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BOTOX ® is a protein complex that interferes with muscle contraction. It temporarily blocks nerve stimulation of muscles where it is injected, so that muscle contraction is weakened or inhibited. BOTOX ® has been safely used for many years to treat spasms of the muscles that move the eye (strabismus) and uncontrollable blinking (blepharospasm). In 2002 it was approved by the FDA for cosmetic use, and since that time it has been marketed as BOTOX ® Cosmetic.
Many facial wrinkles and creases are active lines caused by muscle contraction, which can be blocked by BOTOX ® injection. The effect is temporary, usually lasting 3 to 6 months. With repeated injection, the effect may regularly last up to 5 or 6 months. Although some wrinkles and creases may completely disappear (temporarily), it is important to understand that some may improve but not completely disappear. Some people (very few) are resistant to BOTOX ® and achieve little or no response.
Where does BOTOX ® work the best?
Areas of the face that respond well include 'crows feet' lines around the eyes, vertical frown lines between the eyebrows, and horizontal ('worry') lines on the forehead. BOTOX ® can also be administered just below the lateral aspect of the eyebrow to produce a temporary lateral browlift, which opens up and brightens the eyes.
In some instances, BOTOX ® can be used to soften vertical upper and lower lip lines, to reduce muscle bands in the anterior neck, and even to elevate the nasal tip. While there are some good 'lower face' indications for BOTOX ® administration, in my practice the majority of injections are for 'upper face' (especially eye area) rejuvenation.
One truly remarkable consequence of BOTOX ® administration that I have seen over and over again is the gradual complete disappearance of deep, vertical furrows between the eyebrows (frown or 'scowl' lines). With long-standing muscle contraction, the vertical lines between the brows may become actual physical clefts or grooves in the dermis, resulting in creases that are still apparent even when the skin is spread apart tightly with a finger on each side of the crease. In such instances, the initial BOTOX ® injection will soften but not completely eliminate the deep furrow. With regular BOTOX ® treatment, however, such that the frown muscles are never allowed to fully regain their normal ability to contract, the deep furrows may gradually fade completely.
Some patients with chronic, deep furrows between the brows achieve improvement but not complete correction of these creases with repeated BOTOX ® injection. In these cases, a soft tissue filler can be used to eliminate what remains of the furrow. I have used Restylane for this indication in a number of patients with excellent results, and for several of these patients I have performed structural fat grafting of the remaining furrow to provide a permanent correction.
What is a BOTOX ® treatment like?
BOTOX ® is precisely injected through a tiny needle into specific facial muscles. The areas to be injected are cooled with an ice pack immediately prior to injection to significantly reduce needle discomfort. The complete treatment lasts just one to three minutes (depending on the number of areas being treated) and does not require the use of topical or local anesthetics. BOTOX ® begins to show its effect after 2 to 5 days, although some patients report a noticeable difference the very next day.
Could I get a "frozen face" from BOTOX injection?
As is my goal with facial rejuvenation surgery, I seek to produce natural-appearing results with non-surgical treatments like BOTOX ®. The effect of BOTOX ® is dose-dependent, and thus the degree of muscle contraction impairment can be varied by the amount of BOTOX ® that is administered in any given treatment area. While my goal for vertical frown lines between the brows is to completely eliminate them, my goal for horizontal frown lines is to soften them while maintaining the patient's ability to elevate their brows.
Nobody seems to miss being able to scowl, but everybody wants to retain the ability to express hope, surprise or concern. Thus injection of the forehead to reduce horizontal creases should be conservative. Over-treatment of the forehead will also have the effect of lowering the brows, which is without question an undesirable BOTOX ® result.
Patients will often ask me if I can "get rid of this line" in regards to facial lines and wrinkles that may not necessarily contribute to the appearance of age or fatigue. My strong feeling about the softening of facial lines and wrinkles is this: if it doesn't 'age' you, and it doesn't make you look tired or worried, then don't spend your hard-earned money trying to make it go away. Some lines actually do add warmth and character to the face, and an older face with NO lines usually looks a bit odd.
Who should inject BOTOX ®?
It is my opinion that a surgeon's intimate knowledge of the anatomy and physiology of the muscles of facial expression make a surgeon, or a surgeon-trained and supervised medical professional, the ideal person to perform BOTOX ® injection. A plastic surgeon has, without question, the best three-dimensional understanding of facial anatomy, and therefore also has the greatest ability to perform precision injections that produce exactly the desired the effect (and that avoid unintended and undesirable effects, as well as treatment complications).
Many of my BOTOX ® patients have other aesthetic concerns, some of which are amenable to treatment with other non-surgical technologies, and some of which are surgical issues. Many are interested in discussing the treatment possibilities and in reviewing 'before and after' photographs. By choosing for their BOTOX ® injection the office of a board-certified plastic surgeon, which is fully integrated with a state-of-the-art medical spa and laser center, our patients avail themselves of the full spectrum of medical and surgical aesthetic technology.
Is there a permanent alternative to BOTOX ®?
Permanent improvement in facial wrinkles and creases can be accomplished with a variety of techniques, including non-invasive laser skin rejuvenation, laser resurfacing, structural fat grafting and surgery. Not all wrinkles are appropriate 'targets' for BOTOX ®, so the evaluation and treatment of every face must be individualized.
For vertical frown lines between the brows, surgical interruption of the corrugator muscles that produce these creases is available. These frown muscles can be approached through an upper eyelid incision (in patients undergoing upper blepharoplasty) or endoscopically through small incision behind the frontal hairline. The muscles are divided, partially removed, and the ability to form the 'scowl' lines is significantly reduced or eliminated.
What about 'BOTOX ® parties'?
BOTOX ® is an injectable pharmacologic agent, and is most appropriately administered in a medical setting. It is my feeling that a 'party' is not the appropriate setting for the administration of a medical treatment, particularly an injectable one. The 'BOTOX party' that is held outside of a medical setting is a marketing strategy used to promote the treatment and to perhaps make it less intimidating to the general public. Before joining the 'party', ask yourself the following questions:
- Have I been asked to provide a complete medical history?
- Have I been advised of alternative treatments?
- Have risks or potential complications been discussed?
- Have I been asked to give my informed consent?
- Will I receive adequate follow-up care?
BOTOX ®, like all other injectable medications, belongs in a physician's office. Period.
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