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Is Botox Skincare? Understanding How Neurotoxins Affect Skin Quality · The Science of Skin

• 0:09
  SPEAKER_00: Hello and welcome to Skincare Confidential, the podcast supporting the Science of Skin Care Summit.
• 0:15
  SPEAKER_00: The Science of Skin Care Summit is an annual educational event occurring in Austin, Texas, September 5th through the 7th, 2025.
• 0:22
  SPEAKER_00: My name is Dr.
• 0:23
  SPEAKER_00: Ted Lane.
• 0:24
  SPEAKER_00: I am a board-certified dermatologist and your host for today.
• 0:27
  SPEAKER_00: And I'm so excited to uh interview Dr.
• 0:30
  SPEAKER_00: Mark Nestor.
• 0:32
  SPEAKER_00: Dr.
• 0:32
  SPEAKER_00: Nestor is the director for the Center of Medical and Cosmetic Research in Aventura, Florida.
• 0:38
  SPEAKER_00: He is also a volunteer professor in both the departments of dermatology and plastic surgery at the University of Miami Miller School of Medicine.
• 0:46
  SPEAKER_00: But the reason Dr.
• 0:47
  SPEAKER_00: Nestor is on today, besides being an incredible dermatologist, he's also been with toxins from the beginning.
• 0:53
  SPEAKER_00: He did some of the seminal research on Botox and has been involved with nearly every toxin that has been approved in the United States thereafter.
• 1:01
  SPEAKER_00: So I thought it was a great idea to have Dr.
• 1:04
  SPEAKER_00: Nestor and his incredible expertise on to educate all of us on neurotoxins.
• 1:10
  SPEAKER_00: And when I say neurotoxins, most of us just think Botox.
• 1:12
  SPEAKER_00: It's like a commodity, right?
• 1:14
  SPEAKER_00: Botox like the clean exofacial tissue, right, Mark?
• 1:17
  SPEAKER_00: Yeah, absolutely.
• 1:18
  SPEAKER_00: Yeah.
• 1:18
  SPEAKER_00: But really, Botox refers to, you know, all these type A toxins that we have available.
• 1:24
  SPEAKER_00: So I think it'd be helpful just to lay the groundwork of what a type A neurotoxin is, like the chemical structure.
• 1:31
  SPEAKER_00: Absolutely.
• 1:32
  SPEAKER_00: Thanks, Ted.
• 1:33
  SPEAKER_01: So tie all the approved toxins except one that's nobody uses very often, myoblock, are type A toxins.
• 1:41
  SPEAKER_01: And they all have exactly the same mechanism of action.
• 1:45
  SPEAKER_01: And that's really important.
• 1:46
  SPEAKER_01: There are really three components to a toxin.
• 1:50
  SPEAKER_01: There is what's known as accessory proteins, and I'll get to that in a minute.
• 1:54
  SPEAKER_01: And then two components that form the core 150 kilodalton central aspect that does all the work.
• 2:02
  SPEAKER_01: That's called the heavy chain and the light chain that make up that component.
• 2:06
  SPEAKER_01: And this is how all these type A toxins work.
• 2:08
  SPEAKER_01: The heavy chain binds first to the postsynaptic membrane of the neuron, to the SV2 receptor, and it's brought in.
• 2:16
  SPEAKER_01: It goes forms in the vesicle and it's brought into the neuron.
• 2:20
  SPEAKER_01: Inside the neuron, uh there is a disconnection, so to speak, within that vessel of the heavy and light chain, and the light chain is extruded into the uh cytoplasm.
• 2:32
  SPEAKER_01: The light chain is what does the work in the cytoplasm.
• 2:35
  SPEAKER_01: What it does is it cleaves what's known as the SNAP-25 protein of what's known as the snare complex.
• 2:41
  SPEAKER_01: And what that is important with, that's where the acetylcholine vesicles bind inside to get outside the neuron.
• 2:49
  SPEAKER_01: And if there is nothing for it to bind to, then guess what?
• 2:53
  SPEAKER_01: The acetylcholine can't get out and the muscle can't contract.
• 2:57
  SPEAKER_01: So that's really how it works.
• 2:59
  SPEAKER_01: Now, what's interesting is that the uh light chain stays in the neuron for up to 10 months.
• 3:05
  SPEAKER_01: So it's there a lot, but as we know, toxin doesn't last for 10 months.
• 3:09
  SPEAKER_01: So there are other things that are involved.
• 3:11
  SPEAKER_01: There's pseudopods that occur, uh, there's u-regulation of genes.
• 3:15
  SPEAKER_01: These are things that are kind of sketchy that we don't know about from that perspective.
• 3:20
  SPEAKER_01: But that's how all the toxins work.
• 3:23
  SPEAKER_01: Now, the important thing to realize, uh, and I should say the the accessory proteins uh are there for certain toxins like Botox and Dysport, but for other toxins like um incobiculinum toxin, uh it's just 150 kilodollin.
• 3:39
  SPEAKER_01: And this is also uh for daxate, there's just 150 kilodolin, as well as the accessory um um um uh peptide as well.
• 3:50
  SPEAKER_01: Now, what's interesting is therefore, what is the difference for the different toxins?
• 3:56
  SPEAKER_01: And the difference has to do with two things.
• 3:58
  SPEAKER_01: It's what we call molecular potency.
• 4:00
  SPEAKER_01: And molecular potency is something that I've I've published and all that, and molecular potency could be defined as really the number of active 150 kilodalton uh units that are available to bind.
• 4:14
  SPEAKER_01: And the two things that are available, you have to have a number of them, how many are there, or or what is the picograms or nanograms of toxin?
• 4:22
  SPEAKER_01: And the second is are they active?
• 4:25
  SPEAKER_01: So what happens, unfortunately, with toxin is a lot of these either aggregate or essentially get ruined and they can't work, they can't do the job of binding.
• 4:35
  SPEAKER_01: So, number one, the you have to have an uh a certain amount of it here that and that that can be measured in a different way that we'll get into a little later, because that's how you can differentiate it.
• 4:46
  SPEAKER_01: And number two, they have to be active, they can't be um inactivated either from sticking to the side of the vial when we mix it up or clumping together so they don't get active.
• 4:58
  SPEAKER_00: Wow.
• 4:59
  SPEAKER_00: So that's that's wonderful.
• 5:00
  SPEAKER_00: So, and and you know, a lot of our colleagues try to compare the potency of toxins by looking at the number of nanograms or picograms of toxin within the bottle.
• 5:10
  SPEAKER_00: But to your point, that cannot be the only variable that we look at to to to really be able to compare them, correct?
• 5:17
  SPEAKER_01: Absolutely.
• 5:18
  SPEAKER_01: And molecular potency, this is what I talk about all the time.
• 5:22
  SPEAKER_01: That's essentially the key, not that one toxin is better than the other, they just have different variations of ultimate molecular potency.
• 5:30
  SPEAKER_01: And what I tell everyone is okay, the ultimate arbitrage of this is what effect you want.
• 5:37
  SPEAKER_01: And that's so important because two things cannot go together.
• 5:41
  SPEAKER_01: You can't have significant duration, and you can't have this idea that I want uh not to have a frozen look.
• 5:49
  SPEAKER_01: I want to be natural and have movement.
• 5:52
  SPEAKER_01: Those don't go together.
• 5:54
  SPEAKER_01: To have the long duration, you have to have that frozen look.
• 5:58
  SPEAKER_01: And if you want to have movement, if you want to use less toxin, that's fine.
• 6:02
  SPEAKER_01: It's what the patient wants, but it's not gonna last as long.
• 6:05
  SPEAKER_00: And what we found in a lot of the studies, uh, Dr.
• 6:08
  SPEAKER_00: Nestor, is that there is a dose response curve with the toxin.
• 6:13
  SPEAKER_00: Absolutely.
• 6:14
  SPEAKER_01: And for all toxins, in other words, remember, first of all, you can't compare commercial toxins on their units.
• 6:20
  SPEAKER_01: They're all proprietary.
• 6:22
  SPEAKER_01: So they use, you know, different models for this, uh, different, what's known as LD50s, usually, uh, which is the the lethal dose uh for rabbits or from mice, et cetera.
• 6:34
  SPEAKER_01: Okay.
• 6:35
  SPEAKER_01: And you can't say 20 units of this is comparable to that.
• 6:39
  SPEAKER_01: There was a study by uh a guy by the name of Fields who actually started looking at nanograms of toxin and activity.
• 6:47
  SPEAKER_01: And this was actually a breakthrough paper because they looked at things like Botox and Dysport uh and others.
• 6:54
  SPEAKER_01: And what's happened is that they said, okay, there was actually differences in the number of picograms of toxin in the doses that were approved for globella.
• 7:06
  SPEAKER_01: So 20 units versus 50 units of dysport, et cetera.
• 7:10
  SPEAKER_01: And that was interesting because that was one variable that said, okay, there were different amounts of toxin in the approved units of these commercial toxins.
• 7:20
  SPEAKER_01: And it kind of went along with some of the data on longevity as well when you're using those variables.
• 7:29
  SPEAKER_00: Speaking of longevity, right?
• 7:31
  SPEAKER_00: We we've had some issues with longevity with some of these toxins promising longevity.
• 7:35
  SPEAKER_00: And remember, for anybody listening that that injects toxins, when you think about longevity, it's all based on a median value, right?
• 7:43
  SPEAKER_00: So there are people that last longer, there are in whom it lasts longer, and there are always people in whom it doesn't last as long.
• 7:49
  SPEAKER_00: So we can never promise longevity no matter what we're talking about.
• 7:53
  SPEAKER_00: Absolutely.
• 7:54
  SPEAKER_01: Now, what's so interesting here is that we just we just went over this.
• 7:58
  SPEAKER_01: We had a big meeting in uh in Paris, and you were there at MCAS.
• 8:03
  SPEAKER_01: And one of the observations that's being made, and this was a study that was done in Israel, is we we constantly see some patients now who feel that they're not getting the same longevity in their toxin.
• 8:15
  SPEAKER_01: Right.
• 8:16
  SPEAKER_01: They are not necessarily non-responders, but they don't respond as well.
• 8:21
  SPEAKER_01: And the Israeli study showed something very interesting.
• 8:23
  SPEAKER_01: They showed that after COVID, and it wasn't clear whether it was COVID or the vaccine because everybody had both.
• 8:30
  SPEAKER_00: Right.
• 8:31
  SPEAKER_01: People for some reason had shorter duration of the effect of the toxin.
• 8:36
  SPEAKER_00: Interesting.
• 8:36
  SPEAKER_01: So the question really arises of what is modulating this?
• 8:41
  SPEAKER_01: And you know, the the thought process has always been uh immunity, or no, in other words, antibodies uh that were affecting the toxin.
• 8:50
  SPEAKER_01: That doesn't seem to be the case because when you test these people for antibodies that are less respondent, they don't test positive.
• 8:59
  SPEAKER_01: Now, that could mean that there are other antibodies that are out there that we are not testing for, but it's probably of other combinations where the body is upregulating the system, so to speak, to kind of battle the effects.
• 9:14
  SPEAKER_01: The body doesn't like when it's not working properly, right?
• 9:17
  SPEAKER_01: And it does anything it can to undo those effects.
• 9:20
  SPEAKER_00: That is so interesting.
• 9:22
  SPEAKER_00: Yeah, but one would assume it would just be neutralizing antibodies.
• 9:25
  SPEAKER_00: Doesn't seem to be the case.
• 9:27
  SPEAKER_00: Interesting.
• 9:28
  SPEAKER_00: Uh and so now, Mark, you know, we've got all these different toxins that are already available to us, right?
• 9:34
  SPEAKER_00: And I'm gonna say brand names here, and we kind of are interchanging brand names and their chemical names.
• 9:39
  SPEAKER_00: Uh so we've got uh onabotulinum toxin, which is Botox, been kind of the grandfather of toxins.
• 9:45
  SPEAKER_00: And remember, all of these, well, most of these toxins now, the vast majority of them are used for medical purposes, actually, and not cosmetic purposes.
• 9:53
  SPEAKER_00: And that was the case with Botox.
• 9:55
  SPEAKER_00: It was kind of a fluke that Botox was found to be useful cosmetically, wasn't it?
• 9:59
  SPEAKER_01: Gene Cruthers, uh, Gene and Alistair Cruthers, uh, Gene's an ophthalmologist, Alistair's a dermatologist, and they were using it for the original indication, which was blepospasms.
• 10:10
  SPEAKER_01: And what Gene noticed is that hey, if I treat the muscles in the gobella, the corrugating and proceris, people are happy and they look better.
• 10:19
  SPEAKER_01: So this opened up the world to toxins aesthetically.
• 10:24
  SPEAKER_00: Yeah.
• 10:24
  SPEAKER_00: And it toxins are used just dramatically medically for all sorts of different purposes.
• 10:29
  SPEAKER_00: I mean, we could go into screens.
• 10:31
  SPEAKER_01: Right.
• 10:32
  SPEAKER_01: And we could get into even what what we're seeing now is making people feel better because you're not frowning.
• 10:39
  SPEAKER_01: You can't be depressed the same, and it's an incredible treatment for depression, anxiety, PTSD, and other things.
• 10:46
  SPEAKER_01: Uh, and it actually even enhances how other people see us when we don't frown.
• 10:52
  SPEAKER_01: So it's an incredible, you know, social benefit as well as cosmetic benefit.
• 10:58
  SPEAKER_00: I've got a good friend who's a psychiatrist who's been involved with the development of a Botox used for depression.
• 11:03
  SPEAKER_00: And unfortunately, there was a phase three trial done for Botox for depression.
• 11:07
  SPEAKER_00: It just didn't hit the p-value.
• 11:09
  SPEAKER_00: And some thoughts were, well, they had psychiatrists doing the injections who have never touched a patient.
• 11:14
  SPEAKER_00: Well, haven't touched a patient since medical school.
• 11:16
  SPEAKER_00: And so perhaps it wasn't the right people to do.
• 11:20
  SPEAKER_01: Studies are incredibly positive.
• 11:22
  SPEAKER_01: There's a study from Walmer and others that show even with treatment through resistant depression, if you use enough to really knock out those muscles for months, you have tremendous benefits.
• 11:35
  SPEAKER_00: And I think that's anecdotally, many of us who do these injections will tell say the same thing.
• 11:39
  SPEAKER_00: Many of our patients come back and just say it's much better without question.
• 11:43
  SPEAKER_00: And one of the reasons on a skincare podcast, we're talking about toxins is because of their effect on skin quality as well.
• 11:50
  SPEAKER_00: Lots of data on that, right, Mark?
• 11:52
  SPEAKER_00: There is.
• 11:53
  SPEAKER_01: So it's interesting because you can look at this in a few ways.
• 11:56
  SPEAKER_01: We've known for years that when you treat the muscles, and I I will I tell my patients it's like paper.
• 12:02
  SPEAKER_01: When you're folding paper and folding paper, you get these, you know, heavy lines in the paper.
• 12:07
  SPEAKER_01: If you don't fold the paper and you kind of lay them out, the lines get less.
• 12:12
  SPEAKER_01: And that's essentially how we see the gobella, especially, but in the crow's feet and other areas as well.
• 12:18
  SPEAKER_01: If you're not contracting the skin, those lines tend to fade to some degree.
• 12:24
  SPEAKER_01: Now, there's some interesting data, especially on Daxy as well, that there may be other components as well from the uh the peptide that's injected with it may enhance uh essentially elastin and collagen production.
• 12:39
  SPEAKER_01: So there may be other aspects to it as well.
• 12:42
  SPEAKER_01: Um, but that's what I'm saying.
• 12:44
  SPEAKER_01: Everything is a little bit different.
• 12:46
  SPEAKER_01: Each toxin varies by a few different things.
• 12:49
  SPEAKER_01: As you talked about, there's different molecular potencies.
• 12:52
  SPEAKER_01: And molecular potency is really the key issue here that we have to think about for toxin.
• 12:58
  SPEAKER_01: And as I said, there is three different components for molecular potency.
• 13:02
  SPEAKER_01: How much toxin is there?
• 13:04
  SPEAKER_01: Okay.
• 13:05
  SPEAKER_01: The ability for the toxin to bind, in other words, is it uh aggregated?
• 13:10
  SPEAKER_01: Is it clumped together?
• 13:12
  SPEAKER_01: Is it sticking to the side of the bottle?
• 13:14
  SPEAKER_01: How much is actually there to bind?
• 13:16
  SPEAKER_01: And the third component is um is there a way of getting the toxin um into the neuron more efficiently?
• 13:25
  SPEAKER_01: And there are two different interesting studies that have been done.
• 13:28
  SPEAKER_01: First of all, with Daxy, the the idea is that the uh peptide has a charge.
• 13:36
  SPEAKER_01: And that charge does two things theoretically.
• 13:38
  SPEAKER_01: There are studies that show, but you know, other studies that dispute this.
• 13:43
  SPEAKER_01: Number one, it um prevents aggregation uh in some studies, but number two, because of the charge, it brings the toxin closer to those SV2 receptors, therefore, more can get in.
• 13:58
  SPEAKER_01: Now, what's so interesting is there was a company um uh was just sold fairly recently called FastHox that looked at something else.
• 14:06
  SPEAKER_01: They looked at postsynaptic inhibitors, and what that tended to do is increase the number of SV2 receptors on the neuron.
• 14:15
  SPEAKER_01: And if you think about this from a concert model, let's say you go to a concert and there are small numbers of people at the concert, and that would be equated to low molecular potency versus high numbers of people.
• 14:27
  SPEAKER_01: There'd be more getting through those exits.
• 14:30
  SPEAKER_01: But if you have more entrances or exits out there, those more, you'd get a lot more in in a short period of time.
• 14:38
  SPEAKER_01: And that's what this postsynaptic inhibitor, FastTox, seemed to do.
• 14:42
  SPEAKER_01: No matter what toxin you used, the molecular potency went up.
• 14:47
  SPEAKER_01: You got you got uh quicker onset and longer duration with exactly the same amount of toxin.
• 14:53
  SPEAKER_01: So I think in the future, what you're seeing is that we can modulate this ability to get things in and out of the neuron.
• 15:01
  SPEAKER_01: Now, the interesting thing is we can already modulate this because we know that up to a point, if we increase the dose, increase the molecular potency, the number that we could do, we get longer duration and a uh shorter onset.
• 15:15
  SPEAKER_01: And those go hand in hand.
• 15:17
  SPEAKER_01: If you think about it, you'll get it in more quickly, but you get more in so it lasts more quickly.
• 15:22
  SPEAKER_01: Okay.
• 15:23
  SPEAKER_01: That only goes to a certain point, though.
• 15:25
  SPEAKER_01: The idea somehow that we can get so much in that it'll last for years doesn't happen.
• 15:30
  SPEAKER_01: You can only, because of the number of SV2 receptors, you can only get so much in.
• 15:35
  SPEAKER_01: So I think that what you see is that for almost all toxins, you can take it probably double, maybe a little more, and get a longer uh uh um duration with almost any toxin.
• 15:49
  SPEAKER_01: So if that's the case, as we have more toxins, and you talked about two uh that are coming out very shortly, latibo, which has already been approved, okay?
• 16:00
  SPEAKER_01: And latibo's claim to fame is it's a very good toxin.
• 16:03
  SPEAKER_01: They did some very good studies essentially on the um not only cosmetic benefit, but also the psychological benefit.
• 16:12
  SPEAKER_01: And I think what you're gonna see is it's gonna come out at a much lower cost point for latibo.
• 16:18
  SPEAKER_01: The next toxin is relobotulinum toxin, which is uh hopefully soon to be approved by the FDA.
• 16:24
  SPEAKER_01: That's Galderma's new toxin.
• 16:26
  SPEAKER_01: That is a liquid toxin.
• 16:27
  SPEAKER_01: And the liquid toxin is interesting from a couple of different perspectives.
• 16:31
  SPEAKER_01: Number one, it seems to be a very highly potent toxin.
• 16:35
  SPEAKER_01: Number one.
• 16:36
  SPEAKER_01: Number two, um, because of the way it's made, it's made in a way that it doesn't uh ever have to go through the freeze-drying process.
• 16:46
  SPEAKER_01: And so the toxin um is much more uh non-aggregated.
• 16:51
  SPEAKER_01: In other words, there is still a lot more available, even at a certain number of picograms.
• 16:57
  SPEAKER_01: So it is more molecularly potent.
• 16:59
  SPEAKER_01: The second part of that is it may be easier to draw up.
• 17:02
  SPEAKER_01: You don't have to mix it, et cetera.
• 17:04
  SPEAKER_01: So there's some benefits to that that we'll see.
• 17:07
  SPEAKER_01: Uh it hasn't been approved yet.
• 17:09
  SPEAKER_01: It's going to be approved soon, I believe.
• 17:11
  SPEAKER_01: And then we're going to have to see what the price is when it comes out.
• 17:14
  SPEAKER_00: Yeah, you make a really good point.
• 17:15
  SPEAKER_00: You know, one of the things I've always wondered is, for example, many of these toxins come lyophilized, right, as a powder and you reconstitute them.
• 17:22
  SPEAKER_00: But you always wonder if there's a gradient in that, in that mixture that you've made yourself, right?
• 17:26
  SPEAKER_00: Whether there's more toxin at the top or at the bottom, and whether, you know, you're pulling up 20 units, but are you really pulling up 20 units or not?
• 17:34
  SPEAKER_01: Well, it's interesting you bring that up.
• 17:36
  SPEAKER_01: Um, the FDA guidelines for this, it's plus or minus 20%.
• 17:42
  SPEAKER_01: And that's very interesting.
• 17:43
  SPEAKER_01: It probably doesn't happen in real life, but if you think about it, that's a 40% differential.
• 17:48
  SPEAKER_01: So somebody can come in at one point in the differential in one vial, okay, and then all of a sudden the next point, it's 40% less, let's say, and they're saying it's not lasting as long.
• 18:00
  SPEAKER_01: So, so by nature, you know, there is a potential differential gradient in toxins you mixed up.
• 18:07
  SPEAKER_01: And as you said, people mix it up differently, they could they avert the vinyl differently.
• 18:11
  SPEAKER_01: There's all sorts of things that may lead to ultimately different differential molecular potency.
• 18:18
  SPEAKER_00: Yeah, I just think this ready-made liquid toxin is going to solve for a lot of the issues that we have.
• 18:23
  SPEAKER_00: And some of the issues kind of fly under the radar.
• 18:25
  SPEAKER_00: We don't really think about them, but they certainly are issues.
• 18:28
  SPEAKER_00: And whether they're business related in terms of number of lost units because of inadvertent mixturing errors uh or mixing errors, or are they truly, you know, patient satisfaction issues where at to your point, we're between injection sessions, we may be injecting up to 40% different amounts of toxin.
• 18:47
  SPEAKER_00: I think that this liquid toxin is very exciting because of that.
• 18:50
  SPEAKER_00: And and I agree with you, the price point is really going to determine the uh the market considerations, but uh just from my viewpoint, I'm excited about it.
• 19:01
  SPEAKER_01: Yeah, no, I I think it's very, very interesting when you see that.
• 19:04
  SPEAKER_01: So the two interesting things about this, number one is the last paper I wrote, I talked about a molecular potency quotient.
• 19:11
  SPEAKER_01: And what that means essentially is let's say you want to get an effect, okay?
• 19:16
  SPEAKER_01: Depending upon which toxin you use, you can get that effect.
• 19:20
  SPEAKER_01: The question is, how much is it gonna cost you for both you and the patient?
• 19:25
  SPEAKER_01: So if it's you, what is your profit margin?
• 19:28
  SPEAKER_01: Okay.
• 19:28
  SPEAKER_01: If it's the patient, what are they gonna pay?
• 19:30
  SPEAKER_01: Somehow they may or may not be related, okay?
• 19:33
  SPEAKER_01: And that's one of the things that we need to see.
• 19:36
  SPEAKER_01: Okay, you're gonna have toxin, this toxin that's gonna be more potent, but it's three times as expensive as this toxin that's not quite as potent, but still works, and you could go up on the units, okay?
• 19:48
  SPEAKER_01: Which is better to use?
• 19:50
  SPEAKER_01: And and again, remember, all of them work identically, and that's very, very important.
• 19:56
  SPEAKER_01: Now, what's interesting for the future is uh if you look at the literature, there are some new things that are going to come down the pike.
• 20:03
  SPEAKER_01: There's what's known as hybrid toxins.
• 20:05
  SPEAKER_01: And hybrid toxins take um, for instance, a the heavy chain component from the B toxin and the light chain component for the A-toxin, and it's a essentially a hybrid toxin.
• 20:19
  SPEAKER_01: So what's interesting, the reason the B toxin is so interesting is there are different types of receptors, and there are a lot more of them than the SV2 receptor, uh symbosatin receptors than the SV2 receptors.
• 20:34
  SPEAKER_01: And because of that, there's many more places, as you said, to bind, and you get much more in the neuron.
• 20:41
  SPEAKER_01: So this is going to be in the future, but what you could see is a lot more ability to go in with these hybrid toxins and longevity.
• 20:49
  SPEAKER_01: The other thing that's gonna happen is there's a type E toxin.
• 20:53
  SPEAKER_00: Yes.
• 20:54
  SPEAKER_01: Type E toxin is uh should be approved uh uh very soon in the U.S.
• 20:58
  SPEAKER_01: Allegrin has the first one coming out.
• 21:01
  SPEAKER_01: And type E toxin has a different receptor from there, and it actually has a different light and heavy chain.
• 21:08
  SPEAKER_01: And what you see is very, very quick onset, but it only lasts a few weeks.
• 21:13
  SPEAKER_01: It only lasts maybe four to six weeks.
• 21:16
  SPEAKER_01: So the thought process or the discussion there is for people who are nervous about going or using a toxin, they don't want it to last very long.
• 21:24
  SPEAKER_01: This is something that may, you know, work.
• 21:27
  SPEAKER_01: But my way of looking at this for the future is you're gonna mix these, okay?
• 21:32
  SPEAKER_01: Like anything we mix.
• 21:33
  SPEAKER_01: So you use a little type B with some type A, and all of a sudden you have really quick onset, and you have the duration of type A as well.
• 21:41
  SPEAKER_01: So there is going to be a lot of interesting work that goes on for this as well.
• 21:46
  SPEAKER_00: Yeah, the type B toxin is really interesting.
• 21:49
  SPEAKER_00: We were involved in the clinical trials and we had patients, you know, we injected them in five o'clock in the morning and we followed them for the next 12 or 15 hours.
• 21:56
  SPEAKER_00: And you could just slowly see uh their globellar lines.
• 22:00
  SPEAKER_00: Improving over those 12 hours.
• 22:02
  SPEAKER_00: So truly does, based on my experience at least, it truly does have a very quick onset of action.
• 22:07
  SPEAKER_00: And I think, you know, this is totally off label, but I was excited about it regarding scarring, you know, and post-surgical relaxation with such a quick onset of action at lasting three months, or excuse me, three, three or four weeks.
• 22:20
  SPEAKER_00: And then uh, you know, for for pain relief when related to herpes ostra, for example.
• 22:25
  SPEAKER_00: I mean, there's a lot of opportunities for short acting, short duration toxin.
• 22:30
  SPEAKER_00: And I think many, many of our peers really look at this with kind of a little squint and and uh they kind of don't understand why they would bring this out to the market.
• 22:38
  SPEAKER_00: But I certainly see opportunity for us to use this and and maybe it's in the mixing, like you said.
• 22:43
  SPEAKER_01: Yeah, oh no, no.
• 22:44
  SPEAKER_01: It's exciting because it gives us a new tool.
• 22:47
  SPEAKER_01: And as you said, so if you remember, and and you've kind of laid this out, toxin is good not just for the lines here, the the lateral canthal lines, the frontalis and and mentalis.
• 22:59
  SPEAKER_01: I mean, there's a lot of different things cosmetically.
• 23:01
  SPEAKER_01: However, what's interesting is there's great data on scars, post-surgical scars.
• 23:07
  SPEAKER_01: If you if you're doing an excision on the forehead, for instance, you get a better scar if you use the toxin first.
• 23:14
  SPEAKER_01: So you're not getting that movement.
• 23:16
  SPEAKER_01: And it only makes sense.
• 23:17
  SPEAKER_01: The movement is going to affect the way the scarring heals.
• 23:20
  SPEAKER_01: So there are benefits to that.
• 23:22
  SPEAKER_01: There's also benefits for things like pores and the overall skin quality that's been looked at, without question.
• 23:29
  SPEAKER_01: Um, then there's benefits for acne and rosacea.
• 23:32
  SPEAKER_01: There's so many different interesting um uh side effects to toxin um from that perspective.
• 23:41
  SPEAKER_01: Uh, you know, we're just beginning to look at that.
• 23:45
  SPEAKER_01: And what's interesting is that with toxins coming out that are lower cost, we may be much more inclined to use it in these uh aspects for the decottage, for other areas of the body that we before would have been very expensive, but now, hey, it's something that patients uh would like to do and it could be more affordable.
• 24:07
  SPEAKER_00: Yeah, there's a there's an intradermal technique of injecting very small doses of Botox that helps to improve skin quality, what we were talking about before.
• 24:14
  SPEAKER_00: One of the things it can do is is relax, it helps with very, very fine lines, helps increase luminosity and radiance on the skin by reducing sebum production.
• 24:24
  SPEAKER_00: And then there is some thought as to you know collagen production as well and basement membrane integrity with these.
• 24:29
  SPEAKER_01: And hair growth.
• 24:29
  SPEAKER_00: And hair growth.
• 24:30
  SPEAKER_01: It published studies on engine genetic alopecia.
• 24:33
  SPEAKER_01: So again, we've got some very interesting opportunities for toxin for the future.
• 24:38
  SPEAKER_00: It's a miracle drug, isn't it?
• 24:40
  SPEAKER_00: It really, like, I don't even know that we've touched the surface on all the opportunities that's available with this drug.
• 24:44
  SPEAKER_01: No, I I agree.
• 24:45
  SPEAKER_01: But to me, what is most interesting, and I've published on this, is the effect on the psyche.
• 24:51
  SPEAKER_01: So what we know is that there's a feedback mechanism from the Gabella, especially, and this is something that Eric Finci did years ago and has been looked at many, many uh ways by a number of different investigators, but it works through the amygdala.
• 25:08
  SPEAKER_01: And what happens is that if you can't frown, you you're not getting the feedback to be sad.
• 25:15
  SPEAKER_01: And it's a very interesting phenomenon because it it works in a way called mirroring.
• 25:20
  SPEAKER_01: So when somebody around us frowns, we we automatically frown as a response to that and feel that uh unhappiness.
• 25:31
  SPEAKER_01: You you know, some people will say that's the mechanism for empathy.
• 25:35
  SPEAKER_01: I don't believe that.
• 25:36
  SPEAKER_01: I think you can still listen to them and have sympathy.
• 25:39
  SPEAKER_01: You don't have to have the pain uh to uh feel another person's pain, so to speak.
• 25:45
  SPEAKER_01: So what happens is that you all of a sudden have a world where you're not getting as much frowning and people are happier.
• 25:53
  SPEAKER_01: What's so interesting though is if you knock out the lateral canthal lines, okay, which we do very often, it totally abates that.
• 26:01
  SPEAKER_01: So it doesn't allow us to have that happiness because the lateral canthal lines are associated with smiling.
• 26:10
  SPEAKER_01: And you want to have the smiling there.
• 26:12
  SPEAKER_01: So what I do in a number of patients is I treat them for their psyche and their people around them rather than aesthetic.
• 26:20
  SPEAKER_01: So what I do is I treat the globella and I treat the lateral habicularis.
• 26:25
  SPEAKER_01: So their eyes open up, they still can smile from the lateral canthyl and they won't frown.
• 26:31
  SPEAKER_01: And what it what this seems to do is it even enhance the psychological benefits for them and the people around them.
• 26:38
  SPEAKER_00: Yeah.
• 26:38
  SPEAKER_00: It's and just to reiterate, if you treat the glabella, you get the the improvement in overall mood.
• 26:45
  SPEAKER_00: If you treat the globella with the crow's feet, you lose that improvement.
• 26:49
  SPEAKER_01: Absolutely.
• 26:50
  SPEAKER_00: So in that study I found so interesting.
• 26:52
  SPEAKER_01: And if you just treat the globella, I mean the lateral canthal, you have less happiness.
• 26:58
  SPEAKER_01: It goes down.
• 26:59
  SPEAKER_01: It goes down.
• 26:59
  SPEAKER_01: There's so many other the this study and and uh this was such an interesting study.
• 27:05
  SPEAKER_01: It actually went into the issue of women's orgasms, okay?
• 27:10
  SPEAKER_01: And the study showed that if you treat the lateral canthal lines of cobella, women don't enjoy their orgasms as much.
• 27:18
  SPEAKER_01: Um, and this is actually, and it's funny because whenever I give a lecture about this, I ask the audience.
• 27:23
  SPEAKER_01: Nobody seems to raise their hand saying their orgasms are affected.
• 27:27
  SPEAKER_01: I don't know.
• 27:27
  SPEAKER_01: But uh the bottom line is that um it it shows that there's such a connection between how we feel and how we experience things and our facial expressions.
• 27:40
  SPEAKER_01: It's just, it's it's incredible to, you know, kind of open up this whole world of how we modulate our feelings and how we can modulate based on what we do to individuals with toxins.
• 27:54
  SPEAKER_00: You know, just again, just to round it out with skincare, there's a lot of products now that use neuropeptides, which are, you know, we call them Botox mimickers, but really what they do is is they try their very best to reduce the um activity of muscles and and help to ri relax the skin at the very highest surfaces, which which more than make you feel happy, they really just improve the the tone and texture of the skin, right?
• 28:20
  SPEAKER_00: That's when I was talking about intradermal Botox, that's the idea with neuropeptides.
• 28:24
  SPEAKER_01: But and I think, you know, to your point, the most important thing is toxins are a part of what we do.
• 28:30
  SPEAKER_01: Okay.
• 28:31
  SPEAKER_01: It's a it's probably they are by far the most common aesthetic procedure um that anyone does.
• 28:38
  SPEAKER_01: That goes without saying.
• 28:39
  SPEAKER_01: Uh, and obviously they're used more and more for things like masseters, and masseters can be both aesthetic and certainly for TMJ and things like that and other treatments as well.
• 28:51
  SPEAKER_01: Um, but you know, with this, we still want to use our fillers when we need to, use our devices, and certainly use our skincare products.
• 29:00
  SPEAKER_01: I think this is something that is uh, you know, a combination, and of course, our sun luck.
• 29:05
  SPEAKER_01: We have to be our dermatologist first.
• 29:07
  SPEAKER_01: That's important.
• 29:08
  SPEAKER_01: We almost lost our licenses there.
• 29:10
  SPEAKER_01: Exactly.
• 29:11
  SPEAKER_01: But I think that, you know, this, you know, this is so great.
• 29:15
  SPEAKER_01: And and part of this, you know, Science of Skincare Summit, it's so wonderful because it melds all these together.
• 29:22
  SPEAKER_01: And I'm looking forward to next year because, you know, this is this evolution that's occurred in terms of both topical products and toxins and you know, devices and everything can really take us a whole nother level in terms of what we can do for our patients.
• 29:40
  SPEAKER_00: Thanks, Dr.
• 29:41
  SPEAKER_00: Nestor.
• 29:41
  SPEAKER_00: As always, I learn something every time I talk to you.
• 29:44
  SPEAKER_00: So I so appreciate your time.
• 29:46
  SPEAKER_00: It's my pleasure.
• 29:47
  SPEAKER_00: Thanks so much, Ted.
• 29:48
  SPEAKER_00: Um I look forward to seeing you soon.
• 29:50
  SPEAKER_00: That's great.
• 29:50
  SPEAKER_00: So this is Skincare Confidential.
• 29:52
  SPEAKER_00: My name is Dr.
• 29:52
  SPEAKER_00: Ted Lane.
• 29:53
  SPEAKER_00: I've been interviewing the wonderful Dr.
• 29:55
  SPEAKER_00: Mark Nester, who is in Florida.
• 29:57
  SPEAKER_00: Uh, thank you so much for listening.
• 29:58
  SPEAKER_00: Please subscribe and tell your friends all about it.
• 30:01
  SPEAKER_00: And till next time.