An Introduction to Neurotoxins

Neurotoxins are injectable solutions that temporarily block nerve receptors in the muscle, leading to temporary muscle paralysis. They do this by disrupting the nerve signaling processes that stimulate muscle contraction. Neurotoxins are the single most popular cosmetic treatment in the United States. Botulinum toxin type A is an injectable neurotoxin and is best known under the brand names Botox®, Dysport®, XEOMIN®, and Juveau®. These are the four injectable neurotoxins currently available in the U.S. Despite being toxins, these injections are safe and can have benefits when they are performed correctly by an experienced provider.

Of the four neurotoxins, Botox® is the most widely used as well as the first to come to market. It has an FDA indication for both medical and aesthetic use. Botox® is frequently used to treat muscle spasms in the neck, migraines, temporomandibular joint (TMJ), bladder disorders, and a variety of other medical conditions. The primary use of Botox®, however, is cosmetic—  to reduce the appearance of fine lines and wrinkles on the face. The most commonly treated areas are in the upper face, including frown lines, forehead creases, and crows feet near the eyes. Botox® can also be used for smaller muscle groups, such as thick bands in the neck, thick jaw muscles, lip lines, and gummy smiles.

In addition to these more common cosmetic uses of Botox®, the substance is at times used to decrease the size of facial pores, reduce oil and sweat production, and influence skin texture. In these circumstances, Portrait Medical Director, Dr. Patrick Blake, MD explains, “instead of targeting the acetylcholine release that you get in the nerves, you are targeting the tiny nerve bundles that influence oil gland production.”  

The Origins of Botox®

In the 1970s, ophthalmologist Alan Scott turned a particular toxin called botulinum– a powerful paralytic– into a pharmaceutical. He began investigating it as a medical treatment for eye impairments, and in 1978 he first injected botulinum into the eye muscles of a patient with strabismus (crossed eyes). The procedure was successful and Dr. Scott later came to be called the “Father of Botox®.” Doctors began using the toxin to treat migraines and jaw clenching. Patients soon picked up on the product’s temporary ability to paralyze targeted facial muscles, smoothing the lines around them as a result.

Allergan was the first pharmaceutical company to license botulinum toxin and brand it Botox®. The treatment received approval from the FDA in 1989, after which its indications quickly expanded. In 1992, Dr. Alaistair Carruthers and his wife Dr. Jean Carruthers issued a report suggesting that Botox® could be used for cosmetic purposes. It was around this time that the field transitioned to using the treatment for cosmetic indications.

Difference Between Botox®, Dysport®, XEOMIN®, and Jeuveau®

The four neurotoxins each contain the same active ingredient: botulinum toxin type A. All four products are FDA approved and have been used safely and effectively for many years. The main distinction between products lies in their formulation, including what dosage to use, how the product spreads, and how quickly a patient can expect to see results. XEOMIN® is often called the “naked injectable” and contains only botulinum toxin A with no added proteins. In contrast, Botox®, Dysport®, and Jeuveau® contain botulinum toxin A encased in proteins. The longevity of each treatment can be long-lasting but will vary from patient to patient. On average, results from treatment begin to wear off after three to four months. Each injection has specific characteristics, and the decision of which product to use will depend on a patient’s unique anatomy, their treatment goals, and their provider’s recommendations.

Choosing a Provider and What to Expect During Treatment

While injections are non-surgical, they are a medical procedure that requires specific training, knowledge, and skill to administer safely and effectively. Most individuals benefit from using care and scrutiny when selecting a provider, and will often rely on personal testimonies from their social network about a certain provider or public reviews on the internet when making a decision. As with other treatments, it can be helpful to come prepared with questions in order to ensure a patient has all of the information they need before the procedure begins. Many patients request to see before and after photos of previous patients from a provider.

Initial treatment begins with a consultation, during which a patient and provider will discuss goals and concerns. During this consultation, the provider will review a patient’s medical history and evaluate their area(s) of concern. Depending on a patient’s unique situation, they may be given a topical anesthetic to numb an area prior to injection. However, the needles that are used to inject botulinum toxins are very thin, and the injections are not deep. Most patients report a pinching feeling during the procedure but do not report much pain.

Depending on the patient, the product used, and area treated results are typically reached in three to fourteen days following treatment. Normal activities may resume immediately after treatment with minor exceptions. Provider’s typically request one day with no exercise or strenuous activity following treatment, and that the head is kept upright for the rest of the day.

Potential Side Effects

Most people are good candidates for injectable neurotoxin procedures. Side effects are rare and the injections are generally well tolerated across age groups. The most common side effects are mild redness, swelling at the injection site, and bruising. While rare, it is possible to have an allergic reaction to one of the products. It remains unclear whether the toxins can impact a developing fetus or spread to a nursing child through breast milk, and as a result pregnant and breastfeeding individuals should avoid the procedures. Individuals with pre-existing neuromuscular disorders such as Myasthenia Gravis or Lambert-Eaton Syndrome should also avoid these injections.

Most people are great candidates for neurotoxins. The exceptions are rare and include people who have an allergy to one of the products, pregnant or breastfeeding individuals because there is a lack of data, and people who have a pre-existing neuromuscular disorder.
Dr. Patrick Blake, MD

Cost and Insurance Coverage

The cost for these treatments is highly variable. There are a few factors to consider when it comes to cost. First, different products cost different amounts because of the unique technology that goes into their manufacturing. In addition, there are charges for the provider's time, the supplies used in the procedure, and possibly a facility fee. In the U.S., Botox® typically costs between ten and twenty dollars per unit. Multiple units are needed at each injection site. The amount and location of the injection is unique to each patient, and thus the cost of the cosmetic procedure is largely determined by the concern being treated.

Most insurance plans including Medicare and Medicaid will cover injections for medical indications, such as chronic migraine headaches or cervical dystonia. Injectable neurotoxins will not be covered for reducing signs of aging or other cosmetic indications that do not provide a medical benefit. In these cases, procedures will consist of out-of-pocket cost.

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