Dysport (At Least) Equivalent to Botox (?!)

Dysport is the new Botox.  On April 30, 2009, Dysport became the second botulinum neurotoxin FDA-approved for cosmetic use.  I received my first shipment just 1 week ago, and here are my initial impressions after using Dysport on 10 patients in Ventura, California:

• Dysport seems to work faster than Botox.  Dysport appears to kick in within 1-2 days, while Botox doesn't start to work for 3-4 days.  For any patient who shows up to my office on Thursday or Friday and who expects to have fewer wrinkles for her party on Saturday night, Dysport may be the better option.
• Although I have limited experience with the product, I have had no complications with Dysport:  no allergies, no droopy eyelids, and no excessive "spread."
• Dysport is helping to hold down the price.  Every year, I have had to raise my prices for Botox, because its manufacturer (Allergan) raises its prices.  This year, the launch of Dysport forced Allergan to hold its prices steady.  So, competition is a good thing!  Botox will not increase in price this year, and equivalent amounts of Dysport should cost the same.

So far, I am nothing but positive about Dysport.  However, questions remain...

• Will Dysport last longer than Botox?  (lasting for 4 months rather than 3-4 months)
• Will Dysport's safety profile remain as enviable as Botox's?  (I have NEVER had a major complication with Botox, such as an allergy or infection.)
• What are the optimum dosages of Dysport?  (It took years to figure out how best to dose Botox at the glabella, crow's feet, forehead, etc.  Should I just multiply those numbers of units by 2.5 to obtain the appropriate dosages of Dysport??)

More on these issues over the next few months as I gain more experience with Dysport.

Gravity is Over-Rated in Facial Aging

At a recent plastic surgery conference in Paris, most physicians admitted that we have been wrong.  Gravity is not the primary cause of facial aging.

Surely, as the face ages, muscles and ligaments do grow more lax.  Therefore, the skin is definitely subjected to the vicissitudes of gravity.

• As we age, the eyebrows do tend to descend--by a few millimeters.
• 3% of aging patients have a downward movement of the corners of the mouth--by 1-2 millimeters.
• In many patients, the upper lip does tend to lengthen.

"Just a few millimeters?  And just 3%?!  Then, why do I look so old?" you might be thinking.

Here are the real reasons why the face ages:

1. volume loss (wasting of fat and osteoporosis of bone)

2. repeated contractions of facial muscles (muscle hyperactivity)

3. skin damage (especially from sun and tobacco)

While the eyes of an observer may perceive significant downward movement in facial structures, objective measurements do not support these common assumptions.  What we are seeing is a combination of cutaneous aging and structural aging that gives the illusion of descent.

Since gravity is not a primary cause of facial aging, should you cancel your lift?  Not necessarily.  Sometimes, a surgical lift does give a great result, even if it is not addressing the issue of aging entirely appropriately.  Plastic surgery is, in truth, as much art as science, and sometimes art does trump science!

However, with this new information, I am going to recommend to my patients in Ventura that they consider...

1. more fillers (especially Sculptra) to increase the facial volume
2. more muscle relaxants (like Botox and Dysport) for over-active muscles
3. more skin care and lasers to minimize skin damage

Hey, Ventura, There Will Soon Be FOUR Botoxes

Within the next 2-3 years, you won't call your local plastic surgeon and just ask for Botox.  You and your doctor will have to choose between at least 4 types of botulinum neurotoxin type A....

• Botox
• Dysport
• Purtox
• Xeomin

In 2002, the FDA approved the first botulinum neurotoxin for the cosmetic reduction of dynamic facial wrinkles--Botox.  Botox has since established itself as the first-line treatment for...

• frown lines between the eyebrows
• horizontal wrinkles on the forehead
• crow's feet
• bunny lines on the sides of the nose
• non-surgical eyebrow lifting
• non-surgical lifting of the corners of the mouth

My patients and I have loved Botox.  The results have been outstanding; there have been few (if any) side effects; and overall satisfaction rates have been greater than 90%.

On April 30, 2009, Dysport became the second botulinum neurotoxin FDA-approved for cosmetic use.  I just received my first shipment today, and I suspect that this product will function nearly identically to Botox.  (Next week, I'll blog about my initial experiences.)

The Mentor Corporation (Santa Barbara, CA) has completed clinical trials for a 3rd botulinum neurotoxin--Purtox.  While this product may truly be more pure than Botox and Dysport, it remains to be seen whether that purity really matters.  For example, I've never had an infection, allergy, or any major side effect with Botox, so Botox is already pretty darn pure.

Xeomin is still in the "pipeline"--still in the middle phases of clinical trials.  I don't have much information on this product (except that it is being developed in Greensboro, NC, and in Newark, CA), but I will try my best to keep you in the loop!

Multiple Plastic Surgeries in Mexico: Don't Do It!

I am going to have a tummy tuck, breast lift, and breast augmentation done at the same time with a board-certified doctor in Mexico. He says he can also do minor liposuction and inject the fat in the buttocks to give me a more smooth look.  He says this is included on all tummy tuck patients if they wish to do so, but I am a little nervous. Is it possible to have the three procedures done, along with the lipo and Brazilian butt lift?

- Housewife in San Diego

I am sorry to pick on you "Housewife in San Diego," but your question is very concerning to me. Frankly, I don't think you are being safe.

You're surgery is going to be far too long....

Dual-plane breast augmentations        1 1/2 hours

Wise-pattern (anchor) mastopexies     3-4 hours

Tummy tuck                                      3 hours

My math indicates that you're now up to about 8 hours.  Frankly, that's already pushing it.

I try to avoid operating on a cosmetic patient for longer than 6 hours at a time.  If she is young and very healthy, then maybe I'll do 8 hours. If I think that the case is going to last longer than 8 hours, I never do the operation in an out-patient surgery center.  I do these ultra-long procedures in a real American hospital with all of the safety precautions. The patient stays overnight for close monitoring by an excellent nursing staff.

OK, but now you want to add Brazilian butt lifting.  (Truthfully, I don't think BBL even works. It has never produced long-term success in my hands, and so I don't do this procedure at all anymore.  But anyways...)

Liposuction                                         1/2 hour

Brazilian butt lifting                              1 hour

So, now you've been in the operating room for at least 9 hours. 9 hours is way too long since I bet, Housewife in San Diego, that you will not be having your surgery in a fully accredited hospital.

Sorry. But this plan sounds unsafe.

Practicing in Ventura County, California, I take care of 5-10 patients annually, whose aesthetic surgeries were botched during Mexican plastic surgery adventures. To me, the thought of obtaining medical care—especially surgery—outside of the USA is ridiculous. Many plastic surgery procedures come with significant risks.  For example, most honest American/European/Asian research studies of breast reductions report 30-40% rates of complications!  For tummy tucks, 25-35%!  Many of these complications do not manifest themselves for 2-3 weeks.

So, Housewife in San Diego, what are you going to do if you have a complication?  Drive back to Mexico?  Who is going to take care of your complication at 2 am?

Well, in my community, I do. So, yes, I am bitter. I do resent going to the emergency room in the middle of the night to take care of a patient who had bad surgery done by a foreign doctor who had no intention of looking after her.

And, frequently, my hands are tied because I do not know the details of the surgery. Is the patient supplied with information regarding antibiotic usage? Suture type? Implant size and manufacturer? The answer is always, “No.” Have the patients and I ever been able to obtain this information from the foreign surgeon? Almost never.  Ultimately, my management of the patient’s complications is necessarily suboptimal because I do not have the specifics.

I certainly admit that not every physician in the United States is outstanding. In fact, while there are approximately 60,000 American physicians performing cosmetic procedures, only 6,000 of us are certified by the American Board of Plastic Surgery. Certainly, we need to clean up our own backyard.

Likewise, I am more than happy to refer patients to any number of outstanding Mexican plastic surgeons. Many of the world’s leaders in plastic surgery come from Mexico, particularly Mexico City.

But if you're going to get plastic surgery in Mexico, then do it right. Make sure that the surgeon is truly Board Certified. Which Board? The plastic surgery board or the general surgery board?  Is the facility accredited? What's the policy for complications? Who do you call in the middle of the night?

After you've found a Mexican plastic surgeon who gives you all of the "right" answers, then plan to stay in Mexico near his clinic while you recuperate.  Make sure that you follow-up with the surgeon who did the actual surgery.

Because of the need for prolonged follow-up, even my Mexican colleagues who are fantastic surgeons are not right for my Californian patients.  Follow-up is a crucial part of any surgery.  Surgical care does not end when you leave the operating room!  Patients need to be nursed through complications--some of which don't manifest for 4-8 weeks.  Patients also need reassurance; they must have the opportunity to come to see me, any day of the week and any time of day, to make sure that their experiences are “normal.”  Patients need continued compassion.

And a doctor can’t do any of those old-fashioned duties across the border.

Moreover, a doctor needs to see his/her results. How can I make improvements in my technique if I don’t get to see my results after complete healing?  This might be the biggest flaw of the cross-border surgeons.  They don’t even know that they are continuing to make mistakes, because they never see their own complications.

Some things just shouldn’t be “out-sourced.” Medical care is one of them.

The 5-Finger Solution for Aging Hands in Ventura County

Practicing in Ventura, Oxnard, and Camarillo, in Southern California, I have many patients who have been sun worshippers.  Botox, soft-tissue fillers, lasers, and facelifts have rejuvenated their faces, but many women are concerned that their hands "still give me away."

My "5-Finger" solution for aging hands:

• Radiesse:  Calcium hydroxylapatite, better known as Radiesse, is a safe way to plump up the backs of your hands.  It fills the tissue beneath the skin, thereby hiding tendons and veins.

• IPL:  Intense Pulsed Light treatments are like lasers.  They remove freckles and age spots, while improving the texture of the skin.

• Moisturizer:  Dry, cracked skin itself looks old.  Hydrating the skin with a good moisturizer refreshes and rejuvenates the skin.

• Sunscreen:  At least SPF 30!  Prevent any more damage by wearing sunscreen all the time--even when you are not intending to be outside.  (It's amazing how much sun you get just by driving around town and by walking to and from your car between errands.)

• Readjust when you "play" outside:  I certainly don't want to ruin your good times.  Lord knows that we could all use more exercise.  However, try to avoid being in the sun when its rays are strongest--between 10 am and 3 pm.  Of course, when you go for your morning run or when you are playing in that afternoon softball game, don't forget your sunscreen.

Silicone Breast Implants Still Not as Popular as Saline

In the current edition of the Aesthetic Surgery Journal, Drs. Reece, Ghavami, et. al., surveyed current practice patterns in breast augmentations by Board Certified Plastic Surgeons throughout the USA.  While the study was mostly predictable, I was shocked to read that plastic surgeons still use saline implants more frequently than silicone implants!

Here's what implants plastic surgeons seem to prefer...

• 92% used smooth implants (rather than textured)
• 96% prefer round implants (rather than tear-drop shaped)
• Saline still outsells silicone.
• At least 40% of plastic surgeons prefer saline implants over silicone implants.
• 23% use saline implants exclusively!

Compared to my peers, my numbers are similar, except when it comes to saline versus silicone.

• I prefer smooth.
• I prefer round implants.
• I do like saline implants.  Saline still has a role to play, especially when a patient wants the smallest possible scar.
• However, in general, silicone is my preferred option.  I recommend silicone to 90% of my patients.

Why do I like silicone in most cases?

• Silicone has a more natural feel.
• Silicone produces less "rippling."
• I think that silicone implants will probably be more durable.

Most of the other results of the study were predictable.  Overall, I am happy to say that I follow the standard, majority opinion in all of the following circumstances:

• Most plastic surgeons and their patients prefer outpatient surgery centers rather than hospitals.  (I use both, but most routine breast surgery is done in a same-day surgery centers.)
• About 2/3 of plastic surgeons work with physician anesthesiologists; the other 1/3 employ a nurse anesthetist.  (I prefer a Board Certified Anesthesiologist for maximum safety.)
• Most (93%) do not use pain pumps.  (I place long-acting novocaine-type medication into the breast "pocket," but I do avoid pain pumps.  I worry that the pump tubing could increase risks of infections.)
• Average implant size is between 300 cc and 400 cc.  However, there were minorities of plastic surgeons who usually placed 200-300 cc implants; still others seemed to preferentially use 400-500 cc implants.  (My average is in the high 300s.)
• Regarding incision location, 64% prefer an incision in the fold beneath the breast, and 25% use an incision around the areola.  (These are the two approaches that I use.)  Very few use the arm pits, and almost none still use the belly button.  (I don't use these techniques at all anymore.)
• Regarding implant location, 78% attempt some coverage of the implant beneath the pectoralis muscle.  (I place implants below the muscle in 95% of patients.)

What would be interesting to know is how California is different from the rest of the country.  Is California "bigger" than the other states?  In Ventura, Oxnard, and Camarillo, patients tend to be conservative; how would suburban Ventura County compare to Los Angeles?  Thoughts for the next research project....

Dysport Not Much Cheaper than Botox in Ventura, Oxnard, and Camarillo

While Dysport is much cheaper than Botox in Europe, the price for Dysport for American physicians and patients will not be substantially less expensive than Botox.

Dysport is a muscle relaxant that is very similar to Botox.  It was going to be called Reloxin, but the FDA has limited the name to Dysport.  Regardless, there remains much medical controversy regarding the two products.

• Will Dysport work faster than Botox?  (starting to work in 1-2 days rather than 3-4 days)
• Will Dysport last longer than Botox?  (lasting for 4 months rather than 3-4 months)
• Will Dysport have fewer allergies than Botox?  (which are extremely rare anyway; I've never seen this complication)
• Will Dysport have more "spread" than Botox, and thus have more side effects?  (???!)

While we all wait for definitive answers to those questions, I do have some hard data.

• Dysport was FDA-approved in April 2009.  This is a really good sign.  The FDA is very tough, and dangerous products almost never get past the FDA.
• Dysport will be widely available in July 2009.  Currently, the product is passing customs.

• The suggested retail price for Dysport is virtually identical to Botox.

So, for all of my patients in Ventura, Oxnard, Camarillo, Ojai, Santa Paula, Somis, etc., don't expect a big change in price when treating your "frown lines" between your eyebrows, your "crow's feet," etc.  Whether you prefer Botox or Dysport, you're still going to be paying $200-300 per area.