Is Dysport Better Than Botox Injections?

Q: Dr. Eppley, do you offer Dysport injections? If so, what is the cost per unit? Do you think Dysport is better than Botox? And if so, why?

A:  I do both Botox and Dysport injections for aesthetic facial wrinkle treatments. In my opinion, they are essentially equivalent and Dysport has no significant advantages over Botox. The cost per Dysport unit ($5.00/unit) may be substantially less than Botox but it also takes 2.5 units of Dysport to equal the effects of 1 unit of Botox. Thus one does not choose Dysport because it costs less which is a common misconception. The only real value of Dysport is if one has developed a ‘resistance’ to Botox, Dysport offers a very slight molecular structure variation that may make it more effective. In addition, because Dysport has a greater zone of diffusion it may be more effective in the crow’s feet area This is because the orbicularis oculi muscle is spread out and requires a broader zone of drug spread to get a maximal aesthetic effect.

Perhaps the greatest advantage of Dysport is that it offers competition to Botox which had been the sole provider of this aesthetic treatment for over a decade. (and that only includes the time when it become formally FDA-approved for wrinkles and not the decade before when it was used off-label) Unfortunately, competition for Botox has done little to affect its cost. This is probably because Dysport has just a small fraction of the aesthetic injectable wrinkle market in the U.S.. Dysport at this point can not even claim the analogy that it is Pepsi compared to Coke.

Dr. Barry Eppley

Indianapolis, Indiana

Is Dysport Better Than Botox For Forehead Wrinkles?

Q:  Dr. Eppley, I had Botox for the first time a year and a half ago for free. A local doctor was training a woman on it and he did one side and instructed her on the other side. It was just okay, one side felt heavier than the other and one eye brow was higher than the other.

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

What Can You Tell Me About Medicis' Products, Restylane and Dysport, As A Potential Salesperson?

Q: Dr. Eppley, I am looking into working for the Medicis company and was wondering what you could tell me about their two aesthetic products, Restylane and Dysport.

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


Can Botox and Dysport Help A Droopy Eyelid?

Q: Hi, I just would like to know if BOTOX and DYSPORT would lift a droopy upper eyelid? Thank you.

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

Injection Treatments for Laugh Lines

Q :  Which is better for my laugh lines, Botox or fillers?

A: It is very common that Botox and injectable fillers are confused as to what they do. Because both are administered by a needle and are used in the face, many assume that they do similar things. In fact, they are quite different both in chemical composition and the effects that they create and in how they are used.

Botox works its magic by being a muscle weakening or paralyzing agent. It is primarily used in the forehead and around the eyes to decrease unwanted expressions caused by overactive muscles. As a result, Botox (and now Dysport) is really a ‘northern facial’ procedure. It effectively reduces horizontal forehead lines, furrows between the eyebrows, and crow’s feet around the eyes.

Injectable fillers (there are now over a dozen commercially available brands) work by adding instant volume to deep wrinkles and folds as well as enhancing the size of the lips. By adding a material under the skin or into the lips, the outer skin and lips is pushed outward. Injectable fillers are primarily used around the mouth making it a ‘southern facial’ procedure.

While there are crossover areas in the face where Botox and fillers are otherwise used, they are largely separated in application to these northern and southern hemispheres.

Folds around the mouth are commonly referred to as laugh lines. When one smiles, indentations or wrinkles are created beyond the sides of the mouth. They are different than the nasolabial folds which run from the side of the nose  to outside of the corners of the mouth which are situated above the laugh lines. Injectable fillers can be effective at softening one’s laugh lines.

Dr. Barry Eppley

A Few Wrinkles About Botox

Almost everyone has now heard of the facial wrinkle treatment, Botox. While some may not know exactly what it is really good for, its recognition and popularity is because it simply works. When it comes to softening facial expressions, it does something that even surgery can’t do.

Many misconceptions exist, however, about Botox (and now Dysport) and it is time to reveal some of its secrets. Here are some facts about its use that are not commonly known.

Botox is a poison and can be quite lethal if the dose is high enough. It is administered in units which originally stood for mouse units. A unit was the dose of Botox that could kill a mouse. Fortunately, there is a big difference in size between a mouse and a human. To poison a human, it is estimated that it would take about 25,000 or more units to do so. The average dose for wrinkles is around 20 to 30 units, so it is well within the margin of safety. (mathematically, cosmetic dose units are a mere 0.001% of the doses that could be fatal). Cosmetic injections are precisely placed 2 to 4 unit doses in select facial area.

While Botox is touted for a lot of facial uses, it is largely a ‘northern’ face procedure. The areas of the forehead and around the eyes accounts for much of its use. Weakening of the muscles between the eyebrows, in the forehead, and at the sides of the eyes produces the desired effect of less frowning, a more relaxed forehead, and less lines around the eyes. While some do use it down south around the mouth, it is not effective as a primary wrinkle reducer in that area. A little too much Botox there can affect the way you smile.

Botox injections do not produce immediate results. It usually takes one week or more to see its effects. This is because it blocks the release of chemicals from the nerve endings that cross over to stimulate the muscle fibers to which it is attached. Because there is a supply of chemicals in the nerve endings to start, they must first be depleted. As a result, the muscle will work normally for a few days before it begins to weaken as its ‘gas supply’ diminishes.

The effectiveness of Botox can vary from one doctor to another or from one treatment center to another. This seems initially unusual because one of the benefits of a prescription drug is that it has been tested and approved for the uniformity of its effects. But Botox differs from a pill and many other prescription medications. It comes as a dry powder and must be formulated or reconstituted prior to treatment. How well it works, therefore, is affected by how it is mixed and how long ago it was prepared. It is designed to be mixed according to the manufacturers recommendation in a very specific way. (2.5ml of saline per vial) and it should be used either immediately or within a few days after preparation. But treatment centers vary on how they mix it and how quickly they can use it. You have no way of knowing if you are getting diluted or old Botox. If it doesn’t seem to be working well or lasting very long, this could be the reason.

Like all drugs, there is an effective dose to Botox or a ‘sweet spot’ at which it works well. What you want as a patient is to find the Minimum Effective Dose as well as the right injection spots. You may regularly be getting 40 units in the forehead are, for example, when 32 may work just as well. More Botox than necessary does not make it work better or any longer. Don’t be afraid to ask your injector to adjust the does or injection locations to see if the results improve…or become less.

Botox and Dysport have a very consistent duration of effect of around 4 months. Repeat treatments, unfortunately, do not make it last longer. But some patients feel that it does. This is likely an effect of muscle re-education, a chemical training if you will. It may take your body awhile to begin using those muscles again if they have been weakened repeatedly. Conversely, most people will not build up tolerance or immunity to Botox. But a few patients say that they have and resistance to any drug is always possible. One can than switch to Dysport which has a slightly different molecular structure.

Dr. Barry Eppley

Botox and Breast Augmentation: Plastic Surgery's Commodities

While plastic surgery is comprised of hundreds of different procedures that are used to correct problems all over the body, they are all true medical operations and treatments. Yet some of the most popular cosmetic treatments have almost as much in common with a retail or commercial product as they do with being a medical procedure.

Botox as a non-surgical procedure and breast augmentation as a surgical operation have begun to acquire many retail product characteristics over the past decade. Both are highly marketed and promoted, so much so that few people in the world would not recognize what they are. From billboards to magazines, and endless exposure on the internet, the offering of services and the recruitment for paying customers is extensive. Some of these are from the commercial product suppliers on a national front and many others are from physicians on a local basis. Such enticements are right in line with what has also occurred in the pharmaceutical industry by the manufacturers for certain prescription medications.

Unlike most drugs, however, Botox and breast augmentation largely targets the fee-for-service customer.  These are cosmetic services which are either paid for at the time the treatment is done (Botox) or some time in advance. (Breast Augmentation) With the allure of immediate cash payment comes the inevitable price war and the potential slide into a commodity service. Ads are a plenty for Botox at specific per unit prices and flat low-end fees for breast implant surgery. Dysport, the recent competitor to Botox, has offered incentives if you are unhappy with your Botox results. Breast implant manufacturers have lifelong replacement warranties and even $3500 cash for surgical costs should an implant need to be replaced in the first ten years after surgery.

But unlike most commodity services or pure retail products, these medical procedures do have other intrinsic values. It is obviously important to be able to receive these services with the lowest risk possible and be able to get the desired outcome. The intrinsic value is in the expertise and experience of whom is performing it. Lowest price for medical services is not always the best value. Price alone is not the best barometer to judge whom and where these services should be received.

Competition amongst cosmetic providers has fueled the reduction of services like Botox and breast augmentation into partial commodities. Prices amongst them in any community usually stays within a fairly narrow range as a result. Such competition is not necessarily bad. It keeps all providers sharp and makes sure that their prices, no matter how much intrinsic value they may have, stay within a reasonable range. Be wary, however, of really low prices that are different from the community average. There may be a good reason why they are priced that way and it is not usually for your benefit. You do not want inferior quality medical services when it comes to having something injected or implanted into your body.      

Dr. Barry Eppley

The War of the Wrinkle Reducers

Since its commercial availability since 2002, Botox has revolutionized wrinkle treatment of the face with emphasis on improvement in the forehead and eye areas. There are few people who would not recognize the name, even if they may not understand what it exactly does.

Botox is so effective (although only temporary) and simple to do, it has given rise to an entire industry of treatments, cosmetic practitioners, and business models based out of strip malls to doctors offices. Billions of dollars of annual revenues have been created out of what is essentially a chemical poison. But the doses used are so small to treat wrinkles that it is harmless to humans. But calculated out per pound, Botox would roughly cost a trillion dollars… making it the most expensive material on the planet.

With such a proven and desireable commodity, it is no surprise that other manufacturers have been feverishly working on coming up with a competitive product. The recently available Dysport can now stake its claim as second in line. Whether it will make a significant dent in Botox’s business remains to be seen.

Dysport is not new and has been used around the world for years. In those countries where Dysport and Botox co-exist, the market shares of each are not that different. But Botox in the United States has tremendous brand awareness and a huge headstart. As a result,  it will likely be the ‘Coke’ for a long time in facial wrinkle treatment and Dysport can best hope to become ‘Pepsi’ in time.

Like any new product, Dysport must seek a marketing edge. Claims have been made that it lasts longer and costs less…the holy grail doctrines of the cosmetic industry. But a close look at the scientific studies and available evidence on Dysport does not support those marketing theories. The company does not actually claim them as the FDA would not allow such unsupported statements based on the studies that were submitted. Such claims appear to be the propagation of rumors and hope… and zealous physician marketing. In my experience, Dysport appears to be a good but equivalent treatment to Botox. In time, it may show a few select advantages (or disadvantages) but they are not obvious yet.

While competition usually drives down price, that does not appear to be the case in this battle of wrinkle reducers. Because they are given in different doses, it is not even possible to compare Botox and Dysport prices on  a unit basis…which is how they are given by injection. Because Dysport is new to the public, it is natural to assume that it may be better. Its value at this point, however, appears to be as a treatment alternative for those few patients who are either resistant to or becoming less responsive to their current Botox injections.

For those patients clamoring for a cheaper and better Botox, Dysport will not be the new fountain of youth.

Dr. Barry Eppley