Neuromodulators is a group of drugs, that relax the muscles by blocking nerve impulses that otherwise invigorate them. In cosmetic surgery neuromodulators is used to treat lines and wrinkles. Botox is the most widely known neuromodulator and other two FDA approved neuromodulator are Xeomin and Dysport. The efficacy and prices of these three neuromodulators are roughly equivalent.

Dr. Mark G. Rubin, M.D., is a dermatologist in private practice in Beverly Hills, according to him, the treatment usually last for around three months, so patients have to come back every three months or so for their neuromodulators. This may become frustrating for them , so extending the durability of results would be a good idea for the treatment if possible.

Here comes the concept of adding epinephrine to neuromodulators to achieve better and longer-lasting results.

Neuromodulators with epinephrine

In the year 2007 a study was performed by Dr. rubin to see the effect of neuromodulator mixed with epinephrine. In this study, researchers injected 12 units of onabotulinumtoxinA to the periorbital rhytids on one side of the faces of 14 patients’. They injected the other side with 12 units of onabotulinumtoxinA mixed with epinephrine (in the ratio of 1:100,000). After 90 days, the neuromodulator with epinephrine side showed better efficacy.

At that time, Dr. Rubin restricted the use of epinephrine to only those patients who did not respond normally to onabotulinumtoxinA and he observed better results.

When Dysport or abobotulinumtoxinA came out Dr. Rubin tried switching to Dysport for the patients who did not respond normally to onabotulinumtoxinA, and many of those patients responded. If the patients did not respond to Dysport or Botox then he tried Xeomin or incobotulinumtoxinA. Dr Rubin restarted use of Epinephrine only recently, when two new studies showed the efficacy of adding epinephrine. This one anecdotal evidence of enhancement needs to be further evaluated with other studies.

The dose of the different neuromodulators is definitely different, but the efficacy is about the same. One of the new studies was performed with 40 patients with crow’s feet. In this study it was found that injecting one site with 36 units abobotulinum on each side of the face yielded no significant difference in results versus injecting three sites with 12 units of Botox on each side of face through 120 days of follow-up.

Adding lidocaine to the mix

Another study was performed involving 181 patients who had been treated with onabotulinumtoxinA diluted with saline and the treatment sites included the glabella, the perioral and the periorbital areas. Investigators gave injections of onabotulinum toxin mixed with lidocaine and epinephrine to these patients. Three months after the treatment, about 58 percent of patients rated the combination treatment more superior than previous one.

According to the opinion of 86 percent of patients the combination was better and they experienced immediate improvement. The immediate improvement is due to the presence of lidocaine, a local anesthetic causing muscle paralysis. Many of them also thought it lasted longer.

Dr. Rubin Opines that future research should help to clarify what patients think of the treatment and will help to draw better inference.

Positive value

Based on current studies the combination of neuromodulators and epinephrine appears to have positive value.

According to Dr. Rubin, although adding epinephrine shows better results but some patients may not respond well to the treatment and can show few side effects such as palpitation and anxiety. It is often seen that patients with ruddy complexions develop significant vasoconstriction (narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels), that causes appearance of temporary white blotches.

The combination injection of neuromodulator and epinephrine causes little more stinging sensation than a traditional neuromodulator injection.

So it can be concluded that the new combination injection show very good results in some patients and moderately well in other.

Preparing the mixture is very easy, just mix 0.1 cc of 1:1000 epinephrine solution then inject it into 10 cc of saline and use that as the reconstituting solution.