Dermal Filler Providers Must Also Be Proficient With Hyaluronidase

The adoption of dermal fillers for age related volume replacement has contributed to the surge in aesthetic patients. As patients become more savvy, it becomes obvious that filler outcomes are dependent primarily on the provider and not the brand of the filler injected. Somewhere between 80-90% of the fillers used are based on Hyaluronic Acid, a naturally occurring substance found throughout the skin, and joints. (It is an interesting side note that the structure of HA is similar throughout all species.) One of the attractive qualities of HA is that there is an “antidote”, an enzyme called hyaluronidase, which can dissolve HA based dermal fillers.

There are several versions of hyaluronidase available in the US. There are animal based products such as Vitrase (ovine based), Hydase (bovine), and Amphadase (bovine). The one product, Hylenex, is actually a recombinant form of the human hyaluronidase. There is some risk of allergic reaction to the animal based products but not Hylenex (author’s preferred choice). The intended use of hyaluronidase is to allow for increased tissue permeability, thereby allowing for greater dispersion and delivery of products injected. It is also used when hyperosmolar fluids extravasate into the skin and in improving uptake of radiopaque solutions in the bladder. The primary reason it is used in aesthetics is to dissolve HA filler.

The reasons to dissolve HA filler are:

Poorly placed filler giving an aesthetically poor result
Where too much filler was placed
Filler that is infected
Filler is forming a granuloma
Filler is causing ischemia/vascular occlusion
Filler is causing visual changes or blindness

The are more and more fillers being introduced to the market each year. Each one has it’s own characteristics and nuances when injecting. There are also, many new injectors entering the industry daily. It is fair to say that the number of poor outcomes and complications is inevitably going to rise. Unfortunately, trainings are not being done for the indications and administration of hyaluronidase. It is beyond comprehension that there are many offices, I dare say, a majority, who either don’t normally have any or adequate doses of hyaluronidase.

It is absolutely imperative that a facility that injects HA fillers stock at least 1000 units of hyaluronidase. Doses of 400 units or more need to be injected in areas of vascular occlusion immediately to achieve optimal outcomes. If no response, additional doses need to be injected. If an ophthalmologic complication occurs, at least 1000 units needs to be injected immediately to have any chance for recovery of vision. Even with doses in the thousands of units, there should be no concern regarding loss of naturally occurring hyaluronic acid as it will replaced by the body’s normal regenerative process over 24-48 hours.

Unfortunately, the majority of providers have little or no experience with hyaluronidase and/or have none available in their facilities. It is beyond comprehension the lack of preparedness for not only reversing poor outcomes, but in resolving medical emergencies. The industry must rise up to educate about complication identification and treatment protocols. Poor outcomes and complications affect the entire aesthetics field and not just the individuals involved.

Amazing Things That Can Be Done (By the Experts) With Dermal Fillers

This is the golden age for minimally invasive cosmetic procedures. Who would have ever thought 15 years ago, that procedures done in the office in a matter of 20-30 minutes could result in demonstrable improvements in one’s appearance with results lasting, in some cases, a year or more? Without the need for downtime, anesthesia, or significant costs, cosmetic procedures have flourished, with many people who never would consider enhancements, “dipping their toe” in these procedures. The concept of “preventative maintenance” has spurred the younger generation to start earlier, with smaller, less dramatic, but noticeable procedures as well.

At the forefront of the wave of cosmetic enhancements are dermal fillers. When Restylane was FDA approved in 2003, a revolution in the field was born. Although the main focus was to improve the nasolabial folds, the “smile” lines, in its inception, the broad “off label” use of it, along with subsequent FDA approval of other fillers, treatments have spread to just about every area of the face. There are now about a dozen dermal fillers on the market, with the majority of them based on hyaluronic acid, a naturally occurring substance that is found in skin and joints. Hyaluronic acid fillers (Restylane, Perlane, Voluma, Juvederm, Belotero) provide a soft, very well tolerated fill, with an extremely safe profile. There is also a level of security knowing that these fillers are generally completely reversible, using the widely available enzyme, hyaluronidase, that can dissolve hyaluronic acid, in minutes to hours.

Although less popular, it must be mentioned that there are other dermal fillers which are FDA approved, each with their own niche market. Radiesse is composed of microspheres of calcium hydroxyapatite, and is known as a very robust filler, that has a very high G prime, a measure of it’s lifting ability. Sculptra is composed of Poly L Lactic Acid (PLLA), also naturally occurring as a sugar in the body, and is known as a collagen stimulator. Its use is for global, long lasting, volumization of the face. The longest duration FDA approved filler is Artefill. It is composed of microspheres of Poly Methyl Methacrylate (PMMA) which is a synthetic molecule. Artefill is considered a permanent filler and works as a collagen stimulator, similar to Sculptra.

The understanding of the aging face has made great strides in the last decade. It is now widely understood that loss of volume is the primary cause of the aging face. Leading this volume loss is the shrinking of the multiple fat pads of face, primarily of the cheek and periorbital area. This is why aging often begins to show around the eyes. Gravity contributes to our aging problems and often manifests itself by the descending of these fat pads. Relegated to a less relevant problem than 15 years ago, is the aging related to excess skin. Plastic Surgeons have tightened loose skin for decades during facelifts, often leaving people appearing skeletonized and hollow, but without wrinkles. It is now understood that most of the redundant skin can be improve with proper volumization of the offending fat pads, and most facelifts incorporate this during surgery presently. (In the author’s opinion, most of the patients undergoing the knife could have had their concerns addressed using a combination of fillers and skin tightening devices.)

The common manifestations of volume loss are:

Temporal hollows
Loss of cheek volume
Tear trough deformity
Excessive crows feet and forehead lines
Low hanging eyebrows
Hollowness of the eye (orbit)
Jowls
Poorly defined jawline
Small lips
Dropping of nasal tip
Lip lines (smokers lines)
Corners of mouth dropping causing sad look
Saggy neck
Elongation and narrowing of the face

All the above mentioned aging effects can be improved with dermal fillers. Expertise is required to recognize exactly what areas need to be treated to replenished the lost volume, while still maintaining a natural appearance. It’s been shown that the brain can recognize less than a 1mm change in brow position. When corrections are not done properly, it is very easy for the brain to catch it. Poor corrections of the lips probably stands out in most people’s memory, where they are either too full, out of proper proportion, or there was poor attention to landmarks.

Experienced dermal filler injectors are no longer “chasing lines”, the symptom of aging. The goal is to lift and replenish lost volume by addressing the cause of the aging of the face. Of note, even the neck’s problems can be improved by properly injecting the face. Choosing a doctor that has experience in recognizing the areas affected by volume loss and has the knowledge and expertise to improve those areas is essential for optimal patient outcomes.

Slimming Ones Facial Appearance with Botox/Dysport

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The ideal shape for an aesthetically pleasing face has been referred to as “an upside down egg” or heart-shaped. It is desirous to have the upper face wider than the mid/lower face. It brings more attention to the eyes, the center of beauty. Widening of the lower face can give a female a more masculine appearance, and also is a sign of aging. The causes of enlargement of the mid/lower face are:

Enlarged masseter muscles. Often caused by bruxism (grinding one’s teeth)
Obesity
Genetics. Asian females tend to have this issue
Jowling associated with the aging face

By injecting the masseter muscles with Botox or Dysport, the muscles can diminish in size and atrophy over time. If the procedure is repeated and regularly administered, a long-term slimming of the mid and lower face can be achieved. Candidates for this procedure are people who fall into the #1 and #3 category. Risks are minimal, but this can affect your smile if not done by someone who has experience with the anatomy and performing this procedure.

Many people would also benefit from injecting the temples simultaneously with filler to help create the upside down egg-shape to the face (from a square-shaped face).

For the person that falls into the #2 and #4 category, there is some literature that suggests that Ulthera might be helpful. Although a much newer technology, Infini might work for this as well, time will tell. By going to depths that are much deeper than the skin, into the fat layer, it might be possible to decrease the amount of fat in these areas and thereby slim the face.

Hyaluronidase – The “Magic Eraser” for Hyaluronic Acid (Juvederm, Restylane, Voluma) Dermal Fillers

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Hyaluronic Acid dermal fillers are the most popular fillers used worldwide. In the United States, the commonly used HA fillers are:

Juvederm Ultra and Ultra Plus
Voluma
Restylane
Restylane Lyft (Perlane)
Restylane Silk
Belotero

The beauty of HA fillers is that they are very well tolerated because hyaluronic acid is a component of skin, so it is a naturally occurring substance. It’s a soft product, and will last anywhere from 4 months, to up to 2 years, depending on the brand used, and the location it is placed.

Another key attribute to the HA fillers popularity is that it can be completely dissolved with an enzyme called hyaluronidase. It is manufactured from either bovine (cow) or ovine (sheep), so there is a remote possibility of having an allergic reaction to the commercially available products (Vitrase, Hydase, and Amphadase). There seems to be a crossover with people that are allergic to bees for these animal derived products. Hylenex is a recombinant form of hyaluronidase that is the human form that is the preferred form of Dr. Weiner for there are no allergies, yet it is a bit more expensive.

Hyaluronidase is useful for dissolving HA filler in the following instances:

The filler was over done/”over filled” and it is not aesthetically pleasing
There is prolonged swelling, particularly around the eye and most often with Juvederm
An infection has occurred in the area of prior filler
The filler is lumpy or has nodules and doesn’t respond to massage and time (especially lips)
Rare possible allergic reaction to the HA filler
When there is vascular compromise secondary to the HA filler injection which can be caused by external compression on a vessel or intraluminal (within the vessel) injection

My experience with hyaluronidase has been mostly with patients that have had Juvederm injected in the tear trough area from another facility. I strongly recommend that Juvederm not be injected in this area because of the risk of prolonged edema. The reason this happens more with Juvederm is speculated to be due to its ability to attract more water, higher concentration of HA in the product, and because it spreads more diffusely than the other fillers.

When injecting emergently for vascular compromise, at least 200 units (more is better) should be injected in and around the original site of injection of the HA. It has been shown that extravascular hyaluronidase is able to traverse the vessel wall to make it intraluminal, useful knowledge for the cases where the HA is within the vessel. (Blindness needs emergent Ophthalmology evaluation and might require arteriogram for placement of hyaluronidase. Even with such extraordinary measures, blindness is almost always permanent.)

When injecting hyaluronidase, it is mixed with lidocaine by the physician, so it is a fairly comfortable procedure. There are a couple limiting factors with the injection. It is not as precise as the filler injection, so it can remove some of the filler that you wanted to stay along with the unwanted filler. Also, dosing/how much to use, is not an exact science. It may take more than one treatment to dissolve the HA filler. The results can occur within minutes, but usually take about a day to fully appreciate. Also, Juvederm and Voluma tend to be the hardest to dissolve, and it is thought that this is related to the way it is cross linked (manufacturing process).

The bottom line is that you don’t have to live with HA filler that you are not happy with. You can easily reverse lips that are lumpy or too big, swelling around the eye from filler, or dissolve an over correction or asymmetry with hyaluronidase. An injection with hyaluronidase can get you back to where you used to be in about 24 hours. Also, it’s nice to have a little piece of mind when getting injected with an HA filler that the process can be completely reversed with a small procedure.

Dr. Steve Weiner is a Facial Plastic Surgeon who “laid down his scalpel” in 2005 and concentrates solely on non invasive and minimally invasive cosmetic procedures at The Aesthetic Clinique. His website is http://www.theclinique.net . Call for a consultation: 850.622.1214

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

How to Score Some Points with Your Plastic Surgeon/Aesthetic Physician

Getting on the good side of the doctor that makes you look better can definitely have its benefits. Following these suggestions can get you some brownie points.

Stay well informed. Search out your Doctor’s website, Facebook Page, Blog, and YouTube Channel to learn about the procedures that are offered. This can make the initial consultation go more smoothly. You can narrow the options before the office visit according to your lifestyle and concerns. Watching videos of the procedure being performed can greatly improve your comfort level by knowing what to expect.
Be Nice and Smile. Smiles are contagious. We are all here to make you look good and feel better about yourself.
If you have a budget, let us know. It’s very important that everyone is on the same page when deciding on a particular treatment. For example, lasers are usually more expensive for treating certain skin conditions (sun damage), but they get faster and better results than the less expensive options (chemical peels). Treatment plans can be tailored to meet all budgets.
Try to stay with one physician. The lure of a “Groupon Special” on Botox or fillers is enticing. However, pricing should not be the primary motivation for choosing where you go. Qualifications, experience, and customer service should be much more important factors in your decision-making. It’s often hard to piece together what was done if you have gone to several different physicians.
If you have a social event, try to get treated a week or two in advance. Waiting too close to an event can cause undue anxiety when there is some minor bruising or swelling. Give us doctors a little leeway (a week) so that everything can settle down from your filler administration. Even though Dysport may kick in faster than Botox, it still needs 3-5 days to see its full effect.
Try to hold off the blood thinners when coming in for injections. If you take herbal supplements, aspirin, anti-inflammatories, vitamin E, or fish oil, the chance of having bruising is much higher than if they were held for a few days (aspirin needs about 12 days). Even a physician with the most delicate touch and technique can’t always avoid bruising when injecting someone who has “thinner blood”. Of course, if the thinners are medical necessary, you must continue their use.
Don’t ask your doctor to make your lips too big. Remember, every patient is a walking billboard for the doctor’s practice. Most doctors want to be known for natural looking enhancements. There needs to be dialog between the patient and doctor when the patient’s wishes are beyond the realm of what is naturally appearing.
Don’t tan or use sunless tanners before laser procedures. The risk of pigmentary issue goes way up when lasers are used on tan skin. Usually at least 3 weeks are needed to be out of the sun for laser work. The problem with sunless tanners is that the pigment in the product can absorb or reflect the laser and cause potentially even more damage to the skin than a tan would.
Follow the recommended post treatment instructions. To get the maximum benefit with the least amount of side effects, there are certain do’s and don’ts after all procedures. Most physicians will either give a printed instruction sheet or will have them on their website.
Don’t use grandma’s homeopathic remedy on your skin after peels or lasers. After a laser resurfacing, the skin is 50 times more sensitive to topicals creams. Please use the skincare regime outlined by your physician.
If there is some issue after a procedure, LET US KNOW! Almost always, there are minor little adjustments which can be made to your Botox or filler treatment that can correct an undesired result. From a doctor’s perspective, we want to have happy clients. We would much rather have you call or come in for any issue rather than lament at home.
Give us a shout out. If you are extremely pleased with how you look and feel after a treatment, tell your friends. In fact, bring your friend(s) with you to your next visit. Write a review on Facebook, Yelp, or Google Plus.

Dr. Steven Weiner is a Board Certified Facial Plastic Surgeon practicing in Santa Rosa Beach, Florida, between Destin and Panama City Beach, Florida. After laying down his scalpel in 2005 he has devoted his practice to Lasers and Injectables.

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

Are superficial chemical peels obsolete? The Spectra Laser Peel (“Hollywood Peel”) might make that happen.

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Chemical peels have been a staple for skin care for decades. There are dozens of different types treating various skin conditions. This blog will be directed at the superficial chemical peels used to treat: fines lines, pigmentation, sun damage, acne, large pores, and to rejuvenate the skin. These peels are usually placed by an aesthetician in a spa or physician’s office. After about 2-3 days, the peeling starts and lasts for a couple of days and sometimes up to 5 days. During the peeling phase, there’s various amounts of flaky skin, treated with moisturizer. The skin eventually looks great, 3-7 days after the initial placement of the peel.

Let’s turn to the Spectra Laser Peel. The Spectra Laser is a Q switched 1064 laser that has a tremendous affinity to pigment. It is designed for (and state of the art for) tattoo removal and treating various pigmented lesions (freckles, seborrheic keratosis, lentigos, cafe au lait, nevi, post inflammatory hyperpigmenation, and melasma). The laser peel begins by placing a carbon liquid on the skin for about 10-15 minutes. The carbon is absorb superficially in the skin. This liquid is essentially tricking the laser into thinking its attacking pigment when it is applied to the face. As the laser is first passed over the skin, the carbon absorbs some heat which is passed to the underlying skin. The next several passes cause vaporization of the carbon as well as a very superficial layer of the skin – 15-30 microns. What’s better is that there is no discomfort during the procedure!

The end result is a glowing and radiant skin tone with NO associated peeling or recovery time.

I believe the effectiveness for the various skin condition (acne, pores size, fine lines, pigmentation, melasma) is marked better with the Spectra Peel than with traditional chemical peels. Active acne outbreaks seem to resolve within days. Just like other laser procedures, the Spectra Peel can’t be performed on tan or recently sun exposed skin, or people on Accutane. It can not be done on darker skin types as well.

If you’re looking for a quick skin rejuvenation with essentially no downtime, do what they are doing in Hollywood just before they hit the red carpet, The Spectra Laser Peel.

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

Voluma is the latest filler to be FDA approved – What makes it different? Dr Steve Weiner explains

Front view before and after 12 syringes of Voluma: cheeks, temples, marionette lines, and preauricular area.

45 degree view after 12 syringes of Voluma injected.

45 degree view before and after 12 syringes of Voluma: cheeks, temples, marionette lines, and preauricular area.

Voluma, 12 syringes injected, 90 degree photo

After 12 syringes of Volume, 90 degree view. Injected cheeks, temples, marionette lines and preauricular area.

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Juvederm Voluma was approved by the FDA today for treatment of age related volume loss in the cheek area. This is the first filler to be approved for this purpose. Its main component is Hyaluronic acid which is also found in Juvederm Ultra, Restylane, Perlane, and Belotero, all FDA approved fillers. Juvederm Voluma is a thicker, more viscous version of Juvederm Ultra which gives it more “substance”. The technical term for this property is called “G prime”. The higher the G prime, the better ability for the filler to lift and support skin and surround structures. Compared with Juvederm Ultra, Juvederm Voluma has about 10 times (10X) the G prime. A comparison graph is shown below (from Going With the Flow: An Overview of Soft Tissue Filler Rheology and Its Potential Clinical Applications, Part II by Hema Sundaram, MD, FAAD):

As seen in the chart, Radiesse, Perlane, and Restylane have higher G primes than Juvederm Voluma. Although these others are not approved for volume loss of the cheek, they are all used commonly “off label” for this application.

Being very thick/viscous, Voluma will need to be injected with large bore needles or blunt cannulas. It is mixed with lidocaine (numbing medication) from the factory, so the procedure is very well tolerated. It’s longevity is longer than most fillers, lasting up to 2 years in their clinical trials. At 2 years, 76% of patients were still satisfied with their Voluma results. (It was 90% at 6 months). Also, at 2 years, the average patient’s perception was that they looked 3 years younger since the Voluma treatment. (It was perceived as 5 years after 6 months).

Obviously, the volume needed for correction varies from patient to patient, depending on their degree of volume loss. During the clinical trials, the average volume needed for correction was just over 6cc. Some patients needed up to 13 syringes.

An advantage of Voluma over Radiesse, Artefill, or Sculptra is that Voluma can be “erased” or dissolved with an easily obtained enzyme called hyaluronidase. Although it is seldom used, it can give patients the piece of mind that their results don’t have to last for a year if they aren’t happy with it.

Initially, Voluma is being released to a select number of physicians who are very experienced injectors. These physicians will then become trainers for the other physicians with less experience. Dr. Weiner has been chosen as one of these initial users of Voluma, and it should be available at his office in November.

Dr. Weiner is Facial Plastic Surgeon who laid down his scalpel in 2005 and now concentrates on minimally and noninvasive cosmetic procedures. His website is http://www.theclinique.net His YouTube is: http://www.youtube.com/user/StevenFWeinerFacial

Dr. Steven F. Weiner answers questions about Botox

Q: Shouldn’t 30 units of botox be sufficient for glabellar 11’s? (Photo)

A: Movement persists after 30u of Botox – several reasons

Someone with a very strong glabella can’t expect to have complete movement cessation with Botox. There is a scale 0-4 and you can expect 1-2 drops in the scale with proper placement and dosing of Botox. Some people will not respond as well as the general population. Also, placement and dosing could be incorrect. In the future you can try Dysport or Xeomin and see if they work better.

Q: Is it safe to have Botox if you have SLE?

A: SLE/Lupus – Safe to have Botox

There should be no problem getting Botox if you have SLE. Mainly neurologic diseases are what you have to be careful with like MS or ALS. Steve Weiner, MD, Facial Plastic Surgeon.

Q: 1 week post op. I just got 20 units of botox around my eyes & crows feet, I don’t see a difference yet. Is this normal?

A: No effect from Botox around crow’s feet – either not enough time, they aren’t treatable with Botox, or you need more.

Botox can take up to 10 days for kicking in fully. Some of the wrinkles around the eyes can’t be treated with Botox. If you have etched in lines or lines that occur when you smile that are formed from the cheek moving up, these can’t be treated. Only the lines that form when you squint are the lines that can be treated. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Side of my face looks like I had a stroke – Botox or bell’s palsy?

A: Facial paralysis 4 weeks after Botox is most likely Bell’s Palsy and not due to Botox

Bell’s Palsy is when all or a portion of one’s facial nerve doesn’t function properly and there is NO OTHER CAUSE FOUND. Not all facial palsy is Bell’s. You need to see an ENT doctor to get properly treated and to rule out other causes such as: tumors, autoimmune disease, zoster, systemic disease, trauma, botox. A hearing test and balance test might be needed and nerve testing too. Botox as a cause, if it was Botox you got, would lead to problems within 10 days. It would be very unlikely that is was due to Botox but I’ll never say never.

Q: Hard lumps on head after botox which are still swollen after 3 days. Why did this happen? (Photo)

A: Bumps after Botox are either an infection or allergy

I have seen a similar reaction on a patient that was allergic to the preservative in the saline which is mixed with Botox at most offices. I proved it by injecting just the saline with preservative in the patient’s arm and got the same reaction. Most docs use the saline w preservative because it is less painful. I think it’s about 1-3% will be allergic. Allergy to Botox would be extremely rare. Infection is possible and would be associated with warmth, fever, and pain. They are treated differently so you need to go to the doctor to determine what is going on.

Q: 20 units of Botox were injected into my forehead for horizontal lines. Will my brow drop improve? (photos)

A: Heavy brows and upper lids after Botox injection to forehead can be improved with more Botox

I know it might be the last thing you want to do, but injecting the lateral brows and the depressor supracilii can improve the lowered brow. If you do nothing, it will get better in about 3-4 weeks in most cases. Steve Weiner, MD.

Q: The corner of my mouth is no longer raising when I smile. What went wrong with my Masseter Botox?

A: Botox injection for slimming masseter caused abnormal smile – Botox improperly injected is reason.

There are a couple muscles which could cause this problem, the zygomaticus or the risorius muscle. If injected too high, the zygomaticus will be affected, to anterior, the risorius will be affected. Either way, time will heal the problem and you have no worries about it being permanent. Steve Weiner, Facial Plastic Surgeon.

Q: How much of a brow lift can botox alone achieve? (photo)

A: Brow lifts from Botox will give about 2-3 mm of lift

I think that most patients expect more from Botox for brow lifting then can be realistically achieved. It will give about 2-3 mm of lift. In a young person like you, that should be sufficient. Steve Weiner, MD, Facial Plastic Surgeon.

Q: Can botox cause dry skin?

A: Can Botox cause dry skin? Possibly

It is well known that Botox can help improve acne. This is due to the fact that it decreases sebum production. Sebum is an oil that has been found to be excessive in acne patients. It is possible that you might need that sebum production to maintain a healthy feel to your skin.

Q: Is it safe to use Botox when you have been diagnosed with Hepatitis C?

A: I have injected patients with Hepatitis C with Botox without any problems

I think that you are at risk to have more bruising than the normal Botox patient, but other than that, it’s perfectly ok to have Botox. There is no metabolism of the Botox by the liver so you are fine. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Eyes drooping after Botox?

A: Drooping eyelid or eyebrow after Botox will be seen within 2 weeks, not 60 days.

The effects of Botox take about 10 days to be fully appreciated. At 60 days, it is already starting to wear off. There are 2 different problems that can occur, drooping of the eyelid or lid ptosis, and drooping of the eyebrow, brow ptosis. If the forehead is injected incorrectly – (too much, too low, in a poor candidate for the injection), the brows will fall. If the Botox is placed too close to the brow, some could leak down into the elevator of the eyelid and cause the lid to fall. This is a major cosmetic problem that reverses over a few weeks. In any event, you need to see an eye doctor to see why there is drooping that is unrelated to your Botox injections.

Q: What treatments can be used for excessive groin sweat that are not injections?

A: For groin sweating, I would wait for Revance approval, topical “Botox”, otherwise try Miradry, Sweat X treatments

I think the perfect solution for you is Revance which is a topical neurotoxin that will be approved sometime this year. True, it won’t be a permanent solution, but it will be painless and effective. For more permanent results, Miradry is very effective, but you need more than one treatment and they are painful. Numbing the area with injections helps. There is also some swelling afterwards. More treatments but less downtime is the soon to be approved Sweat X from Alma. I heard that you will need up to 6 treatments for results, but the pain is minimal. Ulthera is coming out soon with a hyperhidrosis indication, but that could be painful too in that area. Steve Weiner, MD, Destin, Florida.

Q: How long does 2 units of Botox last?

A: 2 units of Botox in crows feet? Not worth the pain or $$$

I doubt that you will see much difference in the crows feet after treatment with 2 units per side. The usual dosing is 5-15 units per side. Duration of action, if you see any, will be less than one month. I’d get another opinion from someone more familiar with Botox. Yes, the more units used, the longer the duration of action. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Under eye wrinkles, hollows and dark circles. What are my options to restore youth? (photos)

A: To rejuvenate the eye area, use Restylane and consider skin tightening with the Infini RF

You have loss of volume around the eye which is best treated with Restylane. I would recommend using someone that uses blunt cannulas for this injection so the chance of bruising or complications is reduced. For crepey skin around the eye, I would use the Infini, which is a new microneedling RF device. Botox might help as well. I written a blog all about this very situation, see below. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: I just purchased a Botox package, and Radiesse from a separate place. Should I get Botox first or fillers first?

A: The best way to get cosmetic treatments such as Radiesse and Botox is to get them from the same physician

Trying to scope out the absolute best deal for filler and Botox is the wrong way to do cosmetic procedures. You need to research the physician and figure out if he/she is qualified and has the experience you are looking for. It’s your face and you can’t hide a poor result. If there is something that needs attention after the procedure, how available is that person, and how long do you have to wait to see them? “Time is money” as well. Customer service, experience, reviews, outcomes, friends experiences should be much more important than price. Also continuity of care is very important and when you get things done at different offices, it’s very difficult to tell what results are from one doctor’s work and what are from another doctor. It doesn’t matter what procedure you have first, I often do filler and Botox at the same visit.

Q: The corners of my mouth turn down. Will Botox help with this or is there another non surgical treatment which will help?

A: Turning a sad smile into a happy smile can be done with Botox or Fillers, or both

Downturn of the corners of the mouth can be corrected by injecting the DAO with Botox but the best result will be also to add a filler like Restylane or Perlane. The Botox lasts only about 4 months max and won’t have as dramatic a result unless the filler is also added. Steve Weiner, Facial Plastic Surgeon, Panama City Beach, Florida.

Q: What should I do about crooked smile after Botox to treat bruxism and TMJ?

A: Nothing you can do to fix smile after poorly placed Botox for bruxism

Without a picture it is difficult to tell what exactly is the problem but my guess is that the risorius muscle was hit with the injections. Either the injection was too anterior or the Botox migrated and hit it. I have not heard of anyone mixing Botox with lidocaine and I don’t think its a good idea. Lidocaine is acidic and can partially inactivate the Botox. I’d seek another injector in the future. Everything should return to normal in about 3-4 months. Facial Plastic Surgeon, Dr. Steve Weiner, Destin, Florida.

Q: The corners of my mouth turn down. Will Botox help with this or is there another non surgical treatment which will help?

A: Turning a sad smile into a happy smile can be done with Botox or Fillers, or both

Q: What should I do about crooked smile after Botox to treat bruxism and TMJ?

A: Nothing you can do to fix smile after poorly placed Botox for bruxism

Q: Is it safe to do Botox injections around the same time as my Carpal Tunnel surgery?

A: Safe to get Botox around the time of carpal tunnel surgery.

I don’t see any problems with what you are proposing. I wouldn’t probably do on same day incase the anesthesiologist does some neck positioning or rubbing that could move it around. Otherwise, good to go.

Q: Will the muscles around the corner of the mouth recover from Botox paralysis? (photos)

A: Remember that Botox is not permanent, all things will go back to the way they were.

It sounds like the injector hit the DAO on the right side to turn up the corner of the mouth on that side. Perhaps you only needed it on the one side. This is routinely done in my office but almost always done on both sides. You are right that it affects the way you make a sad face (but why do you want to do that?). You can get the other side done for symmetry or just let it gradually wear off. Steven Weiner, MD, Facial Plastic Surgeon, Destin, Florida

Q: Alternatives to botox for the “11” wrinkles between eyebrows?

A: I really wouldn’t worry about Botox in the “11’s” but there are alternatives, ThermiRase and Frotox.

There are 2 alternatives to neurotoxins for the frown lines. The first is using radiofrequency to ablate the nerves that cause the muscles to contract. This is promoted by the company ThermiRase. It gives a long term correction (a few years) but will cost you in the $1500 range. The other technology uses a freezing solution to cause injury to the nerves and this has been dubbed “Frotox”. I don’t think this is available yet in the states. I think it also isn’t giving as long a result – months. I wouldn’t worry about dropping brows if just injecting the 11’s and you go to an experienced injector. There are millions of people who have had Botox treatments.

Q: Need to raise the tail end of my eyebrows

A: Droopy brows (brow ptosis) from Botox can be helped with further injections

Having brow ptosis after Botox can be improved by injecting the crows feet (if that hadn’t been done), and further injection around the tail of the brow, and even more medial in the brow area (this is a delicate injection). Also, injecting the depressor supracilia with a couple units can raise the medial aspect of the brow. If nothing works, it does improve before the Botox completely wears off, at about 3 weeks. Steven Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: When reconstituting the botox with saline, does it matter whether or not it is with preservative, or preservative free?

A: Mixing Botox using saline with preservative is what most doctors use

Even though the FDA approved why to reconstitute Botox is with normal saline, most doctors use saline with preservative because it hurts less when injected. There have been no studies that I’m aware of that says the Botox is negatively affected by this.

Q: Do I keep the botox frozen? The doctor said the injections would hurt less.

A: Botox needs to be kept within a certain temperature range after reconstitution and it’s above freezing.

Freezing Botox after adding saline may affect the effectiveness of it. I don’t think this is a good idea. Adding saline with preservative to reconstitute it does decrease the discomfort when compared to saline without. Also applying ice to the area treated is helpful. I have seen an article that states topical lidocaine can decrease the effectiveness of the Botox so I don’t use that.

Q: Droopy eyelid and hard sore lump on eyebrow after botox

A: Need to see another Botox provider

It doesn’t sound like they know what they are doing or that you are getting the real Botox. If you indeed have eyelid droop (not eyebrow droop), injecting further Botox would not have helped. The lump is also unusual. Eyelid droop is extremely rare and related to poor placement of the Botox.

Botox – When will my brows lift again?

I had an unfortunate experience in that I had Botox injected in my forehead, and it fell. I asked the woman three times if she was sure my brows wouldn’t fall. She said they wouldn’t. They did. Now I have a tightness in my forehead above my eyes, and I’m getting headaches. I also look angry and tired. To compound matters further, I’d just had an upper bleph to lift my sagging lids and they looked great. Do I have any recourse with her or the PS for whom she works? I’m not happy…

Having brows fall from Botox is due to one of these 4 issues

Unrecognized need for the forehead to lift the brows because of an inherent heavy brow. There are many people who subconsciously lift their brows and get wrinkles in their forehead. If you take that ability away with Botox, the brows assume their “normal” position which is low. Many middle aged men have this problem so I treat this group with less Botox or not at all.
The placement of the Botox was too low. If Botox is placed too close to the brows, your brows will drop. In general, injections need to be about 2cm above the orbital rim (brow bone).
Too much Botox was injected.
Didn’t use the microBotox technique. Using the microbotox technique, the Botox is more evenly spread across the forehead and there is less chance for brow drop.

I generally treat the forehead with a conservative dose that that there still is movement. Some people prefer the frozen look but that’s not my style. By treating with less Botox in the forehead, the duration of action is somewhat less, but the results are more natural.

Corrugator botox problems?

I have had botox for glabella frown lines. I have had repeated doses after 2 weeks and it makes little difference. I am told I am mail using my corrugator muscles and that botox here would cause eyelid drooping and I should have dermal fillers instead, is this the case (I’m only 33yrs)?

Botox for someone with very strong glabellar muscles (corrugator) will not completely relax muscle

For someone that has very strong corrugator muscles, Botox treatment will improve but completely resolve the movement. Strength/”degree of frown” is graded from 0-3 with 3 being “severe”. In Botox clinical trials, a responder is considered to move at least 2 grades. So, if you have gone from a 3 to a 1, you still are a responder but you will still have movement. Also, there are about 15-20% that won’t respond, according to their (Allergan’s) studies (less than a 2 grade improvement). Over time, the people who respond but don’t go to 0, will have continued improvements with subsequent treatments at 3 month intervals in my experience. If you are a non responder, I would try Dysport or Xeomin. Hope this doesn’t confuse you. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Why are my Frown Lines Still There After One Week of my Botox Injection?

Lines in frown area after Botox are called “etched in” or static lines and are not treatable with Botox

If you stretch the skin in the frown area and still see lines, they will still be there after Botox. These are called “etched in” lines and can be considered almost like scar tissue. They will gradually improve over time with additional treatments of Botox, but probably won’t go completely away. Belotero can be used there, but my preference is to just have routine Botox injections. You got a good treatment because you say you can’t move the area at this point.

Botox and Chin Implant?

Botox is fine with a chin implant

There is no problem in treating the chin area with Botox if you have a chin implant. Botox is sterile and should not pose an infection risk.

Head Ache After a Botox Injection?

Headache after Botox can usually last a few days

A headache after Botox injection is not that uncommon and can last a few days. It is actually not related to Botox but the injection because injection saline in similar areas can produce headache as well. I would take tylenol and it should get better.

Could You Please Tell Me How Long the Effects of Botox in the Jaw Muscle for TMJ Will Last?

“Just over a couple of months ago I had my upper and lower jaw muscles injected with botox to relieve the symptoms of TMJ, however about 2 weeks after the treatment I noticed I can’t smile as wide as I used to and one side of my mouth looks like it is drooping when I smile. I have had the treatment before and it was successful, but I only had botox injected in the lower jaw muscle that particular time. I am a little concerned as I don’t want to look like this permanently.”

Botox in masseter muscle for TMJ will last 3-4 months

If the Botox is injected too anteriorly, you hit the risorius muscle, which will affect your smile. I’m sorry you have this side effect but emphasizes that Botox in this area needs to be done by experts, experienced in the anatomy of this area. I’ve been injecting for TMJ with Botox since 1995. A Facial Plastic Surgeon is perfect to see for this injection.

When I Laugh my Upper Gum Show Which I Don’t Like. Can I Get Any Treatment in Botox to Numb my Upper Lip Muscles?

Gummy smile can be helped with Botox with 2 small injections

The muscle that needs to be weakened is the Levator labii superioris alaeque nasi muscle. About 2 units on either side of the lateral nose can help a gummy smile. I warn you that your smile is definitely different which some people don’t like.

Will Botox Be Suitable for Me? I Am 24 Years Old with Forehead Lines and Don’t Want to Look ‘Frozen’.

“I have had TMJ for years, chronic jaw clenching during the night. I noticed my forehead also feels very tight and sore when I wake up! I think I am clenching my forehead too. This may be why I may have so many fine horizontal forehead lines despite my efforts to stay out of the sun and wear SPF daily Will botox or dysport be best and how many units of each to correct the forehead. Also should the glabella be treated? (No lines here yet but it is tense)”

Sounds like you have a muscle tension issue: Face, jaw – TMJ, forehead. Botox is a great solution

I think you can have benefit from Botox without getting a frozen look. The application of Botox years ago led to frozen looks, but now less is being used and results look more natural. Specifically for you, I’d inject massters (10-20u ea), temporalis (20-25u ea), glabella (25-35u), and forehead (8-12u). Breaking the cycle of tension is needed. The dosing could be increased from those recommended if results are what you want.

Botox for Bruxism – As a Side Effect Will This Also Slim the Face?

“Hi there, I had 25 units of botox injected to the masseters (in each side – 50 units in total) – to help with bruxism. However, I’ve since learnt botox to the masseters can also slim the face. I have quite a thin/narrow face so am a bit worried about slimming my jawline any further. Is 25 units a big dose? Is there a chance this can just help with bruxism, without slimming down my jawline too much? Thank you!”

Botox in masseters for bruxism will cause a slight slimming effect of the face.

25 units of Botox in each masseter will reduce the bulk of the masseters and leave your face slightly slimmer. The goal is to weaken these muscle so you don’t clinch. By weakening them, there is some atrophy is this is done repetitively. If you notice too much slimming, it will fill out as the muscle regains it’s function when the Botox wears off. Standard doses for slimming the face are 30-40 units per side.

Can Botox Be Used to Widen the Smile?

“I was wondering whether it is possible to use botox to change the shape of the nasal labial fold lines so that the smile widens. I have quite a small smile for a wide face and so was wondering if this is possible.”

Botox to modify smile – you can help a downturn, gummy smile, but not widen it.

Botox is useful to help lift the corners of the mouth by injecting the DAO muscle and improve a gummy smile by injecting the levator labii superioris alaeque nasi muscle. However, widening the smile is not possible to my knowledge. You can make the mouth slightly smaller by injecting the risorius muscle, but I haven’t done this and its probably not a good idea.

Is It Ok to Have a Bath 28 Hours After First Botox Injections? Also is the No Alcohol Rule Only for 24 Hours?

No problem bathing and drinking alcohol after Botox

I would probably wait about 3-4 hours after Botox to bathe, but alcohol is fine after the treatment. The reason for no alcohol is that it can thin the blood, but after the injection, it’s OK. As for bathing, if its hot, it can potentially cause the Botox to spread. Also, it the needle holes are not closed, there is a very small risk of infection.

I Had a Facial Massage Right After Botox, Will This Damage Eyes, Eyelids Permenantly?

Facial massage after Botox is one if the few things you shouldn’t do

A facial massage can move the Botox if its done within 3-4 hours of the injection. There is nothing that can be done at this point. If it did move, all side effects will not be permanent and go away in 3-4 months. Other things you shouldn’t do after Botox: no hot tubs, no saunas, no working out, no placing your face in a horseshoe for massage for 3-4 hours. I also avoid procedures which cause swelling like Fraxel Dual on same day because I’ve seen diffusion into areas where I didn’t inject.

Botox Side Effects Injecting Hands, Sweaty Palms?

Botox for sweaty palms works very well

Using Botox for sweaty palms works very well. Side effects are usually minimal, and consists mostly of soreness and bruising at most. Although none of my patients have experienced this, you can possibly have some minor weakness of the hand. In the past, I did nerve blocks which was unpredicatable and painful. Now, with using an ice technique, it goes very smoothly and quite comfortably. You can expect between 3 and 6 months improvement, and the more times it is done, the longer the results. I use 50 units per hand.

Botox Caused Droopy “Captain Spock” Eyes – Help!

“It has been a 5 days since botox and I look like Captin Spock. I have very expressive eyes and over the last couple days when I talk my outer brow will raise up while my inner brow does not move. It looks horrible. In addition my eyes are droopy and I feel a heaviness between the bridge of my nose. I called the Dr and she thinks I need more botox. I am terrified that this will make the droopy eyes even worse. Help. I am getting Married in 2 weeks. I can’t look like this.”

“Spocking” from Botox is easily corrected

By injecting a very small amount of Botox on the lateral forehead (towards the sides) “Spocking” can be corrected. Drooping of the brows in the middle is harder, but sometimes injecting between the brow and the the nose can lift the medial aspect of the brow when done judiciously. Congrats!

I Am on Amoxcillin for UTI Treatment and I Have Had a Botox Injection in Forehead 11 Months Ago. Is This Ok?

Antibiotic 11 months after Botox is fine

There is nothing to worry about with taking an antibiotic 11 months after Botox. Antibiotics will not interact with Botox. I would probably not inject a person who is on antibiotics, but it depends on the person and the reason for the antibiotic.

Can Have Botox in Bunny Lines Cause Deformation on the Nose?

Treating bunny lines with Botox does not change your nose

Bunny lines are the lines on the side of the nose you see when you smile. They are treated with injections on the side of the nose. They will usually improve but do not completely go away. There is no change to the shape of the nose.

Can Botox Be Used to Change the Shape of my Eyes?

“One eye is perfectly almond shaped and the other is slightly larger and too round. I want both to appear almond shaped. Can botox and/or fillers help with this?” By injecting in the lower lid a small amount of Botox, you can loosen up the lid and make the eye look more rounded. You want the other effect, which you might be able to achieve by injecting filler in the upper cheek or tear trough area. However, it might look asymetric with unilateral filler, so be careful.

Will Injecting Botox Only in the Brow Area in Turn Help with Forehead Lines?

“I have had Botox done before but went to a different Dr recently. I told him I was interested in Botox for my forhead however he seemed to only inject my brow area. I believe he injected 25 units”

25 units of Botox for the forehead is plenty to improve the lines

I typically inject 6-12 units in the forehead and about 10 in the glabella area to treat the forehead wrinkles. I believe that 25 should do it. I would wait the 7-10 days until the Botox is fully effective before I go back to evaluate the treatment.

Can Botox in the Masseter Be Permanent and How Is This Muscle Different Than Others?

“I had a botox injection into my masseter muscle a week ago, I heard that usually one only needs 2 botox injections to achieve a permanent dystrophy for this muscle. Can anyone please confirm if this is true and if so, how is the masseter muscle different to other muscles on the face in terms of its reaction to botox? Thanks”

Botox in the masseters (for slimming the face and tension) is similar to all other muscles – lasts only 3-4 months

Botox is used in the masseter muscle for 2 reasons. One is to reduce the tension in it that might be leading to headaches and TMJ. The other is to decrease the hypertrophy in some people to make the profile a little thinner in that area. I don’t know where you got your infomation but the masseter behaves like all other muscles and the Botox results are only temporary.

Is It Possible for Me to Still Have Botox when I Get my Period Next Month, Even Though I Have Plans to Have Baby?

Is it possible for me to still have Botox when I get my period next month, even though I have plans to have a baby? I believe although Botox is a bacteria, it is concentrated only in the injected site, and won’t get into the blood stream. I’m just wondering if it will have any effect on my baby if I have Botox on October and happen to conceive around November or December.

Botox is not a good idea if you are trying to get pregnant

There have been no studies with Botox and pregnancy, but it’s not a good idea to have Botox injections at the same time you are trying to get pregnant. Having said that, there are probably thousands of women who have had Botox when they didn’t now they were pregnant and I haven’t heard of any problems with babies born to these women. The Botox would only be in your circulation for a few hours after the injection and then it is bound and incorporated into the nerves in the area injected.

Can I Have Filler or Botox Above the Lip Line As I Have Wrinkle Lines There?

Upper lip lines (smokers lines) are treated fairly well with combo of Botox and Filler

Probably the most common treatment of lip lines in my practice is the combination of dermal fillers (Restylane or Juvederm) and Botox. I like to treat this area using blunt cannulas in a horizontal fashion and no “chase” each individual line.

Are Botox Results Permanent After Long-term Use?

“I read somewhere that Botox results become semi-permanent after perhaps 8-12 treatments. Is this true? If so, would it only be true for certain areas or for any area treated with Botox? I’m getting Botox for down-turned corners. Thank you!”

BOTOX results are usually not permanent

Botox causes weakness of muscles which are causing wrinkles or in your case, downward turning of the corners of the mouth. Over repeated treatments, the muscles will atrophy, provided there is not a long period between the time the effect of Botox wears off and your next injection. I tell my patients you can think of Botox as a chemical cast on the muscles. Just like when you wear a cast on your leg or arm, the muscles get weak and smaller over time. But when the cast comes off, you can build your muscles back to the same shape they were in before. What you can expect over repeated injections is that the dosing might lessen, and potentially the length between treatments might get longer. In some cases, longer might be 9 months or more, but usually not permanent.

Can You Have an Allergic Reaction to Botox?

“I recently get Botox injections in my upper forehead, and all of a sudden I am getting whitish welts under the skin, and purplish brown pigmentation on random places of my face. Can this be the Botox going through my system? I have been to 4 Dermatologists in a week and no one seems to have any answers for me. Please Help!!

Allergic reaction to Botox is extremely rare, hadn’t seen it…but did you really get Botox?

This does sound extremely unusual to me. I don’t think this is an allergy to Botox. The only issue I’ve ever seen with Botox is an allergy to the preservative in the saline used to mix it up. The reason I know this was not the Botox and was the saline is because I injected the saline with preservative only and it gave welts. These were immediate, before the patient left the treatment room. I have subsequently injected the same person several times with Botox mixed with nonpreserved saline. I would question whether you got real Botox or a knock off.

Side Effects from Botox for Under Eye Wrinkles?

“Does Botox cause thinning of the skin or a reduction in collagen over time? I am considering it for under eye wrinkles.”

Botox for undereye wrinkles won’t affect the collagen

The only risk that is different for injecting the undereye wrinkles with Botox is that the injector must be very careful with dosing, placement, and selecting the correct candidate. If you don’t have strong enough lower eyelid tension, you can get ectropian, which is when the lower lip everts. Although this will be temporary, it’s a problem for several weeks with tearing and possibly drying of the eye. No skin issues can be caused by this injection.

Can to Many Units of Botox for Crows Feet Make Condition Worse?

“I go evey 6 weeks because I have a high metabolism. Dr put in 25 units it didnt work so I went back 4 days later for another 25 units. wrinkles look worse and have a bruise. What can I do to improve my lines?”

Yes, too much Botox in crows feet can make it look worse. You might have wrinkles from cheek which don’t respond.

You might have wrinkles from raising your cheek that will not respond to Botox. The best way to tell which wrinkles will and won’t respond to Botox is to squint. The wrinkles you see with squinting are those which can improve with Botox. If you smile and your cheek raises and creates wrinkles, some of those can not be improved. Filler may or might not help for those. Also, adding too much filler can sometime make the under eye area look worse because some people need some tension in the lateral aspect of the eye. 50 units is too much for crows. I usually use 10-25 total for both sides

Can You Get a Professional Facial As Well As Botox Done on the Same Day?

Botox is fine on days you have a facial

The only caveat is that the facial is done first. After Botox, I tell my clients to avoid strenuous activity, avoid putting yourself in a horseshoe for a massage, avoid hot tubs and saunas, and caps for 3 hours.

Botox on the Depressor Anguli Oris Muscle?

“Hello! I am 21 years old yet I have downturned corners of the mouth and what seems to be like a very slight marionette line. I was wondering if putting botox on the Depressor Anguli Oris muscle would reduce the marinette line and the downturned corners of my mouth. How much should be injected and how difficult is it? Any side effects or risk of deformation or lumps? Thank you!”

Putting Botox in DAO helps with downturn of corners of mouth and slight marionette lines

But….the combo with Restylane is better. When you are putting a total of 5-6 units of Botox in the DAO’s and spending about $60, you can’t expect huge changes. If you keep up with it about every 3 months and consciously avoid that “frowny” motion, it will gradually improve.

Took Mesobotox on Cheeks for Open Pores. After 2 Weeks I Notice Cant Smile or Laugh from One Side of my Face. Is This Permanent?

Mesobotox was done improperly, either too deep or too much, and caused smile abnormality

Mesobotox is a very dilute Botox injected very superficially to help with pores, acne, or fine lines. If not done properly, it will affect the deeper muscles in the cheek, which will affect your smile. Over the next 2-3 months, this should resolve back to normal. There is nothing which can be done in the meantime.

Cannot Smile After Botox for Migraines

“I Had Botox Injected in my Cheeks for Migraines and Now I Can’t Smile. Is This a Normal Side Effect?”

Botox should not be injected in the cheeks, it will affect the smile muscles

As stated earlier, you shouldn’t inject Botox in the cheeks because it will affect the movement of the zygomaticus muscle which raises the corners and the upper lip. There is nothing which can be done except let the Botox wear off over the next 3-4 months.

Doctor Rubbed Botox Area to Massage It In?

“I recently got botox done for the second time. She injected my 11’s and the muscle above my brow. It was much more painful then the first time and she massaged the area to spread the botox out. It didn’t work well at all I still have faint lines and can move my one eyebrow. She reinfected it again 2 weeks later and still no results. I feel she’s injecting too deep and that the massaging is hindering it as well.”

To massage or not to massage after Botox…no consensus for forehead, other areas NO

When attending the Carruther’s (Jean and Alastair) symposium about 7 years ago, they debated whether or not to massage the forehead injection (not glabella). The two were split, one did and the other did not. I personally massage only the forehead injection so as to spread the Botox more evenly in this area because it is such a large and wide muscle. I also do massage in the masseter and temples for the same reason when doing TMJ Botox. (For those who don’t know the Carruthers, they are the authority/discoverers of Cosmetic Botox.) Massage in any other area of injection is highly NOT recommended because it can cause migration of Botox into areas not intended to be affected

Why Does Botox Make Forehead Look Shiny?

Botox is being used off label for acne

Botox works for acne by inhibiting the sebaceous glands secretions. This might be why your skin becomes shiny. Also, less wrinkles mean a smoother, shinier surface. It also decreases the sweat gland secretions. Probably a combination of all these factors.

Unable to Smile After Botox and Fraxel Laser

I had Botox injected for frown lines, forehead lines, and crow’s feet. The following day, I hadFraxel Laser on my face. I’m 16 days post-procedure, and unable to smile. My upper lip turns under when I try to smile, and I’m unable to raise my cheeks. My doctor is experienced with Botox and has never had this adverse reaction occur. Have you seen this happen, and if so, how long will it take before my smile will return? I’m depressed, anxious, and look like a freak.

I heard of this before

Even though botox is supposed to be absorbed after a few hours, there have been a couple people I’ve heard of that have had similar stories with the 2 procedures very close together. I guess that the edema from the Fraxel has caused migration of the Botox, but can’t be sure. In that case, it might take a few months to resolve.

Can Botox Caused a Crossed Eye, and if So How Can It Be Corrected?

I got one unit of botox above each eyebrow to correct and eyebrow that when I lifted, appeared to overcorrect with a fold above it. Immediately after at home my opposite eye began to cross and I developed a migraine headache. The Dr would not return my call and had a nurse assure me it was not botox related. I saw an eye doctor who thought it was a strong possibility. Three days later the eye is still turning inward and I’m having difficulty focusing.

Botox causing a “cross eye” is possible if injected too close to orbital rim

I’ve heard only case reports of this problem, but if the Botox diffuses into the orbit and weakens one of the muscles which moves the eyes, it can cause “cross eye” problems. People that have had childhood “lazy eye” will be at greater risk for this. It will reverse, but it won’t be pleasant for the time it takes to wear off. You might need to wear a patch to avoid seeing double. One of the earliest FDA approvals for Botox was to fix strabismus, which is lazy eye. You would inject the stronger eye muscle to weaken it and make it equal strength to the opposing muscle.

Is Botox for Crow’s Feet Less Likely to Cause Eyelid Droop?

With Botox for crow’s feet are there more or less chance of getting eyelid/eyebrow ptosis (drooping)? My question is, is there more chance of getting ptosis from crow’s feet treatment compared to frown lines or forehead treatment?

Botox around crows feet cannot cause eyelid droop

The only way to get eyelid droop from BOTOX is by injecting too close to the browline in a line that is vertically placed from the pupil. This should be an extremely rare problem from BOTOX. Injecting the crows feet will not cause eyelid droop.

Can Botox Treat Facial Sweating?

I understand Botox can be effective in treating hyperhidrosis for underarms and palms. But can it be injected to treat facial sweating? My entire face gets drenched in sweats even when I’m sitting still, maybe due to medication I’m taking. It’s really embarrassing and starting to affect my social life… Please give advise. Thank you!

Sweating of all areas can be treated with Botox

Botox can be used to treat facial hyperhidrosis. The Botox must be injected superficially so as to not affect the muscles if expression. This is done with multiple small injections with dilute Botox.

How Can Experienced Botox Injector Get It Wrong? Are There That Many Injection Techniques for Same Area?

Had Botox 8 wks ago. Used it 7yrs with PS, always loved results. Decided to try new Dr offering new patients $9 Botox. After researching, He was thought to be Best Botox injector in Utah, Runs Botox blog & been on local TV. I felt certain I could save $ & still get great results. NOT! Fastest Botox ever 42u under 5 min. Injections felt much different & Results – visible dents in forehead, deep dents around eyes, 11’s still visible & eyebrow droop. Can I get botox to correct his Botox injections?

Results from Botox on sale were bad. Don’t always go for the cheapest price!

Sometimes, the only way for a practice to attract new clients is to put their Botox on sale. Be warned, it doesn’t always get you to the results you were expecting. Just because someone is in the news or advertises a lot, does not mean they are good injectors. Often, it just means they have a great marketing department. Correcting bad Botox can be done in certain cases but not all. It’s unfortunate that this happened to you. When you go in for a cosmetic procedure you expect to look better, not worse, after getting treated. This is an all to familiar story that I see almost everyday. It ends up costing even more than going to the regular priced physician, as well as more time, and frustration. Best advice, go to someone you are comfortable with, your friends recommend, and has been doing it for years. I’ve been injecting since 1994 and have previously taught other physicians how to inject.

Doctor Injected Botox in Zygomaticus Major/minor?

I had one session of botox for bells palsy around my eye and forehead area. The second time the neurologist said that she has a little left and can inject it on my Zygomaticus major to see if it releases the very slight pull that I had in my lips. After a week my face was completely paralyzed and it is six weeks not but still cannot lift my upper lip. I have been reading a lot here and am very worried that because of my history of bells palsy would this by any means cause permanent damage

The effects from Botox are temporary and should last 3-4 months

For a Botox injection gone bad, there is no need to worry about permanent side effects or paralysis. In 3-4 months after the injection the normal movement will start to return.

Side of Face is Paralyzed After Botox for Crow’s Feet

I had botox for crow’s feet and now the right side of my face is paralzed. Will this get better? 6 days after botox the right side of my face felt numb. When I smile my mouth pulls down severely on the right. My doc said she believes the botox migrated to the nerve in my cheek and will be fine in a few weeks. Have you ever seen this before and is it reversible?

Very important that you get BOTOX from an experienced injector

The only reason BOTOX “migrates” is because it was placed inaccurately. The paralysis of the face you mention can last up to 3 or 4 months. There really is not much that can be done. I sorry you have this issue. It sounds like it was placed too low on the cheek.

Why my Frown Lines Are Still There After One Week of my Botox Injection?

I’m 29 years old and I’ve had my first botox injection a week ago. I can’t frown anymore but my frown lines are still there! should I repeat botox with higher amount?

Lines in frown area after Botox are called “etched in” or static lines and are not treatable with Botox

Can Botox Be Used to Treat Assymetry in Upper Lips?

I had thin lips which I’ve recently had subtly plumped with juvaderm. I love the effect. It’s not too much and it’s smooth, no lumps. The only thing is that one side of upper lip lifts more than the other. I was already uneven to behind with but they were so thin, it wasn’t noticeable. But now it is. It has been 2 wks since injection,all swelling is down. Can a tiny bit of botox on the weaker upper lip make it even up with the other side? I don’t want to make it worse or unable to smile properly

Asymmetry in smile is hard to correct, wouldn’t do Botox

Many people have asymmetry when the smile which is more noticeable after having their lips enhanced. Outside of injecting the filler to correct small differences, there is not much to do. Botox might make the matter much worse. Your smile makes you unique and I would try to change it that much.

Can Botox Make You Feel Ill?

I had Botox yesterday and felt fine, I was shopping for clothes afterwards and became very hot but I was still feeling well,then I had to run for the bus home and was worn out,a few hours later I felt unwell and as the night went on I got worse,sore throat head aches and feel run down,is this the cause of botox?

A rare side effect from botox is flu symptoms

Some people will experience symptoms of the flu after boots. Symptoms can include aches, headaches, weakness, and headaches. It is usually self limited to a day or two. Tylenol can help. I have had a few people experience this. It seems to be dose related, more units means more symptoms. I switched a couple clients to dysport and they had no symptoms with it. Xeomin is another option too.

How Often Should One One Use Botox if You Are 34 and a Smoker?

As far as I know, smoking doesn’t affect Botox. Recommend follow up treatments every +/- 3 months

Botox does not appear to be affected by smoking. It will last about 3 months, a little more in glabella, a little less in the forehead. If you allow the muscles to regain their full activity, you lose out on the long term benefits of weakening these muscles. This is the average time it takes for the Botox to wear off but I have some people that it last for about 6 months. You can wait longer if you wish with not detrimental effects.

What’s new in Botox Treatments, MicroBotox, and the Upcoming “Botox Cream” by Revance Theraputics

New Botox techniques: MicroBotox, Mesobotox. Revance RT001.

Dr. Weiner answers questions about Botox

Botox was originally FDA approved for treating stabismus (lazy eye) and blepharospasm (spasms of the eyelids) in 1989. When treating around the eye, patients and doctors were noting the wrinkles around the eyes were improving and brows were elevating. Studies were then initiated by Drs. Jean and Alastair Carruthers to test the cosmetic effects of Botox. It actually took 4 years to recruit enough patients to complete the study. In 2002, the first indication for Botox cosmetic use in the glabella (frown line) was approved. Botox has since become the most popular cosmetic procedure in the world. Its no downtime, consistent and effective results have made it a mainstay for people desiring a quick wrinkle improvement. Earlier this year, the FDA approved the second indication: for use in the lateral canthal rhytids (crows feet). Although the crows feet and other areas of the face and neck have been used (legally) off-label since the early 2000’s, this new approval will allow the company, Allergan, to market this new indication to the public. This will create more public awareness about what Botox can do, and make it even more popular.

The newest buzz about Botox is a technique that has been used by Dr. Weiner for several years is called “MicroBotox”. This is when the diluted Botox is injected in multiple very small doses in the area treated. The theory here is that the effects of the Botox are more evenly spread over the areas treated and the chances of having areas over treated is less. The most notable area for this technique is in the forehead. The result of MicroBotox is a more natural look which is not frozen and the dosage of Botox is less. This technique has also been described for use in the neck by a Korean physician at a recent meeting. It was shown to mildly improve the neck wrinkles and improve the texture of the skin. For some people who have recalcitrant acne problems, MicroBotox (sometimes called “mesoBotox” when used in this situation) can be injected very superficially into the facial skin. However, there is a risk of affecting facial muscles and Revance’s RT001, a topical “Botox”, should be a better alternative to this technique.

In the near future, a cream to apply a substance similar to Botox will be FDA approved. Revance Therapeutics is developing RT001 for use in the lateral canthal rhytids (crows feet) and has shown great promise. It will be a cream which is applied in the physicians office and stays in place for about 15-30 minutes. This will eliminate injections for this area and is completely painless. The results seem to be impressive, possibly better than injections. The reason the results are better is similar to why MicroBotox is better for the forehead- the dosing seems to be more evenly applied to the muscles around the eyes. Other areas being tested by Revance are: underarm hyperhidrosis (sweating), migraines, and rhinitis (runny nose). Off label potential uses are for acne and general overall skin improvement of the face and neck. Unfortunately, the other areas which Botox is injected in, frown lines and forehead line, have muscles which are too deep to allow the topical ingredient to get to those depths. Whether or not the upper lip lines (smoker lines) will be treatable with RT001 has yet to be tested.

Even though Botox has been FDA approved since 2002 for cosmetic uses, there are still new techniques, new uses (approvals), and a new delivery model (topical) for a competitor which will soon get approval. The aesthetic industry is constantly changing and Dr. Weiner works hard to stay at the forefront of all the latest techniques and technologies. To learn more about Dr. Weiner, visit his website: http://www.theclinique.net For a consultation call: 850.622.1214. Dr. Weiner is a Facial Plastic Surgeon who devotes 100% of his practice to noninvasive and minimally invasive cosmetic procedures. His practice is called the Aesthetic Clinique and is located in Santa Rosa Beach, which is between Destin and Panama City Beach, Florida.

Link to the app for Brilliant Distinctions, the reward program for Botox, Juvederm, SkinMedica Products and Peels, and Latisse

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Blog: http://stevenfweinermd.wordpress.com/

Don’t Forget The Hands and Decolletage When Thinking About Your Cosmetic Refinements!

Before and after hand volumization with Radiesse.

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Most of the procedures advertised and touted have to do with rejuvenating and beautifying the aging face and neck. This blog is to bring attention to the often ignored areas: The Decolletage (chest) and The Hands. There are some simple, quick, and little to no downtime procedures that can be performed to bring these areas up to speed with your face and neck cosmetic improvements.

Just as the other parts of the body, the hands and chest lose volume from fat loss, and thinning of the skin. In the hands, the vessels and tendons become more apparent, and in the decollete, wrinkles form the “cleavage” area. The easiest way to improve this problem is with filler. Using micro blunt cannulas, the procedure becomes nearly painless and without any downtime. Filler of choice for the hands would be Radiesse, and for the chest, Sculptra. For the Sculptra treatment, it will take 2-3 sessions, but this will give 2 or more years of improvement. It thickens the skin by stimulating the skin to produce collagen.

Most people these days protect their face from the sun, but the chest and hands are neglected. Sunscreen is important fo r these areas as well. Sun damage on these areas presents as:

Hyperpigmentation, “sun spots”, lentigos
Wrinkles
Thinning of the skin
Skin cancers and pre cancerous lesions

Hyperpigmentation is treated with skin care, peels, and lasers. Proper skin care can include: Sunscreen, Retin A or Retinol (for the chest), Growth factors like TNS Essential Serum (for the chest), and body skin care like Environ which exfoliates and hydrates. For more extensive damage chemical peels can be done, or laser procedures. If just wanting a few spots removed, the Spectra Q-Switched Laser is state of the art to remove individual spots. They will darken and then flake off over 2-3 weeks. If the skin is covered with pigmented lesions, the Fraxel Dual 1927 is required. This will require 2-3 treatments and is a nice laser peel that rejuvenates the underlying skin as well and thickens the dermis. Peeling from the 1927 takes about 2 weeks to resolve. Subsequent treatments can be done after 1 month. The Fraxel Dual is also a great tool to remove and prevent pre cancerous skin lesions called actinic keratosis. It is FDA approved for this purpose and is equal in efficacy to the topicals used for this like: Aldera, Efudex, and Carac.

There are 2 technologies which have yet to be used extensively in the chest and hands but offer promise. Ulthera (Ultherapy) and Infini. These devices create small injuries in the dermis which lead to the body tightening the overlying skin, laying down collagen, and thickening the skin. There are already FDA trials of the Ulthera on the chest. Infini is a very new technology and Dr. Weiner is one of the first in the country to have it. Soon hands will be done with the Infini at The Aesthetic Clinique and results will be posted.

Often people who look much younger than their stated age, the truth is seen in their hands. Don’t ignore this area, as well as the chest! There are several easy ways to get them to match your youthful facial appearance.

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net