Toxin Tips

Successful toxin treatment requires careful patient selection and thorough counseling. This entails providing accurate information about what various offerings can achieve, including a somewhat controversial over-the-counter product that may or may not prolong neuromodulator results.

CONSULTATION

Above all, said Jeanine Downie, MD, people want natural botulinum toxin results that last at least 3 months. Dr. Downie is the director of image Dermatology PC in Montclair, New Jersey, and an assistant attending physician at Mountainside and Overlook Hospitals in Montclair and Summit, New Jersey, respectively.

The key to achieving natural results, she commented, is to assess every face and frown individually. All of Dr. Downie’s consultation and treatment rooms are equipped with TouchMD (TouchMD). “I use the photographs and direct-to-consumer marketing aspect of the TouchMD screen to show the patient their picture, point to their forehead, and have them frown,” she said. “Patients are able to see themselves on-screen so that we can focus on what they want. Additionally, I have them frown while looking in the mirror to assess their faces further.”

Selecting patients with reasonable expectations can save injectors many headaches, according to Dr. Downie. “We have patients who only want to spend $400 or $500 but need $1,000 worth of Botox Cosmetic (onabotulinumtoxinA, Allergan Aesthetics, an AbbVie company) to look the way they want to,” she explained. “I tell them that you can just do a little bit, and you’ll like the effect. But ultimately, when it comes time to commit to what you need, you’re going to have to pay a lot more.” She said that, often, seeing how they look after a small amount of neuromodulator convinces such patients to commit to more.

EXPECTATIONS

Clear Communication

Dr. Downie frequently finds she must warn patients against getting toxin injections from brand-new injectors or from beauticians who are not licensed to use these materials. “Here in New Jersey,” she said, “people will go through Groupon, unfortunately have a bad experience, come see me afterward to fix it, and then stay with me.”

“A few times a week,” she added, “people come in thinking that Botox is going to be completely magical.” Alternatively, patients with etched lines treated unsuccessfully elsewhere tell her that onabotulinumtoxinA failed them. Previous physicians might have told these patients that neuromodulator treatments would eradicate etched lines, Dr. Downie said, adding, “I tell them that was an unrealistic expectation, so let’s start all over again.” She explains to them that neuromodulators work for everyone but that deep lines require additional modalities (Figures 1 and 2).

Figure 1. A 64-year-old Black woman with etched lines before (left) and 1 month after (right) treatment with 55 units of Botox Cosmetic and Juvéderm Ultra Plus (hyaluronic acid, Allergan Aesthetics)
Images courtesy of Jeanine Downie, MD.

Figure 2. A 57-year-old man before (left) and almost immediately after (right) receiving 45 units of Botox Cosmetic and Juvéderm Ultra Plus XC (hyaluronic acid, Allergan Aesthetics).
(Images courtesy of Jeanine Downie, MD)

“It wasn’t explained to them well enough that Botox is going to soften their line but not necessarily take it away,” said Dr. Downie. “The misconception is that you don’t have to explain everything clearly to every single patient, because you do. I try my best to, and I’m not perfect, either.”

Pretreatment

Administering Zytaze (zinc citrate and phytase, OCuSOFT) before treatment may prolong neuromodulator results, according to Wm. Philip Werschler, MD, a dermatologist in private practice in Spokane, Washington. “Since Botox requires zinc in order to work,” he said, “the idea of Zytaze enzyme supplement is that it’s supposed to help absorb zinc from your diet.”

Approved as a medical food for ophthalmic toxin treatment in 2010, the product has found an audience in dermatology and plastic surgery. In a 77-patient pilot study, 92% of patients who administered zinc citrate and phytase before toxin treatment for wrinkles and other indications experienced an average duration increase of nearly 30%, and 84% of participants reported a subjective increase in toxin effects.¹

According to Dr. Werschler, however, beliefs that zinc citrate and phytase extend toxin effects and perhaps reduce related side effects remain unsubstantiated. “Some offices heavily promote it,” he said. “Some offices don’t believe in it. We have patients who swear by it, and we have patients who have been doing it for years and say that, when they forgot it, their toxin didn’t last nearly as long.”

Dr. Downie has been a clinical investigator for Allergan, Evolus, Merz Aesthetics, and Revance.

Dr. Werschler has been an investigator, consultant, and trainer for Merz Aesthetics; a consultant and trainer for Allergan; and an investigator for Galderma and Revance.

1. Koshy JC, Sharabi SE, Feldman EM, Hollier LH Jr, Patrinely JR, Soparkar CN. Effect of dietary zinc and phytase supplementation on botulinum toxin treatments. J Drugs Dermatol. 2012;11(4):507-512.