WHAT IS A BOTOX INJECTION?
Botox injections are a non-invasive way to help soften lines, wrinkles and in some instances reshape the face. The merits of Botox therapy have been popularized within the lay press. Dr. Shah has pioneered several techniques with Botox. His unique approach to this procedure allows for lines to be softened while still allowing for a natural appearance. He works with each patient’s anatomy to customize an approach for their face. This allows for patients not only to look younger, but also have a better balance to their overall face, as well.
The key to proper Botox injections is the elimination of bruising and swelling, coupled with effacement of wrinkles. A common misconception about Botox is that the goal of the procedure is to eliminate facial movement and expression. Sophisticated injectors of Botox will preserve facial expression while softening the patient’s wrinkles. Another key component to Botox therapy is to carefully map the patient’s facial muscles and remove movement in select muscles while lessening movement in others; thereby, creating a natural appearance for the patient’s face.
How is Dr. Shah different?
Dr. Shah and Chughtai are diamond injectors of Botox (Allergan tier ranking for physicians) making them in the top 5% of all injectors in the world. They are an all physician injection practice where they specialize in the best of botox including specific contouring and applications not found in other practices. Dr. Shah is one of the only injectors in the world to use Botox for lines in the face, oil in the face, masseter hypertrophy and reducing pore size. Many of the techniques they use require advanced knowledge of the face and its anatomy.
Dr. Shah has been featured in several lay press articles regarding his injection techniques for botulinum toxin, in particular for Botox pore reduction. Dr. Shah was one of the first injectors in the world to utilize botulinum toxin in an effort to reduce pore size and sebum production. He wrote the first paper in the Scientific Paper describing this technique and his results. He has written a seminal chapter on botox in, a leading academic text.
Before and After
Who is a candidate for Botox?
Botox is typically injected into the upper portion of the face to help improve the appearance of the number 11’s (glabella), crow’s feet (orbicularis oculi) and horizontal lines of the forehead (frontalis) muscle. Botox is ideally injected to smooth lines and in some cases lift brows.
How to avoid bruising with Botox
Dr. Shah and Chughtai have worked tirelessly to help decrease the chance of bruising. While this can not be guaranteed, they use several technical advances and details to help minimize the incidence.
- Vein finder- Most bruising occurs from a vein. Veins can lead early and late bruises. The use of a vein finder can help decrease the chance of bruising. In addition, since the botox does not go in the vein, many patients report longer effect than other places.
- Small gauge needle. Most injections with botox take place with a medium to small sized needle. The problem is that this can create pain and more likely to cause a bruise. Dr. Shah and Chughtai use an extra fine needle which creates less impact on skin and bruising (Based on results seen in our practice)
- Pre injection prepping- For those patients who bruise easily, patients can avoid blood thinners and take MEND cosmetic to prep the patient by adding arnica, bromelein, and other blood thickening agents
How to make botox pain free?
For most patients, botox is an easy process which requires no additional steps. However, there are several steps we can incorporate to make botox an easier process:
- use of distraction tools- vibration tools can help distract patients from botox and make it relatively pain free. We use a variety of tools to help patients feel less discomfort.
- use of numbing cream- there are a variety of numbing products on the market. Numbing cream tends to not be as impactful as other modalities
- use of ice- many patients have mixed results with ice. It can be incorporated for those who desire it.
- nitrous- Nitrous is rare for patients receiving botox but can help decrease the edge seen with it. We utilize Pro-nox in our office to help with procedures but most patients feel like this is not necessary for botox. We do offer it for those rare patients who can not tolerate injections (extremely rare with our use of distraction devices)
Cost of Botox
The cost of botox varies from office to office. Since we are a diamond level provider, our cost is typically less than competitors. Please note, we only use AUTHENTIC products, including Botox from Allergan and Dysport from Galderma. We charge Botox (Allergan) by the unit and is $15 per unit. Most patients typically need anywhere from 10-40 units. Many patients who sign up for Brilliant Distinctions or Aspire awards will get discounts with each injection as well.
SPECIAL PRICING WITH NURSE INJECTOR JONATHON
Our nurse injector, Jonathon, is currently offering special pricing for Botox (Allergan) at $10 per unit.
Areas to treat
BOTOX FOR FACIAL WRINKLES
Forehead
- The fibers are vertical and the contraction of the muscle results in horizontal lines
- Variability in anatomy here with some patients having significant overlap in the midline and others not
- Interdigitates with the procerus and orbicularis oculi
- Contract the superior portion – a descent of hairline
- Contract lower portion – elevation of the brow
Glabella
- Composed of corrugator and depressor supercili muscles
- Brow depressors are deep and some have advocated going deeper to lift medial brow – difficult to demonstrate clinically
- Corrugator supercili – only muscle with a bony connection (medial on the skull) – laterally inserts on to the skin of eyebrow and underlying fascia of frontalis
- Procerus- horizontal lines and descent of brows- botox can slightly elevate brows here
Crow’s feet
- Keep 1-2 cm away from the oribital rim
- Bunny lines
- Caused by nasalis muscle and create transverse lines here
Perioral use of Botox
- Smoker’s lines – caused by excessive contraction of orbicularis oris – creates vertical lines- usually avoid cupid’s bow area
- Gummy smile – levator labii superioris alaque nasi
- Downturned smile – inject into depressor anguli oris
- Peau – d’orange – mentalis muscle injection- helps dimpling
- Complications – drooling, dysarthria, inability to drink from straws or purse lips
Masseter muscle
- Complications- facial expression alteration, speech disturbances, dysgeusia, transient muscle bulging
Eyebrow-raising
- Brow depressors vs brow contractors
- Main elevators are frontalis muscle and temporparietalis
- Temporoparietalis muscle – rarely described and highly variable – raises eyebrows, widens eyes and wrinkles skin of the forehead
- Depressors – procerus muscles, corrugator muscles, and orbicularis oculi muscle
BOTOX FOR JAW REDUCTION
Botox jaw reduction is a specialized technique to reduce the width of the jawline changing an overly square jawline to a more attractive oval or heart shaped face. In some patients, the masseter muscle, a chewing muscle, is enlarged creating extra facial width. Botox selectively weakens this muscle over time leading to an overall reduction in the size of this muscle.
Read more here about Masseter Reduction Chicago.
BOTOX FOR PORE REDUCTION
Botox represents the latest technique for pore reduction. In fact, intradermal Botox is the only treatment for which directly targets pores. When all of the pores reduce in size, the surface area of the skin is reduced and the skin is tightened, creating a lift effect.
Read more about Botox Pore Reduction Chicago.
BOTOX FOR HYPERHIDROSIS:
Hyperhidrosis is a condition where a patient suffers from excessive sweating from their sweat glands. Botox can be used to treat this issue by temporarily blocking the chemical signals of the sweat glands’ nerves which stimulate the glands overproduction of sweat. To read more about Hyperhidrosis, click here.
BOTOX FOR ACNE:
“Botox definitely clears up acne,” said Anil Shah M.D. He is just one of the many doctors that are using Botox to clear the skin. It can eliminate large pores, oil production, and acne.
Acne is produced when the skin releases too much oil into the skin pores. Bacteria eats the oil, causing inflammation and creating a pimple. According to Dr. Shah, Botox stops the production of the oil and deprives the bacteria of its food.
The plastic surgeon has treated over 100 patients using this new Botox application. He recently published a study that shows how intradermal Botox can lower the skin’s oil production.
As explained in Medical News Today, “The plastic surgeon believes Botox works by blocking the chemical acetylcholine in the skin’s dermis. Acetylcholine is known to increase the skin’s sebum production. In addition, the treatment literally paralyzes the tiny erector pili muscles that surround the skin’s pores and cause them to expand.”
However, Dr. Shah does exercise caution when selecting his patients. “I only treat patients over 20-years-old,” he explains. “Their hormonal changes are likely permanent. For them Botox is now the safest most effective treatment we have.”
OTHER TREATMENTS WITH BOTOX:
Dr. Shah is a leading innovator of Botox uses. Other treatments using Botox include: Hyperhidrosis, Botox for Oily Skin, TMJ Disorders, Headaches, Facial Nerves, and Underarms.
Types of Botox
- Onabotulinumtoxin A (Botox by Allergan)
- approved in 1979 by FDA for strabismus
- approved for glabellar wrinkles FDA 2002
- approved crows feet FDA 2013
- 900kDA complex of 150kdA botox and nontoxic proteins through purified ethanol and crystallization
- onset is 1 week and effects last 3-4 months depending on areas
- AbotulinumtoxinA (Dysport by Galderma)
- approved in 2009 by FDA for cervical dystonia
- approved in 2009 for glabellar rhytides in patients younger than 65
- 500-900 KDA complex purified through an ion-exchange process
- Clinical onset is 5 days and duration is 3-4 months
- IncobotulinumtoxinA (Xeomin by Merz)
- homogeneous solution of 150 kda BoNTA created by ion exchange and pH elution
- FDA approved for glabellar wrinkles in 2002
- found to have faster onset (3 days) as well as longer duration of effect
- 1 study found that patients switched from Xeomin from botox due to lower cost but switched back citing less efficacy and duration ( Banegas RA,Farache F, Rancati A, et al. The South AmericanGlabellar Experience Study (SAGE): a multicenter retrospective analysis of real-world treatment patterns following the introduction of incobotulinumtoxinA in Argentina. – Aesthet Surg J. 2013;33:1039–1045.
- RimabotulinumtoxinB (Myobloc, Solstice Neurosciences)
- not clinically used for cosmetic use
- least duration
- higher levels of immunologic resistance
ETHNIC BOTOX
African American Botox
African Americans are seeking cosmetic surgery in record numbers. Find statistic One popular question is do I need Botox. First of all, Botox, which is the brand name for botulinum toxin, is an injectable which helps erase lines. It takes about 4-7 days to work and lasts from 2-8 months. Most African Americans age differently than Caucasians. While Caucasians frequently age with wrinkles, African Americans more commonly do not. In the lower portion of the face, African Americans will likely not develop prominent wrinkles. There is an exception to this. On the upper portion of the face, along the forehead and between the brows, some African Americans will have lines of expression form etched lines. These are the lines which are best treated with Botox.
So, how is it different treating Botox different in African Americans? Typically, African American patients may need a slightly larger does than either Asian or Caucasian patients. However, this is not a hard and fast rule and the dose is customized for each patient.
Asian Botox
Asian patients age differently than Caucasian patients. This is often most reflective in the skin, where formation of fine wrinkles is less prominent, so Asian patients are often not candidates for Botox until their 40s of 50s. At this time, many Asian patients can turn to Botox to soften lines and improve eyebrow position.
Caucasian Botox
Caucasian patients seeking botox are typically interested in treating dynamic wrinkles, or those created from movement. This is typically confined to the upper one third of the face including the eyes and forehead. Dr. Shah also uses botox to help patients with acne, large pore size, excess oil, brow reshaping, brow lift, thinning the face. In many of these techniques, Dr. Shah is one of a select number of physicians or the actual pioneer of this application of botox.
Hispanic Botox
More and more Hispanic patients are seeking techniques to look younger. Botox and now a newer version of Botox called Xeomin are used to help the face look younger. In some Hispanic patients, the skin is very fragile, and fine lines can develop with age or sun exposure. Botox can be helpful in softening or reversing lines. In other Hispanic patients the skin can be thicker and more resistant to lines. These patients often will not need Botox until their late 40’s to 50’s.
Indian Botox
Indians are seeking more and more plastic surgery. Botox is less discussed amongst Indian patients, but the increase in popularity is undeniable. Indian patients are classically thought to have more resistance to finer lines. This is often the case, as most Indian patients are not a candidate for Botox until their 40’s and 50’s. What Botox can do is soften lines of expression so that the face will have younger, more pleasing appearance.
Middle Eastern Botox
Middle Eastern patients are seeking plastic surgery in much greater numbers in recent years. Botox is less discussed amongst Middle Eastern patients, but the increase in popularity is undeniable. Middle Eastern patients are classically thought to have more resistance to finer lines. This is often the case, as most Middle Eastern patients are not a candidate for Botox until their 40’s and 50’s. What Botox can do is soften lines of expression so that the face will have younger, more pleasing appearance.
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- Real patient
Recovery Time
Typically, most patients experience a few moments of redness from the injection site. Dr. Shah recommends patients avoid blood thinners if possible before Botox therapy to minimize downtime.
A botox procedure typically takes several minutes.
Frequently asked questions
Botox lasts as long as the muscle takes to regenerate the nerve (presynaptic release of acetylcholine). Some muscles will regenerate the nerve faster than others. In the upper face, botulinum toxin typically lasts about 4 months. In the lower face (masseter muscle), botox typically lasts 6 months. Since every patient will regenerate the nerve at their own pace botox can last longer or shorter depending on each patient.
Most patients experience little to no pain during the procedure. This is in part due to the gentle injection technique administered personally by Dr. Shah.
Dr. Shah does not believe in the use of assistant injectors or physician extenders. His opinion is that even some established physicians struggle with creating a balanced and harmonious appearance after Botox injections. Facial anatomy is complex and must be tailored to the patient and is best done with a skilled and knowledgeable physician.
Anyone can inject Botox, just as anyone can potentially cut with a scalpel. The problem is knowing what to do with the Botox. If the injector does not place Botox in the right location or does not use the right dilution, serious consequences can take place which include a droopy eye, facial nerve paralysis, eyebrow droop or a poor aesthetic outcome. Botox is not like taking a vitamin, it needs to be injected in the proper location. There is not a map of where to inject it since the facial anatomy varies significantly from person to person. It is highly recommended to go with someone who has experience with the facial anatomy and understanding of how the face should appear, both functionally and aesthetically, such as Dr. Shah.
How does Dr. Shah charge for Botox?
Dr. Shah’s office charges for Botox by the unit rather than by the area.
Can Botox be used for sweaty underarm areas?
Yes. Botox can be used here to control sweating. It works on the inhibition of acetylcholine from releasing sweat.
What are the risks of botulinum toxin?
There are several risks. Although bruising is rare, it is the most common side effect of botulinum toxin. Asymmetries can result from the use of botulinum toxin, as well. A lowered brow (brow ptosis) or lowered eyelid (eyelid ptosis) can occur but is rare with experienced hands.
When was botox first developed?
Botox began its use originally as a treatment for strabismus (abnormal eye muscles) in 1973.
Later on, it was approved by the FDA in 1989 for hemifacial spasm and blepharospasm.
The first aesthetic use of Botox was also in 1989 for treatment of a nerve injury after a facelift. In this case, the patient’s face was balanced to mimic the paralyzed side. Since then the use of botox has ballooned and become commonplace having millions and millions of satisfied patients.
How does Botox work?
Botox causes paralysis in muscles by inhibiting the release of ACh (Acetylcholine) at the neuromuscular junction. Of the seven known subtypes of Botox, types A and B are the only ones used for commercial preparation. Botox A works by cleaving synap protein 25 which prevents the release of ACh and Botox B cleaves synaptobrevin which is essential for presynaptic vesicle fusion and ACh release.
Paralysis often occurs within a few hours after a Botox injection but the full clinical effect takes up to one week. The reason for this delayed effect is that there may be persistent ACh release at the neuromuscular junction. The blockade created by Botox is irreversible with axonal sprouting and formation of new muscular junctions responsible for the clinical effects over time.
Is Botox dangerous?
Botox is one of the safest procedures performed. There are several advantages to Botox therapy which include the fact that it stays where you inject it (meaning it does not course its way throughout the entire body) and it requires small amounts. The major disadvantage of Botox is that it requires a skilled injector to perform it.
How long does Botox last?
Botox typically lasts about 3-4 months for muscles of the face. The exception would be the masseters (typically last about 1 year). For the use of sweating, oil and other factors botox typically lasts about 6 months.
How does Botox compare to Dysport and Xeomin?
The strength of botox varies due to the dose, injection technique, and patient factors. In an individual 3 month study looking at the clinical response for glabella, the study noted that improvement was noted to be 50% for Botox, 40-50% for Dysport, 25% for Xeomin (however Xeomin was looked at 2 points and others were looked at 1 point of improvement). Less than 20% of patients maintained improvement beyond 4 months. This study points out that the most improvement was seen in Botox with Dysport either being the same or slightly less response. It is hard to compare products head to head since dosing is not interchangeable between each of these neuromodulators.
Will increasing my dose increase the duration?
Increased doses may prolong duration and number of responders but maximal dose where additional benefits are gained has not been established.
There are cases of partial secondary failure and complete secondary failure with botox. Most are a result of cervical dystonia and this is due in part to large regular doses required. The formation of antibodies is thought to be extremely low. Theoretically Xeomin may offer less immune response due to less complexing proteins. Factors to develop antibody resistance:
– large single doses
– booster treatments closely following initial treatments
– the preparation used for injection
– patient’s immune system
For patients for nonaesthetic indications- switching to Xeomin may be more effective than either Botox or Dysport, due to large doses and potential formation of antibodies.
Smallest needle has less pain has been found in several studies. A 33 gauge needle will have less pain than a 30 gauge and less bruising in several studies.
Allow alcohol solution on the skin to completely evaporate to prevent denaturation of the protein.
Botox can diffuse up to 3 cm from injection point depending on dilution.
Injection of BoNT has become the most frequently performed cosmetic procedure in the United States. In 2014, more than 6.6 million cosmetic injections of botulinum toxin type A (BoNT-A) were performed, an increase of 748% since 2000.
According to several studies, treatment of glabellar rhytides with botulinum toxin type A can improve quality of life and may reduce negative moods. This makes sense since when we see a smiling baby, we reflectively mimic the baby’s facial expression. When a patient scowls, we reflectively scowl back at the patient. By removing our natural lines suggesting discontent (such as the #11’s), less discontent may be directed back at us!!