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Posts Tagged ‘botox injections’

Botox Injections Using Ultra Small Needles

Wednesday, September 16th, 2015

Botox Injections Dr Barry Eppley IndianapolisBotox injections into various areas of the face are tremendously effective at reducing specific wrinkle areas, particularly around the eyes and forehead. While effective they are not necessarily pain-free. Despite using a very small 30 gauge size needle, some discomfort still exists with Botox injections. This has led to a variety of pain management strategies from ice to topical anesthetics to help make the injections as comfortable as possible.

In the September 2015 issue of the JAMA Dermatology journal, an article appeared entitled ‘Pain Perception with Botulinum Toxin Type A Injections’. In this study the authors compared differences in the perception of pain with Botox injections using 30 vs 32 gauge needles. Twenty (20) patients were studied using a blinded randomized clinical trial approach for their glabellar and forehead wrinkles with one side of the forehead injected with a 30-gauge needle and the other side with a 32 gauge needle. Similar injections were also done in the arms. For facial injections, more pain was seen with the  30-gauge needles which were associated with more pain in 8 patients (40%) compared with the 32-gauge needles, which were associated with more pain in 3 patients (15%) Mean injection pain scores for the face were somewhat lower with the 32-gauge needle (3.4/10) than with the 30-gauge needle (4.15/10). The mean pain scores were lower for the arm injections (1.2 with the 32-gauge needle and 1.66 with the 30-gauge needle).

The study found that significant pain was almost 4X times more likely with facial injections with 30-gauge needles than with 32-gauge needles. This was different in the arms where there was very little if any differences in pain associated with the two needle sizes.

small needles for injectionWhile this study is far from conclusive, it is logical to assume that the smaller the injection needle the less pain that may likely result from its use. While no injection can be absolutely pain free, use of 32-gauge needles may be as close as one can get. Because they are more expensive, however, many practices are likely to not routinuely use them and save them for the most pain-sensitive injection patients.

Dr. Barry Eppley

Indianapolis, Indiana

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

Differences in Botox Dosages in the Upper and Lower Face

Saturday, March 2nd, 2013


At this point in time, almost everyone has heard of Botox and know it as a changer of facial expression. To those people who receive these neuormuscular injections, they are aware that to receive it is given in dosages known as units. They often are aware of the exact units that they have received because the cost of their treatment is priced per unit in many practices.

While the most common area to receive Botox injections is in the periorbital region (forehead and around the eyes), the perioral region (upper lip and chin) is also treated in a much lesser numbers of patients. What has always been interesting has been the dose differences between these two areas in the amount of Botox to get an effective result. The perioral area requires much fewer injected units by a significant amount. To date, no one has understand why such dose differences exist

In the recent February 2013 online edition of the JAMA Archives of Facial Plastic Surgery, a paper was published entitled ‘Electromyographic Differences Between Normal Upper and Lower Facial Muscles and the Influence of Onabotulinum Toxin A’. An electromyographic (EMG) study was done to investigate why upper facial muscles require substantially greater paralysis than lower facial muscles to get a visible aesthetic wrinkle reduction effect. In 26 adults the dose response to Botox injections of the corrugator muscles in the forehead (20 units) and the depressor anguli oris (DAO) muscles of the chin. (4 units) were given. Muscle activity was tested both before and after the injections. While the activity was similar in the upper and lower facial muscle prior to the injections, the upper facial muscles had a significantly greater response to a much higher dose of Botox. This suggests that there is a need for near-total paralysis of the forehead muscles to get a good result. The lower facial muscles are much more sensitive to Botox and are effected by a much lower dose.

Why do the upper and lower facial muscles differ in their response to Botox? There may be some inherent susceptibility differences in the motor endplates between the muscle groups to the effects of Botox. It may be equally possible that, despite being dose-dependent, that it merely requires less muscle weakening in the lower face to create the desired aesthetic result. Two units to the DAO muscle (to create a mouth corner upturn), two units to the paranasal muscles (to improve a gummy smile) or 6 to 8 units for upper lip wrinkles can create good results. Conversely, a few more units can create aesthetic problems such as smile and lip animation disruptions. Thus the mouth area has a much more narrow therapeutic window than the forehead muscles.

Botox is effective in both the upper and lower face for expression control and wrinkle reduction. But the lower doses needed in the lips and chin means their treatments are very economical but must be precisely placed to avoid aestheti lip and mouth problems.

Dr. Barry Eppley

Indianapolis, Indiana

Oral Supplements for Enhancing the Effects of Botox

Saturday, July 14th, 2012

The use of Botox and other analogues for the treatment of facial wrinkling, particularly in the forehead and crow’s feet area, has become as mainstream as Starbuck’s is for coffee. A testament to the success of Botox is that there is a good reason it is a multibillion dollar business per year…because it works. But despite this success, cosmetic neuromuscular injections are not perfect. They are relatively expensive, require some mild discomfort to be administered, and do not last.

Of the three negatives associated with Botox, the one that most patients would love to be improved is the duration of its effects. If Botox only lasted longer, patients would be even more pleased and I suspect even more patients would have the treatment or stay with it longer. But despite new competitive products to Botox that have appeared, such as Dysport and Xeomin, none of their benefits have been an improved length of effect.

In the June/July 2012 issue of Cosmetic Surgery News, an article appeared that discussed one promising method of enhancing the effects of botulinum toxins. This report focuses on the use of an oral supplement to achieve this effect, certainly a novel approach to this problem. The theory of this approach is that these toxins require the use of zinc to function and some patients may have marginal zinc levels. The oral supplement proposed is a combination of 50mg zinc and phytase. (known commercially as Zytaze) In a study of 77 patients who were treated for either cosmetic facial wrinkles, hemifacial spasm or blepharospasm, over 90% of the patients given the supplement showed improved effects. The increase in toxin duration was nearly 30% . In the placebo arm of the study, no significant increase in duration or effect was seen. One interesting aspect of the study is that the patient’s age did not diminish its effectiveness.

Despite the improved toxin effects demonstrated in this study and report, and the availability of this supplement commercially, it has not caught widespread clinical use. The report does not indicate the cost of this supplement which is available as a prescription in a blister pack of  10 capsules. Its cost is relevant because it causes an enhancement of botulinum duration and effect but not the equivalent of doubling or tripling it. The other issue that is not clear in the report is how long and often does the supplement need to be taken. Is it just taken around the time of injection or does it have to be continued for some period of time after the treatments. My assumption is that that it is taken only around the injection period.

Improving the effects of Botox and its equivalents is of great patient interest. It could decrease the number of treatments per year, lower the number of units (dose) needed per treatment, and perhaps improve the effects of those patients who have become resistant to botulinum injections. Time and more widespread clinical experience will determine if the effects of Zytaze is as good as this report indicates.      

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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