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Archive for the ‘Botox’ Category

Botox Injections for Lower Facial Contouring (Masseter Muscle Reduction)

Monday, August 11th, 2014


The large masseter muscle (masseteric hypertrophy), unlike the prominent bony jaw angle, does not have a surgical solution. Surgical muscular reduction is associated with a high rate of complications and potental disability. As a result, the use of botulinum toxin type A injections (most commonly Botox) has become the standard of treatment to improve lower facial contour due to large masseter muscles.

There is little question that Botox into the masseter muscles can be effective but there is little standardization in dose and injection points of treatment. Dosage amounts vary amongst practitioners as well as treatment schedules. Long-term outcomes of a sustained effect remain wanting.

In the August 2014 issue of Plastic and Reconstructive Surgery, a paper on this topic was published entitled ‘Classification of Masseter Hypertrophy for Tailored Botulinum Toxin Type A Treatment’. In this  paper over 500 masseter muscles were classified into bulging types with three degrees of thickness. Over 200 patients were treated with Botox injections of 20 to 40 units per side with one to three injection sites per muscle. After injection, masseter muscle thickness decreased by an average of roughly 33% (13mms to 9mms approximately) as measured three months later. There was a corresponding improvement in the width of the lower face to the upper facial intercanthal distance. Overall patient satisfaction was 96% without any serious complications.

This study provides evidence in a large series of patients that an injectable approach to massteric muscle reduction is effective. Its maximum effect occurs by three months after treatment with a visible reduction is lower facial width. Dosages in units should be increased based on the muscle characteristics anywhere from 20 to 40 units per side. It is important to keep the injections into the bulk of the muscle closer to the jaw angle area to avoid a temporary weakening effect on the buccal branches of the facial nerve.

What this study does not address is how long this muscular facial thinning effect lasts and how many treatments it takes to achieve its maximal effects. It is still unclear as to whether Botox causes a permanent muscle atrophic result in the muscles of mastication.

Dr. Barry Eppley

Indianapolis, Indiana

Comparing Botox, Dysport and Xeomin Injectable Facial Neuromuscular Modulators

Sunday, April 20th, 2014


The announcement this month that Johnson & Johnson (J & J) has pulled any further development of their aesthetic neuromuscular modulator PurTox was a surprise. It was certain several years ago that a fourth injectable drug would soon be on the market to compete with the big three, Botox, Dysport and Xeomin. But it now appears that these three cosmetic drugs will only have only to compete amongst themselves for some time into the foreseeable future.

Botox Facial Wrinkle Injections Dr Barry Eppley IndianapolisIt has now been three years since the last of the big three (Xeomin) was approved. And while there has been some minor new FDA approvals for indications that were already widely done off-label anyway (crow’s feet), the number of men and women seeking this injectable cosmetic treatment continues to grow. Having multiple products to treat unwanted facial lines and wrinkles has helped create awareness and grow the market. These drugs today are as accepted as capuccinos and are done almost just as much. To some degree, Botox and his competitors have very much become commodities where the lowest cost per unit often sways what provider/location that a patient will go to.

This raises the question of how do these drugs differ and, what advantages if any, do any of them offer over the others? What all three drugs share is that they are FDA-approved Type A botulinum toxins. They work exactly the same through the same mechanism of molecular action and all have the same type of heavy chain receptor. While Dysport and Xeomin have a little shorter onset (1 to 2 days), they last the same amount of time as Botox having a duration of action of between 3 and 4 months after injection.

Dysport Indianapolis Dr Barry EppleyThey do differ significantly, however, in their dosing and methods of storage. The dosing of Dysport is very different from that of Botox or Xeomin. This makes it difficult to compare Dysport to the other two in clinical studies. While the biologic activity is the same for Botox and Xeomin, it is quite different for Dysport and there is no standard dose conversion. While all three must be reconstituted on the day of administration, Xeomin does not require refrigeration which makes it more portable and not prone to be accidentally left out of cold storage after a treatment.

From a marketing and public awareness standpoint, Botox is the dominant force occupying close to 80% of the market. It is the ‘Coke’ of the injectable neuromuscular modulators, the most studied and also the most expensive. Dysport and Xeomin are the ‘Pepsi’ and ‘Seven-Up’ by comparison and are still trying to gain market share. As a result they are priced under that of Botox and is there only real method of improving their small market share given that they have no other advantages.

Xeomin Indianapolis Dr Barry Eppley IndianapolisSome small claimed advantages over Botox for Dysport is that it has wider zone of diffusion from the injection site. This may be an advantage in the bigger muscles areas of the frontalis muscle of the forehead and the orbicularis muscle of the crow’s feet area. But would be a disadvantage in a discrete muscular area like the glabella which is also the number one area for all aesthetic neuromuscular injections. Xeomin claims a less risk of allergic reaction than with Botox because it does not contain hemagglutin and non-hemagglutin complexing proteins. While this may be theoretically true, the incidence of allergic reactions to Botox is so insignificant after over twenty years of clinical use that this advantage is meaningless.

While there are other aesthetic injectable neuromuscular drugs under development, none of them seem to have any major advantages over the big three that are available now. Every patient would like them to last longer (or be permanent) and cost less but that does not appear to be likely for as far as one can see into the future. The one promising approach is that of a topical botulinum type A gel of which several companies have ongoing clinical trials. Avoiding needle sticks could be the one advantage a new product could have that would help shakeup the market as we know it now.

Dr. Barry Eppley

Indianapolis, Indiana

The Tissue Level of Botox Injections in the Forehead

Friday, April 11th, 2014

Botox Facial Wrinkle Injections Dr Barry Eppley Indianapolis

Botox is the most common method of forehead rejuvenation used today. Literally billions of injections has been done in various locations around the brows and upper forehead over the past two decades around the world. Its effectiveness is unquestioned  and there is no indication that the number of treatments provided in the foreseeable future will be any less.

While there are variables in the administration of Botox, including dose and forehead injection locations, injecting into the forehead tissues seems straightforward. But to those who have ever done Botox injections, the forehead tissues are thick and there are a number of different tissue planes where it can be deposited. From just under the skin to all the way down to the bone, the deposition of the neuromuscular toxin can be done. But what is the correct tissue level and does it matter?

In the March/April 2014 issue of JAMA Facial Plastic Surgery an article appeared entitled ‘Subcutaneous vs Intramuscular Botulinum Toxin – A Split-Face Randomized Study’. In this paper, a study was done to determine the difference between subcutaneous (SC) and intramuscular (IM) injection location. In nineteen patients, Botox injections were done on a randomized basis so that each patient received SC injections on one side of the forehead and IM injections on the other side. At two weeks and two and four weeks after injection, the degree of eyebrow elevation by measurements was assessed. These measurements showed no differences between the SC and IM injections. IM injections were rated as having greater discomfort than SC injections.

This study showed that the SC injection of Botox is equally effective in achieving denervation of the forehead muscles as IM injections. And what is known from my experience is that the deeper the injections are placed the more uncomfortable it can be for some patients. And with no benefit for effectiveness, there is no reason to place the needle any deeper than just under the skin.

Dr. Barry Eppley

Indianapolis, Indiana

Botox Injections for Keloid Scars

Monday, January 6th, 2014


Keloid Scar Surgery Dr Barry Eppley IndianapolisKeloids represent the extreme of scar problems. As a tissue overgrowth response to an injury, and often progressive and unremitting, keloids are a true pathologic scar problem. Besides being an overly obvious scar problem, it is also highly refractory to conventional scar therapies. While many strategies have been used for difficult keloids after excision (e.g., steroid injections, radiation treatments), there still remains a very high recurrence rate. There remains a need to for new and novel approaches to see if lower recurrence can be achieved.

In the Summer 2013 issue of the Canadian Journal of Plastic Surgery, an article was published entitled ‘Eradication of Keloids: Surgical Excision Followed By A Single Injection of Intralesional 5-Fluorouracil and Botulinum Toxin’. This study involved eighty (80) patients with keloids of at least one-years’ duration. Following total surgical excision of the keloid, a single dose of 5-fluorouracil (5FU) was injected into the edges of the healing wound on postoperative day nine (9) together with botulinum toxin.

The concentration of 5-fluorouracil used was 50 mg/mL and approximately 0.4 mL was infiltrated per cm of wound tissue, with the total dose <500 mg. The concentration of botulinum toxin was 50 IU/mL with the total dose <140 IU. Patients were followed-up to two years and a recurrence rate of 3.75% was found.

The present study shows a very low recurrence rate by keloid scar standards that is comparable to other studies with post-excision radiation treatments. One has to assume that it is the Botox that has a significant pharmacologic effect as 5FU injections alone would not have such a low recurrence rate.

Botox Injections for KeloidsSince Botox has a known effect as a muscle weakener/paralyzer, how then does it work on scars? Several clinical studies and reviews have been done on the effects of Botox injections on scars. Besides the obvious benefit of preventing muscle pulling on the edges of a fresh wound or scar (which is really only a consideration in certain types of facial scars), its potential benefits are largely conjecture. Some have hypothesized that it inhibits fibroblast proliferation or the action of myofibroblasts, which makes theoretical sense, but that has never been scientifically proven or verified.

This is a fairly large clinical series of keloid treatments and would thus indicate that there  is merit to the injection of Botox after their excision. The mechanism of action remains speculative but its use is certainly more convenient and less costly than post-excision radiation treatments.

Dr. Barry Eppley

Indianapolis, Indiana

Five Things You May Not Know About Botox

Sunday, December 29th, 2013


Botox Facial Wrinkle Injections Dr Barry Eppley IndianapolisBotox is the trade name of the first commercially available preparation of botulinum toxin A (BTN-A). It is the miracle drug in aesthetic medicine, plastic surgery and neurology. Botox is so popular in aesthetic medicine because it predictably works each and every time. It is a medication in the real pharmacological sense of the word. Like a blood pressure pill which lowers the blood pressure if taken as directed by the doctor, Botox decreases facial wrinkling if injected correctly by an experienced practitioner. Like any other medication, Botox has to be reapplied at certain intervals to maintain its anti-aging and facial rejuvenation effects.

Botulinum toxin A (BTN-A), the pharmacologically active substance in Botox, is a very potent neurotoxin. It is naturally produced by spores of the bacterium Clostridium botulinum and results in severe poisoning if ingested in high doses. Clostridium botulinum produces a range of neurotoxins, which were named very creatively Botulinum Toxin A to F. They bind to the junction of the nerve endings with muscle fibers and prevent those nerve endings from secreting the neurotransmitter acetylcholine in response to electrical impulses. Without acetylcholine the muscle fiber at the downstream end of the junction does not contract.

Botox Is Both A Poison And A Cure. Swiss physician Paracelsus in the 1500s stated that the main difference between poison and medication is the dose. This statement is no better illustrated than in the use of Botox. When used in minute doses as a Botox preparation and injected directly into the relatively small target muscles in the face then activity of those muscles and formation of wrinkles at right angles to the course of the muscle fibers are reduced without any systemic toxicity. How different is the dose between the treatment of wrinkles and systemic toxicity? Try the difference between 20 units and 35,000 units.

The Use Of Botox Is Not New. It has been used since 1989 to treat painful spasticity in the context of various neurological diseases. One of the first applications in the face was in the treatment of spasticity of the eyelids, so-called blepharospasm, which subsequently led to its use for facial wrinkles. Use of Botox for cosmetic purposes was not approved by the FDA for the longest time, although large quantities were used off label for wrinkles since the early 1990s. Only in 2002 was it officially approved for treatment of forehead wrinkles and glabellar wrinkles and frown lines. Although used to treat the small radial wrinkles around the eyes, the so called crow’s feet, for decades, it was not formally FDA-approved until much later in 2013.  

Botox Wears Off By Nerve Sprouting. Why does the effect of Botox not last indefinitely? The reduced but still present activity of muscle fibers represents a stimulus for the sprouting of new nerve endings secreting acetylcholine without impediment of previously applied Botox. Thus the activity of muscle fibers is again increased. This process takes three to four months on a molecular level. One can picture it like a potato forming sprouts if left in darkened storage. Additionally, nerve endings replace the entire blocked mechanism of acetylcholine secretion.

Botox Is No Longer Alone. Botox was originally manufactured by the US company Allergan under the trademark Botox and marketed worldwide. Until fairly recently, Allergan owned a patent which conferred a monopoly on the market. The latter was lost when alternative preparations of botulinum toxin were approved in the form of Dysport and Xeomin. From a patient perspective and clinical effectiveness standpoint, there is hardly any difference between them. They differ mainly in their pharmaceutical preparation, dose equivalents, necessity of an intact cooling chain, and activity after reconstitution, all concerns for the manufacturers and injectors but not things patients need to worry about.

The Applications for Botox Continue To Grow. Being a true miracle drug, the areas of application for Botox are far from over. One of the milestones in the Botox success story was undoubtedly the recent approval of Botox in the treatment of migraine headaches, which are caused by certain hyperactive muscle of the face which compress sensory nerves running through them causing a migraine.

Dr. Barry Eppley

Indianapolis, Indiana

Unnatural Facial Appearances after Botox Injections

Monday, November 4th, 2013


The use of botulinum toxin A, otherwise known as Botox, has become a common aesthetic practice around the world. It is used daily as a treatment to soften wrinkles, helping to prevent and correct tired and aging appearances. In today’s society looking as young on the exterior as people are feeling on the inside is becoming more and more important. Botox is allowing this to happen in a quick, safe and effective manner.

There are, however, undesired aesthetic consequences from Botox that prove that facial expressions are complex and can easily be imbalanced to create peculiar aesthetic appearances that many find unattractive and want to avoid. At the least they are the telltale signs of having had Botox injections.

Spock Eyebrow The famous “Spock eyebrow,” also referred to as the evil eyebrow, leaves people with a consistent angry look on their face. It is the result of glabellar injections or treating the 11s. The glabellar creases are formed because of the actions made by both the procerus and corrugator muscles, pulling the eyebrows inward. If the frontalis muscle is also injected directly above the procerus, this will paralyze the entire central forehead and brows, causing the medial brows to drop and the lateral brows to remain high. In addition, there may be residual small horizontal wrinkles left above the lateral brows. Treatment for the “Spock eyebrow” can be done by injecting the frontalis muscle laterally above the eyebrows to help lower them to the same level as the medial brows. This treatment will also eliminate the small horizontal wrinkles above the lateral brows as well.

Frozen Face A heavy forehead and brows is also another unaesthetic sequelae from Botox injections. This is also commonly referred to as a “frozen face” or being left with the feeling an elephant is sitting on one’s forehead. This can occur when many areas of the forehead are injected from the glabellar creases, horizontal forehead lines and the crow’s feet. When all three areas are treated, people are often left with the appearance of a “frozen face” because all that appears to move is the mouth. Although this is the look some people are after with Botox treatments, often times it is not. This proves that it is possible to have too much of a good thing.

Heavy Brows When injecting the glabellar creases in addition to the forehead it is important not to block the frontalis muscle directly above the procerus as well as not to over inject (use too many units) in the frontalis muscle as a whole. When too many units are used, the muscles become so relaxed that the brows become heavy and sag lower. In a patient who already has some degree of hooding, it doesn’t take much Botox to potentially tip the balance towards further brow ptosis. of It is important to assess a patient prior to injection, paying close attention to the amount of hooding that may or may not already be present in the upper eyelids. The administration of too many units can easily make this hooding worse, and leave the patient feeling they have heavy brows.

The only treatment for heavy brows or the frozen face is time. While Botox normally takes a full three to four months to wear off, fortunately these adverse effects seem to improve more quickly often being much better by six to eight weeks after the initial injections.

Lora Dillman RN

Dr. Barry Eppley

Indianapolis, Indiana

Botox for Platysmal Neck Bands

Wednesday, October 9th, 2013


Botox has a profound influence as a neuromuscular modulator in improving facial aesthetics. It is used to relax muscles, therefore softening and sometimes eliminating wrinkles on the face and neck. Most commonly known for its use in treating glabellar creases, horizontal forehead creases and crow’s feet, Botox has created a paradigm shift in the treatment of the aging face. In addition to the upper third of the face, Botox is also used to treat vertical lip lines, gummy smiles, and even vertical neck bands.

One of the most uncommon use for Botox is in the treatment of vertical neck bands, also known as platysmal neck bands. Platysmal bands are caused by the separation of the platysmal muscle that runs as a thin muscular sheet from the collar bone to the lower border of the jawline. This separation occurs over time as we age and creates the appearance of bands on the neck. These bands are commonly as part of a facelift procedure. Along with liposuction to remove excess fat from the neck, the platysma muscle is sutured together to repair the separation that has occurred and rid the neck of the vertical bands.

Although a facelift is the definitive treatment for platysmal bands, often it is not on the radar as an option for many patients whether it is because of the recovery time or economics of the surgery. Therefore, the use of Botox to treat them may be an alternative temporary solution for some. The first step in the possibility of Botox as a treatment option is to select the correct patient. Botox is great for treating the platysmal bands of a patient who does not have excess neck fat and excess skin. Botox works to relax the platysma muscle but does not reduce fat or tighten skin, therefore patients with these issues will not see good results from these muscle injections.

The bands are injecting by grasping the band and directly injecting them with approximately fifteen to twenty units of Botox, divided into three injections along the length of the band. Depending on the injector and cost per unit, the cost of this treatment may range from $400 to$750  and as with any other cosmetic Botox injections, the results will last three to four months. It has been found to provide excellent results in patients with very minimal neck fat and excess skin. Thin-skinned patient with prominent bands can get very noticeable improvements. There usually is no bruising or recovery. It takes a full week to see the full muscular relaxing effects on the neck bands on this ‘Turkey Neck Botox Treatment’.

Lora Dillman RN

Dr. Barry Eppley

Plastic Surgery’s Did You Know? Rhytiphobia and Botox

Tuesday, September 24th, 2013


As we age the development of wrinkles on our faces is inevitable. The motion of the muscles of facial expression eventually cause permanent creases or wrinkles to develop in the skin. For some people wrinkles represent a positive reflecting signs of knowledge and experience. For others they are a sign of losing one’s youth and getting older. While no one really wants to develop wrinkles on their face, and many people fight it by a variety of anti-aging treatments, for some it is a real phobia. The morbid fear of developing facial wrinkles is known as rhytiphobia. People with rhytiphobia have an extreme fear of getting wrinkles  and will go to great lengths to avoid them. It is the lengths that people go to in avoiding their fears that define it as a phobia. Thus does getting Botox injections constitute treatment of a phobia? It is extreme to undergo facial injections to avoid or lessen facial wrinkles. Perhaps in the past the concept of having one’s face stuck with needles may have seemed extreme for something as innocuous as a few facial lines and creases. But today Botox is such a common and everyday occurrence that no one would think of it as a phobia treatment. Some people get Botox a few times to see if they like it, others get it with great regularity (every 3 or 4 months) to avoid any new wrinkles developing. To the most regular Botox users perhaps it is a form of phobia treatment, but at least it is a very effective one.

Dr. Barry Eppley

Indianapolis, Indiana

Botox Approved for Crow’s Feet Wrinkles

Thursday, September 12th, 2013


It was announced today that the most well known cosmetic drug, Botox, has been approved by the FDA to treat the wrinkles that radiate out from the eye, known as crow’s feet. This may come as a surprise to many since millions of people have received Botox injections around the eyes for years. Why is this newsworthy?

Although Botox has been used for decades to treat facials wrinkles, it was only formally approved by the FDA in 2002 for the temporary improvement of one very specific type of facial wrinkle, the glabellar lines between the eyebrows. This was what it was studied for in clinical trials and that is what the manufacturer is limited to in requesting FDA approval. That is what it says on the product packaging and that is what the company can say it does in any marketing and advertising pieces. This is how the FDA understandably works.

But Botox has been used for a whole variety of facial wrinkle areas since 2002, well beyond the glabellar area.  This use is known as ‘off-label’ and technically means that it is being used for an indication not approved by the FDA. Does this mean it is dangerous or unsafe? Absolutely not, as one facial wrinkle occurs by the same mechanism as another and Botox works the same for all of them. Doctors have known this for decades as treatment of the crow’s feet area is one of the three main cosmetic uses for Botox today. (glabella and horizontal forehead lines are the other two)

Now that Botox has been approved for the treatment of crow’s feet, it will not likely change how doctors employ Botox in their practice or in the number of patients being treated. But it will change how the manufacturer markets Botox and in the advertisements you see. Expect to see a big push and awareness of the crow’s feet problem and how it can be effectively treated. This will be particularly so since Botox’s competitors (Dysport and Xeomin) do not yet have this same approval.

Out of the over 800 patients that had crow’s feet treated in the clinical trial submitted for FDA approval, the most common side effect was some temporary swelling of the eyelids. This is interesting because that is a temporary side effect that I have never seen. I have seen some bruising due to large hidden veins that run through the crow’s feet area that get nicked from the needle but never eyelid edema.

But as for effectiveness, the reduction or eradication of crow’s feet occurs just as predictably as Botox injections do for the glabellar lines.

Dr. Barry Eppley

Indianapolis, Indiana

The Uniqueness of Male Plastic Surgery – Facial Procedures

Saturday, June 15th, 2013


The facial aging process is one that is well known as everyone will eventually see it on their face. The eyes get heavy, the brows descend, the cheek fall, jowls develop and the neck sags. Women become concerned earlier in the aging process and proceed to do procedures to treat or slow it down in an overall more comprehensive manner. Men take a much more delayed approach to it often waiting until one facial area becomes a major concern or until the facial aging process is fairly advanced.

While the face ages largely similar in both men and women, the facial procedures used to treat them are often done differently. Not as many men have facelifts as their aging neck and jowls are more tolerated. But in men that have facelifts they must be done very carefully, respecting the natural hairlines of the temples and behind the ears and being careful not to displace the beard skin into the ear canal. Incisions must be placed very inconspicously and often less of a tightening result must be accepted to keep the scars hidden. That is not a bad thing as men look better underdone than having their faces pulled too tight anyway.

While men also develop heavy upper eyelid skin and lower eyelid bags just like women, their eyelid lifts (blepharoplasties) need to be done more conservatively. Browlift options in men are more limited due to the frequent lack of adequate scalp hair and a well defined frontal hairline. The most common male browlift method is through the upper eyelid (transpalpebral browlift) using the endotine device to accomplish the lift. This produces a very modest browlift but creates no visible scars and with more conservative eyelid skin and fat removals can avoid overfeminizing the male face and creating an unnatural overdone look.

Men do not engage in as many Botox and injectable fillers treatments as women as some wrinkles and signs of aging are more tolerated. A more natural result for men is one that reduces the worst of the wrinkles but does not eliminate all of them. This is the same reason men, at best, will only do a bare minimum of facial skin care. Many men would rather seek more definitive surgical procedures, or do nothing at all, that engage in non-surgical procedures that require frequent efforts to maintain.

Facial reshaping surgery is vastly different in men than women. Male rhinoplasties must keep a high and straight dorsal line and avoid an overly upturned tip while most women desire a smaller less projecting tip and lower dorsal lines. The shape of the face in men is dominated by a strong jaw and requests for chin, jaw angle and even total jawline enhancements are not uncommon to pursue a more masculine appearance and even the so called ‘male model’ look. Men favor higher more angular cheek augmentations while women prefer a lower more anterior rounded cheek prominence. Men pursue brow bone surgery for either reduction of an overlying prominent one or for augmentation to create a more masculine brow prominence and a more backward sloping forehead profile.

Plastic surgery for men has its own unique requirements both in the type of surgeries and the demeanor of the patients. One should not assume that every plastic surgeon or plastic surgery practice is equally adept about meeting the needs of the male patient. Just like breast reconstruction for women or body contouring after massive weight loss, the male patient presents unique challenges for a satisfying surgical outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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