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BOTOX® for Wrinkles :: Hints & Tips
Charging for BOTOX®
The amount of botulinum toxin needed per site depends on the musculature of the individual patient. Therefore BOTOX® should be priced by the number of units used and not by the area treated. When using a consistent dilution technique, one can charge by the number of 0.1cc's used. The price per 0.1cc varies according to the area of the country that one lives in. It is important to explain to the patient that further injections (and charges) may occur at the next visit because everyone's musculature is different.
How to lower the incidence of bruising
Cosmetic patients are very unhappy when bruising results as a complication of botulinum toxin injections. The incidence of bruising can be decreased by avoiding the following for 10 days prior to botulinum toxin injections:
- Aspirin
- Motrin or Ibuprofen
- Vitamin E
- Green Tea
In addition, ice packs can be placed on the area to be injected just prior to injection. This may help decrease the pain of injection (which is minimal) and decrease the incidence of bruising.
When bruising does occur
When bruising occurs, the bruises are best covered by a green concealer make up followed by a foundation of normal skin color. Many companies make the green concelaer including Estee lauder, Neutrogena, Joe Blasco Cosmetics. Bruises usually resolve withing 7 - 10 days.
A recent study performed at the University of Miami (publication pending JAAD) demonstrated that topical Vitamin K cream may hasten the resolution of bruises when applied twice daily. Some patients prefer to use the Vitamin K cream prior to injections to prevent bruising, however, the study at the University of Miami showed no beneficial effect from pretreatment with the Vitamin K containing cream.
How do I avoid brow ptosis?
Do not inject in the area 1cm above the eyebrow.
How do I avoid lid ptosis?
Do not treat the forehead (only the glabella and crow's feet) in patients that have excess, loose eyelid skin. Patients over 60 are at an increased risk if they have not had prior blepharoplasties.
How can I reduce bruising? Have patients avoid NSAIDS, aspirin, vitamin E and green tea 10 days prior to injection?
Apply EMLA or ELA-Max as a local anesthetic for at least 15 minutes prior to injection. This causes vasoconstriction. Application of ice packs prior to injection also causes vasoconstriction. In the crow's feet area, take great care to note the position of the blood vessels prior to injection. Application of Vitamin K or Arnica containing creams may speed resolution of bruises.
How can I reduce pain in sensitive patients?
Topical anesthetics such as ELA-Max and EMLA. Taking to them calmly and slowly helps to reduce their anxiety, which seems to decrease the perceived pain. I always treat the glabella area first because it tends to hurt less and then the patients feel more relaxed. Some patients state that gently pressure applied with the fingers to the injected area just after injection eases some of the pain of injection. However, other patients find this uncomfortable. Woman seem to be more sensitive to pain during menstruation so I advise them to be treated when they are not menstruating.
While treating forehead lines, what are the cautions to be exercised in older vs. younger patients, male vs. female?
Older patients- if there is excess eyelid skin, avoid treating the forehead area. Males- a V shaped forehead injection technique can lead to arched brows. Men should be injected in a horizontal pattern in the forehead while women should be injected in a more V shaped pattern. Men with male pattern balding may need injections higher up in the lateral forehead, so take care to examine this area for muscle movement.
How long can I keep reconstituted/made up BOTOX®® and how do I store it?
It should be stored in the refrigerator and used within 24 hours for maximal results.
Can I add local anesthetics to reconstituted BOTOX®®?
Yes, unbuffered lidocaine can be added however this will increase the pain of injection. Buffered lidocaine would lower the PH of the preparation and affect the toxin complex, therefore this is not recommended.
How do I get best results while treating crow's feet?
Inject superficially (upper dermis) with care to avoid the veins that are common in this area. I inject every 1 cm where I see muscle movement following the line of the orbicularis oculi to medially to the midpupillary point. I do not inject more medially than the midpupillary point.
How can I avoid lateral elevation of brow when I treat Crow's feet?
I have never had this side effect- I think you mean forehead?
How do I avoid medial elevation of brow when I treat Frown lines?
Medial elevation is a desired side effect of treating the glabellar area. This elevated brow produces a more youthful appearance because brows naturally lower with aging. I massage the procerus muscle after injection to ensure this effect.
Tips on use of BOTOX®® below the eye?
- For crow's feet -
Inject along the line of the orbicularis only in area that you see movement with smiling. Do not use medially past the mid papillary line to avoid ectropion. This area below the eye has a tendency to bruise so use ice prior to injections.
- Hypertropic muscle below eye -
Inject 2 units into the muscle immediately inline with the pupil and another 2 units halfway between the midpupillary line and the lateral canthus. This gives the eye a more open appearance and is great in patients with an Asian genetic background.
In Forehead lines and crow's feet, is the injection subcutaneous, intradermal or intramuscular?
Both are intradermal. A small wheal may be seen.
How do I avoid headache?
Do not hit the periosteum. Stay superficial to the bone.
How can I achieve a BOTOX®® brow lift?
4 units are placed in the procerus and massaged laterally into the depressor supercilli muscle. This causes a medial brow lift. Injection of 2 units of BOTOX® just above the lateral margin of the eyebrow may cause a lateral brow lift in some patients. This latter point is debatable because it depends on the individual patient's anatomy.
Do I massage the areas of injection?
No but firm pressure on the wheal after injection feels good to some patients.
How wide does a single site of injection diffuse?
Most studies show 2cm when using a 2.5 cc dilution technique.
Do I inject while patient lies down or sitting up?
Whatever is more comfortable for you and the patient.
Do I put the needle tip bevel up or down?
Up
Do I inject upwards or downwards or medially or laterally in forehead lines, frown lines and crow's feet?
It does not make a difference. It is where the tip of the needle ends up that is the important part.
How can I avoid diplopia?
Do not inject within the orbital rim.
If I use preserved saline, will BOTOX®® work?
Yes, although many suggest that this decreases the potency of the toxin. I use it every day without a difference in clinical response.
Can I laser BOTOX®® injected area on the same day as giving BOTOX®® injections? If not how far apart should they be?
No. I suggest performing BOTOX® one week prior to a resurfacing procedure. The goal is no movement after the procedure, therefore you must give BOTOX® time to work.
Can I inject fillers on the same day I inject BOTOX®® around the areas of BOTOX®® injections?
ABSOLUTLEY!!!
How about chemical peels in conjunction with BOTOX®®?
Do the chemical peel first, then apply ELA Max or EMLA, wait 10 minutes then inject BOTOX®.
If BOTOX®® solution spills while injecting, should I take any precaution?
Wipe it up and try not to think of all of the money you wasted!
Which is the best way to photograph frown lines, crow's feet and forehead lines both before/after?
With a camera system such as the Canfield Scientific System. Show patients at rest and at maximal muscle contraction. Take off all jewelry and make up, and put a black cloth over the patient's collar so the before and afters are similar.
Tips on use of BOTOX®® around the mouth
I do not recommend this. I think that it gives patients an unnatural look.
Tips on use of BOTOX®® in neck lines.
Tendency to bruise so avoid NSAIDS and aspirin 10 days prior. Use as little as possible to prevent neck weakness.
How do I get every drop out a diluted BOTOX®® vial?
Take out the rubber stopper on the vial. Use diabetic insulin syringes that do not have "dead space".
Are there any dosing differences between Asians and Caucasians?
No
After first injection, how soon can I inject with out worrying about antibodies?
No, studies have shown antibodies in patients treated with cosmetic doses, therefore I do not worry about this and reinvest in a week if necessary.
Can the patient use make up soon after BOTOX®® injection?
Yes, but they should not massage the treated areas.
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