Shino Bay 
Dr. AguileraAguilera, D.O., a Fort Lauderdale, Fla.-based dermatologist has built a reputation and following based on his signature “Dynamic-Tox” approach, using Botox (Allergan) and Dysport (Galderma) to rejuvenate the face.
Dr. Aguilera says he uses an average per patient total of 36 to 44 units of both neurotoxins to treat the crow’s feet, glabellar lines and frontalis; whereas, many others in the industry might use 50 to 70 neurotoxin units to treat the three areas of the face. And the effects of treatment with the smaller amounts of neurotoxins last an average three to four months.
Dr. Aguilera tells Cosmetic Surgery Times that his goal is to achieve a soft, natural result with neurotoxins.
“The emphasis is on dynamic movements, so my patients look fresher and younger; yet, they still have some movement on the face,” he says. “The human face is meant to move when you talk to people. What I see from years of doing this is that some are so frozen in all facial areas, they start recruiting other muscles to show the gestures that they used to show. And they start getting lines and wrinkles in other places.”
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Combining Neurotoxins
Dr. Aguilera says he started using Dysport because of patient demand for “the new Botox.”
“I would do my technique [with Dysport] and noticed that it didn’t look like my work. It was very severe. My patients would say, ‘I’m not sure about this new Botox. I feel quite heavy on the forehead. I don’t feel that I look fresh,’” he says.
There was controversy among his colleagues about whether Dysport diffuses more than Botox, according to the dermatologist. And while, he says, that didn’t pan out in studies, he did notice the severity of results in practice. He decided to use Dysport in the glabellar lines and to treat the crow’s feet but kept using Botox for the forehead.
“My patients are always happy with the combination,” he says. “If somebody wants a more severe look [on the forehead], they usually do their fillers with me and the neurotoxin somewhere else.”
NEXT: Injection Pearls
Injection Pearls
Dr. Aguilera says he injects neurotoxins into all the standard areas that are taught to those who learn how to use onabotulinumtoxinA products.
But, he changes his approach to treatment in middle-aged to older adults.
“As patients get older, they start losing fat and tissue on the forehead, which supports the frontalis muscle. What happens is they require less and less Botox in this area. And if the frontalis has dropped so much that the brows are below the brow bone, we cannot hit the frontalis anymore with any neurotoxin, unless we volumize the forehead,” Dr. Aguilera says. “That happened to me. I’ll be 47 this year. I had a dent on my forehead that I never noticed until a colleague of mine Plastic Surgeon Dr. Jackie Yee pointed it out. But what I used to notice was that whenever I put Botox in my frontalis, the bridge of my nose started looking wider, and I had a line across it, so it looked like my forehead was drooping. And whenever my Botox wore off, the bridge of my nose got better.”
The dermatologist says he uses Voluma (Allergan) for an off-label indication to volumize his forehead before using Botox. As a result, he doesn’t get the unwanted effect on the bridge of his nose.
Dr. Aguilera, who is on the advisory board and is a trainer for Allergan and Galderma, says he only uses Xeomin (Merz) on patients who are not candidates for Botox or Dysport. Dr. Aguilera, who also is a consultant and trainer for Merz, says Xeomin didn’t last as long as the other neurotoxins when he tried it on his forehead.
“My colleagues have told me that one of the problems with Xeomin is that you need to do something special when you mix it. You need to shake it like a martini, then you need to put the bottle upside down for a few minutes, before you use it. Then, you will have the right amount of units and same results as all other neurotoxins,” he says. “We weren’t doing that and, after two months, the product was pretty much completely gone. So, I’m going to revisit Xeomin [with the new approach].”
NEXT: Another Doctor’s View
Another Doctor’s View
Dr. NiamtuCombining neurotoxins makes sense and can improve outcomes, in the right hands, according to Joe Niamtu, III, D.M.D., an oral and maxillofacial surgeon with a practice limited to cosmetic facial surgery, in Richmond, Va.
“Injectable treatments are a paradigm shift that has totally changed the landscape of cosmetic surgery. For the basics, neuromodulators and fillers are really pretty easy to use and obtain predictable outcomes. The average injector probably does it all the same; 20 units here, 12 units there, etc. Same with fillers. I have taught filler (and neuromodulator) techniques to hundreds of doctors from every specialty and for the most part a doc picks up a syringe and plumps the folds or lips and it works out OK,” Dr. Niamtu, a fellow of the American Academy of Cosmetic Surgery, tells Cosmetic Surgery Times.
In every discipline, however, there are devotees that totally embrace care, precision and art in what they do.
“This same art and precision carries over into cosmetic surgery. Many injectors love what they do and continually challenge themselves to improve their art. This requires experience, the ability to challenge dogma and close observation and follow-up of patients and techniques. Some docs do injections, and some docs are students of the art,” Dr. Niamtu says. “Also adding to this there has been a big change in patient desires. As Dr. Aguilera mentions, no one wants a frozen face now. Fifteen years ago, patients would get mad if they had movement, and now they get mad if they don’ have movement.”
Dr. Niamtu estimates that about 30 percent of his patients are using fewer neuromodulator units for each area.
“Whereas many patients used to get 40 Botox units in the frontalis and glabella, we may now treat the same area with 15 units. This is probably a combination of patients wanting less paralysis and me becoming more accurate and precise in my technique,” he said. “Regardless of ‘standard injection technique,’ artistic injectors have learned how to deliver maximum results with less product. They also have learned to harness the strengths and weaknesses of the available products.”
Dr. Aguilera’s combined approach, using Dysport and Botox, is a good example of understanding what works well in one’s hands and how to harness that for precision treatments.
“Regardless of what the literature says about diffusion, Dr. Aguilera tailors his injection technique by how products work in his hands,” Dr. Niamtu says.
While Dr. Aguilera’s approach is novel, combining products on the same patient is not new.
“I have patients that tell me what to put where and how much to put. I embrace this as they have input in their treatment,” he said. “It is also very common for me to use multiple filler products on the same patient.”
In the end, Dr. Aguilera’s technique is evidence of physician refinement of products to more precisely benefit the patient, which of course, benefits the doctor, too, Dr. Niamtu says.
Disclosures:
Dr. Aguilera is a consultant and trainer for Merz. Dr. Niamtu is an advisory board member for Allergan and Valent.
