What is a neurotoxin?
Neurotoxins in the aesthetic world are formulations of botulinum toxin that are typically injected into the facial muscles to relax the muscles and smooth or eliminate wrinkles. Neurotoxin injection is the most frequently performed cosmetic procedure in the US and offers predictable results with few side effects and high patient satisfaction. There are several different brands sold commercially, including Botox, Dysport, and Xeomin.
Botulinum toxin is derived from the Clostridium botulinum bacterium and inhibits the release of acetylcholine at the neuromuscular junctions between nerves and muscles, which causes localized relaxation of the muscles within 2 weeks that can last 3-4 months. Neurotoxins have a more dramatic effect on dynamic wrinkles, which are only seen during muscle contraction (smiling), compared to static wrinkles, which are seen at rest. Wrinkles form because of dermal atrophy (loss of collagen and elastin in the skin) and repetitive contractions of underlying facial musculature.
What are neurotoxins used to treat?
The FDA has approved the use of neurotoxins for the treatment of frown lines (glabellar lines) and crow’s feet, although other areas of the face and neck can be treated effectively including forehead wrinkles, perioral lines, platysmal bands, and horizontal neck lines. Neurotoxins can be injected into the masseter muscles to reduce grinding at night and slim the face because the muscles atrophy or shrink over time. For patients with migraines, neurotoxins can be injected into the muscles of the head and neck as a treatment. Neurotoxins can also be used to treat hyperhidrosis, which is excessive sweating from areas like the armpits and palms by blocking the signal between nerves and sweat glands. Several additional less common indications for neurotoxin include blepharospasm (blinking or twitching of the eyelid that can’t be controlled), strabismus, cervical dystonia, and overactive bladder.
What are the differences between the neurotoxins?
Botox, Dysport and Xeomin all use Botulinum toxin serotype A, which is the most potent serotype. These neurotoxins differ in whether they have complexing proteins surrounding the core neurotoxin. Xeomin is the only one of the three that does not have a complexing protein. It is not clear if the complexing proteins significantly impact the effectiveness, diffusion, or immunogenicity of the neurotoxins. These neurotoxins are not interchangeable because they vary in their formulation, dosing, and clinical response.
What do I do after neurotoxin injection?
After neurotoxin treatment, patients are advised to avoid lying down for at least 4 hours, avoid massaging and applying heat to the treatment area, and avoid activities that cause flushing such as exercising, consuming alcohol, or using a hot tub or sauna. The consensus is that these practices limit the unwanted spread of neurotoxin, although there are no high quality clinical trials that support these recommendations.
Some injectors will instruct patients to move or massage muscles to increase the uptake of toxin, smooth post-injection bumps, and aid physical spread within the muscles injected. Patients can use ice or cooling for comfort and to prevent bruising due to vasoconstriction of blood vessels. However, there is some evidence that temperatures below 68 degrees Fahrenheit can inhibit the botulinum toxin from crossing the neuron surface to inhibit release of acetylcholine.
What factors influence outcomes with neurotoxin treatments?
The major factors that influence outcomes with neurotoxin treatments include:
- How much neurotoxin is injected during the treatment
- Treatment of the upper third of the face compared to the lower two-thirds of the face: results are more predictable and reproducible in the upper third of the face
- Frequency of neurotoxin treatment: multiple treatments often lead to better results
- Age of the patient: younger patients have stronger muscles that sometimes require more neurotoxin, whereas older patients may experience a shorter duration of results due to less collagen/elastin and more prominent wrinkles
- The patient’s unique anatomic considerations
- Adherence to pre and post treatment instructions
- Activity level: more active patients may experience shorter periods of results
- Skill and technique of the injector (correct placement and amount of neurotoxin)
What are the injection reactions and complications of neurotoxin treatment?
Injection reactions
- Mild erythema, edema, and tenderness at the sites of injection are expected and resolve within a day.
- Bruising is common and can range from pinpoint needle insertion marks to quarter-sized ecchymoses that can take up to two weeks to resolve. Ice and Arnica (plant supplement with anti-inflammatory properties) can be used to treat bruising.
- Headaches can occur with facial neurotoxin injection and spontaneously resolve within a few days of treatment.
- Paresthesia or dysesthesia in the treatment area is rare and thought to be related to nerve trauma.
Complications
- Temporary blepharoptosis (drooping of the upper eyelid by 2-3 mm; reported rate of 1-5%) and eyebrow ptosis (descent of the eyebrow from its normal position) are rare complications of neurotoxin treatment and considered technique-dependent, meaning that these tend to happen more commonly with inexperienced injectors and incidence declines as skill improves.
- Formation of antibodies to the neurotoxin, which can render treatments ineffective (reported rate of less than 1%).
- Immediate hypersensitivity and allergic reactions are extremely rare and present with signs of urticaria, edema, and sometimes anaphylaxis
Neurotoxin injections are generally contraindicated in patients with keloid scarring, neuromuscular disorders such as myasthenia gravis, allergies to the constituents of botulinum toxin products, and body dysmorphic disorder.
Are injections of neurotoxin painful?
Neurotoxin injections are performed using small-gauge needles (we use 31 gauge) to minimize discomfort and bruising. Localized burning or stinging sensation during injection is commonly reported and resolves within a few minutes. There are maneuvers such as using a vibrator on the face during injection that can mitigate the sensations during injection. The vast majority of patients do not need a topical anesthetic.
What other treatments can be performed for static wrinkles?
- Chemical peels /chemical-peels/
- Microdermabrasion /facials/
- Injection of dermal fillers /dermal-fillers/
- CO laser resurfacing /laser_skin_rejuvenation/
- Radiofrequency microneedling /rf-microneedling/
Summary
Neurotoxin injections are the leading nonsurgical cosmetic procedure worldwide with a high rate of efficacy and patient satisfaction. These injectable medications can be used to treat a variety of conditions, most commonly dynamic wrinkles of the face. There are several formulations of neurotoxin available without significant differences between the different types. At Studio R Aesthetics, all toxin injections are personally performed by Dr. Segura because she believes that the results achieved with toxins are greatly dependent upon the training, experience and skill of the person performing the injection. Be sure to only trust a skilled injector or doctor with a conservative approach to administering treatment, particularly for first time treatments. As with most things in life, when you only consider price, you get what you pay for.
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Watch Dr. Segura performing a toxin injection with Xeomin
