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Botox Stuff You Didn’t Know

Tim Neavin

Beverly Hills plastic surgeon Dr. Tim Neavin discusses Botox.

Tim Neavin, MD

Board Certified Beverly Hills plastic surgeon

1. What is Botox®?

Botox® is one of the many trade names for the neurotoxic protein called botulinum toxin. This toxin is produced by the bacterium Clostridium botulinum. It is prepared as a drug used cosmetically to remove wrinkles by temporarily paralyzing facial muscles, for the treatment of migraines, overactive bladder, hyperhidrosis (sweaty palms, armpits, or feet), and for management of strabismus.

2. Why is Botox® used for migraines?

On Oct. 18, 2010, Botox® was approved by the FDA to treat chronic migraine headaches in adults. Though the mechanism is not fully understood, Botox® is thought to prevent certain chemicals from reaching nerve endings, thereby reducing migraine pain Thus, Botox® interrupts neuropathways in pain to treat chronic migraine. This is achieved with the injection of Botox® into muscles of the forehead, the side and back of the head, and the neck and shoulders to produce a partial and temporary chemical “denervation” of the muscle. Injections of this neurotoxin produce weakness of the muscles, inhibiting their ability to maximally contract, and ultimately treat pain associated with migraine headaches related to this muscle activity. Fortunately, the dosage used to treat chronic migraine headache pain is very low since the muscles related to the condition are small.

3. What are the Side Effects?

It should be noted that Botox® is not a cure for migraine. However, it is generally a very safe method for treating migraine headaches. It may take one to two weeks for the Botox® to begin its effect reducing migraine related head pain. Once the neurotoxin is at work, effects can last up to 3 months or more. Even if Botox® therapy does not prevent or eliminate all migraine headache pain, it may reduce need for medication dosage and frequency.

Despite the toxicity of Botulism neurotoxin, Botox® is incredibly safe because the dosage used is far, far below the levels necessary for serious side effects seen in the fatal illness of botulism. The most common side effects associated with Botox® injections include bruising and slight discomfort or pain at injections sites. In rare cases, injections too close to the eye can cause a temporary droopy eyelid. Larger doses of Botox® in the forehead can cause paralysis of the forehead muscles which may effect animation of brows, or generate a (correctable) asymmetry of brow movement. For these reasons, I strongly recommend that Botox® injections be performed by a physician experienced with Botox® injections in treating migraines or wrinkles to reduce unwanted side effects related to the concomitant muscle weakness that the neurotoxin imparts.

4. How to know if Botox® will work on your migraines?

Some studies indicate that up to 40 to 70 percent of people with migraine headaches will have a substantial reduction of symptoms of their migraine related head pain after injection of Botox® in appropriate dosage and region. However, most headaches are not migraine related. Tension headaches are far more common than migraine headaches and there is little data to suggest that Botox® works well for these more common pattern headaches.

5. What is the treatment plan?

For one, ensure a proper diagnosis of migraine headache. Often primary care physicians or neurologists can decipher a migraine from tension or cluster headache. Botox® has been shown to improve the pain of migraine headaches, not pain generated from some of the other, more common types of headaches such as tension and cluster headaches. Botox® is injected with a very small needle, with up to 30 injections among 7 discrete regions around the head. Effectiveness emerges roughly one week after injection and fades typically around three months.

Article: Botox® Cost

1. How much does Botox® cost? Does price differ depending on the region of the country?

The purchase price of Botox® is around $5.25 a unit for a practioner. The mark-up is generally at least double the purchase price, ranging from $9.00 to $14.00 a unit dependent on geography and experience of injector. For example, a Board Certified plastic surgeon often charges more than a nurse. Unfortunately, few insurance companies cover Botox® for the treatment of headaches despite the literature that supports its efficacy.

2. How to estimate the cost before going to an appointment — i.e. How to figure out how many syringes you’ll need before going to an appointment.

It is important to understand that one does not pay for volume of product, or “cc’s” or “syringes”. Dilution techniques differ from practioner to practioner.

One pays generally by either “anatomical region” or “per unit”. A region is determined by the practioner, but often includes “forehead”, “glabella”, etc. Regions may require anywhere between 8 and 25 units for effect. Thus, regional injections range anywhere from 100 to 300 dollars. For migraine therapy, count on a price range between 300 and 600 dollars regardless if “region” or “per unit” policies are applied by the practioner. And expect symptomatic relief of migraines to fade in approximately 3 to 4 months.

3. Should Botox® only be administered by a plastic surgeon, or are medical “spas” good places to get Botox®?

Generally, Botox® should be injected by one who understands the principles of technique and can appreciate the muscle anatomy.

Understanding the depth, course, and actions of the various muscles injected in routine Botox® therapy afford a more efficient use of the product and reduce risks of droopy lid, animation deformities, asymmetries, and misplacement of product. To that end, I recommend that a plastic surgeon perform such injections.

Article: Botox® Side Effects

1. What are the side effects of Botox®

While Botox® is indeed a neurotoxin (and Botulism, the disease caused by the neurotoxin is fatal) , the drug is exceptionally safe because it is injected in very low doses that are far below the levels necessary for the serious side effects one sees with botulism toxicity. The most common side effects associated with Botox® injections include bruising and slight discomfort or pain at injections sites. In rare cases, Botox® injections too close to the eye can cause a temporary droopy eyelid. Such droopy lids can be managed with the aid of eye drops to stimulate the weakened muscle that serves to elevate the upper eyelid. Thankfully, droopy lids related to Botox® therapy are uncommon. They are generally related to errors in technique. Larger doses of Botox® in the forehead can cause significant weakness or paralysis of the forehead muscles which in turn may affect animation of brows. Other more common side effects of Botox® therapy included asymmetry of brows or brow animation. However, this can often be easily corrected with follow up touch-up injections. I strongly recommend the injections be performed by a physician trained in this procedure to reduce potential undesirable cosmetic side effects.

3. What should patients do if they experience side effects?

Thankfully, serious side effects are exceptionally rare. Nausea, flu-like symptoms, indigestion, headache, backache and blurred vision have been reported, but are not common. Allergy to Botox® or components in the mixture are indeed possible, but again, exceptionally rare. If anyone after Botox® therapy experiences a rash or itchy welts, wheezing or difficulty breathing or swallowing, or dizziness or faintness, they should contact their doctor or emergency room r immediately. It is more common for an allergy to develop from some of the more common topical numbing creams applied to reduce pain on injection rather than the Botox® itself.

4. Are any of these side effects dangerous or fatal?

Botox® therapy is not fatal when injected in the routine quantities and with standard technique for migraine headaches, hyperhidrosis (condition of sweaty palms, sweaty armpits, sweaty feet), overactive bladder, or wrinkle reduction. One would have to severely deviate from standard dose and injection technique to experience any potential life threatening complications. Despite the potential potency of the product, it is one of the safer injectable drugs even among dosing error because the lethal dose is difficult to achieve in one setting with subcutaneous injections of even a greater than normal amount of product. In fact, the LD 50 (a number that determines the dosage between medical efficacy and lethal dose) of acetaminophen (active ingredient in Tylenol) shares a more dangerous value than Botox® therapy for the treatments of wrinkles, migraines, and hyperhidrosis. That is, one could argue that Botox® therapy is more safe than Tylenol therapy for the treatment of migraine headaches.

Article: Botox® or Fillers

1. What is the difference between Botox® and fillers?

In purely cosmetic terms, Botox® therapy are multiple injections used to reduce fine facial wrinkles generated by muscles in the face. Fillers are injections that function to add volume to very deep wrinkles and reduce shadows generated by deficient facial volume.

2. How to know whether Botox® or fillers are needed?

Botox® and fillers are two very different therapies. Fine wrinkles of the forehead and around the eyes are often best managed with Botox®, which is a drug derived from the bacterium Clostridium botulinum. Botox® acts to weaken or paralyze muscles of animation that generate wrinkles of the forehead and around the eyes. Of note, Botox® efficacy is not really determined by its ability to paralyze the muscle; its efficacy (or preferred use) is to eliminate the wrinkles of the forehead and around the eye at repose, or rest. That is, successful Botox® therapy will reduce or eliminate wrinkles without paralyzing muscles of animation. There is a fine line (and dosage) between over-correcting and under-correcting the wrinkles of age and sun damage.

Fillers are best utilized to add volume to the face to eliminate shadows or very deep wrinkles. Shadows or hollowed-out areas impart an aged look to the face. Areas that may benefit from fillers include laugh lines, regions under the eye, areas along the jawline, the cheeks, or under the corners of the mouth. Many of these areas are considered “off label” uses by the FDA and are probably best addressed by an experienced physician such as a plastic surgeon. Fillers may also be used to enhance the lips or remodel the face when used in larger quantities, such as in the augmentation of cheeks or jaw.

3. What are the different types of fillers?

Most of the fillers used for facial cosmesis nowadays are made of hyaluronic acid, which is a natural component of the skin. Hyaluronic acid based products include: Restylane, Perlane,Captique, Hylaform, Juvederm, and Belotero. Generally, these products last anywhere between six and nine months depending on region of injection, and depth of injection.

After the hyaluronic acid products, calcium hydroxylapatite (Radiesse®) is generally the most commonly used agent for facial augmentation. While Radiesse® is not indicated for the lips, it has a very good role for filling some of the deeper shadows of aging (i.e. laugh lines, under the eyes), and for facial remodeling of the cheeks and jawline. Again, many of these uses are considered off label by the FDA and should be injected by s skilled physician with experience in the product and good understanding of facial anatomy.

Article: Botox® for Overactive Bladder

1. Why is Botox® used for an overactive bladder?

Overactive bladder is a condition in which the bladder squeezes too often or squeezes involuntarily resulting in potential leaking of urine (urinary incontinence), or the feeling of sudden and urgent need to urinate, and frequent urination.

Botox® acts on muscles to relax or weaken them. When Botox® is injected into the muscles controlling the bladder, the Botox®-induced relaxed bladder’s storage capacity is increased. In essence, the bladder becomes less tight, and thus less pressure is generated within the bladder. This is turn can reduces episodes of urinary incontinence.

Botox® injection for overactive bladder or incontinence is generally performed using cystoscopy by a urologist. This is an invasive procedure that allows a doctor to visualize the interior of the bladder for proper injection.

2. What are the side effects?

As one can imagine, too much relaxation of the muscles that provide the contractile forces for urination can lead to the inability or difficulty of voluntary urination. Thus, because Botox® injections have a paralyzing effect on the muscle of the bladder there exists a small chance that one will experience problems in bladder emptying. Fortunately, this unwanted effect is generally less than 4 percent and is temporary, resolving in around 6 weeks. In such cases, one may need to learn how to self-catheterize to empty the bladder until some of the Botox® effects fade, and the muscle’s ability to contract for bladder emptying is restored.

3. How to know if Botox® will work on your overactive bladder?

Overactive bladder is often managed initially with oral drugs such as anticholinergic agents and bladder muscle relaxants drug. However, like any drug, undesired side effects are associated with this therapy, such as dry-mouth, constipation, blurred vision, gastroesophageal reflux and urinary retention. Because of these negative side effects, Botox® therapy may be a better choice for certain individuals. One should see a specialist for proper diagnosis and information on options to discuss overactive bladder.

4. What is the treatment plan?

One, a proper diagnosis of overactive bladder must be made by your doctor. If oral medications have been tried with limited success or unwelcome side effects, discuss Botox® therapy as an option to reduce the symptoms of incontinence, urgency, and urinary frequency. The treatment of Botox® for overactive bladder requires the surgeon to inject up to 100 to 200 units of Botox® into the bladder using cystoscopy, a somewhat invasive procedure where the doctor can see the inside of the bladder. This visualization technique affords the physician a very accurate landscape for injection. Effects of the Botox® injection can begin within a week and last up to 6 months.