Published: April 4, 2016

This month, we’re discussing all things related injectable neuromodulators like Botox and Dysport. Dr. Cox has been working with Botox long before it was a household name, and in fact is one of a small number of physicians worldwide involved with clinical trials of Botox and other injectables. So we’re excited to offer a little of the back story on this product that started with a spoiled sausage and has been used to treat everything from crossed eyes and writer’s cramp to bladder spasms and excessive sweating! We sat down with Dr. Cox to learn more.

Q: Let’s start at the beginning: what are Botox and Dysport, and what are the differences among them?

A: Botox and Dysport are different brands of a naturally-occurring, purified protein called Botulinum Type A. These products are all part of a class of drugs called “neuromodulators,” which can be used to safely and temporarily disable muscles by blocking neurological signals. Neuromodulators have many medical uses. In aesthetic medicine, we use it to prevent contraction of the muscles that cause creases, wrinkles and other contour features of the face and neck.

I often tell my patients that Botox and Dysport are like Nike and Adidas – think of them as different takes on the same product, more alike than they are different. Botox was the first product approved for cosmetic use. It remains the most popular product and is often considered the gold standard. Dysport came next, and has a slightly wider field effect than Botox which can be useful for larger areas or to reach muscles we don’t want to directly inject.

We all share the same basic facial muscle structure, but mass, placement and activity vary. We work with each patient to determine which product or combination of products are right for their goals.

Q: It’s easy to forget, but Botox is actually a relatively new drug. Can you tell us more about its history?

A: That’s true. Although forms of it have been used medically since the 1950’s, Botox was only approved by the FDA for cosmetic use in 2002.

The discovery of Botulinum Type A for cosmetic use came about unintentionally. My friend and colleague Dr. Jean Carruthers was using it to treat patients for eye spasms when she noted significant cosmetic “side effects.” She and her dermatologist husband, Dr. Alastair Carruthers, dedicated themselves to exploring this new wrinkle solution.

Dr. Cox (right) pictured with colleague and friend Dr. Jean Carruthers (center), who pioneered Botox for cosmetic use with her husband, and Dr. Shannon Humphrey (left), a partner in her practice.

This March actually marks 25 years since the Carruthers presented their findings at the annual American Society for Dermatologic Surgery meeting. I remember the widespread disbelief that one of the most potent toxins was being injected to erase wrinkles. Over the years, of course, skeptics quickly became converts and built their practices with Botox as a gateway procedure. ASAPS statistics show a 18.9% increase in the number of neuromodulator procedures between 2014 and 2015 (3.59 million to 4.27 million respectively). Botox has proven itself as one of the safest, most reliably effective treatments aesthetic medicine has to offer.

Q: How have you been involved in the development of Botox?

A: It’s been exciting and a lot of fun to be part of the Botox story. I performed many of the early clinical trials for Botox (and Dysport), and continue to work with Allergan (maker of Botox) and other manufacturers on upcoming products. Over the winter I helped Allergan develop rating scales that will be used in clinical studies seeking approval of new treatment areas, so the excitement continues. Along the way I’ve been invited to lecture all over the world on facial anatomy and injectables, direct a number of training courses for other physicians at the American Academy of Dermatology and American Society for Dermatologic Surgery, and published a numerous papers on Botox and other injectables. It’s a great honor to pass along my experience to the next generation of aesthetic physicians.

Q: What is the role of dermatologists in the development of Botox and similar products?

A: Dermatology has been the driving force in developing non-invasive aesthetic treatments, including Botox and other neuromodulators. A recent study confirmed dermatology is the specialty with the greatest contribution to aesthetic neuromodulators like Botox – as well as dermal fillers, laser treatment, chemical peels and non-invasive body contouring. I’m proud to see my colleagues and I recognized as pioneers in the aesthetic space.

Q: What are the most popular treatment areas for Botox and Dysport?

A: Vertical lines between the eyebrows (the “11” lines) and crow’s feet are among the most commonly treated areas. People often notice wrinkles and creases in these areas first. I’ll often pair that with a small amount just under the outside tail of the eyebrows to produce a little lift, and make the eyes look more inviting and open.

Botox (as well as Dysport) can also do wonders for other parts of the face. We can treat crinkled “bunny” lines on either side of the nose, lips that turn down at the edges, small vertical “smoker’s lines” above the lips and “gummy” smiles.

These products can also be used to reshape the lower face, making a square face more feminine by slimming down the jawline. Another interesting treatment is reducing the prominence of platysmal bands (vertical bands of the neck) often noticeable in women with long necks.

Q: What can patients expect when they come in?

A: I sometimes joke these are truly “lunch-break procedures.” After cleansing the treatment areas, the product is administered using a very small needle. Patients often compare the sensation to having their eyebrows plucked. The actual procedure only takes a few minutes, and there is no real downtime. The only evidence is a few small pin-picks, which fade within a few hours.

Because the procedure is so quick, we recently started offering an “Express Lane” for our regular patients receiving their routine Botox or Dysport. For those who only need this treatment, the Express Lane appointment usually allow same-week, sometimes even same-day, appointments. These appointments are restricted to current patients only, and can’t include any other services or consultation, though.

Q: Once the injections are complete, how does it feel and look?

A: There is usually mild swelling and redness around the pin-prick injection sites that dissipates within a few hours. The product will typically begin to take effect within 3-4 days, with full results visible by the tenth day. Some people describe the initial feeling as a light pressure in the treated areas, but this sensation is not uncomfortable, and quickly fades.

Occasionally, a small bruise can occur at one or more injection site. This is more likely to happen if you are on any medication or supplement that thins the blood. We do everything we can to minimize this possibility, but if it occurs, we offer a free VBeam laser treatment to greatly reduce the healing time of the bruise.

I’m a big proponent of conservative treatment. We’re never trying to completely eliminate expressiveness. I keep the patient’s preferences in mind, and target a balance between treating bothersome wrinkles and preserving facial movement and naturalness.

Q: Is there any danger in using Botox or Dysport for an extended period of time?

A: There is no danger in routine injections spaced out as treatment wears off, usually every 3-4 months. In fact, studies indicate a positive effect over time, as patients train themselves to stop using the muscles that cause the wrinkles and creases that most bother them. There is evidence that this can actually result in the need for less product over time.

We also see preventative benefits. Botox and Dysport treat dynamic wrinkles – the ones you make when you contract your muscles – as well as static wrinkles – the ones still visible when your face is at rest. Think of your skin like cloth. If you stop folding it repeatedly, lines and creases will fade. While these products don’t stop the overall aging process, they can alleviate the severity of wrinkles and creases caused by muscle contraction.

Q: Do you have any other advice for patients treated with Botox or Dysport?

A: As a group, Botox and Dysport treatments make up the most common cosmetic procedure in the US. This is partially due to a rise in treatment performed by non-core providers, including nurse-injectors, practitioners at med-spas, and doctors who specialize in a different kind of medicine but administer Botox on the side. As a patient, it’s important to understand the qualifications of the person performing the injections, and protect yourself from providers who may not have an intimate understanding of these drugs, or facial anatomy and physiology.

I encourage anyone using or considering these drugs to seek a medical doctor who can demonstrate they perform these procedures regularly and have happy patients with great results. We call Botox and Dysport “products,” but they are really just tools. The real product is great results from an expert!

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If you have any questions, or are interested in learning if Botox or Dysport might be right for you, get in touch. We can be reached by phone at (919) 403-6200 or contact us here.