Neuromodulators and Injectable Fillers: Evaluations and Updates

Dr Galadari is an assistant professor of dermatology at the College of Medicine and Health Sciences of United Arab Emirates University. After completing his dermatology residency at the Boston University/Tufts University program, Dr Galadari completed his dermatologic surgery and laser fellowship at the University of California, San Francisco.

He is a fellow of the American Academy of Dermatology (AAD) and a member of several international societies. He also currently serves as Treasurer General of the International Society of Dermatology and Secretary General of the International League of Dermatological Societies, representing more than 100,000 dermatologists worldwide.

Transcript:
Dr Galadari:  Both are very different. They're both injectables, but at the same time they both act differently and they both are indicated for different reasons. Let's take botulinum toxin, which is your neuromodulator.

The way that it works, that it affects the movements of the muscles, it relaxes the muscles in which that area is being treated. For example, if we're using it for the forehead lines or glabellar lines or even the crow's feet, what happens is that those areas tend to relax and the lines dissipate. Historically, these are known as the dynamic lines. That's where you would use your neuromodulators.

Your injectable fillers, the fillers themselves, they fill from their namesakes. What they do is that there is an area that has a loss of volume or basically a line that happens as person progresses with age. The fillers are able to fill that area up. One of them relaxes the muscles, the other one fills the area up.

Hence, the reason one of them is for dynamic lines. The other ones are more or less for static lines. Now, there are certain times in which you can combine the use in the same location.

Say, if a person has these lines that are dynamic when they purse their lips and you see this barcode lines, then those lines can be treated with both fillers, because some of those lines are static.

They appear even if the person is not talking, but at the same time, some of them can actually appear when the person is dynamic. Here, in those situations, you would use botulinum toxin, your neuromodulator, in addition to your fillers.

Let's look at the neuromodulators first. Currently, there are four that are FDA approved. These will include your onabotulinum toxin, your abobotulinum toxin, incobotulinum toxin, and prabotulinum toxin. In terms of other toxins that are in the pipeline, there are a few of them that are coming out. The most exciting one is probably, daxibotulinum toxin.

Daxibotulinum toxin is the one that, according to the studies, that's been worked on and have been looked at, has consistently shown that it will last at least double the amount of the leading toxin that is out there. It will last longer.

That's very exciting, because most neuromodulators usually will last anywhere between three to four months. This one is going to last for at least about six. That's very exciting in that sense. This is great for both the cosmetic aspect of things, because your patients, specially, who are averse to needles, they want to come back all the time. They can space out their visit a little bit longer.

It's also going to be great for the patients who are using toxins for the therapeutic aspects of things. They're coming in for the treatment of axillary hyperhidrosis, where we use toxins or migraine headaches, where we also use neuromodulators. For those patients, they won't require repetitive treatments and that's a great thing.

As for, in terms of the cosmetic uses, there are also many that are out there. Four years ago, "Time Magazine" came out with these nearly 800 indications of neuromodulators. The ones that are being very excited are the use of the neuromodulators for the treatment of depression.

That's popping up, because patients are getting both benefits. They're treating it cosmetically, but at the same time, they're noticing that their depression, that they have depressive symptoms, also tend to become a little bit less. That's always fun to look at. You're getting cutting edge into that aspect. That's your neuromodulators.

More exciting stuff there than your other ones, which is your fillers. Fillers in terms of techniques, pretty much everything is about the same. People have started using more cannulas rather than the needles. The injection is changing.

The location of how you're injecting those fillers are also changing, because of how anatomy is progressing and knowing exactly which anatomical plane you're injecting your fillers is also optimizing their results.

In terms of what is new and exciting. The one that's very recently, that's been approved in the United States is something called RHA which is a hyaluronic acid-based filler. That's catered for dynamic areas, because we always remember, we talked about fillers being great for static lines. We're not usually static. I'm talking and my face is moving. These lines will tend to move.

Sometimes if you place a filler that's quite thick, they will just stay there and the new fillers that stretch and move along with the person's facial expressions are coming out also and that's recently been approved. Once they get injected, even with facial expressions, those fillers still fill and they also look very, very natural.