So how does a patient know if they are being given a lower-than-necessary dose of neuromodulator that’s been masked by overdilution (sometimes called hyper-reconstitution or hyperdilution)at least until the results start fading fast? To answer that you have to understand exactly how neuromodulators are priced, and injected.
The Price is Right
When a person books a neuromodulator treatment, whether in a doctor’s office or at a med spa, they can usually expect to pay based on the number of units used. An alternative to having patients pay a fixed price based on treatment area, this system has its benefits—and its drawbacks, one of which is that it may contribute to the sort of overdilution consumers are complaining about.
In a per-unit pricing system, unit cost typically ranges from $10 to $30 in the U.S., according to the American Academy of Facial Aesthetics, and depends on factors such as location, injector expertise, or whether it’s an independent practice. As Allure previously reported, larger practices, especially nationwide med spa chains, can negotiate better wholesale prices, meaning they can charge less per unit and still turn a profit. A simple Groupon search for Botox treatments in New York City shows a plethora of deals at med spas, with prices as low as $6 per unit for 20- or 40-unit packages. (That said, please do not let a Groupon deal determine where you get your Botox. Instead, ask the provider the right questions about their training and experience.)
“A lot of practices will make Botox a loss leader, to get you in the door at a very low price even though they know it’s impossible to make a profit at that point… and try to convert you to laser, filler, skin care, or whatever else that isn’t as cheap,” says Saami Khalifian, a double board-certified dermatologist in Encinitas, California, and medical director of the Allergan Medical Institute.
He believes that the current per-unit pricing system can commodify the injector and condition patients to seek out the lowest-cost option rather than experienced, results-driven providers—he also concedes that his practice uses it because it’s common industry practice and patients are most comfortable with it. Other injectors, including Dr. Rabach, prefer the per-unit model because patients get exactly what they pay for. Per-area pricing could mean patients receive fewer units than necessary so the provider does not lose money on the treatment, she says.
Still, the dominant per-unit pricing arrangement could turn patients into their own worst enemies by trying to do more with less, contributing to the overdilution issue. If a patient is only interested in spending a certain amount but is trying to cover large areas, such as the masseter muscle, the neck, or the forehead, injectors have to compensate by hyperdiluting the neuromodulator to cover those areas with fewer units.
When Hyperdilution Makes Sense
Sometimes overdilution isn’t a bad thing: All of the doctors we spoke to for this story say they’ve strategically overdiluted neuromodulators in the past to achieve a softer effect, thereby requiring fewer units. See “Baby Botox,” a technique that involves purposefully injecting fewer units than recommended for what the manufacturer considers full results. But there are no clinical studies on off-label overdilution despite it being a historically-common practice among injectors—just like treating areas like above the brows, where neuromodulator use is technically not FDA-approved.
