Muscles of facial expression over time can cause wrinkling of the skin in a process known as dynamic aging. This process begins as early as the 20s and progresses with age. Treating dynamic aging can be done using medications that are precisely injected into the muscles of facial expression to relax the muscle and thus eliminate or improve the wrinkle.
BOTOX®
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FDA Approval: The OG was first approved by the FDA as a temporary aesthetic treatment to improve the appearance of frown lines between the eyebrows in April 2002. It has since been cleared to treat forehead lines and crow’s feet, too (in addition to all its "off label" uses).
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The Skinny: Botox®, or onabotulinumtoxinA, is a product of Irish drugmaker Allergan, and it currently holds an estimated 80 percent of the BoNT-A injection market. With a molecular weight of 900 kDa, Allergan formulates botulinum toxin type A with protective proteins that a subset of patients may develop an antibody against over time, lessening the effectiveness of the treatment. The inactive ingredients in Botox® include human albumin (i.e. plasma proteins) and sodium chloride. There is also a therapeutic version of product that can be used to treat medical conditions like migraines, excessive sweating, and eye spasms (to name a few), but, as it relates to aesthetics, the average cost per unit is around $6 to the doctor and the number of units injected will depend on the area being treated.
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The Results: Botox® is effective but not permanent. It takes about three to five days post-treatment for the results to appear (though it can take up to two weeks for the final effect to be visible), and it lasts about three to four months in most patients. The longevity depends on everything from the way a patient’s body metabolizes the product to the area being treated.
BOTOX®
- Benefits: Good for treating all areas — especially small ones (think: crow’s feet) -Onset: 3-5 days
- Results: 3-4 months
- Average Units: 20 for forehead treatment
- Drawbacks: Patients may develop antibody resistance over time
DYSPORT®
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FDA Approval: Dysport® was first approved to treat frown lines in April 2009, and, like Botox®, also has therapeutic uses to calm muscle spasticity.
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The Skinny: A product of Medicis Pharmaceutical, Dysport® (a.k.a. abobotulinumtoxinA) is slightly less potent than Botox® due to its molecular weight. While both have the same 150 kDa of BoNT-A at their core, the weight of the protective proteins in Dysport® are not uniform like those in Botox®. As a result, Dysport® has a higher rate of diffusion, which makes it ideal for treating larger areas (think: foreheads) — though more product may be needed to achieve results. Nonetheless, the cost is generally comparable to Botox®. Like Botox®, it is formulated with human albumin, and Dysport® also contains lactose and cow’s milk protein — making it unsuitable for patients with milk allergies.
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The Results: While the effects of Dysport® may show up sooner (within 24 hours) than Botox®, some studies have shown that they may not last as long. The shorter lifespan could make it a good choice for patients who are unsure about whether they will like the results of BoNT-A injections.
DYSPORT®
- Benefits: Good for last-minute treatments because of faster onset time; ideal for treating larger areas (i.e. the forehead) because of diffusion
- Onset: 24 hours
- Results: 3-4 months
- Average Units: 50 for forehead treatment
- Drawbacks: Not suitable for small areas or patients with an allergy to lactose or cow's milk protein
XEOMIN®
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FDA Approval: Xeomin® was approved by the FDA for the treatment of frown lines in July 2011 (and it has also been medically approved to correct muscle spasticity and, most recently, excessive drooling).
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The Skinny: Merz-made Xeomin® (a.k.a. incobotulinumtoxinA) is unique in that it does not blend BoNT-A with complexing proteins (though inactive ingredients include human albumin and sucrose). As a result, the neurotoxin doesn’t need to be refrigerated and it may be slightly more comfortable to have injected because it is stored at room temperature. Xeomin® generally costs about the same as Botox® and Dysport® — but fewer units may be needed to achieve the desired result. Patients who show signs of resistance to Botox® and Dysport® may find success with Xeomin® due to the purified state of BoNT-A.
- -The Results: Results from Xeomin® injections take five to seven days to become visible and last a similar amount of time to Botox®, Dysport®, and Jeuveau®.
XEOMIN®
- Benefits: Ideal for patients who have stopped responding to Botox® or Dysport®
- Onset: 5-7 days
- Results: 3-4 months
- Average Units: 20 for forehead treatment
- Drawbacks: Longer onset time
JEUVEAU®
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FDA Approval: The new kid on the block was approved exclusively for cosmetic use in February 2019.
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The Skinny: You may recall the splashy launch party earlier this year that branded Jeuveau® (i.e. prabotulinumtoxinA) as “#NEWTOX.” Maker Evolus is hoping the newbie will prove to be a worthy competitor to Botox®, as they both carry a molecular weight of 900 kDa, are formulated with human albumin and sodium chloride, and offer similar results. But, with a price point 20 to 30 percent less than Botox® and marketing campaigns largely targeted at millennials, it would appear Jeuveau® is seeking to carve out its own patient niche.
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The Results: Clinical data is limited due to the newness of the product, but trials have shown Jeuveau® to have a similar safety and efficacy profile to Botox®. Patients generally begin to see results in three to five days, and they last for three to six months.
JEUVEAU®
- Benefits: Cosmetic nature eases government pricing regulations, which may lead to more affordability
- Onset: 3-5 days
- Results: 3-4 months
- Average Units: 20 for forehead treatment
- Drawbacks: Newest to market, so long term safety and efficacy profiles have not been established
The Takeaway
As you can see, each of the four neurotoxins have similar safety and efficacy profiles, but subtle differences do exist that may make one a better option for your particular needs. While nothing can replace a consultation with a board certified dermatologist or plastic surgeon, here are the key takeaways for each botulinum type A injectable.