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PST 020: Botox Injectables — Read the Transcript

August 15, 2018

Listen to the full audio here

Welcome to Plastic Surgery Talk with Dr. Steven Mullholland, brought to you by SpaMedica in Toronto, Canada and our latest podcast on Botox Injectable. Botox Injectable is very, very common, been used in North America for cosmetic uses since 1983. Millions and millions of units of Botox Injectable are administered every year. What is Botox Injectable? Why is it so popular? Botox Injectable is a very simple protein, it’s the natural protein product of a bacteria. Bacteria make penicillin, bacteria make Botox Injectable. It’s a little protein that’s linked together, it’s freeze dried, sterilized, quality controlled by a large company called Allergan, which has been around many, many, many years. They make Juvederm, Botox Injectable, breast implants, Latisse. It’s a very reputable company. And then it’s shipped to doctors like me.

It’s then reconstituted with saline, which is a liquid, and liquified. And then we draw it up into very small, delicate cylinders and it’s injected. So what is Botox Injectable? It’s an injectable reconstituted protein that’s used in very, very small amounts in specific muscles to weaken that muscle for a period of time. The weakened muscle softens the animation wrinkles and lines created by that muscle. Botox Injectable can also be used to weaken muscles that pull the brow and the face down to allow the lifting up muscles to create elevations and soft tissue repositioning. Botox Injectable is used cosmetically in very, very small amounts to safely and effectively weaken the activity of unwanted muscle action. Muscles that crunch the skin and create wrinkles, folds and furrows and muscles that pull the face down.

Lastly Botox Injectable can be used to modify and shape and contour based upon diminishing glandular secretions. Botox Injectable is a very versatile little product. It’s extremely possible that it is the most common cosmetic product ever developed. It’s often the starter medication or starter treatment of choice for younger cosmetic patients. Start with Botox Injectable, a little skin care, some sun block. And then it leads into other injectable soft tissue filler energy-based treatments and Botox Injectable is the foundation for maintaining older faces that have undergone facial rejuvenation surgery. Certainly very ubiquitous, very common, very popular, and very effective.

Botox Injectable is approved for use in the United States and in Canada for some very specific areas. The number one indication, the longest indication for Botox Injectable is softening of frown lines, the number 11s on the brow. Softening the muscle that crunches and furrows the brow so you don’t get those angry lines. Botox Injectable is also FDA-cleared and Health Canada-approved for the treatment of crow’s feet, or the smile and squint lines at the side of the eye. Injecting in small amounts into that area can reduce laugh lines. Botox Injectable is also improved for horizontal lines to the forehead or worry lines and these often would create a sense of pensiveness, of uncertainty and softening those lines can be very helpful as well. There are a number of off-label line management uses for Botox Injectable. It can be used to soften the lip lines, the barcodes or the smoker lines of the upper lip. It can be used to soften the line that’s created at the base of the nose and that can soften that upper lip nasal base line.

It can be used to soften the horizontal lines of the neck called the platisma, or necklace lines. Botox Injectable also has some off-label use in shaping the face. We can inject the muscles that pull the brow down and the brow will look elevated. We can inject the very specific muscles that pull the mid-face down and give a Botox Injectable mid-face reshaping. We can use Botox Injectable to roll out the corner of the mouth. We can use Botox Injectable to take the down-going mouth pout and horizontalize it, soften the muscle that pulls the corner of the mouth down. We can use Botox Injectable to inject the master to the clenching muscle of the corner of the jawline to create a more oval or anime shape to the face. Botox Injectable can be used to soften the little crinkly muscles here called the porterage or orbicularis oris muscle. We often use Botox Injectable to soften glandular secretions.

A very large submandibular gland or parietal gland can be shrunken down with the use of Botox Injectable without compromising or creating dry mouth. We can also use Botox Injectable off the face. It’s used very commonly in the armpit to diminish the glandular secretions of your sweat glands. So for hyperhidrosis or excessive sweating we can use it to create dryness of the armpit and that can last many, many, many, many months. We can use Botox Injectable to decrease the size of the calf, the bulk of the muscle of the calf. To decrease an overly-developed shoulder in a woman or to elevate and raise up the pectoralis major in the breast. So it can be used for many, many on-label and off-label applications. The most important thing is find a physician, plastic surgeon, cosmetic dermatologist, facial plastic surgeon who’s very, very experienced in the use of Botox Injectable particularly when you go off-label.

And make sure that that physician understands your needs and you have a solid consultation and a safe and effective treatment. How long will Botox Injectable last and what is the maintenance schedule of your Botox Injectable treatment. So understand that Botox Injectable once you enter into the treatment, it is made to last for a certain number of months and then wear off and you do it again. Just like coloring your hair, redoing your pedicure, your manicure, ongoing skin care, the aging process continues. You need to maintain your Botox Injectable. In general for facial Botox Injectable treatments you need to do treatments three times a year to four times a year when you’re using small amounts of small areas. If you’re using larger, more assertive treatment doses, that is more an increased number of units per area, you can sometimes get away with doing the treatments twice a year.

When you’re first set out you need Botox Injectable less frequently. Let’s say you’re in your early 30s, mid-30s, 40, you start to see the facial aging change as you start with Botox Injectable. You can use small amounts, usually twice a year. As you move into more aggressive treatments and older facial aging changes you might need a lot more Botox Injectable and do it three times a year. In general when you start seeing the animation back and the wrinkle you’re treating or the shape change has lost its efficacy, that’s the time to go back to see your treatment professional. How much does Botox cost? Well Botox is usually sold by the treatment professional as a function of the number of units that you need to treat the number of areas that you have injected. In general a doctor, a physician who purchases the Botox Injectable from Allergan pays a certain amount for a 200 unit vial and passes this on to the patient with a slight profit margin. In general most doctors are paying about $6 USD per unit of Botox Injectable. Most doctors are going to sell that at some profit that reflects their cost of marketing and the expense of the professional that’s injecting and their time. You see some of the inexpensive clinics will charge eight, nine, $10 per unit. Some clinics charge $12, $13, $14 per unit at the medium price range. And some clinics, the higher-end clinics, the ones with the most experience, the most knowledgeable and talented injectors in a large city might charge upwards of $18 a unit. The average number of units used by North Americans is approximately 30 to 40 units. So it’s going to cost you between three and six, $700 per treatment two times a year or three times a year depending on the areas that you have treated.

The more Botox Injectable you do, the more units you use. In general over a certain number of units, let’s say over 60 to 70 units, there’s a sliding scale of decreasing expense per unit as you use more larger volume product amounts. For in the armpits you might use 100 units on each side, you’re going to pay eight or $9 a unit because you’re buying more Botox Injectable. Volume discounting, pricing per treatment, areas treated and the number of units per area. Finally you’ll see some centers and clinics charging by the area. This much for the frown line, this much for the crow’s feet. What they’re really doing is charging for the minimum number of units used in that area and just charging by an anatomic area where really the number of units used is hidden within that cost. You might want to ask a physician, “Well how many units are you going to use on my frown line if I’m paying this much for a frown line?

Are there other Botox-like injectable products out there in the marketplace? There are other types of Botox-like medications from different companies. Botox Injectable is made by Allergan. Botox Injectable is by far the most known in North America. It’s been used for cosmetic treatments for several decades. But there are some other pharmaceutical companies with lesser-used products that work just as well. The first one is Dysport. Dysport is similar to Botox in chemical structure with slightly different cross-linking. The number of units to treat a certain area is slightly different. But once injected it works almost exactly the same as Botox Injectable and can be used ostensibly as a Botox Injectable substitute. Dysport is owned by Galderma.The other alternative, a competitor to Botox Injectable is called Xeomin. Xeomin is made and owned by Merz.

Galderma, Merz and Allergan are competing pharmaceutical companies. Sort of like Cialis and Viagra compete for the erectile dysfunction market, there are three different manufacturers, pharmaceutical companies, making these neurotoxins or Botox-like substances. By far the most common product in North America is Botox Injectable. Consumers know Botox Injectable by name, it’s trusted, we know the dose symmetry, the injection technique. It’s just a more predictable, more deployed and therefore more commonly available product.

What are the common myths or urban myths that have been developed from Botox Injectable that just really aren’t true? One of the first things that’s often commented about Botox Injectable is that it’s okay to use it but once you stop it makes you look awful. You have some accelerated aging pattern over and above what you would have had anyway.

That’s completely untrue. What is true, if you start Botox Injectable at an early age, 30, 35, 40, you will never get a line or wrinkle. If you’re meant to have a frown line, you’re meant to have crow’s feet and horizontal worry lines you will never, ever get them. As long as you maintain your Botox Injectable treatments you will never get facial lines and wrinkles. I’ve got many patients who started Botox Injectable in their early 30s who are now in their 50s and they don’t have a single line or wrinkle. They would have got the same animated pattern that their mother got. So it definitely halts wrinkles in their tracks. Now let’s say one of those patients who’d been on Botox Injectable for over 20 years suddenly stops. The myth is she’ll suddenly age rapidly and shrink down to this wrinkled, deflated, older version of herself that would be more accelerated than she would have had she not done Botox Injectable.

That’s absolutely incorrect. Once you stop using Botox Injectable after that three, four, five, six months it takes to wear off, you start to animate slowly. But you’ve got this pristine skin that has never had a wrinkle on it because you’ve been doing Botox Injectable for a number of years and you start to get wrinkles. But you start to get wrinkles from a new set point, a new age of your skin. Those wrinkles come over time, very slowly like they would have anyway. You’ve just delayed them by however many years you used Botox Injectable. Use Botox Injectable early, start with judicious amounts, maintain it for the rest of your life and you will never get a wrinkle. If you stop you’ll just start to get wrinkles at 50 rather than 30 and they’ll come on slow and steady just like they would have in your early 30s.

There seems to be some myth out there online and in social media sites and in certain unregulated websites where somehow the injection of Botox Injectable will affect your central nervous system, your brain, and make you dumb. Botox Injectable is a wonderful chemical injectable for management of lines and wrinkles. There is no evidence that it affects you cortically neurologically and it certainly isn’t going to alter your IQ. What it will do if your IQ is low and you’re frowning over a problem you can’t solve at least you look smooth and serene. But it’s not going to elevate that IQ or decrease it. It’s just going to make you look smoother amidst life’s complexities.

Another myth commonly perpetuated is that, “Oh, Botox Injectable is only for women.” It’s kind of a sissy thing to do. Tough guys aren’t going to do Botox Injectable. I have to say that that was the cultural mandate of the 80s and 90s but increasingly men, we men are being subjected to the same standards and beauty critiques of wellness, health, vitality, youth, serenity that women are. And so increasingly men are becoming a bigger part of the aesthetic plastic surgery world. Botox Injectable is an awesome injectable medication, especially for guys who have very, very deep frown lines and worry lines. It makes them look too stern, it makes them look unapproachable, it makes them look angry. Now that might be great if they’re a judge or a police officer, but if you’re in business and you’re in sales or you’re single and looking for a new mate online on one of the dating apps you’re going to be judged by your appearance. To look approachable, to look serene, relaxed can be a very important emotive that you want to project. So Botox Injectable and guys, definitely a big part of the aesthetic industry and it’s here to stay. I think that looking your best knows no gender boundaries anymore.

Men and women want to look their best and Botox Injectable is a good foundational keystone element in enhancing your appearance. A very common myth which is being bourne out by this new millennial generation is that Botox Injectable is only for women, A, now it’s for guys too. And it’s only for women and men that are older, let’s say over 45. I have to tell you that in the last 10 years the average age of first Botox Injectable has gone down 10 years. It’s what I call 10 and 10. 10 years, the average age of starting Botox Injectable has gone down from 41 in the year 2008 to 31 in 2018. So what does that tell us? It tells us that increasingly younger and younger people are wanting to control the kind of image they project. They want to look their best, be their best, be perceived as their best and having a smooth, unstressed, unwrinkled, unlined, external envelope is presumably going to help you get a job, secure a job, get a date, secure a date.
Or just feel better about the complexities of a more integrated and disturbing world. So definitely Botox Injectable is not just for the older person. Usually when lines and everything else start to show and rear their ugly, early signs of crevicing, that happens in your early 30s. That’s when a lot of millennial patients will start. Thank you very much for joining me again, Dr. Steven Mullholland here in Toronto, Canada on Plastic Surgery Talk for our latest podcast on Botox Injectable. If you found this interesting, entertaining, please share it on all your social media channels and we’ll see you back again on Plastic Surgery Talk for our next podcast.

Dr. Stephen Mulholland
Posted by Dr. Stephen Mulholland
Dr. Stephen Mulholland has been practicing Plastic Surgery for over 20 years. He is one of Canada’s most renowned and best plastic surgeons in Toronto with his wealth of experience, artistry, and humbleness towards his patients.

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