How Botox Works and What to Expect

Doctor’s Note

Welcome to Plain Talk About Plastic Surgery, a podcast that educates you about all things relating to plastic surgery procedures and operations, with down-to earth and honest information.

I’m your host, Dr. Elizabeth Kerner.  While you listen, I hope you’ll think of me as your sister, the plastic surgeon, who will tell you like it really is.

I have been in practice in Plano TX, a northern suburb of Dallas, for over 30 years.  I am an American Board of Plastic Surgery certified plastic surgeon, and have been a member of both the American Society of Plastic Surgeons and the The Aesthetic Society.

My practice is predominantly cosmetic surgery, doing about 80% cosmetic surgery and 20% reconstructive surgery.

I am a past president of the Texas Society of Plastic Surgeons.  I was also the first female president of the hospital medical staff at Texas Health Presbyterian Hospital Plano, where we have 1,400 doctors.

I am a member of the Texas Medical Association, and the Dallas County Medical Society. I have been on many leadership committees and boards over the years.

Each episode of Plain Talk About Plastic Surgery will focus on one area of plastic surgery in depth, discussing the anatomy, the operative technique, risks, potential complications, and most importantly, who would be a good candidate and who would not be a good candidate.

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Episode Transcript

Introduction

Welcome to Plain Talk About Plastic Surgery, a podcast that brings you down to earth, honest and practical information about various plastic surgery procedures, operations and subjects of interest in the plastic surgery field.

I’m Dr. Elizabeth Kerner and I’ll be your host for this episode. I am a plastic surgeon practicing in Plano, Texas, and I have 32 years of experience.

Today, we’re going to dive into Botox: the uses of Botox, the abuses of Botox, and contraindications.

The (Surprisingly) Long History of Botox in Medicine

Most people don’t realize that Botox has been in use in the medical field for well over 20 years.

It first began, I think, in the ophthalmologic arena to help patients that had tics – so that little spastic twitching of your eye. They found if you injected Botox into the muscle, it would make the twitching stop.

Other uses at the time were laryngeal spasm, vocal cord problems, and then, of course, it rapidly escalated to almost all fields. It has wide use in the urologic field when you have bladder issues or urethra issues. Of course, it also has uses in neurology for migraines, and trigger points, and chronic pain. I’m not sure that there’s actually a field where Botox isn’t used in some form or fashion.

The arrival of Botox in the cosmetic arena really took off about seven to eight years ago. Allergan, who is the big gorilla in the cosmetic field because they provide implants, Botox fillers – gosh, you name it – CoolSculpting, various skin care lines.

Botox Alternatives: Dysport and Jeuveau

In my field they’re one of the two major players for all of the cosmeceuticals, Botox being the number one. Allergan just quietly bought up the patents or companies that were manufacturing Botox. Now, lo and behold, they’re really the only one.

There is another new Botox out called Jeuveau, which is just slightly different. These are all onabotulinum toxins and can be A’s, B’s, or C’s. I’ve used it and it seems like it works pretty well. I think the efficacy is going to be about the same as Botox but the company’s really struggling to get off the ground.

And then, of course, there’s Dysport. I didn’t switch over to Dysport for a couple of reasons. One, I was real happy with Botox and after injecting it for many years I felt like I had a good feel for how much I needed to put, and where, and how I could align expectations of the patients with what the Botox could really do. I think with Dysport you have to use a few more units to achieve the same effect as Botox, and perhaps it doesn’t last quite as long. But this is coming for somebody who hasn’t used Dysport on any patients.

Botox Administration, and the Importance of Choosing A Doctor You Trust

Let me give you some background on Botox. It comes in a little glass vial. It’s frozen. It’s a freeze dried product. To reconstitute it I put preservative free saline in. Each little glass vial has 100 units of botulinum toxin in there.

Depending on how many cc’s of saline that I put in, that will determine how many units per tenth of a CC can inject.

Over the years, I found that for the vast majority of my patients, if I put 33 units – so one cc because I put three cc’s of fluid in there to reconstitute it – that 33 units pretty much allows me to inject the areas between the eyebrow and some in the forehead and maybe a little bit in the crow’s feet.

And I alter that injection pattern, of course, depending on what really bothers the patient. Some men have really thick muscles and some women have really, really bad crow’s feet, and we may need to go up to one and a half cc’s.

When you look at Botox injections and Botox prices, there are a few things you need to think about.

The Importance of a Reputable Provider

One, is this a reputable provider? You know, if you’re just going to the spa down at the end of the block, does that person who’s injecting you really know how to inject and do you really have any idea how many units you’re getting?

They can tell you this, but can you honestly trust them? When you see the ads on the freeway that say Botox is like five dollars a unit, I’m not thinking that’s really true because whoever’s injecting it is really taking a major financial loss.

I would think if you did go in to get Botox and it’s that cheap, they were going to probably try and sell you to do something else to make up for the loss. But I digress.

How and Where to Administer Botox

I will reconstitute the Botox. Then in the office it’s injected with a little tiny needle, a 30 gauge, so there’s a little bitty prick. Then the Botox goes into the muscular area that we want to inject.

The Botox works by paralyzing the nerve that supplies the muscles, so then the muscle can’t activate, which means it can’t wrinkle.

Mostly, the muscles we’re trying to keep from working are the three between the eyebrows; your corrugators and then your procerus in the middle – that’s what creates the “11”.

For the forehead, I will do a judicious pattern because if you’ve listened to my podcast about brow lifts, you know, the anatomy of the forehead is such that there’s only one muscle that lifts up your eyebrows.

So if you come in with lots and lots of transverse forehead lines, you know, deep wrinkle lines across your forehead, and you say “I want all of these gone,” I can make you smooth, but the cost of that is it’s going to cause your eyebrows to drop down. Because that is the only muscle that lifts them up.

If I make that one muscle not work, then your eyebrows – the hairy part of your brow – is going to go downwards by gravity.

For most people that have lots of transverse forehead lines, we’ll do a hopscotch pattern to try and keep a more normal, natural looking shape to the brow and soften the forehead, and hopefully get a little bit of a brow lift, but you’ll still have some function.

So that means when you look in the mirror your brows should look fine, but when you elevate, you’ll get some creasing above the brows, which just means that’s the part of the muscle that’s working.

Other areas it can be injected are the crow’s feet. One does have to be very careful. If you inject too far towards the nose, there are muscles that come up in that area, the zygomatic muscles. When you make them not work, then you look like you’ve had a stroke.

It’s possible to inject the muscles around the mouth and the lips. I try and talk most people out of the lips. You can only put a little teeny tiny bit into each wrinkle line. It hurts like the devil to do it, although that goes right away.

But it doesn’t last very long because you’re only putting a little smidge of Botox. Of course, this is a muscle that functions, and so although the wrinkle line will be better, it’s not very long lasting.

If you put too much in there to get a longer duration, then your lips are not going to move very well. It’s the same thing for around the chin.

I know that lots of people will use it at the corners of the mouth to try and get a little lip lift. All of that can be done. All of that can have great results. It’s just how much money you want to pay because those areas are not going to last very long and you will have to come back in and and have injections more frequently.

When the Botox goes in, it burns. Then we’ll put some cold water on a pad right on the injection site. The burning usually goes away in just a few seconds. Then when you’re done, you can go out and put makeup on if you wish.

Restrictions After Botox, How Long it Takes to See Results, and How Long Botox Lasts

My only restriction is I don’t want you to be exercising or going home and taking a nap or bending down because we don’t want the Botox to diffuse down into the eyelid because then your eyelid would be weak and you won’t be able to open your eye very well.

Most people for their first injection will begin to see a difference in about seven to 10 days. It’s kind of weird and I can speak from personal experience. When you inject Botox, it feels like your muscles are working and you think “oh, gosh, this isn’t working.” Then you look in the mirror and you realize nothing is actually happening.

The muscle around your eye, the orbicularis (if you listen to my eyelid podcast you know all about the orbicularis), that muscle can’t be injected too much because that closes your eyelid. Obviously we want you to have that function afterwards.

I can squinch my eyes down really, really hard, like really squint them in, and I can create a few creases between my eyebrows but it’s really the lower muscle, the orbicularis, that’s pulling that tissue in. It’s not the three little muscles between my eyebrows that have been injected.

My hope is that if you keep up with the injections, the muscles will atrophy and then you don’t need to have as many injections done down the road.

We’d like your duration to get out hopefully to five, six, seven months. Some people, though, have really heavy, thick muscles and they’re very expressive and they only get three and a half or four months. They never get past that.

Some people have had exposure to botulism in the past. If you’ve had that, you will have antibodies. That means when we inject the Botox, it will work for three to four weeks and then it won’t work after that.

That’s too bad because it’s a waste of your money to do any more Botox.

Most of the complaints I get are, “Gosh, I’ve still got a wrinkle or I still have crow’s feet.” That’s a distribution issue. It means I have one cc of Botox to spread across the forehead and the crow’s feet, and I probably undertreated there.

For many of my patients we will do one cc injection and then when they come back for the repeat we’ll do one and a half so we can get a better injection in all areas.

And some people just do one and a half.

I just charge by the cc. This is just my personal thought but I think if you charge by the area – so there would be between the eyes, there’d be the forehead, there’d be the left crow’s feet, the right crow’s feet – then it starts to become really rather expensive.

Complications and Recovery

Downsides are not too many as long as the Botox doesn’t diffuse and make the eyelid weak. The other is just the esthetic result; I don’t want to have too much of an arch to the brow.

We’d like to get rid of forehead creases but still maintain a little bit of activity.

Sometimes when I inject, because this is a blind injection, meaning I’m just sticking it into your skin and I can’t see all the layers underneath, you could get a little bruise. Fortunately, that doesn’t last very long and we do have Arnica to give you to help with that.

About 10 percent of patients will have a very short lived headache after their injection. That seems to last for about two to three hours.

That’s really about it: the bruise, and then a little headache, and will you be happy with the result?

Botox has basically revolutionized what we can do to the upper third of the face because the only other option was to do a forehead lift or brow lift, and those are both surgical procedures that are not completely without their complications or side effects.

I do find for some of my long term patients that I have been injecting that it does seem to become less efficacious, where they were getting six, seven, eight, nine months, and then they may have a period where it only seems to last three to four months.

I’m fully convinced that not all the Botox vials I get probably have the same 100 units of activity. It may just be that that vial that I reconstituted instead of getting 33 units, maybe you got 30. Or maybe you were fighting off an infection and the inflammatory response made the Botox not work quite as well.

There are very few contraindications. If you’re on a blood thinner, I don’t like to inject Botox because then you will get bruised. There are specific medications, mostly if you have a really, really bad bladder infection, some of the real strong medications will neutralize the effect of Botox.

If you have an underlying neuromuscular disorder, you really ought not to have Botox injected as well.

Other than that, Botox is a pretty safe, extremely popular treatment to just slow down the signs of facial aging. I use it myself. I like it.

If you need a facelift or you need your eyelids done or you need a brow lift, it’s not going to make you not need that anymore. But hopefully it’ll make the time when you might consider having that operation a few more years off in the future.

Conclusion

Well, that is all that I have for Botox. You are welcome to look on our website at www.DrKerner.com. That’s D-R-K-E-R-N-E-R.com.

Certainly going to the Botox web site, which is run by Allergan, gives you a huge amount of information. Allergan also has a loyalty program called Brilliant Distinctions and we strongly encourage everyone to sign up for that.

When you sign up and you have an injection, either of Botox or any of the fillers, we will put those numbers into your account. That creates coupons or points which then you can later redeem for coupons.

Over the years that we’ve been doing this, I think our patients have redeemed about $35,000 dollars in money off of Botox and fillers. Allergan is really good about not hounding you about this. I can see absolutely no downsides to joining the Brilliant Distinctions Rewards program.

For other episodes and upcoming episodes you can go to my website, www.DrKerner.com/Podcasts or you can find my podcast almost anywhere you get your regular podcasts, and this is also on YouTube.

Thank you very much for listening. Have a great day and don’t forget to use your sunblock!

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