Now that Botox Cosmetic has been around for more than 20 years, practitioners have learned to optimize their use of that product, Dysport, and other neurotoxin products for their patients. They tweak the ratios; use one, the other, or several; and combine them with other treatments to maximize that heralded youthful natural look.
Michael Persky, MD, FACS, who has practiced facial plastic and reconstructive surgery in Encino, Calif, since 1985, says it succinctly: “Injecting botulinum neuromodulators is an art that should be customized to each individual patient.”
Recently, PSP spoke with several physicians and one registered nurse about their specific techniques and use of neurotoxins.
DOSAGE AND PREFERENCE
Almost all physicians interviewed for this article say the most effective dose of Botox and other products (such as Dysport) will vary depending on the patient’s muscle mass, gender, and desired effects.
“Doses vary a lot person to person,” says David W. Kim, MD, who practices in the Union Square area of San Francisco. “I find if you try to use the same dose for each individual, you will get inconsistent results. In general, men need more than women, and stronger muscle activity requires high doses.”
Whereas some doctors have come up with a specific amount, Kevin Duplechain, MD, FACS, of Laser Skincare of Louisiana, says, “My most effective dose of Botox is 40 units, which allows me to treat the forehead, including frontalis and the brow depressor muscles, the orbicularis muscle, and the depressor anguli oris muscles.”
Joseph Niamtu III, DMD, a cosmetic surgeon in the Richmond, Va, area, lectures internationally on cosmetic facial surgery, has taught on six continents, and has written four textbooks. “I favor 25 units of Botox for the glabellar, frontalis, and lateral canthus regions. Twenty-five units per area (12.5 per Crow’s Feet side) provide predictable results with good longevity.
“For Dysport,” Niamtu continues, “I use 60 units for each area (30 per Crow’s Feet side). I think a 3x amount (compared to Botox) is required to be equipotent.”
Some physicians have reported that they use Botox and Dysport for different occasions. “I use both Botox and Dysport for multiple facial procedures. Although they may be administered as a stand-alone technique, their most common use in my practice is part of a combined rejuvenation program,” says Robert H. Burke, MD, FACS, founder and director of the Michigan Center for Cosmetic Surgery and examiner for the American Board of Cosmetic Surgery.
“One of the problems that are encountered is the mistaken belief that this is a pure commodity rather than a service,” he continues. “In the belief that this is merely a commodity, consumers sometimes seek out the lowest price and ask for a specific treatment. I believe that this is the wrong approach. In my office, we try to educate patients—what are they seeking, why are they seeking it, and what are the solutions or options that we should consider?”
Most commonly, this is a combination of skin rejuvenation, volume replacement, and modification of muscle action, Burke says. “In most cases, these neurotoxins are used interchangeably, and depend on patient preference. Because of the more rapid onset, I may administer Dysport if someone needs a ‘fast’ result (college reunion this weekend, new date, etc). Some patients respond better to one or the other. When modifying perioral muscles, I prefer Botox since it has less peripheral diffusion (which could weaken unintended muscles). I always use Botox for reshaping of the jaw muscles. I have accepted the manufacturer’s suggestions that 10 units of Botox is equivalent to 25 units of Dysport.”
One physician has come out saying that he prefers using Dysport. “After injecting thousands of patients here and overseas comparing Botox and Dysport, I came to the conclusion that Dysport is superior to Botox, since it is more cost-effective, minimizing the number of touch-up revisions, and it lasts longer,” say Yoel Shahar, MD, a cosmetic surgeon in New York City. (Shahar stated he has no relevant disclosures regarding Botox and Dysport.)
CHARGE BY AREA OR UNIT?
The majority of physicians interviewed say they charge by the unit, claiming it is fairer to the patient and less confusing for themselves. On the other hand, a few we spoke to find it less confusing and more appropriate to charge by the area.
For many years, Persky charged by area but changed over to charging by the unit due to, he says, changes in the economy.
Duplechain says, “I charge by the unit as I can never be certain exactly how many units each patient or area will require. I believe it allows me to be flexible in each patient’s treatment without having to guarantee an exact response. Each patient may have a different budget and would prefer to have a broader treatment, including multiple areas, but using smaller doses. As long as the patient understands that results are a dose-dependent phenomenon, I think everyone is treated fairly.”
Steven Pearlman MD, FACS, who is in private practice in New York City as well as director of the Division of Facial Plastic Surgery at St Luke’s-Roosevelt Hospital, explains, “I charge by the unit since treatment varies from patient to patient; also depending on the patient’s desires. Some want nothing moving at all, and they need more Botox.”
According to Jason Pozner, MD, FACS, founder of Sanctuary Plastic Surgery and co-owner of Sanctuary Medical Aesthetic Center in Boca Raton, Fla, charging by the area is “less confusing for me. They are paying for my expertise.”
Kim, who also charges by the area, claims, “As the consumer becomes more savvy about aesthetic treatments, they demand more transparency about costs. Thus, we discuss dosage, cost, and frequency of treatment in detail.”
“My office charges for Botox or Dysport by the region—of which there are three: forehead, glabella, and crow’s feet,” says Jeffrey S. Epstein, MD, FACS, founder and director of the Foundation for Hair Restoration. “If a patient is not having the crow’s feet treated, I will often place a small amount under the lateral brow for a brow lift, at no additional charge.”
There are some physicians who do a little of both. “If I treat typical areas with typical doses of Botox, such as glabella with 20 units, we charge by the area. If someone wants something atypical, such as a half-dose of Botox into the masseter muscle, then we charge by the unit,” says Anthony Youn, MD, FACS, a Michigan-based plastic surgeon.
FEES FOR TOUCH-UPS
Many physicians responded that they give touch-ups for free, or at cost. “Free touch-ups keep patients happy,” says Robert A. Shumway, MD, FACS, based in La Jolla, Calif.
“Depending on the complaint, I typically charge cost for Botox touch-ups or just don’t charge at all,” Youn says. “If it’s just a few units, I typically won’t charge for it. If it’s more than just a few, then I charge cost.”
It depends, says S. Randolph Waldman, MD, a plastic surgeon based in Lexington, Ky, and creator of the Facial Cosmetic Surgery Multi-Specialty Symposium. He explains, “If something appears incomplete and we did not inject the amount we recommended, then I will usually touch it up on a complimentary basis. But we are careful to note this and also careful that this particular patient does not make a habit of returning for touch-ups on a regular basis.”
Duplechain notes one advantage of a per-unit charge is, “If a patient returns and desires a bigger effect than was initially obtained, I am at ease to simply add more Botox since I have already discussed this with the patient prior to the initial treatment. I have found this to work extremely well, and rarely do patients have an objection to that policy. It is important, however, to make this point clear before treatment.
“On the other hand,” he continues, “if a patient returns and has an unusual response to treatment or an area didn’t respond well, I will sometimes add a very small amount, such as two units, at no charge. If a larger number of units are required because of underdosing, I usually charge at a reduced rate for that visit.”
According to Edward Lack, MD, a cosmetic surgeon based in Chicago, “We routinely add Botox to a cosmetic unit after their initial visit. These are not considered touch-ups but rather part of the procedure. This is no different from any other field of medicine in which administration of a drug is titrated to effect. There is no charge to patients.”
Yet another approach is taken by Niamtu. “If it is a first-time patient,” he says, “I may do a touch-up for free as not to disillusion them about the treatment. For regular patients or those who frequent the practice, I may charge at my cost. For the general touch-up population, I charge my normal per-unit price, and this is—and must be—discussed with each patient, pre-injection.”
“MY BOTOX DIDN’T WORK”
How do you manage the patient who returns and says her Botox “didn’t work”? Most physicians suggest doing an evaluation alongside teaching the patient about appropriate expectations.
“I obtain photos on every patient before treatment. I sit down with the patient and review the before-and-after photos, and we observe their muscle action in a mirror together,” says Brett Kotlus, MD, MS, a cosmetic and oculofacial plastic surgeon in Michigan.
“I always delay them 2 weeks from the time of injection before evaluating whether it worked or not,” Youn says. “Some people can take several days to take effect. If it truly appears that it didn’t work, then I offer them more Botox (or switch to Dysport) at cost.”
According to Denver-based plastic surgeon Gregory A. Buford, MD, FACS, “First, I find out why they think it didn’t work. Very commonly, I will have patients who feel that their Botox has not worked simply because they still have some degree of expression or movement.
“In reality, I generally want them to maintain a little movement since this tends to deliver a more natural result overall. There is always a fine balance between expression and line eradication, and I discuss this thoroughly with each patient before proceeding.”
“If there is no effect at all, I will retreat them on me,” Pearlman says, adding that the situation is extremely rare. “The most difficult situation is someone who wants no lines at all and no movement but doesn’t want to risk dropping their brows.”
Agreeing with Pearlman that it is rare to encounter a patient for whom Botox was ineffective, Duplechain adds, “I have found that in older patients it is sometimes less of an aesthetic tool if the patient has significant laxity for obvious reasons. Occasionally, I will choose not to treat such a patient. I have retreated a very small number of patients in situations where, for unexplained reasons, the toxin did not seem to work. I usually do this with the assistance of the vendor.”
One surgeon, Shumway, responded with the simplest solution of all: “Try, try again. It always works if performed correctly, 99.9% of the time.”
STANDARD FIVE-POINT INJECTION
With a couple exceptions, the physicians interviewed explained that the standard “on label” technique of five injection points doesn’t really optimize results for many patients, and that it is important to customize treatments based on each patient’s anatomy.
The surgeons also shared some of their own techniques that they find most useful. For example, “I believe that I may take more injections,” Waldman says, “and also I think I inject more superficially than many of my colleagues.”
Every patient is the same but different, Niamtu smiles. “Some patients need half as much neuromodulator while others require twice as much. Seasoned patients have become very specific about customizing their treatment, and we record their desired effect on each visit in order to duplicate it next session. Ninety-five percent of my glabellar treatments are the standard five injection points.
“Patients with upper lid laxity are prone to pseudoptosis from frontalis deactivation, so on these patients I alter my injection points to allow or encourage the ability to raise the brows. These patients can become quite unhappy if they appear to have more skin redundancy on the upper lids.”
Epstein adds his tips and tricks. “Along the glabella, I find my results are optimized and patient discomfort minimized by a single injection placed along each procerus muscle, then a small additional amount placed right into the midpoint,” he says. “For the crow’s feet, usually three to four injections are made on each side, and enough product injected into each area so it can be then massaged into the surrounding tissue to maximize results.”
Duplechain agrees somewhat with the technique of five injection points. “I generally think that the five injection point technique for glabella frown lines is applicable to most patients,” he notes. “The toxin is thought to spread about 1 cm, and this area should be well covered. Occasionally, patients have unusual muscle movement in this area and require customization. More important, I believe, is depth of injection within the glabella, as it is each to be intradermal or subcutaneously along the periosteum.”
In other practices, as in Pozner’s Florida clinic, there is no equivocation—treatments are “always customized,” he says. “The anatomy books and protocols do not reflect the real-world anatomical variations.”
What should the physician do if a patient receiving botulinum neurotoxin injections gets a result but not the expected result or unacceptable side effects? What adjustments should be made to the neurotoxin recipe or the way in which injections are administered, in order to get a desired good result?
Waldman says, “This is almost unheard of in my practice, but we will do what is needed to have a happy patient.”
“No change in recipe,” Shumway claims. “After 20 years of injecting botulinum toxin, we have the right formula and all clinicians have their own favorite mixes.”
“If a patient is unable to activate or move the injected muscle and still has the wrinkle, I explain to the patient that it will take few sessions until the wrinkle will fade since it took a long time for the wrinkle to be created,” according to Shahar.
Niamtu’s approach varies in that first he apologizes to the patient and explains that they are very susceptible to the drug. “I then suggest that next session we begin with a smaller dose and work our way to the final treatment,” Niamtu says. “Neuromodulator treatment does not have to be a wham-bam single appointment. There is nothing wrong with viewing it as a sculpting treatment with multiple visits, if necessary, to provide a custom result.”
“This is not an uncommon occurrence,” says August Denton, RN, an injection specialist based in Beverly Hills who works with plastic surgeon Robert Kotler, MD, FACS. “It is most often related to an underdosage, in which we just add more product to achieve patient-desired aesthetic results. As far as unacceptable side effects, most often bruising, swelling, headaches, and other temporary events do happen, but all these are self-resolving after a few days.
“One effect seen on the street that no one likes is the animated, arched ‘Botoxed brow.’ It is a sign of a novice injector at work, but easily corrected with lateral frontals injection of five units of Dysport (or two units of Botox),” Denton adds.
OPTIMIZING SURGICAL PROCEDURES
Almost all the physicians interviewed say they use botulinum toxin injections to optimize results from surgical procedures, if not to replace them.
“Botox injections can be extremely helpful in optimizing the results of a blepharoplasty or chin augmentation,” Buford reports. “I generally inject the mentalis a few days before surgery so that there is less pursing and straining of this muscle after chin enhancement. I do the same prior to my blepharoplasty procedures.
“I find that a few units well placed can definitely enhance surgical results and give my patients that extra improvement,” he adds.
In Waldman’s view, “the best use is to perform a pharmacologic brow lift. I do not find it very cost-effective for the mid or lower face.”
Or, as Shumway suggests, “Use small quantities into specific facial muscles after healing from surgery.”
The introduction of Botox to the market almost completely replaces the forehead lift, according to Shahar. “Since it has improved the wrinkles in the forehead and elevates the eyebrows without the need for major surgery that leaves a long scar, loss of hair, long-term itching, and potential sensory loss of the scalp,” he says.
“I used to treat brow lift patients 2 weeks before surgery to minimize pull on the corrugators,” Pearlman says. “However, I was getting too much central lift in my brows. Currently, I still use the corrugators during endobrow lift but try to lift the tail more for a more aesthetically shaped brow.”
Duplechain uses injections postoperatively to support the healing phase. “I believe that particularly with brow lift and laser resurfacing, Botox can improve and certainly optimize the results postprocedure, by preventing unwanted muscle movement during the healing phase. I usually charge a reduced fee or no fee for Botox during this period.”
OPTIMIZING SURFACE PROCEDURES
As Duplechain points out, physicians use botulinum toxin injections to optimize and prolong the effect of surface procedures, working in conjunction with laser-based treatments, peels, and fillers.
“Laser resurfacing and Dysport/Botox/Myoblock work very well together,” Shumway advises. “Inject the neurotoxins a week before resurfacing.”
Persky agrees. “Botulinum toxin injections do optimize results from other procedures,” he notes. “I use pretreatment Botox in patients receiving Ulthera skin-tightening and lifting treatments; and in patients getting Fraxel:repair treatments.
“These treatments work by stimulating collagen production in the skin and muscle, the new collagen bridges form more efficiently when the skin is not moving. It is also helpful in patients with forehead incisions, taking tension off of the wound, allowing for better healing, decreased scarring,” he adds.
Denton recommends using neurotoxins 2 weeks prior to laser and peel treatments so that the skin will lay smoother, allowing for a more consistent surface to be treated. “We then schedule a follow-up appointment for another botulinum toxin in 3 months to maintain this smooth effect. This is especially effective around the eyes and mouth.”
Shahar voices concerns about the use of fillers in the forehead, periorbital area because of the potential for serious complications, such as skin necrosis, “or even blindness if the filler was injected into an artery,” he says. “Occasionally, I inject Dysport or Botox into the lower lid lips to improve wrinkles, the platysma bands, and axilla to reduce sweating.”
Sarah Russel is a contributing writer to PSP. She can be reached at firstname.lastname@example.org.