to the middle and lateral brow junction to avoid a peaked brow look.
Then, inject the corrugators with about 10 U of Botox each side; next, inject the procerus and nasalis as the patient animates her face.
Lateral periorbital injections help to diminish crow’s feet. And while fillers are the standard for addressing perioral rhytides, neuromodulators can be injected into the upper lip for a softening of those areas.
The authors recommend injecting the mentalis with 4 to 10 U, and using 2 to 4 U, if needed, to soften platysmal bands.
They warn that massaging treated areas post injection should be avoided because it could diffuse the neurotoxin. Providers should take detailed procedure notes to document variable patient responses, so that they can optimize patients’ future outcomes, they write.
