Archive for the 'botox cosmetic' Category
One of the great fears of many new Botox® patients is that they will look unnatural. Or like someone they had seen on TV or in magazine who looked ‘frozen’ and artificial with their facial expressions. In reality, I have seen and treated only a handful of patients over the years who want no wrinkles at all and desire that ‘porcelain doll’ look. Almost every patient wants a natural look and certainly does not want everyone to know they have been ‘Botoxed’.
While creating an expressionless look is possible, there are some practical economic issues that makes that difficult to achieve even if that is what the patient wants. Since Botox® is priced per unit given, it takes a lot of Botox® to deanimate a whole forehead and around the eyes. That entire area may take up to 50 units or more, depending on how active and thick the muscles are, to completely paralyze. At an average cost of $12 – $14 per unit, you are talking in excess of $700 - $800 for a single treatment. For the average person, that is an expensive session that most people do not want to invest in two or three times a year. At the typical treatment cost of $300 - $400 per treatment session, which most patients are willing to pay, you can now see that a completely frozen look is not economically possible.
For the first time Botox® patient, I think about the MED or minimum effective dose. What is the least amount of Botox® we can use to create the desired effect. The MED is a concept that all drugs are based on, usually in an effort to prevent side effects or complications. With Botox® the MED approach is an economic one. Find out the least amount you have to pay to get a good result. That is why you start out with a low dose or number of units. Some practitioners may take the opposite approach of maximum or excess dosing for their economic benefit but, like all repeat business, people come back if they think they got a good honest value.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
It is not rare to hear a patient say…’my Botox seems to be wearing off earlier than usual’…or…’I had Botox but it didn’t seem to work’. Some few patients even suggest that they may be immune to Botox or that they are becoming resistant ot it. Many physicians and even manufacturer reps say that such immunity is impossible. But is it? Is immunity to Botox real?
First and foremost any drug, no matter what its mechanism of action, poses the potential of diminished effectiveness with repeated use. The most classic example is that of antibiotics. (although this really represents resistance of the infecting bacteria not necessarily how the body responds to it) But immunity or developing an immune response to a toxin, an unnatural molecule that the body may eventually recognize as both foreign and harmful, is particularly likely. While I hold most responses on the internet as not a source of absolute scientific information, there is too many patient responses on many different websites that claim a lack of response after injection or a dramatic dropoff in effectiveness after a period of years of successful use. (most common) While some, if not many, of these may be the result of using overdiluted or old Botox or from poor injection technique, all of them can’t be completely drug or injector-related issues. Resistance to serotype A of botulinum toxin (Botox and Dysport) has been reported in some physician series but the incidence is quite low. (usually less than 1%) The point is…it has been reported in professional medical journals in large patient series. Anectodal statements by some physicians such as ‘I have never seen it’ and the like does not count as scientific evidence. Never having seen it does not mean it doesn’t exist. Most of us have never seen a platypus in the wild either, but we know they do exist.
Once you develop Botox immunity, what can you do? There is no absolute answer to this uncommon problem. Perhaps waiting a period of time ( 6 months to a year?) before trying repeat Botox is one option to see if your immune response lessens. The other option is to use a different serotype, type B (Myobloc), and see if you get a response. In theory, different serotypes have slightly different molecules so your immune response may be quite specific to type A only.
Whether someone can be completely immune to Botox, without PRIOR injections, is a different matter. There would be no natural immunity to Botox since most of our immune systems have never seen the molecule before. When a first-time patient of mine calls and tells me they have had no response, actual examination everytime demonstrates that they actually have had a response it is just not as profound as they thought it to be. This is an issue of managing expectations and dosing, rather than some natural resistance to the drug.
By far, the most common patient experience in my practice with Botox is that patients actually develop a somewhat lesser need with Botox over time. After three or four treatments, many patients find that the Botox seems to ‘last longer’ and they may only need injections twice a year as opposed to every three or four months. This is not because the patient has developed greater sensitivity to the drug but because they have most likely ‘retrained’ their expressions. which are learned movements anyway. Once you have not moved or have less movement of any muscle for a long enough period of time, you may have inadvertently retrained your expressions to some degree.
Acquired Botox immunity is a real but uncommon event. It usually presents in the patient who has had Botox for multiple treatments, after a year or two, with a diminished response to a proven dose or sometimes as no response at all. Botox resistance without prior exposure is more likely an issue of expectations and proper dosing rather than a natural immunity.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Most people in America have now heard of Botox and if they haven’t, they surely will in the immediate future with its TV advertising campaign. The commonality of Botox has not only generated lots of interest but with that level of curiousity comes misconceptions and wife’s tales. Let me cover some basic concepts of this miracle drug….some of which you may know and others of which you may find surprising.
Allergan, the manufacturer of BOTOX™ or botulinum toxin, was an original dermatology/opthalmology product company. It began developmemt of Botox as an experimental drug over three decades ago in the 1970s. It’s opthalmological researchers tried it on monkeys with strabismus (eye muscle disorder known as cross-eyed or wall-eyed) with surprising curative results. Since then, they have sought and expanded its uses to include cosmetic facial applications which was granted in 2002. It is this cosmetic application that has exploded Botox unto the American and worldwide scene.
The manufacturing of Botox is an interesting story. In the beginning, it was made under the strict supervision of the U.S. Military as it was a poisonous drug. Since then it is manufactured in a secret location in the U.S. and then shipped for bottling in Ireland. Whether this story is actually true, I do not know but it certainly adds to the drug’s mystique. It certainly is the most expensive drug in the world if you break down its price structure . At 5 nanograms of volume placed in each bottle which sells for nearly $500 per bottle to providers, that makes its value over 1 trillion dollars per pound!
Botulinum Toxin or BOTOX™, is produced from anaerobic (lacking oxygen) bacterial cultures creating a toxin. The toxin is composed of seven strands named A, B, C, D, E, F, G. Each strand can block the release of the neurotransmitter, acetylcholine, from the nerve synapse resulting in temporary muscle paralysis. (no power to the muscle so to speak) The different serotypes have different durations of action before it wears off. Serotype A lasts around three to four months while Serotype F lasts just a few weeks. This is why you see on the Botox bottle and in its advertisements, botulinum toxin A, as this one serotype lasts the longest.
The actual Botox toxin is put into small vials of 100 units as a desiccated (dry) powder. But what does the 100 units mean? It means how many units are required to kill 100 mice. Each vial then contains one hundred mice units or 100 units for short. Initially, Allergan used 25 nanograms of the toxin to kill 100 mice. But it has been learned with improved technology and manufacturing that less is needed to do the same job and the amount per bottle is now reduced to 5 nanograms. This has great relevance since Botox is a drug that requires repeated injections over time to maintain its effects. Using repeated lower doses will reduce the likelihood that patients may develop resistance or immunity. And despite what is often touted, some few select people do have a natural immunity to Botox and others do develop some resistance to its effects over time.
As a cosmetic treatment, Botox is what I call a ‘northern’ treatment’. It is superb at controlling undesired expressions around the eyes and forehead. This northern area of the face probably accounts for the vast majority of its cosmetic use as it creates results that sometimes actual surgery can not rival. It can also be used on the southern part of the face around the mouth. But its effectiveness in this area is diminished as surgical treatments are usually more effective and Botox plays more of an ancillary role to complement other types of treatments.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Botox is the #1 injectable cosmetic treatment and has been largely responsible for the wave of non-invasive aesthetic office treatments and for the widespread development of the medical spa concept. It has also been the major impetus for the number of non-cosmetic physicians offering beauty treatments. The simplicity of its use and the predictability of its results makes such treatments seem easy with few complications or problems. For these reasons, many nurses (and even aestheticians and cosmetologists) in some locations provide the actual injection treatments. (purportedly under some physician’s ‘oversight’)
The simplicity of any treatment does not necessarily guarantee a good result. In most cases, it is difficult to not chose Botox as a correct treatment for undesired lines and wrinkles from hyperactive or normal facial expressions. Whether it is the glabellar furrows or crow’s feet, Botox is always the first (and really only good) treatment of choice. Below the eyes, however, Botox is often not the only or even the best treatment for wrinkling problems around the mouth and neck. Most times, the mouth and neck are better off with either other minimally-invasive treatments or actual plastic surgical procedures. The problem is….if all you have in your treatment bag is Botox or a few injectable fillers….a patient’s result will not only be limited and disappointing but a waste of a patient’s money.
For Botox to be maximally effective, it must be mixed properly and used relatively promptly. Botox comes as a powder in a bottle that is so minute it is virtually impossible to see. It is reconstituted with saline on-site and, although the manufacturer provides recommendations as to how it is to be mixed (how much saline is put into the bottle), the treatment provider can do as they will. Because of profit margins involved, it is tempting for some to create a ‘dilute’ Botox mixture by adding more saline than the manufacturer recommends. This creates more Botox available to be injected and a greater number of patients can be treated….but it usually doesn’t work as well, if at all, and it lasts a shorter period of time. You the patient would have no idea whether the Botox you received was diluted…and I have found most patients don’t even know how many units they have or usually receive. They simply know the price they paid. The other factor that affects the effectiveness of Botox is how long after it is mixed is it used. Botox is not like wine….age does not make it better. After it is mixed it should be used within 24 to 48 hours at the longest. While the manufacturer recommends hours to a day, a day or two after mixing does not seem to change its effectiveness. How ‘old’ the Botox you have received is unknown to any patient. One indication that the Botox you may receive is fairly fresh is how busy is the practice or location where you receive it. (how often do they do Botox treatments) Daily? Weekly? Monthly? The busier a practice is, the more likely they will have fresher Botox.
Botox is a remarkable medical treatment that offers unparalleled wrinkle-reduction results in the forehead and around the eyes. While it is a simple injection treatment, its results can be affected by the training and experience of the injector and how it is reconstituted and when after it is used.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www/ologyspa.cpm
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis