Dysport Units and Dilution Versus Botox Units and Dilution: 3 to 1 will get it done.

 

As neurotoxin science continues to advance and more drugs become available, patients will be offered more choices of treatments.  Currently Botox (Allergan) and Dysport (Medicis) are the only FDA approved neurotoxins (also called neuromodulators) to treat facial lines and wrinkles.  Numerous other similar drugs are currently in the pipeline for FDA approval, including products from China and Germany.  Patients outside the USA have more options and US patients will soon have some of these options.  More options are not necessarily better options as Botox and Dysport have long track records of safety and efficacy, but these new products will more than likely also offer safety and effectiveness and may also be more cost effective for patients.

All neurotoxins will be compared to Botox in terms of safety, efficacy, time of onset and duration of the effects.  As with any new product competitor on the market, positive and negative rumors will abound that can assist or detract from the new product.  Finally, all new products will settle in to their niche based solely on their effect and not conjecture.

Dysport has big shoes to fill in taking on Allergan’s previous monopoly of Botox.  Dysport has an excellent track record in Europe where it has been an option for a decade.  Like any new drug, doctors must figure out “the right way to use it”.  More than ever before, drug companies are strapped in getting the word out by Big Pharma regulations.  Although regulation is necessary, drug companies are literally hamstrung and sometimes voiceless.  Dysport would love to tell doctors the “best way” to use the new drug, but simply are not allowed, so it rests in rumor and conjecture as the means of determining “best practices”.

The biggest question of doctors new to Dysport is “how does the Dysport dosage relate to Botox dosage.  Being a consultant for both companies, I am asked this question frequently in my teaching travels around the US.  Initially, doctors were saying that “one Botox unit should equal 2.5 Dysport units”.  Although not an official comparison, this suggested that in order to have an equal effect, a patient that would normally have 20 units of Botox to treat their frown lines would require 50 units of Dysport to appreciate the same effect.  Comparison of units are not “apples to apples” official pharmicopia, but rather convenient conversions to anecdotally arrive at a standard between the two drugs.  Unfortunately, I believe that this first round of “units to units” comparison gave Dysport the short end of the stick.  Here is the reason.  When a new drug is introduced that competes with a standing giant, patients will try it (or not try it) based on numerous factors.  These selection factors include the advice of the treating doctor, cost factors, rumored advantages, the “newness” factor and the possibility that the new drug will simply work different or better.  Herein lies the catch.  If a patient has been getting successful Botox treatments with 20 units to their frown lines and wants to try the new Dysport and their doctor gives the rumored 2.5:1 ratio (50 units of Dysport), the patient is going to be a hard line test of which one works best.  In my experience, the 2.5 conversion is not enough Dysport to produce the effect of 20 Botox units.  If so, the patient will have a less profound or shorter acting effect and Dysport will be “dissed”.  My experience (and that of other surgeons) of using 3 Dysport units for 1 Botox unit seems to be a more accurate dosage in the quest for equipotent treatment between the two drugs.  If doctors are truly interested comparing these two drugs, they must use an equipotent dosage, which I believe to be 3 Dysport units for each Botox units or 60 units of Dysport for an area usually treated with 20 units of Botox.  Failure to use this ratio may give patients a false comparison of the effects and longevity of Dysport. 

Why is all of this important?  Personally, I feel that Allergan and Medicis are both great companies and I use fillers and neurotoxins from both of them.  From a doctor standpoint, you have to offer all contemporary options to your patients and from a consumer standpoint, every Coke needs a Pepsi.  What is important is that when comparing on new product to another, it is done in a fair way for the surgeon and patient to accurately evaluate.  Having said this, I believe the fair and balanced (hey, does that sound familiar?) way to this is to inject 3 Dysport units for where you would use 1 Botox unit.  Then the surgeon and patient can fairly evaluate the drugs.  It is unfair for the company and patients to compare with a lesser amount.  You will never find an official chart that says use 3:1 and Medicis is not allowed to even think that out loud, so it is up to the experience of scientifically minded clinicians to fairly sort this out for everyone else.  I am trying to do my part and I think it is 3:1 ad nauseum. To prepare Dysport for this dilution, 3 cc of preserved saline is added to the 300 unit Dysport vial.  Five one half cc syringes are drawn up and each will contain 60 units.

To find out more about Botox, Dysport and cosmetic facial surgery in Richmond, Virginia visit www.lovethatface.com

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

www.lovethatface.com

The Liquid Facelift: there’s a sucker born every minute!

 

P.T. Barnum, the great circus promoter is frequently quoted as saying “there is a sucker born every minute”.  I am sure he would be quite amused by the new amazing miraculous “Liquid Facelift”!

In this day and age, the best way to promote one’s agenda is to “invent” a really sexy sounding facelift.  First you need an unusual name so the media can key in on it and it will make patients think it is new.  Next, you need to make it sound like it is some new “miracle” that has displaced previous technology.  Finally, you need to make it sound really desirable.  The best way to do this is to tell people that it is non surgical and has little or no recovery.  If someone can put these three things together and find someone in the media to promote it, they will frequently get their 15 minutes of fame.  In the best case scenario the entire hype concept will really take off and the “miracle procedure” will fill the appointment book of the promoting doctor and he or she will frequently franchise their technique to teach other doctors this gift to humanity.  It all goes great guns……………..until…………..well until the other doctors, the public and the media find out four things.

1.  It is really not a new technique, only a hyped repackaged version of procedures that have been around for decades.
2. It is very expensive; it has more recovery that promoted.
3. It is really not a facelift and the results in the average patient are disappointing
4. It doesn’t work.

When all of these factors fall into place, and they always do, many patients are left disappointed and with skinny wallets in the wake of disappointment. 

We have seen this many, many times!  Do names like the Contour Thread Lift, Thermage, The Life Style Lift sound familiar?  I am not sure which is sadder, the fact that so many doctors try to make something out of nothing for personal gain or publicity or the fact that the poor public is so gullible and easily parted from their hard earned cash.  To me, this is much like the weight loss or diet industry.  It is a well established fact based on science and physiology that if you restrict caloric input and exercise you will lose weight.  That simple, no magic!  Yet as I was typing this blog, a commercial came across about the Cookie Diet.   All you have to do is eat these yummy cookies and the weight will fall off!  Please! This should be illegal, but I am sure thousands of gullible people will try the cookie diet and that it will soon fade into obscurity that the thousand diets before.  Will the public ever learn?  If it sounds too good to be true, is it true?

Back to the liquid facelift.  What this procedure really is, is filler injection.  Yep, filler injection, Restylane, Juvederm, the same stuff that thousands of docs do every day.  The liquid facelift is nothing more than a mega filler injection session.  Instead of just filler in the lips or smile lines, it goes in the midface, the jowls, and other place.  Nothing new as most of us that inject filler inject it in these areas when requested.  So, please consider several things.

1. The liquid facelift is not a facelift.
2. The liquid facelift is filler injection.
3. Fillers laser up to a year in the best scenario.
4. Fillers are extremely expensive and a liquid facelift can use up $5-8,000 of filler in 20 minutes.
5. Most people that need a facelift have excess skin and loose muscle.  The liquid facelift does not tighten the skin or muscle; it just fills up hollow spaces.  This is fine, but is it worth it for a year of looking better.
6. A facelift can last 10-20 years, and yes, it required surgery and 2 weeks of recovery.  So what, if you want a real facelift with real facelift results, have a real facelift.
7. All the filler in the world won’t tighten up turkey gobbler skin on the under the chin and under the neck.

 

Is there anything good about the liquid facelift?  Sure, fillers are great and even though I do almost 100 facelifts a year, I am one of the busiest filler injectors in my state.  Fillers are great, but they are not a facelift and should never be used in conjunction with the word “facelift”.

If P.T. Barnum were still alive and if he was a doctor, I bet he would be a big proponent of the liquid facelift.

To find out more about Dr. Niamtu or cosmetic facial surgery in Richmond, Virginia, visit www.lovethatface.com.

 

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

www.lovethatface.com

Dysport: the new “Botox”

If Allergan’s Botox is Goliath, then Medicis and their new neurotoxin is David.  No one can argue that Botox has enjoyed a monopoly in the United States for past 15 years.  After all, Botox was a true paradigm shift in cosmetic surgery.  Never before, without surgery, could a patient have wrinkles disappear.  The introduction of Botox was something so different and so easy that it truly heralded in a new era known as minimally invasive surgery.  What began as a “pretty poison” has grown into “cosmetic maintenance” and now women and men get regular Botox injections with the same regularity that they get their hair colored or teeth cleaned.  Botox has not only continued to be safe and effective, but has gone on to treat many conditions from headaches to hemorrhoids.

Botox has gone largely unchallenged and Allergan has become a corporate giant due to its sales.  Second to Viagra it is the largest selling drug.  A brief challenge came in the “at the turn of the last century” with Myoblock, a similar product but chemically different.  Unfortunately for Myoblock, it did not live up to the effectiveness of Botox, and its popularity was short lived.  It is still used for the few patients that have a resistance to Botox, but is a small player.

Dysport is chemically very similar to Botox and has been used in the United Kingdom for 15 years.  It varies from Botox in its biochemistry and protein structure but basically does the exact same thing.  This drug has recently received FDA acceptance and will be sold in the United States under the same name.  Dysport will make a big bang with the media upon it final FDA acceptance and rumors will fly.  The Dysport FDA trials showed that Dysport took effect somewhat faster than Botox and basically lasted the same amount of time, about three months.  Why challenge the king of neurotoxins (more politically correctly called neuromodulators) with a drug that basically does the same thing.  I call it Coke versus Pepsi marketing.  Consumers and surgeons desire choices in everything from clothes, to cars to, carpet and want choices.  There is also some bragging rights from being the “new kid on the block” (just ask Red Bull).  Cosmetic consumers and media are fascinated by “new” technology and if it is new then it must be better.  Frequently this does not pan out, but a well marketed and effective competitor can certainly gain market share.  When all the US automakers were getting bailed out by the Federal government, Toyota (who was a newcomer to this country) remained strong.

To cut to the chase, Dysport is exciting because it is new and is also taking on heavyweight Botox.  It is likely to become a popular competitor.  What remains to be seen, and could make the difference in the wrinkle wars, is how Dysport is priced in comparison with Botox.  If Medicis significantly undercuts Allergan, Dysport could potentially displace the king.  I doubt that this will happen as corporate America is not fond of less profit.  A similar scenario occurred with Restylane, the revolutionary lip and wrinkle filler from Medicis.  This was the first new filler that was FDA approved and made a meteoric rise to the top of facial injectables.  There was no significant competition for about 4 -5 years until Allergan obtained FDA approval for Juvederm.  In the pre release period, much speculation occurred as to whether Allergan would significantly undercut the pricing of Restylane.  Guess what?  They did not.  Their pricing was almost identical and Juvederm no doubt took a chunk out of the filler sales dominated by Allergan.  Competition is generally a good thing as it offers the public more choices and can sometimes drive down prices, but don’t look for this with aesthetic companies.  They figure if patients will spend $500 for X, then they will spend it for Y.  Time will tell.

To find out more about Botox, Dysport and other cosmetic facial surgery procedures, visit www.lovethatface.com.

 

Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

www.lovethatface.com

Facial and Neck Liposuction

 

Liposuction is one of the most common cosmetic surgery procedures and has become much easier over the past 20 years.  Unlike body liposuction where large volumes of fat may be removed , the procedure is much more conservative in the head and neck.  Most patients do not have large areas of fat in the head and neck and therefore much less fat is removed.  Where quarts of fat may be removed from the body, the amount of fat removed in the head and neck is measured in “tablespoons”.  The main areas in the head and neck for fat deposition are the jowls, the area under the chin, and the neck.

 

Figure 1. shows common areas of fat deposition in the facial region.

The most common misconception about neck liposuction is that it will tighten lose neck skin.  Many patients present for the consult and have a large “turkey gobbler” area of excess skin.  Even if there is fat under the lose skin, removing the fat will only serve to accentuate the lose skin and make it look worse.  The bottom line is that if a patient has excess skin under the chin and neck, they will need a facelift to correct this. 

Having said this, liposuction of the neck and chin (submental region) can be very effective in the proper patient.  This is usually a younger patient with fat deposits under the chin and without significant excess skin.  In these patients, removing some of the excess fat by conservative liposuction can make a huge difference in the patient’s profile.  The younger the patient is, the more the skin will tighten up after removing fat, as there actually is some degree of skin tightening in most patients.  The jowls, cheeks (to a lesser extent) and neck can also respond to liposuction.  It is important to remember that liposuction is not treatment for obesity but rather for genetic fat deposits that are resistant to generalized weight loss.

 

The Procedure

 

Head and neck liposuction can be performed with local anesthesia or with IV sedation.  The area is sanitized  and a dilute solution (tumescent anesthesia) of local anesthesia and epinephrine is used to inflate the tissues to be liposuctioned.  This tumescent solution not only numbs the area but also decreases bleeding and facilitates the actual liposuction procedure.  A tiny puncture is made in a skin crease to hide any scar, and the liposuction cannula (a thin metal, straw-like instrument) is inserted under the skin .  The cannula is briskly moved back and forth through the excess fat and the fat is emulsified into a liquid that is suctioned out.  It is important not to over treat an area because removing too much fat (especially in the neck and under the chin) can cause very visible irregularities under the skin.  The treated area will usually stay numb for several hours after the procedure, so pain is not a common problem.

After the procedure the patient is given a compression dressing (Jaw Bra) to wear for several days.  Depending upon the amount of fat removed and the amount of excess skin the dressing may be worn for 5 days continuously and at night for the next week.  For most patients, this type of liposuction is a weekend recovery unless they bruise, which extends the recovery from a cosmetic standpoint.

 

Figure 2 shows a patient treated with liposuction only of the chin and neck regions.

 

Buccal Fat Pad Removal

All humans have walnut sized collections of facial fat called the Buccal Fat Pads that lie in the cheek.  In patients that desire to have their face “slimmed” the buccal fat pads can be reduced at the same time (or in place of) the liposuction.  This is done by making a small incision inside the mouth, next to the wisdom teeth and the fat pad is teased out of its position and conservatively reduced.

 

Icing on the Cake (Chin Implant Surgery)

 

Another means of dramatically complimenting the liposuction procedure is to place a chin implant in the appropriate patient.  Many patients with submental fat also have a retrusive profile from a weak chin.  By removing some of the chin and neck fat with liposuction and simultaneously placing a chin implant, the result is made better than doing either procedure by itself.

The chin implant can be placed from the inside of the lower lip so no surgical scar is visible.  The recovery for chin implant surgery is about one week.

 

Figure 3 shows a patient treated with liposuction and a simultaneous chin implant.

For more information about head and neck liposuction by Dr. Joe Niamtu in Richmond Virginia see:

http://www.lovethatface.com/cosmetic_facial_surgery_richmond_va/face_neck_liposuction.html

For more information about chin implant surgery by Dr. Joe Niamtu in Richmond, Virginia see”:

http://www.lovethatface.com/cosmetic_facial_surgery_richmond_va/chin_surgery.html

For more information about other Cosmetic Facial Surgery from Dr. Joe Niamtu in Richmond, Virginia see:

www.lovethatface.com

 

Joe Niamtu, III DMD

Richmond, Virginia

www.lovethatface.com

 

Minimally Invasive Cosmetic Facial Surgery: Is Less Really More?

 In this day and age of sensational media coverage for cosmetic surgery it can be difficult to sort the wheat from the chaff in terms of what is good and what is hype.  There is no doubt that many things in cosmetic surgery have gotten easier.  The average hospital stay for a facelift 3o years ago was 4.5 days, now, my facelift patients are home by 4PM on the same day of their surgery.  The anesthesia is also easier.  Most patients don’t need intubated general anesthesia and do well with light IV sedation.  We also have new, technologically advanced instrumentation such as endoscopic surgery.  So from this standpoint, cosmetic surgery is easier.

Minimally invasive surgical procedures have also found a place in the pop culture of cosmetic surgery.  It seems every time we turn on the TV or pick up a magazine we are force fed some new miracle procedure that gives facelift results with minimal everything.  Minimal downtime, minimal scars, minimal price, minimal anesthesia and maximum result.  One should wonder how so many “minimals” can equal a maximum.  Do you ever wonder “do these minimally invasive procedures really give the same result and longevity as the traditional approaches?”  These are questions you need to ask or you can be quickly separated from you hard earned cash.

Let’s take facelifts for example.  It is quite fashionable for some surgeons to market their “miracle” facelift.  They will tell you that it is a new technique that few others know how to perform.  They will tell you that the scars are much smaller than traditional facelifts and that it can be done in an hour, with local anesthesia and no bandages and you can go to work the next day.  Now, doesn’t this sound too good to be true?  If these procedures really do exist, how come all surgeons don’t offer them?  How can you get the same result with 1/2 of the incision?  Can you really get the same results?  Will the results last as long as a traditional procedure?  These are things that many patients fail to question and end up with suboptimal results when compared to a traditional procedure.  Or the result looks pretty good for a while and within a year or so, the sagging jowls and neck skin have returned.  Also beware of the before and after pictures of these miracle surgeons.  They frequently position the head and neck to make the post operative result look better.  Also, it is important to know how long after surgery the picture was taken.  A picture taken at 3 weeks may look very different (and better) than one taken at one year.

Facelift surgery is over a century old.  Most every configuration of facelift procedures have been tried, retried and repackaged as a new procedure since the 1920’s.  To adequately correct significant aging in the neck, cheeks and jowls, most surgeons will agree that an incision in front and behind the ears is required.  There is no doubt that in younger patients a more conservative procedure can be performed.  Patients with minimal neck aging and jowling can be adequately treated with only an incision in front of the ear.  This is not a contemporary innovation; in fact this procedure was well described in the plastic surgery literature in 1927.  Back then, surgeons knew that this procedure was not one for advanced aging and same holds true today.  If you take a patient with significant neck and jowl aging and perform an anterior only incision, you will get some improvement and it will last for a while, but you won’t get maximum improvement and it won’t last nearly as long as facelifts that are made with incisions in front of and behind the ear.

It is not that I don’t ever do a front only incision facelift as once in a while I do.  I reserve these “half facelifts” for young patients that just don’t have much aging.  Although I perform 2-3 facelifts a week, I only do a handful of the limited incision facelifts per year.  I have many more patients that ask for them, but in reality they are not conservative candidates and will be unhappy with the results down the road.  Many patients ask for the more conservative “weekend” facelift” but after they hear the pluses and minuses of result and longevity, they most often opt for the more traditional procedure.  I can then offer them a better result that will last longer.

Most patients that present for facelifts are in the range of 45 on up.  It is not unreasonable to have an incision in front and behind the ear to reverse a half century of aging.  Although proponents of tiny incision facelifts would like you to think that the incisions are a problem, it boils down to about 3-4 inches of incision behind the ear.  This allows more ability to tighten the neck skin and the incisions are hidden in the hairline.  Having this incision only increases the healing by several days, but in my opinion can double the longevity. 

There are also times when a patient presents for a conservative facelift and I turn them away.  The reason is that they have more aging than a conservative lift will correct and the result will be compromised and it will reflect on my reputation.  Since my practice is limited to cosmetic surgery of the head and neck, my work is visible.  A bad breast, belly or butt result can be hidden with clothes, but my result is my reputation.  Fortunately, most patients will opt for the correct procedure once they find out the true details.  I have reoperated many times on patients that fell for some “miracle” lift procedure only to be disappointed.  Another situation that exists (that most surgeons learn early on) is that when a patient gets a short cut procedure, they frequently get a short cut result.  Even though the surgeon and staff have explained to the patient that their result will be less than a traditional procedure and even though the patient signs consents detailing that, some patients soon forget that they had the short cut procedure.  They notice that their result is not as tight as their friends or does not last as long and then they become unhappy.  The bottom line here?  Conservative or short cut procedures are fine for some patients.  Those patients include minimal to moderate aging or patients that need a bigger procedure but have medical problems that prohibit more advanced procedures.  Fact.  You get what you pay for.  A patient with significant jowl and neck aging that gets a short cut procedure (no matter how cool it sounds) will not get the same or lasting result as traditional procedures.  No two facelift patients or no two facelifts are the same.  Each patient presents with unique aging and anatomy and the surgeon has much less ability to correct these unique areas with the limited incision procedures.  A few more inches of incision can make a world of difference for the final result.  It is kind of like the ski vests that some people wear in the winter.  They are lighter because they have no sleeves, and there may be some advantages, but if you have to go out into really cold weather, you are better off with the traditional winter coat.

Although I may sound negative, there is nothing wrong with the small incision facelifts.  They are fine for patients with minimal aging, but most patients present for facelift surgery simply need more.  Some doctors push these procedures because they don’t have the training to do the more comprehensive procedures.  Some doctors push these procedures because they don’t have the training to use IV or general anesthesia.  Some doctors push these procedures because they don’t have an accredited surgery center to do the more involved lifts.  And some doctors push these procedures because they have a place in the cosmetic practice, but not as a “do all, end all” option, and this is a fair choice.

 

Believe me; surgeons want easy procedures just as much as patients.  If there is ever an easy procedure that can truly replace traditional facelift surgery no one will continue to do it the “old way”.  Just like you don’t see people driving horses to work!  The combustion engine was such a tremendous advantage, it supplanted previous transportation.  Same thing with facelift surgery.  If a procedure is developed that produces the same result and longevity as traditional facelift surgery, it will push traditional facelift surgery by the way side.  Also, every surgeon will do it, not just a few.  It will be like the discovery of penicillin; all doctors will embrace the new technology.  Finally, this will be on the front page of all major publications and probably warrant a Nobel  prize.  It won’t be limited to some handful of surgeons with a big marketing budget.

Less can be more I suppose, but most of us would not think of this as an advantage.  You are rarely happy when you get a tiny serving of food, a carwash that leaves dirt on your car, a house painter that misses spots, etc.  In most cases, “less is less”.  The same goes for cosmetic surgery, so let the buyer beware.  Make your choices carefully and research what you may be missing when you opt for a conservative approach to surgery that is usually performed otherwise.  Sometimes it may provide advantages, and sometimes it may provide disadvantages.  And remember what your parents told you when you were young, “if it sounds too good to be true it probably is.”  No tiny procedure will rival the results and longevity of a traditional facelift and for sure, no laser, IPL, smart or dumb lipo, or thread will even come close.  A good general rule is to wait a year to try any new cosmetic surgery miracle that debuts on Oprah or the Today show as we have seen a bunch come and go.

 

Joe Niamtu, III DMD