Botox: Which Toxins To Use?

Hi, Dr. Mok. I have a question about Botox that we hear today. There has been conversations in the media that certain establishments call it Botox, but they may use a different toxin. Can you give an opinion on which you use and why?

I'd rather. I'll review that, but I'll review kind of all the neurotoxins that are currently available in the United States. So Botox came out first in 2003 and it was specifically for the Glabella, which is right between the eyes. And it was approved for. They did 20 units at a time, which turns out that's not the right dose. It should be 30, but it's 20 units between the eyes. And that was the first indication we learned how to use it in other spots at that time. They then subsequently got the indication for the wrinkles around the eyes or the so called crow's feet. And then about 10 years later, and then in 2017, they had the indication for the forehead. Now, we've been treating all those areas all that time, but that's when they got the FDA approvals for them. Next one to come out was Dysport. A Dysport came out right about 2009. And Dysport is the most dissimilar of the neurotoxins that are out there. Most of them are almost identical to Botox. This port is the furthest away and the units don't even match up. So one unit of Botox is equal to about 2.7 units of Dysport. The Dysport has a nice ability to spread. It spreads much further than Botox. Imagine if you inject Botox and spread the size of a dime, then Dysport might be the size of a nickel or a quarter. So that leads to pros and cons. Where places you might want spread, it would be desirable. Places where you want precision, not desirable. I never got a brow lift with Dysport in our patients, so for that reason I choose not to use it. Arguably it would be great for the forehead. 2011, out came Xeomin. Now, Xeomin came out for very specific indication. It was what they would call a cleaner toxin as an oxymoron. But these are toxins. The most potent toxin known to man is the Botox brand. Of course, we're using minute doses and some people get antibodies to the neurotoxin where it stops working. And it's very rare in cosmetic indications. But for medical indications, we're using much higher uses. You'll bear in mind that most toxins are Paid for by insurance for medical uses, muscle spasm, torticollis, that sort of thing. And they get immune to it, they'll get allergic to get immune to it, and eventually it doesn't work. So Xeomin made a, took the toxin, which is very small, it's called 150 kilodaltons and has a 750 kilodalton core around it. That's what Botox is. Xeomin pulled that core off. And this has the ideal talk toxin. So really that might be suitable for, you know, people that are using more units or people starting very young. They'll never get, they'll never get resistant to Botox. In those three toxins we had the most experience with, been around the longest. And I'll tell you these, we can compare the newer ones, those three, because they fall in line. The Botox is kind of in the middle of the spread. Xeomin is the lowest spreading, the most precise, and Dysport is the least precise, most spreading. And when we talk about what is our preferred one, well, it depends on what we're treating. Okay, so I don't use Dysport, not because it's not a great toxin. It does create some product confusion because the units aren't the same and it has a lot of spread. But I think that would be a suitable toxin for the forehead where we want spread and alone number of units. We do use Botox for the forehead because we want the spread in the forehead and we want, we do not want precision. The forehead is the muscle that you can most easily say screw up when people look fake. They've had their forehead over treated. And Botox really delivers well because it spreads a decent amount, it's very predictable and it causes softness. Where I like Xeomin the best is where I want precision, which is specifically for improving the brow position, the eyebrow position. So we put Xeomin here and here. We want to lift the brows that the brows drop over time because most of your muscle, the facial expression, pull your eyes down and make you look pissed off, tired, angry, which is undesirable. And we want those weakened. But if we use Botox here or this part here, it bleeds into the lower forehead and it prevents the brow from lifting very much. In fact, it might drop the brow. So when we see that called so quote unquote Spock brow, which means brows like this here, that sometimes is from, you know, something like this port here, that spreads a lot or from overdoing the forehead, central forehead, so we don't really have a preferred one. It depends on where we're at. But we typically in our practice use Xeomin and, and Botox. We don't use all Botox or all Xeomin. We use Botox in the frontalis muscle, the forehead and Xeomin on the glabella and orbicularis muscle where you want precision. Let's go further from that. Then now came 2019 Juvo. And Juvo was designed to overcome one of the limitations to the toxins. They don't have any insurance indications so they can, you know, mess with the price more allows them to bring the price down. So I think that's put a little bit downward pressure on pricing of toxins. Not a lot of good studies on comparing to other toxins, but appears to have spread similar to Xeum and more precise. So we might use in the same areas. Then there's the Daxify that came out in about 22. Daxify is the one that they first purported to be a six month neurotox. It turns out that's not the case. Some people do get the six month, but you get six month with Xeomin or Botox too and you need twice as many units, so it's not as powerful. That one I don't think has got caught consumer attention because you know, you're paying more for it, you need more units and it's, you know, some people, it's very highly variable. How long will last then? The T Botus came out last month it appears or less this last year and it appears to be a shorter acting neurotoxin. So that being said, let's do a summary. They all work great. There's miracles. Whoever came out first would have been the leader and that was Botox. And Botox is almost like a generic lane, like Kleenex is the facial tissues. But we use in our internally we call it, you know, a toxin because there's different types you might use and I think you can interchange them to some degree. But typically where you want spread and smooth, we want Botox or Dysport and we want precision and lift. We want Zeomin or Jeuveau. Daxify is pretty precise as well. I don't like it because of the unpredictable nature. Now there's something called a duration curve, dose duration curve. And the more units used, does it last longer? Well that is the case with some of them, but not all of them. Botox doesn't have a very strong dose duration curve. Xeomin does, so I like that as well. Also Xeomin on average, if you use the same number use as Botox, you get about two weeks more out of it, maybe even three weeks more out of it. So it gives the advantage of lasting a little longer. In fact, historically, we schedule patients for Botox every three months. And we started putting xeomin in the glabella and the orbiculara. We move people out to four months. So it actually saves them, you know, a treatment a year, basically, or treatment every two years. So the they all work great. I have preferences based on some practicalities. Again, dysport, I think that's a great neurotoxin. We don't use it because there is confusion with the units, and it's uncontrollable in the spread, which might make it great for the forehead, maybe not so great for other areas.