Botox is a prescription medication that initially gained the United States government’s FDA approval back in 1989 for the treatment of eyelid spasm. Ever since its approval, it was used “off label” by many Plastic Surgeons for the reduction of wrinkles known as “frown lines” as well as “crow’s feet” and in the “forehead.”
In 2002 Botox gained its official FDA approval for treatment of Glabellar wrinkles also known as “frown lines” or the now infamous “11 lines.”
Botox is a substance known as OnabotulinumtoxinA produced and distributed by Allergan. That is its chemical name. In laymen terms Botox is a form of medical grade Botulinum toxin, which has been used by millions of people. Botox is used by numerous different medical specialists to treat a variety of issues.
Botox is used by Dermatologists, Plastic Surgeons and Facial Plastic Surgeons to reduce the appearance of wrinkles or to prevent wrinkle formation altogether in the first place. Botox can be used to prevent or reduce the appearance of a “gummy smile.” Botox can help elevate the outer eyebrow in some women to give them more of an arch. Botox can reduce lip wrinkles in some women or prevent their lips from thinning out while smiling in select few. Botox can help reduce the size of the Masseter muscle on the jaw and help reduce the size of a wide jaw often seen in some Asian patients.
Botox has been used much more commonly in non-cosmetic cases by various medical specialists. For example, Botox is used in small children with Cerebral Palsy to reduce the amount of salivation in order to prevent aspiration pneumonia. Botox is used by ENT surgeons to treat vocal cord spasms known as Spasmodic Dysphonia. Botox is used by Urologists to treat hyperactive bladders. Botox is used by Neurologists to treat migraine headaches. Botox can be used by Dermatologists to reduce excess sweating.
Photo 1: Actual patient of The Naderi Center, 24 year old woman smiling before and after Botox. Less lines form with Botox but natural smile is maintained.
Photo 2: Actual Patient of The Naderi Center, “Mrs. Washington DC 2012” smiling before and after Botox. Less lines form with Botox but natural smile is maintained with brighter more beautiful open eyes.
|Figure 1: The nerve ending is show above, with a small space know as the synapse or cleft and then the muscle is shown below. Nerves release their transmitters into this space and do not directly touch the muscle.|
Botox works at the Nicotinic nerve ending by preventing the release of Acetylcholine neurotransmitter vesicles thereby cutting off the communication between the nerve and the target muscle.
This process takes up to 2 weeks after injection to fully complete. This is why Plastic Surgeons tell their patients that although they may see some results after 2-3 days, it may take up to 2 weeks for the patients to see the full effects of the Botox just injected.
The nerve regenerates new endings in about 3 to 4 months and the entire cycle starts again. This is why Botox injections need to be repeated on average every 3 to 4 months for optimal results. Botox leaves no significant residual effects beyond 4 months for most people.
|Figure 2: Botox molecules are shown above binding to the nerve ending and preventing release of neurotransmitters into this space thereby not allowing nerve to muscle communication and resulting in relaxation of teh muscle.|
Botox results usually last around three to four months and repeat injections are needed to maintain the best results. Some patients claim their Botox lasted 6 months or more. In most such cases the actual effects of the Botox have worn off but the muscle-memory has been interrupted and the patient no longer frowns or squints as much as before.
Botox injections must be repeated 3-4 times per year for best results. Ideally, the next injection should be done by Dr. Naderi or Dr. Kulak or your Plastic Surgeon before the results of your last Botox injection completely wear off. The goal is to keep the targeted muscles weak all the time. This is why we encourage our patients to schedule their visits in advance so there is no time period where their frown muscles are regaining bulk or strength. The goal is to have these muscles get weaker and weaker and therefore create fewer wrinkles.
Doing Botox injections once a year is better than not doing Botox at all. Twice a year is better than once a year injections. But ideally for the best results Botox should be re-injected 3 to 4 times per year.
Botox simply relaxes voluntary muscle movement in certain areas of the face. Therefore Botox helps reduce or eliminate “dynamic wrinkles” or wrinkles that get worse with expression and movement. The wrinkles that are already present at rest known as “static wrinkles” will not go away with just Botox. Other additional procedures may be needed to improve those types of wrinkles such as CO2 laser or fillers.
Botox comes in 50 and 100 unit sterile vials in powder form. Each plastic Surgeon or Dermatologist has to add Saline to the vial to reconstitute or dilute the powder. Anywhere from 1cc, 2cc, 2.5cc, 4cc, 5cc or more of saline (salt water) can be added per 100 units. Dr. Naderi and Dr. Kulak prefer using 2cc in order to keep the Botox very concentrated but have enough volume to be able to inject the entire muscle length.
Some doctors and spas put too much saline (4cc or more) in the 100 unit vial and what ends up happening is that there is too much water which can cause wider diffusion of the Botox past its injection site and cause unwanted effects. Too little saline (1cc) is also not ideal because there will not be enough volume to allow injection of the entire muscle length. The best dilution for Botox per 100 unit vial is 2cc or 2.5 cc
Wrinkles on the face are always formed perpendicular to the muscle contracting and forming the wrinkle. To reduce facial wrinkles, Botox must be injected into the muscles, not into the wrinkle. The goal is to weaken these muscles. Devices sold on TV, late at night, claiming to exercise and strengthen facial muscles do the complete opposite and thus create deeper wrinkles!
Overall in relative terms Botox is a very safe substance when injected in the proper settings by a trained professional. There are tens of thousands of people who die as a result of Aspirin or Tylenol use but most people readily take Aspirin or Tylenol for aches and pains without ever worrying about their serious and potentially lethal side effects. In relative terms, Botox is much safer than Aspirin and Tylenol and serious lethal side effects from cosmetic uses are practically unheard of.
The usual risks are minor bruises from the needle itself, although allergic reaction and infection is also theoretically possible. Flu like symptoms or minor headaches can occur despite the fact Botox is used to treat headaches. Muscle stiffness or weakness can theoretically occur especially in people with Myasthenia Gravis. There can be eyebrow or eyelid droop as well as possible double or blurry vision. Most of the risks are temporary and wear off as Botox wears off.
Droopy eyelids occur in about 3% of cases but in Dr. Naderi’s practice, this has never occurred because he is an Instructor for Botox injections and knows exactly what muscles to inject and what areas to avoid.
Botox can diffuse up to an inch each time from its injection site so even the same exact injection method can yield slightly different results each time but these are very insignificant differences.
Botox works on weakening certain muscles of expression in cosmetic cases. Botox must be injected in a correct pattern to maintain natural expression. Unfortunately Botox has gotten lots of bad publicity on TV sitcoms and by comedians because of those unfortunate cases where inexperienced injectors have created a very unattractive look by injecting Botox inappropriately. Dr. Naderi and Dr. Kulak are very experienced injectors and their patients come to them from long distances. Dr. Naderi is a Clinical Instructor for Allergan and teaches other doctors how to best inject Botox.
Dysport and Xeomin are other substances very similar to Botox. Practically all of the information on this page applies to Dysport and Xeomin as well other than the dates for FDA approval. Botox was the original FDA approved neurotoxin for reducing wrinkles and lines but Dysport has gained significant popularity in recent years. Botox and Dysport are the two most popular cosmetic wrinkle reduction substances in the United States.
Men are learning more and more about Botox and Fillers and learning that taking care of their face can pay off in the long run. Botox can be injected in men to reduce the appearance of forehead wrinkles, frown lines and crow’s feet. Since there is no true “down-time” from Botox injections, there is no reason anyone needs to know about the injections and men can keep their secret of their fountain of youth just that – a secret!
Since men cannot wear makeup to cover wrinkles and men cannot use makeup to cover redness after CO2 laser treatments, it is best to avoid getting deep wrinkles in the first place by using Botox 3 to 4 times per year.
It is very important to keep men’s expressions natural and prevent an over-arched eyebrow or a fake look.
Men often have much stronger muscles than women so more Botox is needed to achieve the same relaxation. For example, in most women, 20 units of Botox is the “standard dose” for reducing the frown lines but 25 or 30 units may be required in some men with very heavy muscles.
Some men choose to do a lower dose and have more movement but come in more frequently (every 2 months) for the injections in order to look very natural.
Dr. Naderi and Dr. Kulak are experts at preserving men’s natural looks with Botox.
Botox works best for prevention. Obviously Botox still works for older patients once the “static” wrinkles have formed in order to prevent them from looking deeper or from getting deeper. But Botox works best when started at a younger age in people in their late 20’s and early 30’s.
The best age for Botox is when you notice your skin forming fine lines as a result of over expression, squinting or smiling. If you make lots of expressions with your eyes or eyebrows when you talk, work on the computer or are out in the sun, you may want to consider starting Botox Cosmetic as young as 25 to prevent wrinkles. Some women who do not “talk with their eyes” and don’t form too many expressions may not ever need botox even as they get older. Each person’s muscle movement and expressions are unique.
Think about the actor, Jim Carrey and what he can do with the same muscles and the rest of us have!
Botox has a more limited benefit in older patients when used alone. Patients in their 40’s, 50’s 60’s, 70’s and beyond can definitely benefit from Botox but other procedures may be necessary for the optimum smooth results. In the 40’s, a good skin care regiment combined with chemical peels like VI Peel as well as Fractionated CO2 laser can give the best results by preventing further wrinkles and reducing the ones already formed. Patients in their 50’s, 60’s and 70’s or beyond often need additional surgery such as lower facelift, Brow lift or eyelid lift in addition to Botox and Lasers to get the smoothest results. Ignoring the skin for 50 years and expecting Botox to do magic is not realistic but Botox can be a good start on the path towards a better more rejuvenated appearance.
Botox cost varies significantly based on geographic location and the expertise of the injector. We have seen some Spas or doctors charge as little as $7/unit in California to some doctors in NYC charging as much as $30/unit. Many inexperienced doctors or Spas will run promotions such as Groupon to entice patients.
Getting Botox by “unit” makes the most sense rather than “Botox by the area.” The problem with paying for Botox by “area” is that no two people are exactly the same and each person may require a different amount of Botox. Also, when you pay by the “unit” or “dose” you know exactly what you paid for and how much actual Botox you received. Botox is not injected or charged per syringe the way Fillers are. You must know how much Botox you are receiving thus we highly recommend avoiding Plastic Surgeons who charge by the “area.” You often end up paying more and getting less.
For example, we charge $300 for 20 units of Botox at The Naderi Center for Rhinoplasty & Cosmetic Surgery. That equals $15/unit. Dr. Naderi or Dr. Kulak can use these 20 units for your frown lines. If you ask to have your forehead relaxed as well, they may choose to increase the total dose to 25 or 30 units (additional 5-10 units for the forehead which is usually all that is needed). You would pay $375 or $450 respectively. Or you may be on a tight budget and decide to use the lower 20 unit dose and have Dr. Naderi inject your frown lines and your forehead and pay only $300 for both. But if you went to a Plastic Surgeon who injected Botox and charged by area, the frown lines would be considered one area and the forehead would be considered a second area and you may end up paying $500-600 for the 2 area. What’s more important is that some Plastic Surgeons could be injecting both areas with only 20 units and you would be getting less and paying more and not know what you paid for or received! They offer “free touch ups” to entice patients since their initial dose is usually too low. At The Naderi Center you get what you pay for. If you need more, you will simply pay for the additional Botox.
For most women or men the cost will range on average anywhere from $300 to $600.
Dr. Naderi is a Board Certified Facial Plastic Surgeon and a National Clinical Trainer for Allergen. He teaches other doctors how to inject Botox properly so patients who want to get the best results will go to the actual teacher for their injections.
Dr. Kulak is a Facial Plastic Surgeon with a gentle, artistic female touch and her patient love her nearly-pain-free techniques.
Other doctors from all over the world refer to Dr. Naderi’s instructional videos on YouTube to fine tune and improve their own Botox injection Techniques.
Dr. Naderi and Dr. Kulak spend a long time with each patient analyzing their anatomy and explaining their options honestly, ethically and compassionately.
Dr. Naderi’s gentle yet fast “no down time” injection technique minimizes swelling because the longer a doctor takes to inject, the more trauma is often caused and more pain and swelling results.
No rush, no sales pitch, no pressure to buy anything at The Naderi Center for Rhinoplasty and Cosmetic Surgery.
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