Botox Injections

Botulinum toxin (Botox, OnabotulinumtoxinA) has been known for over a century and has been used for medicinal purposes for over 50 years. Its earliest uses were the treatment of lazy eyes (strabismus), blepharospasm (inability to move the eyelids in a certain way), and curvature of the neck (cervical dystonia). Approved in 2002 to improve and reduce wrinkles in the forehead (glabellar) area between the eyes, it has since been used successfully in more than 11 million patients, as per Allergan data. In 2004, Botox was approved to treat sweating (hyperhidrosis) and in 2010 to treat migraines.

A common misconception is that Botox actually paralyzes the facial muscles. While this can happen with extreme amounts of Botox, most doctors try to inject only an amount that allows the patient limited activity but not enough to induce hyperactivity in those areas. Patients should know that Botox is not used to prevent them from expressing themselves, but only to prevent them from making grimaces and facial wrinkles that have become habitual and involuntary. When done properly, most people who are not trained plastic surgeons will not notice that the Botox treatment has been performed, only that the patient appears more rested and happier.

Preparation for Botox injection

The Botox material is supplied by the manufacturer in the form of a crystalline substance, which then needs to be dissolved in saline. Professionals add varying amounts of liquid during reconstitution. Although there is no right or wrong amount of liquid, most physicians add about 2 to 3 mL (about half a teaspoon) of liquid in each vial. Some add a bit more, which can lead patients to think they're getting more Botox when they're actually getting as much or less Botox than the more intensely prepared samples. It is the total dose of the drug, not the volume of the liquid, that produces the desired effect.

It is therefore important to note that if a clinic or spa claims to administer Botox at a specific amount per unit, it is entirely possible that they are diluting the Botox and not actually administering the agreed amount. It's similar to the concept of a diluted drink at the bar, however the cost is much higher with Botox or its alternatives Dysport and Xeomin.

During the procedure

The patient is placed on the examination table and the injection sites are cleaned with an alcohol-free detergent such as Hibiclens or Betadine. Some doctors use a local anesthetic like EMLA cream during this time. Botox is then injected into selected areas. Typical injection patterns include about four to five areas on each side of the forehead and two or three areas in each eye area. Depending on the type of wrinkles and the desired effect for the patient, qualified doctors can inject several areas. Although ice is sometimes applied first for comfort, the author believes that compression is much more effective than ice in controlling bleeding and bruising.

After the Procedure

After the injections, the patient usually lies in an upright or semi-upright position for about two to five minutes to ensure they are comfortable after the procedure. Patient should then avoid lying down for two to four minutes. If bruising is a concern, it is important that the patient refrain from taking aspirin or similar products such as ibuprofen (Advil, Motrin) or naproxen (Aleve) after procedure, if possible, to minimize bruising.

Results will be visible in 3-10 days. Pictures can be taken before the procedure, allowing patients to see the results themselves rather than relying on memory. It's amazing how many people can't remember what they looked like before surgery and marvel at the difference when shown a photo. Before performing the procedure, the patient must be prepared for the fact that Botox does not actually remove wrinkles, but relaxes them. This means that deeper wrinkles become a little shallower and superficial wrinkles almost disappear. It can be compared to steaming out creases in clothes instead of ironing them.

The patient may need to undergo additional treatments, such as the use of fillers (eg, Restylane, Perlane, Juvederm, Sculptra, or Radiesse) to reduce the now-resolved wrinkles. Also, for deeper wrinkles, it may take two or three Botox treatment sessions before the results are optimal. The area of creases between the eyes is a particularly ideal area for the application of Botox in conjunction with a filler, as these fixed creases do not always respond optimally to Botox alone. 

Botox results

As mentioned above, the results usually show up after three to ten days. For most people, they last up to three or four months. Muscle activity gradually returns to normal over time. Depending on the quantity injected, other areas could also resume operations sooner or later. The interesting thing about Botox is that it usually works quite well up to the third month as a treatment that can last a very short time in full effect and then wear off quickly (filler injections like Restylane, Perlane or Juvederm) usually last 6 to 12 months, depending on the amount used.

Results may vary depending on who is giving the patient the injections. It is very important to consult a doctor who has experience in performing these procedure, does it himself (rather than having a nurse, physician assistant, or other non-physician do it), and who has a good reputation for performing these procedures. Botox manufacturers advise doctors to inject the drug themselves. As with most procedures, the skill of the doctor depends on how often they perform the procedure.