It should go without saying, but no one ever needs to indulge in cosmetic procedures for the sake of turning back time; aging is a natural, inevitable process that every single person will experience, and the way you approach it is entirely personal. But, if smoothing out your crow’s feet or taking a preventative step against those pesky 11s makes you feel more confident, why not? While there’s a myriad of minimally invasive complexion-enhancing treatments that can help reduce or stave off the telltale signs of aging, such as dermal fillers or laser skin tightening, neuromodulators — cosmetic injections of a muscle-relaxing, wrinkle-reducing neurotoxin — are by far the most sought-after, with options like Botox, Dysport, and Xeomin leading the way. In fact, according to the American Society of Plastic Surgeons, they were the most popular minimally invasive cosmetic procedure of 2020, surpassing dermal fillers, with a whopping 4.4 million procedures performed.
Although the exact formulations vary slightly, all of these options work in a similar way and yield comparable results. “Cosmetic results are achieved when the neurotoxin is injected intramuscularly into the muscles of the face that cause dynamic wrinkles [the wrinkles that become visible when you make certain facial expressions],” says Nurse Nancy Pellegrino, nurse practitioner and co-founder of THE ROUTE and founder of NP Aesthetics Inc. “The neurotoxin tells the muscle not to contract, thus temporarily inhibiting movement of the muscles specific to the formation of dynamic wrinkles. The skin overlying the targeted muscles appears smoother and less wrinkled.”
Additionally, neurotoxin injections also reap lasting anti-aging benefits. “In the long term, [neuromodulators] also help prevent dynamic wrinkles from becoming static wrinkles, which are visible even when the face is expressionless,” says board-certified cosmetic dermatologist Dr. Dendy Engelman.
Botox is by far the most widely used and widely known neuromodulator, but it also tends to be used as a blanket term for the other options on the US market, of which there are currently three others: Dysport, Xeomin, and Jeuveau, a newcomer that received FDA approval back in 2019. All four are different brand names for botulinum toxin A, a neurotoxin produced by the bacterium clostridium botulinum. “All are considered safe and effective, and all have at least one FDA cosmetic approval,” explains Pellegrino. However, while similar, they are not exactly the same. “Botulinum toxin A formulations are not identical nor are they interchangeable,” says Pellegrino. “The difference between the neurotoxins is in the formulation and purification procedure... and for patients, the difference is in the outcome, which is based on the skill of the injector for placement and dosage.”
Keep reading for everything you need to know about the three most popular neurotoxins on the market.
Botox was the first neuromodulator to be used cosmetically, earning FDA approval back in 2002. “It was the first to hit the market and the only one that all of us who were injecting before 2009 were trained on,” says Pellegrino. “It has the most studies and collective provider experience to date. It also has the most brand recognition, like Kleenex to facial tissues; even if a patient is injected with Dysport, Xeomin, the patient will typically refer to it as their ‘Botox’ treatment.”
In terms of usage, facial plastic surgeon and founder of AIREM Modern Beauty Rituals Dr. Eunice Park, explains that Botox’s FDA-approved areas are the glabella (the area of the forehead and between the eyebrows, where frown lines or “11s” develop), horizontal forehead lines, and lateral canthal lines (or crow’s feet). But, being that it’s one of the most heavily studied neuromodulators, it’s used for a wide range of therapeutic and aesthetic purposes. “Some ‘off-label’ uses include slimming the jawline, relaxing TMJ clenching with treatment to the masseter muscles, and injection into the neck’s platysmal bands for a smoother neck,” she says. Further, it’s used to treat excessive sweating of the underarms, hands, and feet and can be injected into the shoulder and neck regions to reduce muscle tension.
When administered for wrinkle-reducing purposes, the patient can expect to see subtle results within one to two days, with the muscle-relaxing effect increasing during the first week, explains Pellegrino. However, according to the official Botox website, full results take longer to kick in — up to 30 days.
On average, the effects of Botox will last around three to four months, but this will vary from person to person (as it will for all of the available neuromodulators). “Some patients metabolize it differently,” explains Dr. Park. “It also depends on the concentration and dosing of the procedure; some patients want a more subtle effect, so a lighter concentration is used, which may wear off faster. Some patients want a more intense effect, which will last longer.”
How much Botox costs will vary depending on the provider you visit and where you live, but generally, it’s priced between $10 to $20 per unit, “Which can amount to $550 or more per session,” says Dr. Engelman, as pricing is dependant on the number of units administered and the number of areas treated. Your provider will decide how many units are necessary to achieve your desired results; however, Allergan, the maker of Botox, suggests a dosage of 20 units to address all five sites of the forehead, 12 units per eye to treat crow’s feet, and 20 units to address each of the five forehead line sites. That said, it’ll cost you much more if you treat multiple areas at once, while someone new to Botox or looking to inject for preventative purposes may use a lower amount of units, resulting in a lower overall cost.
Next, there’s Dysport, which is the brand name for another type of botulinum toxin A, abobotulinum toxin A. “It works the same way Botox does to smooth out fine lines and wrinkles by temporarily paralyzing or relaxing hyperdynamic muscles,” says Pellegrino. “It has gained brand recognition in recent years, and patients are beginning to request it by name.”
Unlike Botox, which is FDA-approved for injections around the face, Dysport is only FDA-approved for the glabella, explains Dr. Engelman. However, “Off-label, it is used for the treatment of crow’s feet and forehead lines as well.” In her clinical practice and observations, she’s found that Dysport diffuses more than the other two, meaning the product spreads out to larger areas. This, she says, makes it a great option for crow’s feet and glabella, as the product will cover a larger area of the face, but not so much for the frontalis (the forehead muscle) because it increases the risk of brow drooping (more on that ahead).
Like Botox, the results of Dysport last for three to four months on average, but this will vary amongst patients. (It’s also worth noting that Dysport’s website claims it can last for up to five months). However, its initial onset is believed to be slightly quicker. According to the brand, some patients see results within two to three days, though the full effect will still take weeks.
Dysport costs less per unit than Botox and Xeomin, typically about $4 to $8 per unit, which Dr. Engelman says amounts to an approximate cost of $450 per session. Dysport is more diluted and less potent than Botox and Xeomin, so more units are required to achieve the full effect, resulting in a total cost that’s pretty comparable to the others.
Finally, there’s Xeomin, the brand name for a type of botulinum toxin A, incobotulinum toxin A. “It works the same way as Botox or Dysport to temporarily reduce the appearance of expression lines and wrinkles,” says Pellegrino, adding that, unlike the other two, it contains just one single ingredient (botulinum toxin A), while the others contain additional additives, such as protective proteins. Due to this, as Dr. Engelman explains, the drugmaker claims that there is less of a risk of the body building up resistance because it doesn’t contain any additives that may trigger the body to create antibodies against it. “This reduces the likelihood of an allergic reaction,” she says.
“Xeomin can be used in all the areas Botox and Dysport can, but like Dysport, it only received FDA cosmetic approval in 2011 for glabellar ‘frown’ lines,” says Pellegrino. Still, it’s also used to address certain muscular conditions like blepharospasm (twitching eyelids), cervical dystonia (muscle spasms in the neck), and other irregular muscular activity, explains Dr. Engelman.
According to the brand’s website, visible smoothing effects may be noticeable within three to four days after injection (with the median first onset effect being less than a week), while the maximum effect occurs at 30 days. Like Botox and Dysport, results typically last about three to four months. Though, Dr. Engelman adds that — in her practice and observations — she’s found that Xeomin tends to have the shortest duration of the three, with results wearing off the quickest.
Xeomin is priced similarly to Botox, generally ranging from $12 to $18 per unit, which, according to Dr. Engelman, will end up costing an average of $450 to $500 per session depending on the number of units used.
What Other Neuromodulators Are Out There?
In addition to Botox, Dysport, and Xeomin, there is a fourth option called Jeuveau, which Pellegrino considers the “new kid on the block.” Similar to the others, it received its FDA Cosmetic approval in 2019 to target glabellar “frown” lines, and it costs slightly less at around $8 to $16 per unit. “The brand is targeting the millennial population, who tend to be earlier adaptors than previous generations,” she says. With this in mind, prepare to see it rise in popularity.
Are There Any Side Effects?
As with most any cosmetic procedure, side effects and reactions are possible. Pellegrino explains that the most common side effects of the above are all similar and deemed minor in nature. “They include but are not limited to headaches, pain, and bruising at the injection site,” she says. That’s not to say that an allergic reaction isn’t possible, which can lead to more serious symptoms ranging from itching and rashes to nausea and flu-like symptoms.
Other adverse reactions may include the diffusion or spreading of the effect to distant muscles, as well as ptosis (drooping) of the eyelids or brows, she adds. Ptosis is usually the result of the neurotoxin being injected into the wrong area or at too high of a dose, leading to muscle weakness that causes a drooping effect — which is why it’s so important to choose an experienced and properly trained injector whose aesthetic is most like the outcome you’re looking for.
Which Neuromodulator Is Right For Me?
Again, all neurotoxins work similarly and contain the same core neurotoxin protein, botulinum toxin A, but each type differs in protein structure and formulation. In terms of usage, “Their main differences are their target areas/what they are commonly used for, and how much they cost,” explains Dr. Engelman. The techniques in which they’re administered also differ.
Pellegrino stresses that the cost should never be a deciding factor in which option you go with and that providers should determine which one to use based on a combination of the following: individual patient assessment, the patient’s desired outcome, the treatment area, the provider’s preference and training, familiarity of use, injection style, muscle involvement, and facial anatomy.
If you have prior experience with different types of neuromodulators, how well your body reacts to each should also be a deciding factor. “It’s similar to picking your favorite eyeliner or mascara; clients have different experiences with certain products,” says Dr. Park. “Some people observe different results with different toxins, such as how quickly the product sets in, how long it lasts, or if they feel they had a ‘heavy brow’ experience with one versus the other.” Additionally, Dr. Engelman says Xeomin can be a great option for those concerned about a possible adverse reaction since it has a lower likelihood of triggering an allergic response or resistance.
Ultimately, whether you’re new to injectables or looking to switch from Botox to Dysport, it’s best to discuss the best options for your specific skin goals with a provider that you’ve thoroughly researched and vetted — and be sure to ask all of the questions and state any concerns you may have. Remember: It’s your face, and neurotoxins can’t be dissolved (and therefore reversed) like dermal fillers, so if you end up with unsatisfactory results, you’ll, unfortunately, be stuck with them for months until they wear off.