Botox

Botox has long been the only player in town for treating lines of the forehead and various wrinkles. It has been so dominant in the market that there is probably not a single person on the planet who has not heard of Botox. However, just like the innovation of the iPhone has drawn imitators galore, so too has Botox, as evidence in the array of similar upcoming products. As Charles Caleb Colton famously said, "imitation is the sincerest form of flattery." This is good news to the consumer, as the cost of Botox is expected to go down, mainly as a result of competition.  So, how do all the Botox "competitors" on the horizon stack up? Here is the lowdown on each of the upcoming products:

Dysport

 Dysport (aka Reloxin in Europe) was approved in the United States for treatment of lines in 2009 It has disappointed consumer and physicians alike by coming in at a similar price point to Botox.

In Europe, Dysport is substantially less in cost than Botox, creating a market more favorable to the patient.

Botox continues to dominate the American market due to some of Dysport's several disadvantages, such as: the confusion in amount of product needed for effictiveness (Dysport uses a different metric than Botox) and diffusion (product spreads more rapidly making it harder to control).

In addition, Dysport has little to no name brand recognition.
Few if any physicians will tout Dysport as a superior product than Botox for cosmetic applications. In the use of sweating (hyperhydrosis), Dysport diffusion may be slightly advantageous.

Xeomin

 Xeomin is the latest botulinum type A drug to be released in the United States.

It is produced by Merz, a German pharmicutical company.

Currently in phase 3 testing, it works almost identically to the more readily identified Botox made by Allergan.

The dosing is exactly the same, but the main difference is that it is free of complexing proteins which results in forumulation with less risk of sensitization and antibody formation.

This means that overtime, users of this product are theoretically less likely to develop "Botox Resistance".

"Botox Resistance" is where patients develop less and less effectiveness of Botox over longer period of times.

This is the primary reason why I advocate not using Botox unless there are lines to treat (i.e. Preventative Botox).

Depending on its price point, this product should have a big impact in the United States.

Myobloc

 Myobloc is the only available Botox type B (which is another subtype of Botox) and most physicians do not recommend it as a first line therapy.

It is indicated in patients with hypersensitivity to Botox type A formulations.

The main drawbacks are more painful injections and shorter duration of action.

In addition, Myobloc has a much greater area of diffusion making it harder to control in aesthetic applications.

Purtox

Currently in phase 3 trials in the United States, it is similar to Xeomin (see above) in its advantages.  

Having similar products which are equivalents or offer advantages, allows for more competitive pricing.

Chinese BTX-A

Chinese BTX-A is proof that everything will be made in China someday.

Chinese BTX-A is somewhat less effective than Botox.

I do see patients who have been treated in Asia who have had minimal results and then have greater result in the States from Botox.

Chinese botox contains bovine gelatin protein which can cause sensitization issues as well.

Aside from the above drawbacks, the name itself sounds and feels like an inferior product.

Unlikely to have an impact on the US market, it may be a formulation received by internet advertisements.

CNBTX

  Another variation of Chinese botox, this is probably the variant most likely sold on the internet.

Little regulation exists on the internet due to differences in laws in various countries.

This is where the informed consumer can make a difference in understanding the differences.

Not recommend and not approved in any country in the world.

Neuronox

Used in Korea, supposedly equivalent to Botox.

Below are some questions patients ask about Botox and fillers:

Can I bring in my own vial of Botox?
The answer to this is obviously no. I do not trust any product which is received from the internet as its controls are not regulates and can be an imitation product.  In addition, any drug or pharmaceutical has to be regulated and approved by the FDA and bought in a legal manner. If there is ever a reaction to a product injected (thankfully I have had none), there is a company which assumes responsibility for the quality of the product.

Can I inject myself with Botox?
Again, I don't recommend this for several reasons. First of all, even experienced injectors are working on the nuances of using the product. What little money is saved is likely wasted in creating a result
which is unaesthetic.

Should I have Botox injected in another country?
Any product injected outside the United States should be done in a careful manner and with extreme caution. Regulation of products is much less rigorous in other countries and certain reactions can be permanent or even fatal. Saving a few hundred dollars is not worth having an irrevisible reaction. Botox used in the United States for aesthetic purposes is one of the safest materials on the planet.

Why does the US have the longest delay of approval for products?
The FDA regulates all pharmaceuticals that are released in the US. The main advantage of this is that many products have a long history of use in Europe or Canada, making the introduction to the US a safer decision for many patients here.

Botox Maintenance:  When Should I Start?

No one wants to look older, and some of us don't even want to act any older. So naturally, a hot topic for debate is when do I start botox. Some physicians are even talking about using botox before you have lines, so called “ preventative botox “. But is that really the answer and the best practice?

My motto is “If you can not see it, do not treat it.” Pragmatically speaking, for early lines, botox is very effective in softenening them almost completely after the first session. So based on botox's effectiveness, it would make little sense to try and prevent something that is easily treated and not present. Once a line is more “etched”, it may take several sessions with botox prior to softening it..

There are cases of Botox being less effective and requiring higher doses over time, aka Botox resistance. This phenomenon is usually after multiple and many years of Botox therapy. Using Botox early on in life, may give that individual less of a window to use Botox later in life when he/ she may need it the most.  

Cindy Crawford has admitted to using botox in the press as part of keeping herself looking youthful.

We are living in the Botox Era.  Botox has officially turned 20 years old.  It has a record of unparalleled safety and efficacy during that time.  It was originally approved by the FDA in 1989 for strabismus, an eye condition.  It was approved for glabellar lines, the lines between the brows which form a vertical furrows sometimes called the number 11's in 2002. 

Botox is one of the key components which has changed the way facial rejuvenation has changed.  Traditionally, patients would seek a facelift at age 50 and wait for their face to slowly descend.  Now with Botox and facial fillers, patients are prolonging the time to surgery, and are looking better at unprecedented ages.  A classic example of this is seen in Hollywood actors and actresses.  Forty used to be the age when an actress was considered "old".  Now some of the most beautiful women on the planet are in their 40's (Cindy Crawford, Hallie Berrie, Jennifer Aniston), 50's (Michelle Pfieffer, Christie Brinkley, Kim Cattrell).   Which is good news to all of us approaching our 40's and 50's.

The Food and Drug Administration recently announced that all manufacturers of botulinum toxin, best known for the brand Botox, that there is a risk of paralysis-like symptoms from the distant spread of the toxin and carry a black box label. A black box label is the strongest safety warning that a medication can carry and is named for the black border that surrounds the warning text.

This side effect has been observed in non-cosmetic uses of botox, primarily in the treatment in spasticity (tight rigid muscle) in children with cerberal palsy where injections in and around the spinal cord with high doses have lead to this effect. While the chance of this occuring in cosmetic applications is not known, it is believed to be an an extremely rare side effect.

In China, a 24 year old female received 200 units of Botox toxin in her legs, in order to treat large calves. Most cosmetic patients with Botox receive 15-45 units of Botox, so this patient received 5 to 8 times the standard dose of botox in a non conventional location. She subsequently developed systemic muscle failure which resolved. It was not clear what type of Botox was used but its believed to not be Botox created by Allergan. Another case of a New Jersey woman who developed systemic issues was the use of an off label use of botox.

What are some take home points from the new approval?

1. Only use an approved source of Botulinum toxin. If your injector is injecting in a basement or a non-medical environment, be aware that they are injecting you with the actual Botox. I see alot of patients from other countries who tell me that they had Botox in Asia and it only cost $50 and did not work.

2. Make sure a trained health professional is injecting you with Botox. There are plenty of technicians, aestheticians and other unqualifed individuals, including physicians,  who do not use Botox properly.There are specific applications for the use of Botox and recommended dilutions for its product. Someone trained in the use of Botox will know this.  In addition, knowledge of facial anatomy will allow the injector to specificly target where the Botox should and shouldn't go.  Saving a few dollars to have a lesser qualified person inject you is not worth it from a safety profile as well as just receiving an aesthetic, natural result.

3. There is always risk with any procedure. Although the risk of the use of Botox in cosmetic cases is extremely rare, there is some risk. Now most patients I see would gladly accept this risk with the proven benefit of looking younger. I believe that Botox has an extremely safe risk to benefit profile. However, the risks, albeit rare must be mentioned.