RETHINKING TOXIN TIMELINES

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RETHINKING TOXIN TIMELINES

Bryony Cupitt considers why ‘routine’ retreatments may be holding us back

In 2024, I stood on stage at Aesthetic Medicine London, sharing my perspective on toxin treatments, specifically, on how frequently we should treat our patients and whether we should exercise greater clinical autonomy in developing new protocols.

When I trained in aesthetics in 2017, I was repeatedly told that toxin treatments are a three-to-four-monthly affair, making it standard practice to automatically rebook. Once injected, botulinum toxin cleaves the SNAP-25 protein, ultimately preventing the release of acetylcholine. Inhibition of this neurotransmitter causes flaccid paralysis in the directly treated muscle until the nerve endings begin to regenerate, which takes, on average, between six and nine weeks. Many of us then automatically rebook patients at 12 to 16 weeks for a full retreatment, leading to what we are told is prolonged muscle relaxation and eventual atrophy. This atrophy is what helps patients achieve improved long-term results, so the rationale behind the timeline is understandable.

WHEN TIMING UNDERMINES EFFICACY

In 2023, I had a 38-year-old female patient who had been attending regularly for toxin treatments over the previous three years. At her review appointment, I was surprised to notice residual muscle activity across several areas of the upper face, despite her receiving her usual dosage and placement. This wasn’t the first time; we had observed the same findings at her preceding treatment. When I examined potential influencing factors, I noted that we had changed her toxin brand, which had arguably given her greater longevity. Upon discussing my observations with the patient, she confirmed that there were no lifestyle or medical changes. She was not an isolated case, and it became increasingly clear that a hypothesis I had been quietly considering was manifesting across my clinical practice. This prompted me to conduct a small-scale trial to explore it further.

Given what we know about the mechanism of action of botulinum toxin regarding its role in cleaving the SNAP-25 protein, is it unreasonable to suggest that insufficient nerve regeneration could impair treatment efficacy? If, at the point of injection, there are no new active nerve endings present, there is consequently no SNAP-25 receptor site available to bind to, and therefore no inhibition of new muscle activity. As a result, the toxin is transported directly to the liver to be metabolised without any therapeutic effect (Simpson, L). The clinical consequence? Patients potentially presenting a month later with more pronounced lines than pre-treatment, followed by an explanation from us as to why we cannot retreat due to the risk of developing product immunity. Patient dissatisfaction inevitably rises, which is hardly the aim from any business perspective, and our frustration grows as we question what went wrong.

ADVANCING PRACTICE

As the industry evolves, several factors must be considered. First, advancements in product longevity, as evidenced by published studies, may warrant a reassessment of retreatment timelines. Second, our anatomical knowledge has progressed considerably over the past two decades. Increased access to cadaveric dissections has expanded our understanding of anatomical structures, and we have developed a far more refined appreciation of the motor endplates within muscle groups and how to optimise treatment outcomes. This means patients are getting better results and increased longevity, leading to the logical conclusion that nerve regeneration is occurring more slowly, rendering premature retreatment appointments not only ineffective but potentially counterproductive.

So, with the patient at the centre of everything we do, how do we maximise satisfaction using this knowledge? How do we achieve a purposeful, induced muscular atrophy without treating too prematurely? In my view, the answer lies in clinical judgement. I believe that many of us, having come from established healthcare specialities, enter aesthetics and find ourselves defaulting to protocols simply because the guidance isn’t always clear. The best thing we can do is develop the same clinical autonomy we exercised within our original disciplines – autonomy that can not only grow our businesses, but strengthen our confidence as practitioners. I remember, as a newly qualified nurse working in aesthetics, being reluctant to go against the grain. But a quote I encountered along the way has stayed with me, and I hope it offers encouragement to those who doubt their own clinical instincts:

“If you are not willing to risk the unusual, you will have to settle for the ordinary,” – Jim Rohn, entrepreneur.

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