By now, everyone has heard of Botox but there is a lot to discuss and, despite its popularity, there are still some misconceptions about what it does - and what it doesn’t do.  Both Botox (Allergan) and Dysport (Medicis) are formulations of Botulinum toxin A, a preparation which was found serendipitously to be highly effective in diminishing the appearance of lines on the face and neck.  In fact, Botox and Dysport are among the most remarkable treatments available.  They work by temporarily weakening specific muscles of the face and neck and, as a result, they diminish the appearance of the lines and creases that form when those muscles contract.

The most common areas of the face on which Botox and Dysport are used are (a) the deep creases between the eyes (the glabella), (b) the horizontal forehead creases, and (c) the smile lines at the sides of the eyes.  Depending on where and how much is injected, they can also provide a moderate but effective elevation of the eyebrows.  They are also used, in smaller amounts, on many other parts for the face and neck, including the vertical lines on the upper and lower lips, the chin, and the banding on the neck.  Treatments diminish the lines that form when the muscles are contracted, and they soften the lines that are present at rest.

Botox and Dysport are administered by a wide variety of practitioners, including doctors (such as plastic surgeons, dermatologists, and ophthalmologists, among others), nurses in doctors’ offices (in some states), and non-medical personnel in some spas and similar settings.  It is important to know who will be administering the Botox or Dysport.  While it is not exceedingly difficult to give these injections there is, as always, a range of capabilities among the people giving them.

The injections take about 20-30 minutes (longer if topical anesthetics are used, in which case an additional 20-30 minutes is required for maximum effectiveness).  Via a series of injections with a fine needle, the Botox or Dysport is delivered directly into the target muscles.  The effects typically become apparent within 2-5 days, with the smaller muscles (like the smile lines) being affected first and the larger muscles (the glabella) taking a little longer.  The effects usually last for about 4-9 months, at which time additional Botox or Dysport can be given.

Both Botox and Dysport are marketed as freeze-dried precipitates (powders) that are reconstituted (made into a liquid form) by adding variable amounts of a salt-water solution that approximates normal body fluids.  Dosages of both are referred to as “Units.”  Botox is available in vials of 50 and 100 Units; Dysport is available in vials of 300 Units.  While there’s no absolute formula, about 2–2.5 Units of Dysport is equivalent to 1 Unit of Botox.

The keys to the effectiveness of these treatments are (1) How many Units are injected into each area and in total, and (2) How old is the reconstituted solution?

Number of Units:  The amount of Botox and Dysport to be administered depends on which area(s) the patient wants treated and how deep the lines are (which is related to how thick the muscles are – men typically have thicker muscles than women do), combined with practical considerations, including the costs.  Most people need at least 50 Units of Botox (100-125 Units of Dysport) to have the three major areas treated.

Typical distribution of Botox, then, is about 20 Units to the glabella, 20 Units to the forehead, and 10 Units to smile lines next to the eyes.  For larger muscles (and in men) increased dosages are required to achieve similar results.  Depending on the patient’s preferences, the distribution can be modified.  Since different amounts of solution can be used to reconstitute the product, the only thing that matters is the number of Units being injected:  not the number of cc’s (the volume of injected material), the number of syringes, or the number of injections.

Hold Old is the Solution?:  While most people may assume that the Botox or Dysport is being made up fresh for each patient, that is not necessarily be the case.  Though studies have shown that reconstituted Botox and Dysport can retain their effectiveness for up to several weeks, the package inserts suggest a much shorter duration (in the range of hours, not weeks).  My policy is to use product only within the recommended time periods.  Furthermore, unless other arrangements have been made, I make it up fresh for each patient or treatment.

The cost of these treatments varies widely, but typically range from about $500.00 to $1500.00.  Among the factors that determine the cost are the areas being treated, the dosages – and the doctor. 

When considering Botox or Dysport, it is important to know which product is being used, how many Units are going to be administered, and how old the solution is.  Without knowing all of these, accurate comparisons regarding the effectiveness and the cost of the treatments cannot truly be made.


Alan M. Engler, MD, FACS - Board Certified Plastic Surgeon
122 East 64th Street New York, NY 10065 USA
(212) 308-7000

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