Botox Manifesto

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is the Botox Manifesto. You've intrigued me again. What do you mean by this title, Dr. Bass?

Dr. Lawrence Bass (00:29):
A manifesto is defined as a written summary of the views of its issuer. This will be a verbal rather than a written manifesto.

Doreen Wu (00:40):
What stimulated you to prepare this summary or manifesto?

Dr. Lawrence Bass (00:44):
I do a lot of all kinds of facial rejuvenation treatments. The nonsurgical injectable treatments like Botox and fillers are recurrent treatments, so these take place multiple times every day in my office. Botox is hands down the most popular treatment and has an extremely high level of satisfaction compared to any other aesthetic treatment out there. Still doing these treatments. There are some patterns of good use and bad use, real understanding and insight by patients and by providers and other examples where there's kind of a lack of understanding that emerges patterns that are repeated over and over. So I have the luxury on this podcast of stating my opinion in the matter, not that my opinion is necessarily the truth, but their beliefs that I have about how Botox is best used, that I personally wish more people understood.

Doreen Wu (01:50):
Let's get started. Go ahead and lay out your thoughts.

Dr. Lawrence Bass (01:54):
First, I said Botox, but I'm really speaking about all neuromodulators. Neuromodulator is the term I prefer to all the others to name this class of medications. Currently in the United States, they include Botox, Dysport, Xeomin, Jeuveau, and most recently Daxxify. These are extraordinary medications, not just for the extremely pleasing effects they have on our appearance, but because of the extraordinary quality control in producing exactly the same potency with different lots of medication despite the very tiny amounts of material contained in each vial. That's a triumph of quality control and manufacturing by the pharmaceutical companies that produce these medications.

Doreen Wu (02:49):
And yes, we've talked about these attributes before, but it's always good to review to have it as part of this discussion.

Dr. Lawrence Bass (02:55):
Second, Botox is not good or bad. There's good injectors and bad injectors, and there's a really broad range of background training and experience in those individuals injecting Botox today. The mindset of the injectors and the patients also varies, and we're coming to a discussion of that particular issue. But basically, if someone looks bad after Botox, unnatural or obvious, the injector is likely to blame and not the medication. When a patient comes in my office and they say, well, I don't want Botox because I got it once and I didn't like the effect, or I got this filler and I didn't like the effect, my first question is always who injected you? Because if it was someone who I know is experienced and a talented injector, then suspicious why did they have a problem with the material? But sometimes it's not an experienced injector and we want to at least try again and see if it'll work out. There is an occasional patient who reacts unpredictably to the medication, but this is by far the exception and not the rule. And usually a good injector can work out a pattern of injection locations and dosing that will provide good control with a natural look. This is also the advantage of working with a physician who knows you well and has been treating you over time. Each treatment adds a little bit of learning about your individual dynamics to give you the best custom effect rather than a cut read cookie cutter treatment.

Doreen Wu (04:45):
But what about dosing? Isn't that what gives great control and durability?

Dr. Lawrence Bass (04:51):
It is important to use an adequate dose. That is an important issue. Low dose frequent treatments are not recommended. They may seem a little less expensive each go round, but overall it's really less efficient with your time and your money, it's more tissue trauma and the control tends to be less. And also there's a biological concern about the possibility of becoming sensitized to the medicine. This is rare, but it certainly increases if you do many low dose treatments every month or two.

Doreen Wu (05:28):
So you're saying, if I get enough medicine, I'll be completely frozen.

Dr. Lawrence Bass (05:33):
So again, this is one of my big manifesto points. No, we don't want you to be frozen. The goal is to smooth wrinkles. Position the brow, not to eliminate the ability to move muscles completely, because when we're youthful, we're smooth. Our brow is in a good position, but we can make, so creating a mask like appearance is not the endpoint. The endpoint is not no muscle activity whatsoever, and so many people have become preoccupied with this. The medicine works by blocking release of acetylcholine vesicles that spread across the synapse to the muscles causing them to fire. So this effect is very specific to where the medication is placed and how much is used. So to eliminate wrinkles to the greatest extent possible. At rest, we're just trying to reduce the resting tension in the muscle, reduce the force with which the muscle contracts when we make an expression and we'll succeed in improving dynamic wrinkles, the ones that are the result of muscle motion, but it's not going to help us very much for fixed wrinkles that are ironed into the fabric of the skin from years of muscle tension and sun damage.

(07:01):
Fixed wrinkles require peels, energy treatments or sometimes some of the newer superficial fillers. So again, to go back, we want to minimize wrinkles during animation, minimizing wrinkles with average expressions. If we look at young people even they make some wrinkles when they make an extreme expression. So it's not that we absolutely can't have any wrinkles, even when we make the biggest smile or the most forceful expression we can come up with. And as I said, I see so many people who become preoccupied or one could even say obsessed with having no motion, and that's really not a natural look, and it's not a goal of what we're trying to do with Botox.

Doreen Wu (07:55):
That all makes sense to me. What else?

Dr. Lawrence Bass (07:58):
There are certain areas we can boost in a touch up if there's still muscle activity. So even though I said we don't need to be frozen, there are some areas like the frown or muscles or eyebrow depressor muscles that pull the brow down. There's no functional or adverse aesthetic consequence for those muscles being totally asleep. So if there's still a line where there's still too much motion, we can increase the dose by adding a little medicine and a touch-up. That's not true of every area we treat with Botox. However, there are other areas that are by definition a balancing act, so fully awake, they'd show wrinkles and fully asleep, we would have an aesthetic or a functional problem. So we have to compromise when we treat those areas. And these are areas that get treated every day, including areas that are part of the primary FDA approval for these medications.

(09:08):
And we have to compromise to minimize the lines, maximize brow elevation while preserving function and an awake look. So in treating those areas, a hundred percent of the treatments are compromised. Dosing. There's no absolute of going all the way to a sleep because that's going to be a problem. All the treatments around the mouth are like that. We have to take the effect we can get without interfering with the ability to speak, eat, drink, seal our lips because we'll look unnatural and we'll start to have really impactful functional problems if we overdose those areas. This is what requires so much skill to do these injections well and why an experienced injector with a detailed knowledge of facial anatomy is really important. Where the muscles are on you as an individual, to locate exactly where to inject and looking and assessing exactly how your muscular dynamics work is really important. Something that whomever does the treatment really needs to be involved with and have a lot of experience and insight. Remember Botox injections are medical care, medical knowledge helps make the treatment safe, precise, and predictable.

Doreen Wu (10:40):
Can you give us some examples of different areas that can be treated with neuromodulators?

Dr. Lawrence Bass (10:46):
So there are many, many areas that we treat for aesthetic reasons, and some of these are for wrinkle reduction. Some of these are to reduce contour depression. Some of these are to take contour fullness and shrink it to an extent. And some of these uses are FDA approved uses. Some are off-label uses, but widely practiced on a routine basis. So forehead areas, the frown or 11 lines, transverse lines across the top of the nose are commonly treated. Forehead lines across the top of the forehead, bunny lines or little wrinkle lines at the side of the nose, crow's feet that are dynamic because there's also fixed wrinkles there. We sometimes reduce lipstick bleed lines a little bit with Botox, again, has to be carefully done and always a compromise treatment and doesn't help us too much with fixed lines, but very good for moderating but not eliminating dynamic lines. The depressor angularis muscle is injected, which will soften the marionette line area and cobblestone or pulling in and dimpling of the skin in the chin is often treated as well. The masseter muscle is a strong muscle on the side of the jaw in the back, and for people with very wide faces, they can get some contour slimming and some people also treat there if they have TMJ problems.

(12:27):
Neck banding is another area. Treating the platysmal bands in the center of the neck under the chin can be very helpful in people where it's the muscle tension and not the skin laxity that's creating visibility to that area. So those are some examples and not a definitive list, but just some of the common areas that are routinely treated.

Doreen Wu (12:55):
We've talked about dosing. What about which neuromodulator to select?

Dr. Lawrence Bass (13:02):
I mentioned FDA approvals before. There are a few differences in what approvals each of the neuromodulators has, but there's a lot of off-label use. All of the neuromodulators currently in the United States are botulinum toxin A materials, so they all to a degree work in the same fashion. They certainly all target the same receptor. My advice in this regard is basically if you're happy with what you are getting with your existing neuromodulator, stick with that medication and stick with that injector. If you're not happy and you were hoping for more, you can experiment and try with a different neuromodulator.

(13:52):
Always best to use ones your injectors familiar and experienced with, but experienced injectors usually work with most or all of them. And if you like the new medication, it's doing a better job for you, that's great. You have a new neuromodulator. If not, you can always switch back at the next treatment. Since it's a recurrent treatment, you're not stuck with your new choice, but don't switch right before a big event because if the medication behaves a little differently in an unpredictable way you don't like, you have to wait that out. And so experimenting is not a great idea two weeks before a wedding, if you're still not getting what you want out of your neuromodulator, talk to your doctor about refining the dosing and locations of the injections. An experienced provider will tell you whether you're asking for something realistic or if you're stuck in one of those compromised circumstances where you can get improvement but not total improvement.

(15:01):
Or if you're asking the neuromodulator to do something for which it's not really a good solution. So use your experienced physician plastic surgeon dermatologist to advise you about what you can reasonably expect out of the neuromodulator and how you might be able to optimize the treatment. The other thing is a lot of people will look at study data about the effect of a given medication, about durability of a filler, and the study data is objective. It's extremely useful to FDA in deciding whether something should be on the market and to physicians in understanding how products work. But the studies are done in a very controlled manner with a very monolithic way of doing the treatment and summarizing that effect in a large number of people, it rarely resembles the results we obtain in actual clinical practice where the technique is varied based on the needs of the patient and the judgment of the physician.

Doreen Wu (16:12):
Over the course of this whole episode, you've essentially laid out your manifesto. Now, Dr. Bass, can you take a shot at summarizing for our listeners please?

Dr. Lawrence Bass (16:21):
Absolutely. So bad injectors not bad Botox, you should be able to look perfectly natural with a well performed Botox treatment. Your goal is to be smooth but not frozen. An experienced injector who knows you well, and will take the time to customize your treatment and will learn from each experience. Treating you is a very important component in getting the most out of doing these Botox treatments. It's good to dose adequately for the best control and the best interval between treatments rather than doing low dose treatments. And remember to be realistic about the trade-offs. We all wish there was the free lunch, but we have this trade-off between how much brow elevation, how much smoothing. Sometimes you can shade it in one direction or the other, take your choice, but there's no way to have it all, so recognize there's some compromise there. If the grass looks greener with another neuromodulator, try it. There's not a lot of downside. You can stick with the old one or the new one next time around, depending on how you felt about the results.

Doreen Wu (17:47):
Thank you, Dr. Bass for sharing opinions and viewpoints on Botox. You certainly converted me to a believer in your manifesto. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.