Dr. Steven Fagien & Dr. Elbert Vaca

Botox and Other Neuromodulators

Botox and Other Neuromodulators

What are botulinum toxin neuromodulators (ex. BOTOX® Cosmetic and others) and how do they work?

BOTOX® Cosmetic is just one type of injectable botulinum toxin, or neuromodulator that is used primarily in a cosmetic practice for the reduction or elimination of dynamic wrinkles. Botox® Cosmetic was the first drug of its kind and has been used safely in patients for over 50 years.  Other neuromodulator products that have also achieved US FDA approval include Dysport®, Xeomin® and Jeuveau®.  All of these injectable neuromodulator drugs have also been shown to be safe and effective and are used very similarly to Botox® Cosmetic. The effects of these drugs are similar, and the choice is usually dependent of the patient’s unique individual situation. All of the neuromodulators contain a specific protein that reduces movement in targeted muscles by blocking communication between the nerve and muscle. This decrease in muscle movement leads to smoothing of the skin, and improvement in the appearance of lines and furrows. Dr. Fagien has been involved and continues to participate in FDA botulinum toxin clinical trials and ongoing research with these drugs and is recognized as one of the world’s foremost experts in cosmetic injectables.

To improve “dynamic” lines, including crow’s feet and forehead wrinkles, botulinum toxin is injected into specific muscles with a very fine needle. These injections relax the muscles within a week, in turn softening the appearance of lines in the skin.   Sometimes patients benefit from a combination of treatments utilizing neurotoxins with dermal fillers to obtain the best results.

What are the Different Types of Neuromodulators?

BOTOX® Cosmetic, Dysport®, Xeomin®, and Jeuveau® are FDA-approved botulinum toxin based injectables. BOTOX® Cosmetic was the first to market in 2002 and it remains the most widely used worldwide. Although these products all act in a similar way, there are slight differences in dosing, how quickly results become apparent and how much they spread from the injection site. Dr. Fagien and Dr. Vaca can explain these differences during your consultation and will select the most optimum treatment strategy for each individual patient.

BOTOX® Cosmetic

BOTOX® Cosmetic is the most commonly performed non-invasive cosmetic treatment performed in the United States each year—and for good reason. This injectable has a decades-long safety record, and it provides visible wrinkle-smoothing results within three to seven days after treatment. Each patient responds differently, but results usually last for three to four months and can be repeated as needed to maintain the improvements achieved. On average, patients return three or four times per year for BOTOX® injections of the upper face.


Dysport® is another injectable form of botulinum toxin A that works similarly to BOTOX® Cosmetic to improve frown lines, forehead creases and crow’s feet. Dysport® also limits muscle movement temporarily, which helps the skin appear smoother and less wrinkled. In most cases, patients will see a visible improvement in the area treated within two to three days, and the full effects of Dysport will become more evident over the first week after treatment as lines and wrinkles continue to soften. In addition, the effect of Dysport tends to spread over a wider area – this property can make Dysport® particularly useful in areas like the forehead. Each patient responds differently, but results usually last three to four months and can be repeated as needed to maintain the improvement.


Xeomin® is yet another botulinum toxin type A product that is FDA-approved for the treatment of severe frown lines between the eyebrows. One difference between Xeomin and BOTOX® Cosmetic is that it does not contain the additive proteins that BOTOX has. Many physicians and researchers argue that removing these proteins prevents the body from becoming immune to the product (which can reduce results of over time). However, despite a theoretic advantage, there has been little evidence to prove this as most patient’s experiences with Xeomin are similar to BOTOX® Cosmetic and provides similar results that last from three to four months.


Jeuveau® received FDA approval in 2019 for treatment of frown lines between the brows (glabellar lines). Perhaps the most similar to Botox® Cosmetic yet has shown to also have its unique profile.  One difference is that the effects of Jeuveau tend to be seen sooner than BOTOX® Cosmetic and are often apparent within 48 – 72 hours. In addition, Jeuveau® exhibits the least spread of effect (i.e. the drug works precisely where placed), which may be desirable in certain anatomic areas. Results typically last three to four months.

Despite their similar effects, BOTOX® Cosmetic, Dysport®, Xeomin® and Jeuveau® more often require different injection protocols as each has a unique preparation and dosing that is best provided with experience. During your consultation, Dr. Fagien and Dr. Vaca can recommend which product is best for you based on your needs and goals.

How Long Do Neuromodulators Take to Work?

The effects of all BOTOX® products are typically seen after a four to five days, with the full effects taking place after about seven to ten days. However, Dysport® and Jeuveau® have been found, in many patients, to produce results the fastest.

How Long Does the Effect of Neuromodulators Last?

The results treatment with BOTOX® Cosmetic, Dysport®, Xeomin® and Jeuveau® typically last three to four months while some patients experience results that last for up to six months.

Are Neuromodulators (ex. BOTOX®) Safe?

BOTOX® has been commercially available and used off-label for wrinkle reduction since the early 1980s. It has shown to be extremely safe and effective, and BOTOX® is currently used for over 100 medical conditions beyond anti-aging, including migraine headaches, blepharospasms, and urinary incontinence. Dr. Fagien and Dr. Vaca only uses injectable treatments that have been approved by the US FDA after being subjected to the rigorous testing required in the United States. FDA approved neuromodulators include BOTOX® Cosmetic, Dysport®, Xeomin® and Jeuveau®.

What Do Neuromodulators (ex. BOTOX®) Treat?

Although botulinum toxin-based injectables are most commonly injected to improve lines and wrinkles in the upper third of the face, there are many areas of the face and neck that can benefit from “off-label” uses. In some cases, Dr. Fagien and Dr. Vaca will recommend combining a neuromodulator product with an injectable filler to enhance results and provide optimal facial rejuvenation.

Glabellar Lines (Frown Lines)

Glabellar Lines

The vertical lines that appear between the eyebrows when frowning can be effectively treated with BOTOX® injections. For most patients, neuromodulators alone are usually enough to smooth these frown lines. However, those with more pronounced or etched-in wrinkles that are visible when the face is at rest may require additional treatments such as injectable fillers to effectively improve the appearance of deeper lines.

Forehead Lines

Forehead Lines

The long horizontal lines that run across the forehead can be easily treated with neuromodulators. Similar to frown lines, deeper forehead wrinkles may require additional treatments such as injectable fillers for optimal results.

Crow’s Feet

Wrinkles around the eyes that are accentuated by smiling and squinting are often called crow’s feet, and they can be improved with BOTOX® treatments as well.

Lateral Brows (Nonsurgical Brow Lift)

This off-label use involves injecting neuromodulator near the sides of the eyebrows to help elevate them to and lend a more “open” appearance to the upper eyelid.

Bunny Lines

Wrinkles that appear when you crinkle your nose can be softened with neuromodulator treatment.

Gummy Smile

Small amounts of neuromodulator can improve the appearance of prominent gums when smiling.

Vertical Lip Lines

Fine lines around the mouth that result from years of smoking or lip-pursing can be relaxed with neuromodulators. This treatment can also help prevent lipstick from bleeding.

Corners of the Mouth

Small amounts of BOTOX® can help correct downturned corners of the mouth, in turn creating a smile rather than a scowl when then mouth is at rest.

Dimply Chin

A wrinkly or pebbled chin is often referred to as peau d’orange (orange skin), and the dimples can be relaxed with small doses of neuromodulators.

Neck Bands 

The platysma muscle of the neck often becomes more visible with age, and neuromodulator injections can be used to reduce their appearance.

Jaw Reduction and Facial “Slimming”

The masseter muscle along the side of the jawline can cause this area to appear square and masculine. Small amounts of neuromodulator injected into the sides of the cheeks can help soften the contours of the jawline.

Bell’s Palsy

Due to a variety of causes, this facial paralysis condition lends an asymmetric appearance to the face. The non-affected side of the face can be treated with modest amounts of a BOTOX® to achieve more even facial symmetry.

Eyelid Spasms or Twitching (Blepharospasm)

Uncontrolled muscle contractions that lead to twitching of the eyelids or face can be improved with neuromodulator treatment.


BOTOX® helps alleviate the painful migraine headaches that affect approximately 12% of the U.S. population. By injecting into specific areas of the face and neck, Botox can mitigate migraines for about 3 months.

Upper Eyelid Ptosis and Eyelid Asymmetry

Although a common concern of patients receiving treatments with botulinum neurotoxin is the rare complication of a temporary drooping (ptosis) of the upper eyelid.  Dr. Fagien pioneered the use of Botox® for the treatment of mild to moderate upper eyelid ptosis as well as eyelid asymmetries as an alternative to surgical correction.

Case 1 - Neuromodulators

Meet Dr. Fagien

Dr. Fagien

Dr. Steven Fagien is one of the foremost oculoplastic surgeons in the United States and the world. He completed his medical training at the University of Florida and a fellowship in oculoplastic surgery at the University of Illinois Eye and Ear Infirmary.
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Meet Dr. Vaca

Dr. Vaca

Dr. Elbert E. Vaca is a Plastic & Reconstructive Surgeon who completed his medical training at The Johns Hopkins University School of Medicine and Northwestern Memorial Hospital.
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