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Interview with David Eccleston: How to achieve the best results in the treatment with neuromodulators

Fig. 1: David Eccleston, M.D.

Dr. David Eccleston is the Clinical Director of MediZen, founded in 1999 along with his wife Annie, a registered nurse. Dr Eccleston is an International Key Opinion Leader in the specialty, and an International Faculty Member of the Allergan Medical Institute. His role involves managing injectable-related complications and supporting patients who have received incorrect or substandard treatment. He is a Faculty Member of the International ACE Complications Group. He is the only medical practitioner in the UK to have been a lead investigator in clinical trials on the first UK licensed brands of anti-wrinkle injections and continues to have an active research interest. He also works closely as an advisor and trainer with several major aesthetic product and equipment providers, such as Cutera Lasers, Alumier MD Medical Skincare, Allergan and Evolus. The publisher Douglas Grosse talked with David Eccleston about the newest trends in the field of neuromodulators.


What do your patients expect as far as BTX treatment results are concerned?


Several years ago, I might have answered this question by saying that the patients in my practice that are interested in facial aesthetics treatments, including botulinum toxin, were seeking help to look younger.


Many of my longer-term patients are categorised as Generation X. What I’ve recently noticed is that a younger group of patients, the millennial patients, are now also asking about facial aesthetic treatments. This is not surprising as a Millennial is someone aged between about 25 and into their early 40s. Previously these patients may have had questions about skin quality or other skin issues such as acne. Now, they are starting to explore botulinum toxin treatments for age-related lines and wrinkles.


What I’ve noticed about my Millennial patients tend to research the subject more carefully, and choose their practitioner and procedures accordingly. They have done their homework and come in with fairly clear ideas about what they want from treatment, as well as having high expectations of what treatment could deliver for them.


That said, the quest for natural looking results with a fast onset is something common amongst most age ranges in my clinic. For my patients, duration is less of a driver. Questions about safety of treatments is another area for discussion in the consultation. I find that many patients, especially the younger patients, confuse the potential side effects of filler with those of a toxin. This provides a great opportunity for good quality education about safety and efficacy of facial aesthetic procedures in general.


How important is for them to keep their natural facial expression without being “frozen”?


It’s really important now. For my patients, they really don’t want to look frozen or ‘done’. I appreciate there are patients who do like this look. But for my clientele, it’s much more about looking natural and their best selves.


In talking with my Generation X patients, they realise it’s possible to have expression and no or less lines at rest, if the treatments are done well and a considered choice of toxin is made, based on the needs of the individual. For my Millennial patients, it’s a simpler equation – they don’t want what their mother or aunts had.


In your experience, is it possible to find the right balance between natural expression, showing emotions and having no wrinkles at rest?


Yes. But it takes work. Being able to target muscles precisely gives me more control of the results. The answer is in some of the newer generation of botulinum toxins where the manufacturer has had the opportunity to refine their manufacturing processes. It’s widely known that each botulinum toxin has its own profile and can deliver different results. For example, I’ve been using NUCEIVA® from Evolus recently. It’s manufactured using something called Hi-Pure™ technology which is part of the patented manufacturing process for this product. I am finding that NUCEIVA® allowing me to target the muscles precisely which gives me greater control of the outcomes.


Skin quality can also be a key results enabler as well. This makes sense when you recall that healthy hydrated skin is plumper, more radiant with an even tone and texture. This smooths out and reduces fine lines at rest. That’s why I combine injectables and lasers with medical grade skincare and wellness services in my clinic, maximises the overall effects on health and skin quality. This power duo of great skin and excellent results from facial injectables is a game-changer.


What’s the most desirable?


There isn’t just one look but I think having confidence to leave some movement gives an overall better result. The glassy, over tight appearance is now a real give-away that a person has had work done. For most of my patients, this is undesirable. Afterall, we need some movement to express emotion.


I know some practitioners prefer to undertreat a patient (especially a new patients) and have people come back for top ups. I’ve been treatment patients with NUCEIVA® for about a year now, and I have noticed that I haven’t had to do this. The precision results that I’m achieving allows me to target treatment effectively, reducing the need for tops ups to almost zero. Overall, my experience has been that patients have been happy with the results from the first treatment and are not needing to come back for corrections or additional injections.


How important is the knowledge of anatomy to achieve optimal results with neuromodulator treatments?


It’s essential! I’ve been teaching anatomy courses with Prof. Sebastian Cotofana recently and I am still learning things.


Take the glabellar area. As your readers will know, it is complex. It consists of the medial brow depressors: corrugator supercilii, depressor supercilii, procerus, and the medial fibers of orbicularis oculi muscles; In some cases, nasalis fibers contribute to form the glabellar complex. What makes it a complex area to treat is that the interplay between the muscles working at frown is not the only consideration.


It’s vital to note the impact of muscle movement on the skin during animation and expression. Understanding what happens at maximum contraction and combining that knowledge with the patient consultation is what enables me to deliver the precise results I’m after.


Some years back, several researchers defined five types of glabellar contraction patterns.

1) U – U-shape

2) V – V-pattern

3) ®¬ – Converging arrows

4) W – Omega

5)  – Inverted Omega


The two most common contraction patterns identified were the U and V shapes. For example, the V-type glabellar line contraction pattern was identified as the most frequent type, seen in 37% of cases. It is a more profound movement. At rest, the eyebrows tend to be more horizontal or rectified and lower. And due to increased involvement with the procerus muscle, the medial brow tends to be pulled down more so than in the U type of contraction.


In contrast the U shape was identified as the second most common type of glabellar line, found in 27% of the study cases. The muscles most often involved are the procerus and corrugators. With the U shape, we tend to see approximation and depression of the space between the eyebrows with variable intensity but generally little range. As a result, the movement takes the form of the letter U. At rest, the eyebrows tend to form an arch.


By understanding anatomy behind these five patterns, I have been able to deliver a more personalised approach rather than one-size-fits-all.


What else is important from your point of view when it comes to BTX treatments?


Understanding the impact that the 4Ds – dilution, depth, direction, and dose – have on outcomes. Dilution refers to the amount of saline solution used to dilute the botulinum toxin. This varies between manufacturers as do the units needed for treatment. Depth refers to the depth at which the injection is administered, which can vary depending on the area being treated. For NUCEIVA®, best practice is to inject well into the belly of the muscle. Direction refers to the angle at which the needle is inserted, which can affect the placement and spread of the toxin. Finally, Dose refers to the amount of botulinum toxin that is injected, which also varies depending on the area being treated and the desired effect.


There are some additional considerations when considering something new.

  • Data > Reviewing the clinical data to understand how the product works, what results you can expect and the safety profile
  • Support from the company > Making it easy to try something new for the first time
  • Peer to peer exchange > Conversations with peers about their experiences to gain confidence and evolve your practice


As a final question, you’ve been involved in the clinical trials for most of the botulinum toxins available in Europe. What have you learned? What differences are there between the toxins in the market?


Let’s start with one fact. They all work. That said, understanding the nuances of each is what really matters. Combining knowledge of anatomy with knowledge of the products in addition to the individual patient wants and needs enables me to select the best toxin for the job.


Alastair Carruthers, the pioneer in the use of botulinum toxin in aesthetics, did many studies on how many units of botulinum toxin are needed for longest results. Between 40 and 60 units, longevity grew, but plateaued at 60 units. So, it doesn’t really matter which toxin you use, you actually receive the same results and duration. Latybo® for example is officially licensed for use in patients up to 75 years of age, whereas the others are only licensed for patients up to 65 years of age. But patients in their 70’s are not my main target group. It is more a marketing gag. But Latybo® is also a good toxin.


Compared to other toxins, you achieve with NUCEIVA® great results using less units. The onset is a day earlier


For example, the diffusion characteristics, onset of action, and duration of effect can vary among these products. These differences can shape choice depending on the treatment area and desired outcomes. That said, by varying the 4 ‘D’s’ I can tailor the effect of NUCEIVA® to meet the needs of the individual patient that I’m treating.


Dr. Eccleston, thank you very much for the interview.


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