A: Xeomin will work the same as Botox for masseter muscle hypertrophy. It is just as potent and has the same onset of action as a full week after the injections. Like Botox’s other competitor Dysport, the unit dosing may be somewhat different from Botox and an exact replicative dose is not well established. For a cosmetic effect in the frown lines, reports indicate that Xeomin has similar dosing to that of Botox on a 1:1 unit basis. Whether such a dosing method works the same in the masseter muscle is completely unknown. If I was a patient knowing what I know, I would not switch from Botox for massteric hypertrophy if it is working. It will take a lot more clinical experience to determine what dosing comparisons are between Xeomin and Botox. For now, there is no known advantageous reason to make that switch and there is the risk of less effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Then an anesthesiologist friend offered to give me Botox injections as she does a small group of women from time to time and I wanted to try again. This was like eight months after my first try. Long story short, I had a furrowed left brow for a while which was not cool. Plus she diluted it big time which in hindsight was a blessing because of the furrowed brow. I was starting to think that there is definitely an “art” to this injection thing.  

Then I was out of town visiting friends and a local doctor  introduced me to Dysport. At the time I was totally feeling ugly and wanting to try anything to reduce the fine wrinkles in my forehead, just look fresh. Well he did a first rate job so I loved it! No heavy feeling in the forehead and it took almost immediately and looked great! I’m sold on Dysport for no other reason than it was my best experience to date. You will have to educate me on the cost vs Botox as I have no idea.

So here I am today, looking online for a reputable guy to help me out…I’m due for something, but will not go the route of using anybody but a professional ever again!

A: The apparent simplicity of facial injections does belie that there is actually some art to it. There is also an obvious benefit to knowing the underlying facial muscles and how their movement contributes to facial expression. It is slightly more sophisticated that just throwing darts at the side of the wall so to speak.

The actual differences between Botox and Dysport are very slight and there is no real evidence that one is more effective than another. Dysport may ‘kick in’ a day or two earlier than Botox but otherwise lasts and costs about the same as Botox. The differences you have had with two negative experiences with Botox and the favorable one with Dysport undoubtably reflects technique (injection location) and doses used. I have not seen any differences in my experience with either one. There is some evidence that Dysport may be slightly more effective than Dysport (because it spreads out better) but in the forehead there is no appreciable difference in effect.

All of that being said, you should continue with Dysport because you have had a good experience and there is no change what isn’t broken.

Dr. Barry Eppley

Indianapolis, Indiana

There are a variety of non-surgical eye treatments combining neurotoxins, fillers, lasers devices and topical products. Which ones are used often follows the age of the person. Those in their 30s and 40s usually just need Botox to control their frowning and squinting wrinkles. Fillers and light and laser treatments are added for those in their 40s and 50s. At age 50 and beyond, surgery is needed to remove extra upper eyelid skin and lower eyelid bags. But these non-surgical treatments are still needed to preserve one’s surgical investment.

Botox is the most known name when it comes to facial wrinkle reduction by injection. But it is not alone as two other injection drugs, Dysport and Xeomin, are also available. While there are some that believe one is better than the other, they all are really comparable. They all take a few days to a week to start working and their effects will last from three to four months. One is not more powerful than the other nor does one cost less. These injections are given by the unit and the cost per unit varies for each one but so does how they are prepared. As such their treatment costs are all about the same.

While Botox is the most common non-surgical eye treatments, injectable fillers can also play a role. Many people will develop shadowing and tear troughs under the lower eyelid, sometimes as early as the late 30s. This can be treated with fillers to plump the area out. While they are over a dozen types of injectable fillers, the hyaluronic acid-based fillers (e.g., Restylane and Juvederm) are preferred. They can be delivered under the thin tissues of the lower eyelids with a low risk of lumps and irregularities.

While eye wrinkles can be held in check with Botox and fillers, they can not reverse certain skin problems. Blood vessels and brown spots can be removed with pulsed light treatments. These are often confused with lasers which they are not. When it comes to improving skin texture  and reducing fine lines and wrinkles, laser resurfacing can provide improvements beyond what an eyelid lift can do.

Topical skin care products complement eye the benefits of injectable and energy treatments. The skin around the eyes is so thin that it responds well to many Vitamin C, retinoid and antioxidant-containing products. A new topical product, Latisse, is great for thinning eyelashes and eyebrows and it works like nothing else. Eyelashes and eyebrows can become one-third longer and thicker in a few months.

While surgery may be needed or inevitable for some, younger and less tired looking eyes may be just a few injections or the wave of a laser wand away.

Dr. Barry Eppley

Indianapolis, Indiana

A:  Botox is used for a wide variety of aesthetic facial applications. It was initiallystudied and subsequently cleared by the FDA for glabellar (between the eyebrows) wrinkles and is known as an ‘on-label’ use. Despite this one approved cosmetic use in the face, it is a perfectly acceptable medical practice to use Botox for numerous other expression-reducing/wrinkle reduction indications. This is known as ‘off-label’ use and is commonly done with many drugs. It is neither wrong nor malpractice to do so. The use of Botox in the upper lip can be effective at wrinkle reduction but is technique and dose sensitive. Unfortunately for you, this effort did not turn out to produce the desired effect. The good news is that your Botox will wear off in a few months and you will return completely to normal. I would discuss your dissatisfaction with the treating doctor and see what accommodations they may be willing to do.

Dr. Barry Eppley

Indianapolis, Indiana

A: All I can say about the company’s products is that Restylane is one of the most popular and well known names in injectable fillers The injectable filler market, however, is a crowded one with nearly a dozen other competitors. The name recognition in the market is not only because it is product that works well with very few complications but also because they were the first to enter the modern-day injectable filler era as a hyaluron-based material.  Dysport lags far behind Botox as an injectable facial expression reducer and probably has less than 10% of the U.S. market. They just don’t don’t have the advertising and name recognition that Botox does and as a late entry into the field never established any clinical advantages over Botox. For all intent and purposes, it works the same and has very similar patient costs. As a result, it has had a tough time finding widespread traction in the market place. One day, at best, it may become Pepsi compared to Coke…but it is far from even that now.

Dr. Barry Eppley

Indianapolis, Indiana

The newest FDA-approved indication is in the treatment of migraines. Approved last year it works for migraines just like it does for wrinkles, by relaxing muscles. But it is injected around those nerves in the head which are being squeezed by muscles and thus serve as the trigger for the migraine headache. These are commonly in the eyebrow, temple and at the base of the skull in the back of the head. For some patients the temporary relief is a near-miracle which will last about four months. Botox in migraines is also a test which proves that doing surgery by removing this muscle around the nerve can have a more permanent effect.

Botox has long been approved for halting severe underarm sweating, an embarrassing condition known as hyperhidrosis. This disorder causes so much perspiration that some sufferers are forced to carry several changes of clothing to make it through the day. The excessive sweating is caused by over stimulation of the sweat glands by the nerves of the autonomic system. Botox interferes with the nerves responsible for this drenching. It has a similar benefit to those who also suffer excessive sweating in the palm of their hands. (palmar hidrosis)

Botox is effective for cervical dystonia, a condition that causes the neck to twitch, twist, and go though repetitive movements and carry the head in abnormal postures. This happens because of involuntary muscle contractions which the injections directly weaken. It is similarly effective in cerebral palsy in which patients have stiff spastic arms and legs caused by abnormal signals from the brain to the muscles. Botox interrupts this communication between the nerves and the spinal cord which then causes the muscles to relax.

Overactive bladders are also benefiting by these injections. Caused by muscle spasms of the bladder muscles, urinary incontinence can make it difficult for some patients to undergo even short car trips. Some patients end up wearing  adult diapers. Botox overcomes bladder incontinence by weakening or paralyzing those muscles which contract inappropriately and squeeze out the urine involuntarily.

Botox can also stop chronic pelvic pain which can make it difficult to have sexual intercourse or undergo an examination or a pap smear test. This type of pelvic pain is caused by tight over-contracted pelvic muscles.

While often perceived as a drug of beauty, the many medical benefits of Botox makes its few precious drops life-changing for more just a better look in the mirror.

Dr. Barry Eppley

Indianapolis, Indiana

A: I have heard that question many times from numerous patients and I can tell you emphatically that it is not true. When you understand how Botox actually works, and more importantly, how it wears off you will see that rubbing or massage has no bearing on the length of its effectiveness.

Current understanding of how Botox works is that it goes into the nerve endings and blocks the release of the neurotransmitter, acetycholine, from the mitohondria where it is produced.  This is why it takes days for Botox to work. The nerve ending must use up the acetycholine that still exists (has been released) into the nerve ending. Once depleted (and it is not making anymore) the nerve ending can no longer send its chemical signal to the motor end plate of the muscle and make it move. Conversely, Botox wears off by growing new sprouts or axons from the nerve around its non-working ending to attach to the muscle to start working again. To the best of our knowledge, massage or any other manipulation does not increase the growth rate of these axons. Thus, you can’t really make the muscle start working by pushing around on it.

Dr. Barry Eppley

Indianapolis, Indiana

Breasts always seem to make the news and the more freaky seems to be better. Whether it is basketball-size implants of quadruple FFFF proportions, dancers subject to IRS scrutiny trying to write off their surgery, or breast augmentation as part of a marathon makeover (aka Heidi Montag), women who seek their ten minutes of fame marr the perception of an otherwise highly successful body contouring surgery. While the real breast augmentation news this coming year will be the introduction of a new form-stable (gummy bear) implants, this will likely be overshadowed by the media’s never-ending focus on celebrities, their breasts and Hollywood’s version of silicone valley.

There is always the continued incredulous news of patients suffering complications and even death at the hands of so-called cosmetic surgeons. This seems to be most evidenced with liposuction, largely due to its popularity and the larger body surface areas that it treats. There is an obvious difference in the size of the trauma to the body from abdominal and thigh liposuction from that of a nosejob or eyelid surgery for example. Liposuction attracts a large number of inexperienced and often unscrupulous practitioners because of the relative ‘simplicity’ of the procedure and easy access to new liposuction devices. It only takes a medical license and a credit card to buy the newer laser liposuction machines. Equipment manufacturers are more interested in sales than safety as evidenced by their marketing and selling behavior. Patients died last year from one coast to the other at the hands of doctors with dubious credentials. The public would think that better regulations would exist but they would be wrong. Doing your homework is your best protection.

Botox continues to show its fantastic benefits and those are not only in those worried about their frown lines or crow’s feet. Last year Botox was approved by the FDA for the treatment of migraines. For some migraine sufferers, Botox injections can be a miracle even if its effects are only temporary. The benefits of Botox have translated into an actual migraine surgery procedure developed by plastic surgeons. If Botox injections relieve one’s migraines, a relatively simple muscular decompression around the nerve trigger points can provide a more permanent amelioration of one’s migraine pain and frequency of attacks. It’s a rare example of a cosmetic treatment turning into a really useful medical or reconstructive surgery, usually that works in reverse.

One other piece of fantastic plastic surgery news from last year has been the emergence of face transplants. While once thought impossible and something more akin to a movie or science fiction, more and more partial or complete face transplants are being done around the world. While the patients who need them are last resort problems of massive facial deformities and tissue loss, that is the history also of all organ transplants which are commonplace today. From the extreme technical advances of today come spinoffs that will benefit many more facial reconstruction patients in the future.

No telling what this coming year will bring, but if past history is any predictor of future events, plastic surgery will continue to make the headlines…let us hope it is largely in the fantastic category.

Dr. Barry Eppley

Indianapolis, Indiana

A: I think the article that you are referring to and has been reported in different internet venues was the one in the Journal of Biomechanics that appeared last year. I am familiar with that study and have read it. In this animal study, they examined the effects of Botox on not only the muscles that were injected but on the surrounding muscles as well. They found that Botox did lead to local muscle wasting as well as weakness of other untreated muscles in the region.

This study has caused a little bit of hullaboo about Botox but, in my opinion, it has no relevance to the cosmetic use of Botox. Beyond the fact that this was done in animals (rabbits), the doses were very high compared to what we use in humans. By my calculation, they were giving the equivalent of 200 to 300 units of Botox every six months. Given that the normal cosmetic dose of Botox is around 24 to 36 units, their dosing was nearly 10X that of a cosmetic facial treatment. The muscles that they injecting were voluntary motor muscles as opposed to involuntary muscles of facial expression. These are quite different types of muscles. Motor muscle are well known to atrophy from simple disuse, muscles of facial expression do not display this atrophy phenomenon. Most of our cosmetic patients would welcome that if it happened but there has been no evidence that it occurs.

This article is an interesting piece of science but its findings do not hold a candle to the 25 years of human Botox use in which this permanent muscle weakening effect has never been seen in a low-dose cosmetic application.

Dr. Barry Eppley

Indianapolis Indiana

A: The simple answer is…no. But let me explain why. Wrinkles on the face form perpendicular to  the direction that the underlying muscles move with facial expression. The well known horizontal lines on the forehead are a result of the large frontalis forehead muscle that attaches to our eyebrows and goes across our forehead the whole way to the back of our head. As you move your forehead with expression, the muscle lifts the eyebrows and creates the horizontal lines. The only way to stop them from forming, therefore, is to stop moving your forehead. Notice the difference in the depth of the forehead wrinkles when your forehead is still and not moving versus when you are lifting your eyebrows. (that difference is important for treatment considerations below)

There are only two non-Botox and non-plastic surgery options that can reduce your forehead wrinkles. A state of permanent facial paralysis is one option, otherwise known as death. Very effective but not appealing. The other option is to retrain your facial expressions so you don’t move your forehead anymore. Theoretically possible but if you are successful you will be the first human to have successfully done so.

I tell you this so in your desparate state so you don’t chase worthless treatment options and throw away money…or actually transfer your assets to the benefit of someone else. So do not chase the illusion of innumerable skin lotions, potions and facial exercises that promises a miracle wrinkle cure.

That leaves you with exactly what you want to avoid, Botox and forehead surgery, Unappealing but actually the only things that will work. Back to the depth of your forehead wrinkles when they are still versus moving. If the depth of the forehead wrinkles is acceptable when your forehead is still, then Botox would be the preferred treatment. If the depth of the forehead wrinkles at rest is still not acceptable, then a forehead lift with muscle removal would be the better treatment.

Dr. Barry Eppley

Indianapolis Indiana

A: The use of Botox for the treatment of  glabellar furrows (wrinkles between the eyes) has been done for decades. One of the very interesting findings from that cosmetic treatment was that plastic surgeons discovered that some patients with frontal migraines got a temporary cure, as long as the Botox lasted. The now proven theory is that in those patients with a focus of their migraines that starts above their eyes in the brow area are caused by the muscles squeezing the sensory nerves that exit from the bone there. This is why Botox relieves those migraines…it stops those muscles from working.

If you take that one step further, a browlift (of any type) can create the same effect as Botox except that its results will last much longer and maybe even permanently. That is because during a browlift some of the muscles are removed to prevent that type of wrinkling action. Recent studies and publications in the journal Plastic and Reconstructive Surgery has shown that certain types of migraines can be cured by performing a modified forehead/brow lift. Therefore, the type of forehead lift used to cure migraines could also lead to one looking younger as well. This type of cosmetic operation has been shown to be safe, effective and can lead to a tremendous improvement in the quality of some migraine patient’s lives.

Dr. Barry Eppley

Indianapolis Indiana

A: The fact that your migraines have a focal area of initiation at the eyebrows strongly suggests that their origin is compression of the supraobital/supratrochlear nerves. Contraction of these muscles squeezes the nerves that they surround and causes a painfuol migraine to start. Botox has a good chance of having a positive effect since it weakens the muscles around those nerves as they exit from the brow bone. This is a simple treatment that looks like it may work well for you. For a few hundred dollars, you can easily prove this migraine theory. While the effect of Botox is not permanent, many responsive patients find it to be a temporary miracle that provides a level of relief that no other medication does. In select migraine patients, plastic surgeons have learned many years ago that Botox around the brow area reliefs headaches. The key to whether Botox will be a successful migraine treatment is to have a very specific point of headache origin at one of the major cranial sensory exit sites from the skull. Botox is not effective for many types of migraines, just ones that have a very specific focus or loci.

If Botox is effective, that would mean that endoscopic supraorbital/supratrochlear nerve decompression may provide some long-term reduction in your migraine symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

A: Both Botox and Dysport are equivalent injectable drugs that induce muscle paralysis where injected and weakness in the surrounding region. They are superb at stopping that undesireable frowning between your eyebrows or those crow’s feet wrinkles at the side of your eyes. By weakening the overactive forehead muscles, many people may experience a bit of a browlift. This occurs because the paralyzed forehead muscles no longer pull down on the eyebrow, allowing it to raise a little higher.

It is logical to assume that a similar effect would occur in a droopy eyelid. But that assumption would be wrong. A droopy eyelid, known as eyelid ptosis, is the result of a weak levator muscle. The levator muscle is the primary muscle that moves the upper eyelid. When it is weak for whatever reason or is partially detached from the tarsus of the upper eyelid, the lid margin will hang down lower. It becomes noticeable when the lid margin comes down lower on the iris and it only takes a few millimeters lower to be evident.

Since Botox and Dysport paralyze muscle, it would actually make a droopy lid worse. In fact, one of the most dreaded esthetic complications of Botox and Dysport is a droopy eyelid when it inadvertently diffuses into the upper eyelid from above if it is injected too close.

Eyelid ptosis can only be improved by surgery. The amount of lid droop and its cause determines what type of ptosis repair technique is needed.  

Dr. Barry Eppley

Indianapolis, Indiana

A: Recent research presented at plastic surgery meetings have indicated that such a ‘rumor’ may have some truth to it. A study out of Oregon looked at women between the ages of 30 and 50 who received Botox every four months for two years. After that time, the frequency of their injections could be adjusted down to every six months and still have sustained satisfying results.

The same observation has been seen with injectable fillers. If the treatments are done long enough, they seem to be needed less often. One possible explanation may be the filler’s ability to stimulate new collagen.

Is less Botox and fillers really needed if they are done long enough? One of the problems is assessing long-term effectiveness is that it is very subjective and not able to be quantified objectively. Can facial muscles be re-trained by long-term Botox?  Can injectable fillers create new collagen? Or are these apparent effects more of a function of the patient being able to tolerate a few wrinkles longer or less full lips or deeper nasolabial folds between injection sessions? The economics of regular injection treatments can certainly make patients space out their injection treatment intervals and still be satisfied.

It is tempting to want to believe that Botox and filler’s effects have some long-term benefits after they wear off…but it is far from a proven fact.

Dr. Barry Eppley

Indianapolis, Indiana

A: The development of vertical wrinkles between your eyebrows, known as the glabellar area, is common and is the result of excessive muscle activity. There are a set of six paired muscles that affect the glabella area and create what has been described as a number system of galbellar wrinkles or furrows. As the popular ad goes, are you a 1, 11 or 111? These numbers describe whether one has one, two or three vertical glabellar wrinkles.

The first approach for glabellar wrinkles is Botox which will be highly effective for most people. For many the wrinkling is completely or nearly completely gone by this temporary muscle paralyzing treatment. For those with more deeply etched glabellar furrows, Botox will soften it to some degree but may not reduce it enough for the person’s satisfaction. This is the result of the skin being ‘etched’ or having a permanent v-shaped change in the skin. Muscle paralysis will not change permanent deformation of the skin.

An endoscopic browlift will not create a better effect than that of Botox because it works on the muscle only. It may help decrease the long-term need for Botox and, rarely, the need for Botox at all.

A companion treatment for the deep glabellar furrow is some type of soft tissue fill.  Usually this is an injectable filler but its effect will only be temporary. More permanent options include the threading of an allograft collagen dermis material or actual synthetic implant. (e.g., Advanta)

Dr. Barry Eppley

Indianapolis, Indiana