Board Forum: Neurotoxins in Practice

Do patients get to choose their treatment? How do you educate them?

Todd Schlesinger, MD: I am happy to have patients get the neurotoxin they prefer if I offer what they are looking for. Basically, I tell them that I am able to get very similar results with the available products, accounting for my dose modifications with each type. I do educate them on the commonly stated differences that they may read about and allow them to have the freedom of choice, but in the end, I am confident that I can provide an excellent outcome either way.

Brian Kinney, MD: Patients may always “choose” their toxin, but they rarely elect to do it. I compare and contrast onset, duration, refrigeration, dispersion, etc.

Jeanette Black, MD: Most patients do not have strong opinions regarding which neurotoxin to use for their treatments and prefer for me to choose, but I find that patients still appreciate getting some education about all the available neurotoxins. Taking the time to educate patients about their options helps to develop trust. After educating them about their options they usually opt to let me decide which neurotoxin might be best for them.

Flora Levin, MD: If the patient has experience and knows what works best for them, I use what they prefer. Otherwise, I recommend, depending on areas of treatment and offer to try one, then the other to see if one is better. I often combine both in same patient in different areas (Botox: glabella, Dysport: frontalis).

Joe Niamtu, III, DMD: I’m totally onboard with patients customizing their treatments. Once in a while I have a patient coming from another office because that injector would not allow them to customize, which I think is crazy. Patients know what they want and know what works for them and works for their budget. Period. My only caveat: If somebody wants to treat a very active glabella with half the normal amount of units, I make him/her understand that s/he is not going to get a full treatment result.

Tina Ho, MD: Treatment is very patient directed. If they have had previous neurotoxin, I go with what they have been treated with in the past, if it is effective. If it is a new patient, I will just resort to Botox based on how much more commonly I use it; I am not very good at discussing all neurotoxins out there and marketing other brands, even though in my experience I know Dysport and Xeomin are just as effective. Also what I use is dictated by my practice in what they buy/promote.

Michael Somenek, MD: Most of the time the patient comes in for the result rather than a particular brand to get their result. Despite using a brand other than Botox and educating my patients about the differences in brands, they will commonly refer to a “Botox Treatment” when they call for an appointment. They rarely call for a Xeomin, Dysport, or Jeauveau treatment.

What is the role of neurotoxin in your practice?

Dr. Somenek: While it is certainly not the highest revenue generator in the practice, it is useful for patient retention. Neurotoxin treatments and injectables in general were the lifeline of my practice when I first started. These patients have since converted to surgeries and other procedures, which has been the most useful aspect of offering this service.

Dr. Niamtu: Although I have primarily a surgical practice, our injectable practice continues to bring in new patients and to service my existing surgical patients. It is a big part of my practice, but I have also put a lot of it on my nurse injectors so I can focus more on surgery.

Dr. Schlesinger: Neurotoxin remains a staple in the practice in terms of cosmetic offerings; It is often the first entry point into the cosmetic realm for patients, but it also becomes an add-on in many cases. In my opinion, neurotoxin is an integral part of the overall treatment plan, which is how I present it. My education mentions many of the other benefits besides muscle relaxation leading to rhytid reduction, such as skin quality and psychosocial benefits.

Neurotoxin does bring in new and repeat business, so it is a steady part of the overall cosmetic revenue.

Dr. Ho: It is a good segue for patients to become comfortable with me and consider filler and surgery in the future. I don’t mind performing neurotoxin treatments on straightforward patients, as the procedures are so quick. I offer once a month a discounted Botox day where I see my regular patients in short appointments—typically I see 30-40 patients these days and they are worth it from a time and compensation standpoint.

Dr. Kinney: Toxin administration, in and of itself, is not a big net revenue driver. The companies are making a huge percentage of the charge by us to the patients. However, it is a patient loyalty, maintenance, and volume driver, especially for my surgical patients.

What would you describe as the toxin trends in your practice?

Dr. Schlesinger: I think that the look that patients desire is a very individualized choice. It does seem that once someone likes a product, they tend to want to stick with it. I also think that the “look” people go for is influenced by geography and local trends. My patients seem to like a natural look. They want to look fresh, youthful, and great for their age, not “done.” However, that may be a product of my methods, so like-minded patients seek my treatments.

We have seen overall growth. I believe that the younger segment is looking for value and excellent results, not to label any one particular group. They have the money to spend and they will spend it in the right setting. Among men, we are seeing growth in body sculpting and fillers, then neurotoxins next.

Dr. Levin: It is a big part of my non-surgical practice: Brings new patients in—word of mouth referrals. Because of how quick it is, it’s pretty profitable.

Dr. Niamtu: Patients desire a “less done” toxin result and by now, after 20 years of treatments, patients pretty well know what they want and what they don’t want. Men and minorities have also increased in neuromodulator usage in my practice, which I think mirrors the general population.

Dr. Kinney: My practice has always been emphasizing a “softer” look. For years we have used 2.5u/0.10ml even when Allergan was advising 4u/0.1ml. Doll’s eyes on a frozen face is not what my patients want. There is clear growth among younger patients, but men remain a small percentage of my patients with no recent growth trend.

Dr. Ho: I go for natural, perhaps softer results (e.g., I do not aggressively treat the forehead) in general and I think patients are coming in younger or seeking “baby Botox” for preventative measures. My patients tend to prefer natural, and “less is more.” I do see some male patients and appreciate that they are definitive in trusting your judgment.

Dr. Somenek: Living in Washington, DC certainly carries with it a more conservative aesthetic. Patients, independent of age, will often say they don’t want the frozen look. About 40 percent of my practice are males, and I can say there is an increased interest in exploring more rejuvenating type treatments. A neurotoxin treatment is just the tip of the iceberg for what men are coming in for ,which is actually very refreshing to see. Ever since we talked about “prejuvenation” some years ago, there has been an increase in younger patients coming in for preventative neurotoxin treatments. On average they get lower units, mainly because they have less dynamic lines to treat and less so because they ask for a “softer” treatment.

Dr. Black: Patients are starting to have a greater appreciation for the preventative benefits of neurotoxins and patients are opting to start these treatments sooner, which is driving younger patients into the office.

Dr. Levin: Demand is still very female heavy but some male. I see many new patients in their 20s and 30s.

What are ongoing areas for innovation? What would be a game changer in the neurotoxin market?

Dr. Kinney: Areas of innovation include short- and long-duration toxins, and also low concentration, broad-area use (almost full face) with partial inhibition of muscle action for a subtle look, high concentration use in very small areas to address anatomic irregularities or muscle “spasm,” and intradermal use for fine texture. There is an occasional, small place for use after submuscular breast augmentation and hand surgery.

Dr. Schlesigner: Looking at the available data from up and coming daxibotulinumtoxinA for injection (DAXI), longevity is a differentiating factor, which may be the game-changing part about this new product. Innovation will likely continue to take place in the long-acting neurotoxin realm as well as the ultra-short and quick onset space, as well. We may also see new indications. Topical neurotoxins are also an interesting area of development, as are novel delivery systems, which I remain very interested in.

Dr. Niamtu: I think we will see small changes like neurotoxins that last longer and maybe some that cost less. The whole paradigm of having to reconstitute a product for delivery and having it to deliver by needle injections is medieval, in my opinion. The real breakthrough will be when we are able to provide a less invasive neuromodulator experience.