As stated by the American Society of Plastic Surgeons, Botulinum Toxin Type A injections are the leading cosmetic minimally-invasive procedures in America, nowadays. Moreover, facial rejuvenation procedures continue to experience growth, as 2018 marked the highest number of botulinum toxin type A injections to date, with over 7.4 million injections (1). Botulinum toxin type A is a neurotoxin, also called neuromodulator, which is used in the cosmetics industry to prevent the movement of facial muscles by blocking nerve impulses. It works by inhibiting the release of a neurotransmitter, acetylcholine, by the nerve cells. This prevents the nerve signals from being released by the cells, and hence, neuromuscular blockage. Clinically, what we see is reduced muscle movements and reduction of dynamic wrinkles. In other words, the wrinkles are erased. By reducing the intensity and frequency of contraction-induced wrinkles, neurotoxin injections also prevent the formation of deeper lines in the long run, making them an increasingly popular anti-aging strategy.
In 2002, the US Food and Drug Administration approved the use of Botox to temporarily improve the appearance of moderate-to-severe frown lines between the eyebrows (glabellar lines). It ushered in a new era for medical aesthetics. When Allergan’s Botox was approved for anti-aging benefits over 16 years ago, it was the only brand of its kind on the market in the United States. However, two other companies have entered the market and are having tremendous success: Dysport and Xeomin. Officially, these three neurotoxins are the only US Food and Drugs Administration approved for the treatment of glabellar lines. Galderma’s Dysport allowed plastic surgeons to give patients a choice in neurotoxins when it became available on the market in 2009. Noted benefits of Dysport include that it spreads more than Botox and patients who have stopped responding to Botox commonly use it. Yet with both products, Botox and Dysport, containing an accessory protein to carry the Botulinum toxin (egg or lactose), the body has the ability to build up antibodies over time, causing the results to diminish after continuous usage. Merz’s Xeomin contains no accessory protein, making it a “pure” version on botulinum toxin and reducing the risk of an allergic reaction or natural resistance (2). This solitary agent migrates further and faster to effectively work upon all facial areas upon injection.
Worldwide, more than 84,000 people have been treated with Xeomin injections. The U.S is actually the 20th country to approve this fairly new neurotoxin. It is available in 50-unit and 100-unit vials. The main difference between Xeomin and Botox has to do with the formulation. Xeomin is a “naked” neurotoxin. That is, Xeomin contains only a single ingredient (botulinum toxin A), while the formulation of Botox includes various protective proteins clustered around the active molecule. The benefit of Xeomin’s pure form means users have a lower chance of developing resistance (antibodies) that can limit its desired effects. Botulinum resistance have been reported with Botox and Dysport, but not with Xeomin. Since the Xeomin formulation does not contain additional additives it does not have to be refrigerated before use. This feature simplifies distribution and storage of the product, which may make it more convenient than any other neuromodulator. For its part, Botox and Dysport are both transported in dry ice, which represents an additional expense for distributors, injectors and, ultimately, for patients.
The results of all three neurotoxins on the market are temporary and varies from patient to patient. After a period of time, Botox, Dysport and Xeomin wear off and the nerve impulses begin to reach the muscle again (causing contractions and wrinkles to begin to appear again). Therefore, these treatments do require periodic maintenance (typically every 3-6 months) in order to maintain the results over time. Intervals between treatments may widen over time because your muscles will become more relaxed and require less maintenance. Botox and Xeomin are dosed similarly (for instance, 20 units of Botox equals the strength of 20 units of Xeomin). This is not the case when compared to Dysport, since Dysport requires more units. One unit of Botox/Xeomin is equivalent to 2.5-3 units of Dysport (3). Furthermore, Dysport typically takes 2-3 days until the effects of the treatment are seen. Botox takes 1-7 days, while Xeomin takes 3-4 days. Many patients prefer Xeomin as the onset is more gradual. Dysport may be the best option in areas where several injections are needed because of its easy spreading to cover a greater area on the face. In the areas where the spread needs to be minimized, Botox may be the best options to concentrate on deeper wrinkling.
(1) Plastic Surgery Statistics Report 2018. American Society of Plastic Surgeons. www.plasticsurgery.org
(2) Gart, Michael. “Aesthetic Uses of Neuromodulators: Current Uses and Future Directions”. Journal of the American Society of Plastic Surgeons. www.journalslww.com
(3) Scaglione, Francesco. “Conversion Ration between Botox®, Dysport® and Xeomin® in Clinical Practice. National Center for Biotechnology Information, U.S. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810210/