Medesthetics

MAY-JUN 2017

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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MODULATING EXPRESSION 40 MAY/JUNE 2017 | Med Esthetics homerun would be for you?'" he says. "Then you can tailor your dose to the patient. Sometimes that depends on how much money they want to spend. Once you obtain that information from a patient, you have to assess muscle mass. Have her actually use those muscles in front of your eyes and, with experience, you should be able to calculate in your head—that will take 10 units of Botox or that will take 15 units of Xeomin or 30 units of Dysport to get the result this patient wants." Dr. Wilson has his patients animate prior to treatment so he can mark his treatment areas, as well as during treat- ment to track the results and dosing. He recommends that injectors have new patients come back two weeks after treatment when the toxin is at peak effect. "You want to see exactly what the results are because everyone behaves differently and sometimes unpredictably," he says. "You learn a lot about neuromodulation by bringing the patient back, and looking at how your dose and placement affected her. It's not wise to bring them back too soon because it does take over a week for the toxin to have maximum effi - cacy. If you bring them back too soon and note asymmetry, you may re-treat before the toxin has taken full effect and make the asymmetry worse or overbalance." Comparing Toxins With three botulinum toxins currently available and more coming soon, one of the big questions is: Does it mat- ter which toxin you use? "The reality of these products is that they are more similar than different," says Dr. Cohen. That being said, he has found that certain patients seem to respond better to Dysport in the lantheral canthus. "It's probably more of a dose phenomenon but sometimes endurance athletes, who are outdoors for long periods of time, have these really long crow's feet that go from that orbital bone all the way to their scalp line," he says. "For one reason or another, Dysport sometimes helps people with that longer, thicker, fan shape distribution of lines in the lateral canthus more than the other products." Dr. Wilson was the lead author of a study published in Plastic and Reconstructive Surgery (May 2016) that compared the dynamic strain of the three currently avail- able toxins. "We looked at the movement of dots on the forehead to quantify exactly how much muscle—or movement—change there was given a typical dose of neurotoxin," he says. The researchers compared 20 units of Botox, 20 units of Xeomin and 60 units of Dysport. They found very simi- lar results between Botox and Dysport, "to the point that the differences weren't signifi cant," says Dr. Wilson. "But we did see signifi cant differences in the effi cacy—at least at the dose of 20 units—between Botox and Xeomin. What we also found was increased variability in individual pa- tients when treated with Xeomin, unlike the other toxins." He posits that it could be the result of a slightly different formulation—Xeomin does have less proteins associ- ated with it—but is more likely a dosing phenomenon. "One thing practitioners will do when they see a variable response—which we see with all of the neurotoxins— is increase the dosing, and often that will change the response," says Dr. Wilson. "One thing we theoretically proposed in the paper is perhaps we should be using a higher dose of Xeomin to increase the true response." He notes that because Xeomin comes at a lower price point and doesn't require refrigeration, providers can increase the dosing and still maintain a reasonable cost. "I think what's most important is that people try all of the toxins and see what works best in their hands," says Dr. Wilson. "Bring all of the patients back and really look at their results. Make sure you're taking photographs. This really helps you master neuromodulation. And remember that each patient is unique in her anatomy, in what she desires and in her response to a specifi c toxin, so you may have to vary your dose or change up your toxin depending on the patient." Inga Hansen is the executive editor of MedEsthetics. © GETTY IMAGES NEUROMODULATORS + LASER RESURFACING Patients with deeply etched lines often require skin resurfacing in addition to neuromodulators and fi llers. A few articles have shown that you may be able to improve laser resurfacing outcomes by pre-injecting botulinum toxins into deeply etched areas two weeks prior to laser treatment. "By injecting around the eyes or the mouth and relaxing those muscles prior to resurfacing, the patient is not imprinting that muscle column into recapitulat- ing that same exact line as she heals from the resurfacing. Some newer studies even show a more favorable cytokine/chemokine profi le after neuromodulator pre-injections in dynamic areas of scars, " says Joel L. Cohen, MD, of AboutSkin Dermatology and DermSurgery in Greenwood Village, Colorado. He performs the injections two weeks prior to laser treatment so that the neuromodulator is at its peak effect and not at the day of laser or fi ller treatments as that can increase the risk of swelling and product migration.

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