Botox Manifesto

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Welcome to Park Avenue
Plastic Surgery Class,

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the podcast where we explore controversies
and breaking issues in plastic

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surgery. I'm your co-host, Doreen Wu,

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a clinical assistant at Bass
Plastic Surgery in New York City.

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I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,

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educator and technology innovator.

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The title of today's episode
is the Botox Manifesto.

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You've intrigued me again. What do
you mean by this title, Dr. Bass?

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A manifesto is defined as
a written summary of the

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views of its issuer.

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This will be a verbal rather
than a written manifesto.

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What stimulated you to prepare
this summary or manifesto?

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I do a lot of all kinds of
facial rejuvenation treatments.

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The nonsurgical injectable
treatments like Botox and fillers are

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recurrent treatments, so these take
place multiple times every day in my

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office. Botox is hands down
the most popular treatment and

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has an extremely high level of
satisfaction compared to any

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other aesthetic treatment out
there. Still doing these treatments.

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There are some patterns
of good use and bad use,

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real understanding and insight
by patients and by providers

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and other examples where there's
kind of a lack of understanding that

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emerges patterns that are
repeated over and over.

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So I have the luxury on this podcast
of stating my opinion in the matter,

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not that my opinion is
necessarily the truth,

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but their beliefs that I have
about how Botox is best used,

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that I personally wish
more people understood.

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Let's get started. Go ahead
and lay out your thoughts.

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First, I said Botox,

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but I'm really speaking
about all neuromodulators.

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Neuromodulator is the term I
prefer to all the others to

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name this class of medications.
Currently in the United States,

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they include Botox, Dysport, Xeomin,

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Jeuveau, and most recently Daxxify.

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These are extraordinary medications,

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not just for the extremely pleasing
effects they have on our appearance,

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but because of the extraordinary
quality control in producing exactly

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the same potency with different
lots of medication despite the

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very tiny amounts of material
contained in each vial.

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That's a triumph of quality
control and manufacturing by the

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pharmaceutical companies that
produce these medications.

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And yes, we've talked about
these attributes before,

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but it's always good to review to
have it as part of this discussion.

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Second, Botox is not good or bad.

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There's good injectors and bad injectors,

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and there's a really broad
range of background training
and experience in those

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individuals injecting Botox today.

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The mindset of the injectors
and the patients also varies,

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and we're coming to a discussion
of that particular issue.

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But basically, if someone
looks bad after Botox,

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unnatural or obvious,

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the injector is likely to
blame and not the medication.

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When a patient comes in my
office and they say, well,

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I don't want Botox because I got it
once and I didn't like the effect,

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or I got this filler and
I didn't like the effect,

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my first question is
always who injected you?

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Because if it was someone who I know
is experienced and a talented injector,

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then suspicious why did
they have a problem with the

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material?

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But sometimes it's not an experienced
injector and we want to at

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least try again and see if it'll work out.

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There is an occasional patient who
reacts unpredictably to the medication,

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but this is by far the
exception and not the rule.

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And usually a good injector
can work out a pattern of

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injection locations and
dosing that will provide good

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control with a natural look.

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This is also the advantage of working
with a physician who knows you well and

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has been treating you over time.

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Each treatment adds a little bit
of learning about your individual

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dynamics to give you the best
custom effect rather than a

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cut read cookie cutter treatment.

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But what about dosing? Isn't that what
gives great control and durability?

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It is important to use an adequate
dose. That is an important issue.

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Low dose frequent treatments
are not recommended.

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They may seem a little less
expensive each go round,

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but overall it's really less efficient
with your time and your money,

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it's more tissue trauma and
the control tends to be less.

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And also there's a biological concern
about the possibility of becoming

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sensitized to the medicine. This is rare,

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but it certainly increases if you
do many low dose treatments every

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month or two.

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So you're saying, if I get enough
medicine, I'll be completely frozen.

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So again, this is one of my
big manifesto points. No,

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we don't want you to be frozen.

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The goal is to smooth
wrinkles. Position the brow,

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not to eliminate the ability
to move muscles completely,

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because when we're youthful, we're smooth.

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Our brow is in a good
position, but we can make,

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so creating a mask like
appearance is not the endpoint.

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The endpoint is not no
muscle activity whatsoever,

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and so many people have
become preoccupied with this.

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The medicine works by blocking release
of acetylcholine vesicles that spread

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across the synapse to the
muscles causing them to fire.

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So this effect is very specific to where
the medication is placed and how much

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is used. So to eliminate wrinkles
to the greatest extent possible.

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At rest,

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we're just trying to reduce the
resting tension in the muscle,

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reduce the force with which the
muscle contracts when we make an

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expression and we'll
succeed in improving dynamic

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wrinkles, the ones that are
the result of muscle motion,

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but it's not going to help us
very much for fixed wrinkles that

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are ironed into the fabric of
the skin from years of muscle

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tension and sun damage.

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Fixed wrinkles require peels,

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energy treatments or sometimes
some of the newer superficial

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fillers. So again, to go back,

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we want to minimize
wrinkles during animation,

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minimizing wrinkles with
average expressions.

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If we look at young
people even they make some

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wrinkles when they make
an extreme expression.

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So it's not that we absolutely
can't have any wrinkles,

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even when we make the biggest smile or
the most forceful expression we can come

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up with. And as I said,

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I see so many people who become
preoccupied or one could even say

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obsessed with having no motion,

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and that's really not a natural look,

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and it's not a goal of what
we're trying to do with Botox.

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That all makes sense to me. What else?

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There are certain areas
we can boost in a touch up

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if there's still muscle activity.

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So even though I said we
don't need to be frozen,

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there are some areas like
the frown or muscles or

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eyebrow depressor muscles
that pull the brow down.

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There's no functional or adverse
aesthetic consequence for

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those muscles being totally asleep.

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So if there's still a line
where there's still too much

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motion, we can increase the dose by
adding a little medicine and a touch-up.

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That's not true of every area
we treat with Botox. However,

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there are other areas that are
by definition a balancing act,

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so fully awake,

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they'd show wrinkles and fully asleep,

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we would have an aesthetic
or a functional problem.

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So we have to compromise
when we treat those areas.

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And these are areas that
get treated every day,

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including areas that are part of
the primary FDA approval for these

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medications.

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And we have to compromise
to minimize the lines,

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maximize brow elevation while
preserving function and an

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awake look. So in treating those areas,

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a hundred percent of the
treatments are compromised. Dosing.

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There's no absolute of
going all the way to a

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sleep because that's
going to be a problem.

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All the treatments around
the mouth are like that.

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We have to take the effect we can get
without interfering with the ability to

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speak, eat, drink,

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seal our lips because we'll look
unnatural and we'll start to

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have really impactful
functional problems if we

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overdose those areas.

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This is what requires so much skill
to do these injections well and

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why an experienced injector with a
detailed knowledge of facial anatomy is

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really important.

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Where the muscles are
on you as an individual,

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to locate exactly where to
inject and looking and assessing

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exactly how your muscular dynamics work

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is really important.

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Something that whomever does the
treatment really needs to be involved

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with and have a lot of
experience and insight.

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Remember Botox injections
are medical care,

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medical knowledge helps make
the treatment safe, precise,

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and predictable.

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Can you give us some examples of
different areas that can be treated with

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neuromodulators?

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So there are many, many areas that
we treat for aesthetic reasons,

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and some of these are
for wrinkle reduction.

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Some of these are to
reduce contour depression.

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Some of these are to
take contour fullness and

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shrink it to an extent.

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And some of these uses
are FDA approved uses.

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Some are off-label uses, but widely
practiced on a routine basis.

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So forehead areas,

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the frown or 11 lines,

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transverse lines across the top
of the nose are commonly treated.

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Forehead lines across
the top of the forehead,

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bunny lines or little wrinkle
lines at the side of the nose,

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crow's feet that are dynamic because
there's also fixed wrinkles there.

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We sometimes reduce lipstick bleed
lines a little bit with Botox, again,

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has to be carefully done and always
a compromise treatment and doesn't

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help us too much with fixed lines,

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but very good for moderating
but not eliminating

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dynamic lines.

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The depressor angularis
muscle is injected,

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which will soften the marionette line area

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and cobblestone or pulling
in and dimpling of the

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skin in the chin is often treated as well.

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The masseter muscle is a
strong muscle on the side

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of the jaw in the back, and for
people with very wide faces,

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they can get some contour slimming and
some people also treat there if they have

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TMJ problems.

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Neck banding is another area.

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Treating the platysmal bands in the
center of the neck under the chin can be

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very helpful in people where
it's the muscle tension

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and not the skin laxity
that's creating visibility

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to that area.

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So those are some examples
and not a definitive list,

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but just some of the common
areas that are routinely treated.

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We've talked about dosing. What
about which neuromodulator to select?

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I mentioned FDA approvals before.

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There are a few differences in what
approvals each of the neuromodulators

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has, but there's a lot of off-label use.

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All of the neuromodulators currently in
the United States are botulinum toxin

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A materials,

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so they all to a degree

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work in the same fashion. They
certainly all target the same receptor.

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My advice in this regard is basically
if you're happy with what you are

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getting with your existing neuromodulator,

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stick with that medication
and stick with that injector.

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If you're not happy and
you were hoping for more,

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you can experiment and try with
a different neuromodulator.

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Always best to use ones your injectors
familiar and experienced with,

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but experienced injectors usually
work with most or all of them.

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And if you like the new medication,
it's doing a better job for you,

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that's great. You have a
new neuromodulator. If not,

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you can always switch back
at the next treatment.

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Since it's a recurrent treatment,

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you're not stuck with your new choice,

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but don't switch right before a
big event because if the medication

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behaves a little differently in an
unpredictable way you don't like,

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you have to wait that out.

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And so experimenting is not a great
idea two weeks before a wedding,

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if you're still not getting what
you want out of your neuromodulator,

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talk to your doctor about refining
the dosing and locations of the

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injections.

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An experienced provider will tell
you whether you're asking for

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something realistic or if you're
stuck in one of those compromised

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circumstances

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where you can get improvement
but not total improvement.

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Or if you're asking the neuromodulator
to do something for which it's not

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really a good solution.

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So use your experienced
physician plastic surgeon

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dermatologist to advise
you about what you can

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reasonably expect out of the
neuromodulator and how you might be able

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to optimize the treatment.

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The other thing is a lot of people will
look at study data about the effect of a

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given medication, about
durability of a filler,

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and the study data is objective.

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It's extremely useful to FDA in deciding
whether something should be on the

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market and to physicians in
understanding how products work.

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But the studies are done in
a very controlled manner with

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a very monolithic way of doing the
treatment and summarizing that effect in a

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large number of people,

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it rarely resembles the results
we obtain in actual clinical

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practice where the technique is varied
based on the needs of the patient and the

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judgment of the physician.

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Over the course of this whole episode,

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you've essentially laid out
your manifesto. Now, Dr. Bass,

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can you take a shot at summarizing
for our listeners please?

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Absolutely.

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So bad injectors not bad Botox,

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you should be able to look
perfectly natural with a well

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performed Botox treatment.

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Your goal is to be smooth but not frozen.

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An experienced injector
who knows you well,

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and will take the time to
customize your treatment

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and will learn from each experience.

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Treating you is a very important
component in getting the

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most out of doing these Botox treatments.

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It's good to dose adequately for the
best control and the best interval

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between treatments rather than
doing low dose treatments.

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And remember to be realistic
about the trade-offs.

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We all wish there was the free lunch,

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but we have this trade-off between how
much brow elevation, how much smoothing.

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Sometimes you can shade it in one
direction or the other, take your choice,

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but there's no way to have it all,

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so recognize there's
some compromise there.

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If the grass looks greener with
another neuromodulator, try it.

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There's not a lot of downside.

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You can stick with the old one
or the new one next time around,

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depending on how you
felt about the results.

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Thank you, Dr. Bass for sharing
opinions and viewpoints on Botox.

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You certainly converted me to
a believer in your manifesto.

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Thank you for listening to the Park
Avenue Plastic Surgery Class podcast.

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Follow us on Apple Podcasts,

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write a review and share
the show with your friends.

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00:18:03,870 --> 00:18:06,960
Be sure to join us next time to avoid
missing all the great content that's

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coming your way. If you want to
contact us with comments or questions,

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we'd love to hear from you.

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Send us an email at podcast@drbass.net
or DM us on Instagram

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@drbassnyc.