This has been a big year for botulinum toxin, with the approval of the touted longer-lasting daxibotulinum toxin A. Dr. Goldberg presented a summary of the updates in this principal dermatologic class. He started off by reviewing unit equivalence when diluted with 0.9% sodium chloride: 1U ONA: 1.5U INCA: 1.5U PRA: 2.5U ABO. Addressing a long-standing question on toxin use, he reviewed an open-label clinical trial using high dose (120U) of abobotulinum toxin for glabellar lines to assess impact on duration of effect. Patients were followed monthly for up to 11 months, and the >75% of subjects had a duration of >120 days of at least 1 point improvement on investigator IGA, long over what is considered its typical dose-duration. Enter daxibotulinum toxin, which has been approved by the FDA with a median duration of effect of 6 months. High dose and novel formulations of botulinum toxin will impact clinical care and potentially consistent results until they are adequately tested. 
In the second half of this presentation, Dr. Goldenberg focused on injection techniques discussing lateral brow lift via the orbicularis oculi and the medial frontalis, lip lift via the depressor anguli oris, and “gummy smile” via the levator labii superioris. Perhaps more importantly, he also reviewed danger zones that are rife with poor outcomes. Lastly, in a world where patients can increasingly obtain botulinum injections from outside a physician’s office, Dr. Goldenberg stressed the importance of marketing. Start with the cosmetic consultation, and your connection to the patient already in your office. After this, emailing prior patients with promotions and educational content is a good way to keep them coming back, while social media should present your “brand” consistently to newcomers.