The benefits of Eyelid and Facial Injectables (Botox, Dysport, Xeomin, Restylane, Juvederm, Sculptra, and others)
It is my pleasure to review the uses of Botox and other eyelid and facial injectables because these have now become the most common cosmetic procedures performed worldwide and millions of injections are performed each year. This popularity is understandable because there is a strong demand for treatments that produce results, are less invasive, and have less downtime. Despite these advantages, I encourage you to do your research and make sure that you are a suitable candidate for injectables and that only a licensed, experienced injector perform the treatment. After undergoing any injection, you should get a record of exactly which products were injected (including the expiry date and lot number), how much was injected, and precisely where the products were injected.
An experienced injector will help you avoid complications and get the best value and most natural results. Injectables are not suitable for everyone. Not uncommonly, I encounter patients who spent thousands of dollars only to have unnatural results that draw negative attention to the treated areas. This must be avoided because there are often long-term negative consequences despite what often appears to be such a “simple and easy” intervention.
On a personal note, I’ve worked extensively with medical and cosmetic applications of Botox, Xeomin, Dysport, Restylane, and others, but have no financial disclosures or affiliations with any of the companies that produce these and the other products which I’ll be discussing. I have had the distinct honor of being a Course Instructor for injectables Skills Transfer Courses that train physicians and surgeons, running national level meetings that present up-to-date botulinum toxin research, published on the long-term safety of injectables in the peer-reviewed medical literature, and volunteer as a medical advisor to the Blepharospasm Foundation of Canada (an organization that funds many research studies evaluating botulinum toxin).
Since the 1980s, botulinum toxin A has been used as an eyelid, eye muscle, and facial muscle relaxant with a great track record for predictable results and patient safety. Over these past several decades, many more clinical applications for botulinum toxin have been discovered such as treatment of hyperhidrosis (excessive sweating), dystonia, pain disorders, migraine headaches, and many others. There are currently 3 unique formulations available in North America, each of which are made by a different pharmaceutical company. The trade names for these botulinum toxins are Botox, Xeomin, and Dysport, and we will discuss their specific features and unique advantages later in the blog.
Botox was the original formulation, and works to temporarily suspend communication between a nerve and muscle, thereby causing a type of “controlled paralysis” of the injected muscle without spreading to other parts of the body. It was created by an ophthalmologist in San Francisco named Dr. Alan Scott MD, who used Botox to treat the eye conditions strabismus (crossed eyes) and blepharospasm (involuntary eyelid spasms). During my oculofacial plastic surgery fellowship training in San Francisco, I had the distinct pleasure of meeting Dr. Scott at a dinner party and was very impressed with his scientific mind and humble nature. As Botox became more popular, some smart physicians using it noticed that in addition to helping control involuntary eyelid spasms, it also made the wrinkles around the eyes disappear with repeated injections. It did not take long for the pharmaceutical industry to take notice and they purchased the rights to Botox from Dr. Scott and it’s been increasingly popular ever since.
Botox is made from a type of bacteria called Clostridium botulinum and the toxin blocks the nerve impulse to the injected muscle. The effect lasts on average for 3 months, so injections must be repeated after this time to maintain the effect. Botox must not be used if there is a known allergy, hypersensitivity, or a skin infection near the injection site. Certain medications (including muscle relaxants and aminoglycosides) can interact with Botox and it is best avoided during pregnancy and breastfeeding. If you suffer from dry eyes, injections around the eyes might make this worse. Botox injections are typically done in-office, take 10-15 minutes, and are relatively comfortable with no visible signs that any treatment was done. There are some rare risks to be aware of including over-treatment, under-treatment, bruising, pain, dry eyes, eyelid droop (ptosis), facial asymmetry, difficulty with speech, allergic reaction, and infection. Once again, these risks are extremely rare in the hands of an experienced injector.
Botox injections are repeated every 3-4 months for most patients and once the required dose and injection sites are determined, this remains relatively stable over time. Patients often ask me whether there are any long-term side effects of using Botox, Xeomin, or Dysport. Based on our own published medical research done at the University of Toronto, we found that the long-term efficacy was excellent and there were no long-term negative consequences from using repeat injections. The reference to our article is below:
(Gill HS, Kraft SP. Can J Neurol Sci. 2010 Sep;37(5):631-6. Long-term efficacy of botulinum A toxin for blepharospasm and hemifacial spasm.)
Now let’s discuss the specific differences between Botox, Xeomin, and Dysport.
Botox is produced by the company Allergan and it is considered the gold standard botulinum toxin injection because it was the original product and most of the medical research studying the toxin has been done using Botox. This is the most expensive product amongst the 3 and the onset of action is within 3 days of injection. It lasts for 3-4 months and must be kept in a freezer before it is reconstituted (mixed with preservative-free saline) by the injector.
Xeomin is produced by the company Merz and its main advantage is that there is no “carrier protein” attached to the molecule so there is theoretically less risk of allergy or resistance. The average onset of action is within 3-5 days of injection and it also lasts for 3-4 months. It is cheaper to purchase than Botox. An advantage for the injector is that it can be stored at room temperature before reconstitution.
Dysport is produced by the company Galderma and the main advantages are that it has the fastest onset of action (within 1-3 days) and it is the cheapest of the 3 products. It is also associated with a wider distribution of paralysis, which can make it the most beneficial when injecting larger surface areas like the forehead. Its duration of action is 3-5 months.
All three of these toxins are very popular, used extensively, and have been shown to be safe and effective. Injection sites include the forehead, the glabella (area between the eyebrows), the laugh lines (outside corners of the eyes), bunny lines (along the sides of the nose), treatment of gummy smiles, lip-flip, softening of vertical lines above the upper lip, within a dimpled chin, for softening jaw muscles, and to reduce thick platysmal (neck) bands. Please note that Botox, Xeomin, and Dysport will soften those lines on the face that are caused by repeated muscle contractions (i.e. dynamic lines) but they will not have any “filling” effect for the deeper wrinkles, folds, and static lines caused by tissue deflation or descent.
For the aforementioned deep wrinkles and static lines due to loss of volume (tissue deflation) and gravity (tissue descent) hyaluronic acid filler is a great option. Restylane (produced by Galderma) and Juvederm (produced by Allergan) are popular fillers and millions of injections have been performed over the past 10-15 years. Filler technology is continuously improving year after year because it is such a competitive market.
There are a multitude of products available now, which vary in thickness, consistency, viscosity, and other variables, that will impact how the material will interact within the various facial tissues. For instance, certain filler materials are softer and are more appropriate for injection into structures such as lips, while other materials are thicker and best for deeper injections that will improve projection (e.g. cheeks, chin, jawline). Master injectors will typically use a combination of different filler materials to create a natural, harmonious and balanced result that does not draw negative attention to treated areas.
Some injectors like to use terms such as “liquid face lift” etc. to describe their unique injection techniques. It is paramount that filler injections are only performed by very experienced injectors. The most serious risks from filler injection occur due to blood vessel occlusion and include permanent vision loss, blindness, stroke, scarring, and facial necrosis. Thankfully these risks are extremely rare in experienced hands.
Typically, the injection is performed using a small-gauge needle or cannula to deposit the filler material precisely in the desired tissue location. Topical numbing cream and or facial nerve blocks with local anesthetic are typically sufficient to make the injection experience relatively painless. Restylane and the other products available also come prefilled with local anesthetic to help minimize pain. After the injection is performed, the injected tissues will become inflamed and this may last for 2-5 days depending on the volume of material injected.
Most hyaluronic acid fillers will last for 6-18 months.
Prior to your treatment session, it is best to avoid blood thinners (after consultation with your MD) and alcohol consumption in order to decrease the risk of bruising. The main advantage of using fillers such as Restylane, is that over-filled areas can be smoothed out using hyaluronidase (an enzyme that can dissolve the filler). I would encourage all of you to ask your injector beforehand whether they have hyaluronidase available on site in the office. In the event of a medical emergency such as blood vessel occlusion from filler injection, this enzyme is critical to save you from the very serious and permanent complications discussed earlier.
Another type of filler material is calcium hydroxyapatite (Radiesse), which is a permanent type of bone-substitute material and must be injected by a very experienced injector because it cannot be dissolved. It is particularly effective when injected deep near the bone (i.e. for jaw contouring or chin projection) although it is approved for use in more superficial subdermal areas like the nasolabial folds and marionette lines.
Sculptra (poly-L-lactic acid) is a great option for patients who have had total facial volume deflation and need a more broad-based treatment to improve wrinkle reduction and restore volume. It is very effective in those patients who have been very physically active and lost facial fat volume causing deflation and sagging.
Another popular facial injection is using platelet-rich plasma (also called PRP and Vampire Facial). This involves taking your blood and centrifuging it down so that only the stem-cell rich component is isolated. This blood product is then reinjected into areas of the scalp and face. From my experience, PRP injections are very effective for areas of acne-type scarring but I am yet unsure as to how effective they are for generalized rejuvenation goals or hair growth. Certainly, the injection process alone (even without the blood product) will cause an inflammatory response, subsequent swelling and blood flow, which can make tissues temporary look more hydrated and youthful. I am not sure that beyond this initial inflammatory response, there is a clear longer-term benefit. I encourage any of you getting PRP injections to take selfies prior to the injection and then weekly to determine whether your investment of time and money is worthwhile long-term.
Finally, autologous fat grafts can be taken from your abdominal area and used for reinjection to different areas of the face. Once again, a very experienced injector must perform such injections because the complication rate is higher. The main benefit of using your own fat is that it’s more “natural” and theoretically it should last longer than hyaluronic acid filler. Unfortunately, however, as surgeons, we know that preparation of the harvested fat is the most critical step and will determine whether or not the treatment will be successful. If the fat is not broken up enough, injecting it into the face may result in granuloma formation, scarring, palpable lumps, and abnormal contours. Surgically removing the grafted fat once this occurs is relatively difficult and can cause further complications. If the grafted fat is broken up too much, then the fat cells simply won’t survive long-term. The post-treatment inflammatory response will leave you very happy for the first few months, but then you will wonder why you’re back to square one again 6 months later. From my personal experience, surgeons need to be very selective and make sure this fat grafting option is offered only to appropriate candidates who have high-quality fat available and the appropriate facial anatomy to receive the grafts. In addition, the fat is best injected into deeper structures (like over cheek bones) rather than more superficial areas (i.e. lips, eyelids, nasolabial folds). Fat injected into these superficial areas will have a moderate risk of forming bumpy nodules that you may see and feel.
As you can see, there are many important considerations when deciding upon which injectables are suitable and safe for you to use. Researching the multitude of different products available can often feel like a daunting task and with good reason. This is why it’s very important not to take this decision lightly.
Remember that filler material injected into your face is similar to undergoing a “transplant” of foreign material and this can have significant negative implications when complications occur. Injection of Botox, Xeomin, and Dysport is relatively safer because the effect only lasts for 3-4 months.
At Eye Face Institute, we find that eyelid and facial injectables are a wonderful adjunct to our treatment armamentarium consisting of medical-grade skin care regimens, laser resurfacing, radiofrequency tightening, and surgical interventions. We carefully develop a customized treatment plan depending on your unique anatomy and desired results. A one-size-fits-all approach will not work.