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Botox is a treatment adored by millions of satisfied patients and a staple of facial rejuvenation regimens around the world, but it also suffers from many unfair misconceptions and stereotypes. For those who are on the Botox bandwagon, they can’t imagine looking in the mirror without seeing its wrinkle-softening effects. For the uninitiated, Botox may be synonymous with vanity, and looking “plastic.” Although Botox has been safely used for a long-list of medical indications since the 1970’s and for cosmetic indications for more than 15 years, there are those who still erroneously consider it to be a poison. Some of the terminology associated with Botox can be confusing for newbies – words like glabella, units, and rhytids.

Since Botox is one of the pillars of my non-surgical aesthetic practice and my patients universally love it, I am here to tell the story of Botox including its history, what it’s used for, what its benefit are and what you should expect from your treatment.

Botox was first used in the 1970’s to treat strabismus, or misalignment of the eye muscles, eventually getting FDA approval for this indication as well as for treating eyelid spasms in 1989. Ophthalmologists began noticing that patients who were treated with Botox were also experiencing an improvement in their frown lines. In the 1990’s Botox began to be used “off-label” by dermatologists and plastic surgeons to improve wrinkles and in 2002 it finally received FDA approval for its first cosmetic indication – treating glabellar rhytids (frown lines).

Botox works by relaxing muscles. The cellular effect occurs at the neuron where it inhibits the release of a transmitter at the junction of the nerve and the muscle. The treatment is done in the office with little to no discomfort. The typical appointment takes 15 minutes or less. The effects of your Botox treatment will be noticeable within a week. Results last 3-4 months in most patients.

Botox’s cosmetic use is FDA approved for glabellar lines and crow’s feet. An FDA indication for forehead wrinkles is on the horizon. Additional areas where it is commonly used off label are the bunny lines on the nose, platysmal muscle bands in the neck, dynamic lip lines, DAO (muscles that pull down the corners of the mouth). Additional benefits can be seen when the chewing muscles are injected (masseters and temporalis muscles). Botox can also be used for excessive sweating (hyperhidrosis) and for migraines.

What age should I start doing Botox?
Cosmetic treatments should always be individualized. Not every patient needs a rhinoplasty or a facelift. Almost everyone can benefit from Botox. Some patients begin treating potential problem areas in their 20’s, frequently using smaller doses – a regimen we refer to as “baby Botox.” Botox at an early age has a “pre-juvenation” affect as in “preventative” and “rejuvenation.” By targeting muscle groups that cause frown lines, crow’s feet, and forehead creases before they have had a chance to become etched into the skin, we can prevent and delay the formation of these unwanted wrinkles.

Patients in their 30’s usually begin to make Botox a regular part of their beauty maintenance routine, with patients in their 40’s – 60’s making up the largest segment undergoing regular Botox treatments in my practice.

How often should I do Botox?
Botox tends to maintain its effect for 3-4 months in most patients. Like all medications, a bell curve effect exists – some patients experience a waning of their results after two months while others may notice results lasting 4-5 months. A dose-response effect exists as well meaning that if you achieve a full-correction by using the number of units recommended by your injector, your results will last longer than if you try to cut corners and undertreat with fewer units of Botox.

Will Botox make my wrinkles worse?
Botox does not make wrinkles worse over time. Once the Botox wears off, patients eventually notice a gradual return of their wrinkles. Regular use of Botox over many years has not shown any ill effects or worsening of facial wrinkles

What are common side effects from Botox?
Botox has very tolerable side effects. Occasionally patients may get a small bruise at a site of one of the injections. This is more likely to occur with patients who take blood thinning medicines such as aspirin, fish oil, certain supplements, and anti-inflammatories and with patients who have recently consumed red wine. Avoiding these for at least a week to 10 days before your treatment will minimize the risk of bruising. Even when a bruise does occur, it tends to be very small and easily covered with make-up.

Rarely patients report a mild headache after their treatment. Using ice post treatment can minimize this as well as taking Tylenol. Other systemic side effects such as nausea, malaise, fatigue, etc. have never been reported to me by any of my patients.

How much does Botox cost?
Botox pricing can be confusing for some patients. Some injectors charge by area or zone (a fixed price for the forehead or crow’s feet for example). Some practices charge by syringe. The most common approach is to charge based on the number of units injected. In my practice I currently charge $12 per unit. A unit is a dose measurement for Botox much like milligrams might be used for an oral medication. The number of units needed depends on many factors such as the size and activity of the muscle groups being treated, the height and width of the forehead, and the patient’s desired areas of treatment. Small, weak muscles require fewer units. Large, active muscles require more units. For example, when we treat a patient for a “gummy smile” we may only inject a total of 2-4 units of Botox into the muscles responsible for elevating the upper lip. However, when we are treating a patient with a strong muscle between their eyebrows that causes the 11’s (corrugator muscle), we can inject 25-30 units in some patients. The muscle that pulls down on the lower lip causing the corners of the mouth to turn down might only require 3-5 units on each side. The crow’s feet often require 10-12 units on each side for a full correction. The forehead has a widely variable requirement for Botox – from as little to 4 units in some of my patients to as many as 20 units in others.

As you can tell, there is no single recipe for achieving a perfect Botox treatment. There is not a standard number of units that I use in every patient. During your consultation we will discuss your areas of concern and objectives from your treatment. The number of units I recommend for you is always personalized based on you face and your goals and expectations. Since patients often want a “ballpark number,” I will say that the average patient in my practice is injected with 40-50 units of Botox for a full correction of their areas of concern.

Can I exercise after Botox?
Physicians have different opinions regarding exercise after Botox. There are two concerns: the first is that raising your blood pressure and heart rate after your treatment can increase blood flow to your face and potentially cause unwanted swelling or bruising. The other concern is that the movements that go along with working out could cause Botox to migrate to areas in the face where they would have unintended side effects or change the desired treatment result.

In my practice, I do not place any exercise limitations on my patients, but I do encourage them to get their exercise for the day in before they come in for their treatment whenever possible.

Can Botox be done at the same time as fillers, peels, or lasers?
Botox is routinely done in conjunction with fillers and skin resurfacing procedures such as lasers and peels. If my patient is getting a facial, I have them see my aesthetician first and then they see me for their Botox treatment.

Patients who do fillers to add volume to their cheeks, fill in hollows under their eyes, enhance their lips, etc. almost always do Botox at the same time to give a more balanced and comprehensive rejuvenation effect. Studies have also shown that Botox can improve the longevity of fillers in areas where the repetitive contraction of small muscles might displace or increase the metabolism of the filler.

I routinely do Botox in conjunction with a fractional laser treatment or peel and even will do patients’ Botox for them during surgery (facelift, rhinoplasty, skin cancer surgery, etc.) if they desire.

Will Botox prevent me from needing surgery down the road?
Botox is a fantastic way to look refreshed without downtime. As time progresses, the wrinkle-reducing effects of Botox may not keep up with other age-related changes that occur that are better managed with surgery. Combining regular Botox treatments with periodic filler treatments can often push back the need for more invasive procedures. Eventually, when skin and soft tissues sag, procedures like a face, brow, or eyelid lift will still be beneficial.

Is Botox dangerous?
Botox has been used for decades on millions of patients throughout the world. When used properly by trained professionals, it is extremely safe with very few potential side effects.

Is Botox a poison?
Botox is a medication with physiological effects that mimic the effects of a toxin produced by a bacteria called clostridium botulinum. When used in a controlled, prescribed manner, it is not considered a poison.

Am I too old for Botox?
There is no universal age where Botox becomes ineffective. Rather than age, an individual’s specific anatomy and expectations guide whether Botox is indicated or not. I have many patients in my practice in their 70’s who enjoy the benefits of Botox and even treat a few patients in their 80’s.

Will I bruise from Botox?
A typical Botox treatment involves a series of injections into the skin with very small needles (32 gauge needles). Although large bruises are very rare, an occasional small bruise at the site of one of the injections can occur from time and time and is usually easily covered with makeup. In order to minimize bruising, we ask patients to avoid fish oil, aspirin, ibuprofen, and other blood thinning medication for 10 days before their treatment. We use ice before, during, and after treatment which also helps to minimize bruising.

Does Botox hurt?
Most patients report very little discomfort with Botox. If you happen to be a patient who is a little more sensitive to pain, we can use numbing cream to make the treatment even more tolerable.

What if I don’t like the way Botox make me look?
Having treated thousands of patients with Botox, I can honestly say that I can count on one hand the number of patients who didn’t absolutely love their results. For some patients there is a brief adjustment period during which they have to get used to being wrinkle free. If for some reason you don’t love Botox, it will wear off after a few months.

Who should I go to for my Botox treatment?
Botox is now so commonly performed that you can find it almost anywhere: medical spa’s, dermatologists, internists, nurses, dentists, etc. A thorough understanding of facial anatomy and the elements of facial aging as well as a mastery of available techniques for facial rejuvenation will ensure that you get the best possible outcome from your Botox treatment. Although there are many providers capable of giving you a great result, my extensive education and training coupled with my detailed knowledge of facial anatomy, surgical expertise of the face and neck and dual Board Certification as a Facial plastic and Reconstructive Surgeon make me an ideal provider for your Botox and other facial aesthetic treatments.

Do men do Botox?
Men are great candidate for Botox or “bro-tox” as we like to call it. When I treat men with Botox, the goal is usually to soften deep lines in the glabella and forehead and smooth out the crow’s feet. Men usually prefer to have some movement and opt not to go for the “frozen” look. Because the facial muscle groups tend to be larger and more active in men, men can often require higher doses of Botox than their female counterparts. It is not uncommon for men to have 50-70 units of Botox and still have natural movement.

Where is the most common area to treat with Botox?
When most people consider Botox for their first time, they usually point to the frown lines between their eyebrows (the 11’s) which is an anatomic area we call the glabella. Horizontal forehead lines are also commonly treated as are the fine lines next to the eyes (the crow’ feet). Although individual areas can be treated by themselves, as a rule, I prefer to treat the glabella, forehead, and crow’s feet together in order to achieve a balanced, natural look.

Can Botox be used to lift and shape my brows?
There are two competing muscle groups in the forehead and around the eyes. There are muscles that elevate the brows and there are another set of muscles that pull down on the brows. When I inject specific spots in these different muscle groups, I can give my patients a lifted brow (“chemical brow lift” or non-surgical brow lift) that can help them look more refreshed and rested.

In addition to Botox, what other non-surgical treatments should I consider?
Whereas Botox improves fine lines and smooths the skin, fillers are used to add volume to areas of the face that have become flat and deflated. The most popular fillers in my practice are Volbella which is used for subtle lip enhancement and improvement of lines around the mouth, Voluma which is used for adding shape and volume to the cheeks and temples, and Vollure which I use for the deep lines and folds around the mouth and in the lips for achieving the perfect pout. Kybella is a non-surgical treatment for dissolving fat under the chin which chisels and shapes the neck and jawline.

Daines Plastic Surgery