WHAT IS BOTULINUM TOXIN?

It is a toxin secreted by the bacterium Clostridium botulinum. It can cause severe problems if ingested or injected in high doses. It has been used for decades to relieve muscle spasms associated with stroke or paralysis, and for the treatment of strabismus (when one of the eye muscles is overactive and pulling the eyeball in a skewed way so that a person looks cross-eyed and can’t control it.) The purified protein called BOTOX COSMETIC® is a highly regulated, FDA approved professionally produced PURIFIED PROTEIN used to relax muscles of the face and neck associated with dynamic wrinkling.

HOW DOES IT RELAX MUSCLES?

The purified protein binds to the tiny nerve endings, preventing tranmission of the nerve impulse to the muscle. Once the receptor on the nerve is blocked by the substance, it will not stimulate the muscle to contract, even if you try very hard to move the muscle. Over time, the nerve will create new receptors so that in time, the muscle will move again. This is one of the reasons why BOTOX® is so incredibly safe (and why there has never been a successful lawsuit against Allergan or any physician for its administration) – if something happens that the patient is not pleased with, it will resolve within 3-4 months!

WHERE DOES THE BOTULINUM TOXIN COME FROM?

Originally there was a very small volume of actual toxin isolated from a patient who had botulism poisoning. This was diluted down into incredibly dilulte amounts and distributed when the practice of wrinkle relaxation first started in the 1990’s. Since then bioengineering has taken over to produce the medically useful protein, so there is no risk of getting any communicable disease from the FDA approved botulinum toxins available today.

IS IT SAFE?

VERY safe indeed! The BOTOX® that we administer is the gold standard, FDA approved product, which has strict manufacturing guidelines which assure quality control and consistent dosing. The protein is injected directly into the muscle and does not get into the bloodstream and cannot travel throughout the body, so it has no ability to cause any systemic effects. It has been safely used for decades for medical conditions; Dr. Skellchock has been using it personally for the past 12 years, and has never had any problems because of it.

WHERE CAN BOTOX® BE USED?

This product is FDA approved for treatment of glabellar wrinkles (the “frown” lines between the eyebrows). However, it is safely used in the forehead, and the Crow’s feet area also. Putting a tiny amount just under the lower eyelash line will help prevent lower eyelid wrinkles. Dr. Skellchock has been administering

BOTOX® in every muscle of the face and neck for many years. For example, the muscles which elevate the cheeks, causing BUNNY LINES can be treated, the UPPER LIP can be treated to decrease the fine lines caused by smoking and sun damage. When the lower lip is pushed out, a crease in the chin is created, so the CHIN can be relaxed to prevent the formation of worsening of this chin line. Muscles that attached to the corners of the mouth, pulling it down, can also be treated (the Depressor Anguli Oris muscle) to help prevent the formation of the Marionette lines. Treating the DAO’s will also create a little bit of a lift at the mouth angles which is an added benefit. People who have NECK CORDS or NECK LINES can also be improved by injecting BOTOX® very superficially into the thin muscles in the neck and jawline, and Dr. Skellchock has had great results using BOTOX® to lift the neck, especially when used with skin tightening procedures such as the Accent®.

HOW MUCH BOTOX® IS USED FOR EACH AREA BEING TREATED?

Dr. Skellchock has been using BOTOX® since it first became popular for wrinkles, in the 1990’s, and is a PLATINUM PLUS Allergan Network Member, meaning she is one of the biggest BOTOX® utilizers in the nation. Each individual is unique, and so is treated with what Dr. Skellchock thinks will work best for them. For example, we tend to use 20 units of BOTOX® in the Glabella, 20 units in the forehead, and 24 in the Crow’s feet area. HOWEVER, the number of units needed to achieve the desired response is dependent on how large the area is (for example, some people have HUGE foreheads, while others may have a very narrow and short forehead). The amount of muscle mass will also determine how much is needed – for example, men tend to have bigger muscles so they typically will need more, such as 30-40 units in the forehead, or 25-30 in the glabella. Also, the facial muscles are like any other in the body – if you don’t use it, you lose it, so anyone who has been getting BOTOX® treatments for many years will have weaker, smaller muscles (since they haven’t been used consistently) and will probably end up needing smaller amounts or less frequent treatments of the toxin to achieve good results as time goes on. Dr. Skellchock administers BOTOX® artistically, so you won’t look “frozen” or “plastic” – you just won’t be able to crease your skin enough to cause lines.

WHAT SHOULD YOU KNOW BEFORE YOUR BOTOX® TREATMENT?

Since we use a needle to inject the purified protein, there is always a possibility of pain, bleeding and bruising. The pain is actually minimal, since we use a tiny 31G diabetic insulin syringe which is very sharp, which means less pain. If you are incredibly sensitive to pain, BLT topical anesthetic can be used - apply it one hour and 30 minutes before your appointment. We use ice beforehand to reduce the pain and to cause vasoconstriction, which also decreases the chance of bleeding and bruising. It’s good to refrain from anything that increases bleeding – aspirin, alcohol, Advil, Motrin, Aleve, Naprosyn and similar products, more than 400IU of Vitamin E per day, and megadoses of gingko can all decrease platelet function and cause increased bleeding and bruising. We also like you to refrain
from excessive exercise for 24 hours after your treatment, so it’s best to exercise before you come in for your appointment.

WHAT CAN BE EXPECTED AFTER BEING TREATED WITH BOTOX®?

The first time you get BOTOX® to smooth wrinkling, you will get the most complete “block” or “relaxation” ever – since virgin muscle is highly sensitive to the action of the medicine. The signal between the nerve and the muscle is stopped, so that the muscle cannot move anymore. With the initial treatment, it usually takes 5-10 days to see the full effect. After you have had BOTOX® several times, the onset of action is usually quicker so results are usually evident between 3-7 days. Feel free to bring your make-up so that you can apply it in our cosmetic room before you return to your daily activities.

WILL BOTOX® GET RID OF WRINKLES THAT ARE PRESENT AT REST?

No, it is not capable of eliminating wrinkles that have been incorporated into skin for long periods of time, therefore the best way to use the product is prophylactically, before the wrinkles have developed (this is why Dr. Skellchock is as old as she is and doesn’t have wrinkles – she started using it before she got wrinkles, and has kept it up so they haven’t had the chance to develop.) HOWEVER, it will relax wrinkles that are already there, and when given the chance, the skin will remodel and if kept relaxed, the wrinkle should become less apparent with time. If a crease or wrinkle remains after BOTOX® administration, it can be filled with one of our soft tissue augmentation products.

WHAT ARE THE POTENTIAL SIDE EFFECTS OF THIS TREATMENT?

There are very few side effects. Anytime we inject a needle into the skin, there is always a possibility of bleeding and bruising. For this reason, we prefer you refrain from alcohol, aspirin, aspirin containing products and NSAID’s such as Motrin, Aleve, Advil, Naprosyn, for 7-10 days before treatment, so as to decrease any chances of bruising. We also routinely use ice before the treatment, to decrease any pain and to cause vasoconstriction in the skin to minimize the chance of bleeding and bruising. If you are especially susceptible to bruising, take Arnica montana the day before, the day of and the day after your treatment. Arnica is a homeopathic remedy found at Whole Foods or Tunies which can decrease bruising and bleeding. Take 4 tablets under the tongue and let dissolve four times a day. Rarely, people can get a headache after the treatment – probably related to irritating the large muscle bundle that runs from the forehead up to the scalp and across the head. Some think that headaches are related to the volume of substance injected, and since we use a concentrated preparation, the likelihood of getting headaches is significantly reduced.

WHAT’S THE WORST THING THAT CAN HAPPEN?

The most serious possible side effects are eyelid droop and eyebrow heaviness. This is related to the age of the patient (older patients greater than 50 years of age tend to be the ones who can get these side effects), and the placement of the BOTOX® and how much is injected. Dr. Skellchock is very experienced in this
treatment, and among the thousands of patients she has treated, has had only a handful of patients have any complications - probably because she chooses to be conservative in her dosing, and places the product in the muscles that are causing the movement. We can always put more product in, but we can’t take it out!

IS THERE SUCH A THING AS “DILUTED DOWN” OR “WEAK” BOTOX®?

This product comes as a frozen powder. It cannot be injected into the muscles until it has been reconstituted with saline solution to form a liquid. Each bottle of BOTOX® has 100 units of the toxin (this is why we would never consider using anything that isn’t FDA approved – we know the manufacturing principles of Allergan and know that they have quality control measures to insure that each bottle contains exactly 100 Units). The practitoner decides how much saline solution to use to dilute it with. For example, opthalmologists who are treating for strabismus, must inject the BOTOX® into the tiny muscles which attach to the eyeball. Therefore, they tend to use a very concentrated solution – only mixing 1 cc into the vial. Therefore, the concentration they use is 100U/ml (which is the same thing as 100U/cc since 1cc=1ml). For someone wanting to treat very large muscles, one would want to make a more dilute concentration – using up to 10cc of saline solution, making a concentration of 10U/cc. In dermatology, the standard is to mix with 2 or 2.5 cc of saline solution, and at Integrative Dermatology, we mix ours with 2 cc of saline, creating a dilution of 50U/cc. We always mix it the same, and we always get 100 units in each bottle, so our dosing is as consistent and safe as is humanly possible.

HOW DO I COMPARE THE PRICE OF BOTOX® BETWEEN DIFFERENT PLACES SELLING IT?

The only way to compare apples with apples is by knowing how many units are being used. The volume (cc or ml) doesn’t matter since the concentration can be either very low (where 1cc may only contain 10 units) or very high (where 1cc can contain 50-100 units). Dr. Skellchock has always priced her BOTOX® by the number of units given; this is the only fair way to do it since some patients have bigger muscles or smaller foreheads for example, than other patients. Our pricing structure is such that the more units the patient receives, the price per unit decreases – giving a volume discount.