Blog

By Dr. Jesse E. Smith, MD, FACS
Facial Plastic Surgeon

How did Botox become a cosmetic treatment?

So Dr Alastair Carruthers, who recently died, was a dermatologist and his wife was actually an ophthalmologist. And ophthalmologists are eye doctors. She had a number of patients who had blepharosplasm, which is where the eye muscle contracts quite a bit and it actually does it throughout the day and it’s quite bothersome. And then also strabismus, which is where people can get a little bit of a lazy eye.

They started using Botox in those in the early 1980s in some clinical trials. And by mid to late 1980s, they really started to notice that the crow’s feet and some of the brows really started to dissipate with wrinkles for patients who were treated even three to six months.

Jean told her husband, Alastair, he was a dermatologist, that this was going on, so he started using Botox in some patients, off label, and trying to soften their lines around their eyes. And by 2002 It had enough clinical trials to become not only approved in the 1980s for non cosmetic use, which is blepharospasm and the strabismus, but then went on to become cosmetic use.

That really revolutionized the non invasive procedures that would start to perform even in every plastic surgeon’s office, but also in dermatology oculoplastic surgery, across the board. And it opened the gateway for minimally invasive procedures. It opened the gateway for all of our volumizing injectables.

It’s just really turned the table from everything is surgery to now we have other options that are less invasive.

Now Botox has over 100 medical patents, so we use it in beauty for certain, but it can be used in hyperhidrosis, which is excess sweating of palms and hands and armpits. Overactive urinary bladder. We use it to increase blood flow to, in plastic surgery, to flaps and reconstructive areas. Migraine headaches. Dystonia for children that have chronic muscle spasms that pull their head or their body into certain patterns, for relief of those. And that’s just a few to mention. There’s over 100 medical patents. Pretty amazing stuff. And we use it actually in burn patients to release scar tissue because it actually remodels scar tissue into a better type of skin.

On the cosmetic side, what is trending right now?

There for a while Nefertiti lift was a big deal. It was basically named after Queen Nefertiti, who was known to have a long, beautiful neck. The idea was that people would put Botox along the platysma muscle, which is this muscle that moves the neck.

And the thought was that muscle was actually moving the face down a bit. And by paralyzing it, it would actually lead to a little bit of lift. It was okay, successful in younger patients and the right patient population. Certainly didn’t work in everyone, which is true for all things in cosmetic surgery.

And we did find it somewhat useful for some of the platysmal bands. And that Nefertiti lift then evolved into injecting the platysmal bands, these muscle bands. And that was actually more successful than the Nefertiti lift itself, but it was a social media craze for a while.

We now also have the lip flip. And lip flip also has its advantages and disadvantages. For people who use straws or chronic pursers of their lip. We tend to get these vertical lines around the lip and so we inject those with small units of Botox and that can relax those out. The lip flip itself is best done in younger patients who tend to purse a little bit and when they purse, their lip rolls under and so we put just a little Botox, two or three units along each side and that then allows the lip to roll back up and over.

I would say that it’s not effective as a filler, but if for people who are looking just to do a little bit of something and to get a soft but a natural result, if they’re young enough and have the right anatomy, it’s a home run.

What about the Botox “freeze face”?

Botox is an individual sort of thing that we do. Everybody has different facial movements and motions. Some people force their lips, some people wrinkle their chin.

I’m a frowner, when I think. Botox is used selectively in areas. And when we put Botox in, we have the option of how much we put in. How many units do we use? And the amount that we put in equals not only the duration, but also the effect that we get. So if someone wants more movement in their forehead then we can lightly sprinkle these lines up here so we still get surprise and elevation and friendly looks.

But we don’t have to get the wrinkle down, “I’m mad,” so we would put more here to decrease the frown and leave this slightly done, so that we don’t get wrinkles here, but we still have movement. That’s the art of it. You don’t have to, it’s not a light switch. It’s not all or nothing. Yes, you can get a frozen look if somebody puts too much in the wrong place.

But it can be artful and beautiful and natural if someone who knows what they’re doing is doing it. And looking at the anatomy and treating the anatomy and the person instead of just everybody’s the same.

Is Botox permanent?

So Botox is not permanent and that can be a good and a bad thing. So if you have an injection that you do and it was permanent and you really liked it, that’d be great. However, if someone did a Botox injection on you and you didn’t really like the job, at least it’s not permanent. Botox lasts about three to four months. It can stretch to six in some people. And like I’ve said before, dose equals duration. So if we increase your dosage, then you will get a longer duration out of it. Unfortunately, it’s not permanent. But it can last a long time.

And if it’s done right, it should last at least three months. People do, in some cases, start to see it wear off at about the tenth week, and those tend to be our very active people athletes and very expressionist people like a lot of our folks that do plays and are actors and singers.

Is Botox toxic or dangerous?

So Botox is toxic, is not dangerous. I always joke with my patients that have asked me this question that I figured it out. It would take about eight vials, 800 units of Botox placed in your veins to kill you. And I always joke with them, I was like, there are a lot cheaper ways to die.

Even if we get a little bit mistakenly into a vein or artery, it is not lethal whatsoever. We’re using such small dosages in the muscles and putting them in such precise locations that this doesn’t get spread throughout the rest of the body. It stays where we place it, and that’s what we want.

So we place it in the muscle belly, in the precise location.

Do you only need Botox when wrinkles are deep?

This is a great question and also a bit of a myth. We actually prefer to start seeing patients when their wrinkles occur. When we see patients that come in with deep wrinkles, Botox is actually a little bit more disappointing to them because they’ve already had these wrinkles form over years and now we’re trying to undo years of, these deep lines.

Can it be done? Absolutely. But people are a little disappointed to hear that it might take 12 to 18 months of Botox instead of 3 to 6 months of Botox to fix their problem. So we do like to see people when they first start to occur or have had them for about a year or so.

It’s a lot easier to fix in that situation. Again, it’s an ounce of prevention, pound of cure.

Is Botox addictive?

Botox has no addictive substances whatsoever in it. It is not a drug that is considered an addictive substance. People are addicted to it because they look good if it’s done well, and for that reason, most people want to keep up Botox on a fairly consistent basis, especially if they have a great result with it.

Which goes back to the other question of if I stop my Botox, I look worse than when I started. That’s one of my other favorite. And we take pictures for every client that comes in, and I love to show patients their pictures after they’ve been on Botox and their, before the patients came in, their very first picture with us.

People get used to how they look, especially after three to six months of looking great with, a few fine lines and wrinkles, and then when they stop and go back to where they were, they think they look worse, but they look exactly the same as when they came in.

Is Botox painful?

Botox is not especially painful. I wish that we could walk it in without a needle, but we can’t. In my clinic, we use the smallest, thinnest needle that there is. We buy them special from TSK. They’re made in Japan. They’re really sharp, fine needle. So it hurts about as little as it possibly can for a little needle stick.

We rarely have any patients complain about the pain of the needle sticks. It’s not especially painful. It’s not like any pain medicine or any special treatment to get Botox for.

Does Botox work immediately?

Botox does not work immediately. It would be great if it did. I think that’s one of the things I’d change about it. What has to happen is the Botox molecule actually has to get into the nerve that’s supplying the muscle and stop the transmission of this neurotransmitter that jumps across the nerve to make the muscle move.

That takes about 3 days to start to happen. So I always tell my patients, listen, you’re not going to get out to your car and instantly have results. Please don’t come back in and say you didn’t get your money’s worth. Give it three days. Three days it’s going to start to work. Two weeks is the maximum effect.

And then it will slowly wear off over the course of about three to four months.

Is Botox just for women?

Botox is not just for women. We have a large clientele of women just because they like to come in and look good, but we also have a fairly large clientele of men. I’ve been doing my own Botox since I was about 32 years old because, as I mentioned earlier, when I think, I get the frown lines. I got actually tired of people asking me, are you mad?

And I was like, no, I’m just trying to think. So it takes a lot of effort to think. So we have a large clientele of men that come in for Botox that just want to look better, look refreshed. And as men, especially in me, we get a very heavy brow. And then when we wrinkle and frown, or, this comes down, it looks even heavier.

And so we look a little bit more mad or mean than what we intend to be. Plus we do squint a lot. We get a fine crow’s feet. It works great for that. It’s soft. It can look good. You can still have expression and not have deep lines.

Does Botox continue to work as effectively over time?

A lot of people have the question, does Botox continue to work as effectively over time? And it actually does. There’s very few people that have become immune to Botox. We’re sticklers at my clinic to, we’re like, you cannot have your Botox unless you’ve not had it in 10 to 12 weeks.

We don’t want to give small doses, in frequent intervals. That’s basically giving somebody allergy immunotherapy and you can become immune to it. When I trained in LA we had several people that used to go around and they’d go to lunch and they’d notice a line and then they’d come in and get that little bit injected and so they’re getting small doses in frequent intervals and then it got to be where we couldn’t even dump a five gallon bucket of Botox on them and you know nothing would work and so that was very unfortunate.

I was glad that I saw it while I was there, so we’re very regimented with our patients about, it’s got to be 10 to 12 weeks from your last treatment. If you’re going to get it done, get it all done at once. It’s very effective over time, especially if it works for you. And what I like to do is use the analogy of we’re going to put your arm in a cast.

And so most people can understand this if we put your arm in a cast for six or eight weeks, when we take it out, It’s going to be way smaller than the opposite side. So we’ve told that muscle that you can’t work for six to eight weeks. And that muscle does a thing in medicine called atrophy. It gets smaller because it’s not being used. And then the person has to build that muscle back up, and then it can get to the opposite side. We’re doing a very similar thing to the facial muscles. We’re telling them, okay, you can’t work as effectively as you used to. And while they can still move their face and it can look good, we’re telling that muscle to atrophy a little bit or to slim down a little bit and not be as effective.

If we continue that for months and months, over time for months and years, that muscle will continue to be atrophied. And so it can then begin to space people’s treatments out as much as six to nine months. between treatments because the muscle has gotten to a such a small amount that we don’t have to use as much Botox or we don’t have to do it as frequently.