CME: Re-examining the Optimal Use of Neuromodulators and the Changing Landscape: A Consensus Panel Update

April 2020 | Volume 19 | Issue 4 | Supplement Individual Articles | 35 | Copyright © April 2020

Published online March 20, 2020

Michael S. Kaminer , Sue Ellen Cox , Steven Fagien , Joely Kaufman , Mary P. Lupo , Ava Shamban

aDepartment of Dermatology, Yale School of Medicine, New Haven, CT bDepartment of Dermatology, Brown Medical School, Providence, RI cSkin Care Physicians, Inc, Chestnut Hill, MA dAesthetic Solutions PA, Chapel Hill, NC eSteven Fagien MD, Boca Raton, FL fSkin Associates of South Florida/Skin Research Institute, Coral Gables, FL gLupo Center for Aesthetic and General Dermatology, New Orleans, LA hAVA MD, SKIN FIVE, Los Angeles, CA

are used to target muscles whose excessive contraction is the primary cause of changes seen, while fillers are used when volume loss is the primary cause.5 Soft tissue fillers play a valuable role, for example, in treating residual forehead lines after BoNTA treatment, since it circumvents brow drooping due to use of higher BoNT-A doses. So, having the dual skill sets for soft tissue fillers and BoNT-As is essential to providing great results. Skin resurfacing can also be of value in some patients.

Novice injectors and experienced injectors using a new product should consider seeing patients back in 2 weeks. Even if an injector has used a new agent in a study, it probably was injected in the standard 5-point way, so they need to identify its nuances outside of that protocol. How much does the product move? What’s the field of action? How does the dosing need to be adjusted?

The introduction of a new BoNT-A provides the opportunity to readdress anatomic considerations. It should make every injector reconsider what they have been doing, and why, and how a new agent can improve on that. Less experienced injectors may think all BoNT-As are pretty much like onabotulinumtoxinA, but they’re not, they’re all different. Each new BoNT needs to be thoroughly evaluated to determine its differences and how they can be used to an advantage, to give better results based on how they affect specific musculature as well as the interplay between muscles.

Patients should not be looking for a provider who advertises the cheapest price by the unit, but rather one who uses all 4 of the available agents and understands how each works. This is an essential part of the recipe for success, because each injector treats patient slightly differently, but only some get great results.

DaxibotulinumtoxinA (Revance Therapeutics, Inc) is currently in clinical development for aesthetic (glabellar lines) as well as therapeutic indications.43-45 Phase 3 clinical trials demonstrate safety and efficacy lasting 6 months or more for moderate to severe glabellar lines.43,44 This agent contains no human serum albumin or other human- or animal-derived components but has a proprietary stabilizing excipient peptide (RTP004) that is cationic and binds to the BoNT-A molecule. DaxibotulinumtoxinA is much different than any of the other available neurotoxins. The panelists related that additional experience with daxibotulinumtoxinA is needed to determine how it will translate to off-label use with regard to dosing, diffusion, longevity, and other effects. It will likely be another agent that reveals the separation between really good injectors and those with less skill. EB-001 (Bonti, Inc.), an investigational BoNT serotype E, has the distinct profile of faster onset of action (about 24 hours) and shorter duration of effect (14-30 days) than commercial BoNT-As.46 It has been tested in phase 2a studies for glabellar lines,46,47 for scar reduction after Mohs surgery,48 and for reducing postsurgical musculoskeletal pain.49,50 The fast onset may benefit patients who desire a rapid treatment for facial rhytides before unexpected social or professional events. The limited duration of effect may be a positive attribute for toxin-naïve patients considering treatment but who are unwilling to make a longer-term commitment,46 but is unlikely to be favored by existing patients.


The advancing science and applications of BoNT-A highlight the importance for aesthetic physicians to keep up to date regarding ongoing developments in the field. Due to their differences, no single agent works for all injectors and in all patients. All physicians, regardless of specialty, should continually examine the agents and techniques they use and make an effort to investigate and embrace novel developments that can improve patient outcomes and quality of life. Detailed anatomical knowledge, along with these advances, will allow practitioners to achieve optimal results. With the recent addition of a fourth BoNT-A product into the US market, the panel encourages aesthetic physicians to become familiar with using all 4 BoNT-A products to be able to use them alone or in combination based on comfort, experience, and outcomes with each product.


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