Your Questions
Your Questions
Q: Dr. Eppley, I saw that you mentioned that Botox injections to the posterior temporal area is a possible alternative to surgical resection. I am personally quite interested in this approach, as I’d like to avoid surgery if possible. A few questions:
1. Would the effect after a few sessions be permanent? You mentioned that the posterior temporal area is not used much in chewing, so would this mean that the shrinking of the muscle would stay?
2. Would there be any risk of the Botox ‘spreading’ to the anterior temporal area and causing a hollowing effect?
3. How much temporal width reduction can be achieved with Botox compared to surgery?
Thanks for your time.
A: Like all masticatory muscles, Botox injections can be done to induce muscle atrophy. How permanent the effect size reduction would be is unpredictable. The posterior temporal muscle is much thinner than the anterior temporal muscle but whether the effects of Botox injections is more profound or more permanent is unknown. Botox injections do not migrate more than that of a 1 cm diameter from the point of injection. Compared to surgery, Botox injections at best would produce only about half the the thinning effect of total muscle removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have this terrible vertical line in the middle of my forehead and I really want it gone. Can you help me?
A: Vertical wrinkles in the forehead are a result of overactivity of the corrugator supercilii muscles. These are small muscles that run obliquely from the inner aspect of the eyebrow under the more superficial frontalis muscle and pass inward towards the central area between the eyebrows to insert to the underside of the skin. When these muscle contract they pull the inner half of the eyebrow inward. With both sides pulling inward together this creates the vertical lines between the eyebrows that many people have. This is why the name corrugator supercilii, which comes from Latin, means the ‘wrinkler of the eyebrows’.
The corrugator muscles are known as the frowning muscles and they produce a variety of vertical line patterns between the eyebrows. The most common are a pair of vertical lines, known as the 11s, and is the basis for the use of Botox injections to reduce their prominence. In some people a single deep vertical line appears, just like the one you have. They are often very deep and are the hardest of all vertical forehead lines to treat.
This is definitely not scleroderma which appears more liken shallow groove and does not appear in the midline. This is a deep expressive wrinkle (deep vertical line) which shows deep inversion. I would not think some much of fixing it as it is not that simple…but treating it to make it less noticeable. This is caused by excessive muscle action but not has become a deep etched vertical line which will not be resolved by simply weakening the muscle. (e.g., Botox injections) The hardest part of its treatment is to get the deep indentation back up and level with the surrounding skin. The simplest and most effective approach, but the least appealing, is to cut out the indentation and put it back together in a geometric closure pattern. (small running w-plasty like forehead scar revision) There is no more effective long-term skin leveling strategy than this approach but it is like trading one scar pattern (indented and vertical) for another pattern. (smooth and small irregular line) One could certainly argue that this is probably a much better ‘scar pattern’ than what you have now. The alternative non-excisional treatment would be to place something under the indented scar such as fat injections, a small dermal-fat graft or temporalis fascia. This would create less of an indentation that would not be quite as deep.
As you can see, the ‘fixing it’ strategy is not what can be achieved. It can only be improved and it is just a question of how one feels about either the options of a smoother fine line scar or simply less of a vertical indentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The onset of my Bell’s Palsy right side paralysis was four years ago. My case was severe, and it took many months to see small changes/progress. I have developed Synkenesis, which has caused pain and dimpling of my chin, pain and stiffness in my neck, especially the tendons on the affected side, and have been experiencing a general ache and or soreness, especially during these winter months, on many places on my face. I have not sought out treatment of these symptoms, until just now. I was chewing my food recently and the muscles in my neck involved in swallowing contracted repeatedly, thus, delaying my ability to swallow momentarily. It was quite frightening that this may actually cause me to choke if I don’t seek treatment. I am interested in Botox and,if possible, facial re-training as a treatment for my Synkenesis. Any advice or referral recommendations would be greatly appreciated. Thank you so much for taking the time to hear my case.
A: As you know, synkinesis is a common sequelae when the facial nerve fibers regenerate and start working again after any cause of paralysis. Synkinesis is the inability to coordinate various muscles on that affected side of the face. Unusual combinations of facial movements occur that were never present before the paralysis and have no functional reason for their occurrence.of half of the face. It results in a wide range of both functional and aesthetic changes. Common changes include narrowing of the eye during smiling, smile asymmetry, dimpling of the chin, asymmetry of the forehead an pulling sensations in the neck
Botox for facial synkinesis is an established treatment with proven effectiveness. But its role is most commonly done in the superficial face and platysmal neck muscles that are innervated by the seventh cranial nerve. I have treated such patients from facial nerve issues such as hemifacial spasm and at various period of recovery from facial nerve paralysis. The swallowing muscles are not, however, innervated by the seventh cranial nerves but by other motor nerves and I have no experience in treating those pharyngeal muscles by injection therapy. I am also uncertain that the swallowing sensations you have experienced are caused by muscles not innervated by the facial nerve.
Botox injections are used for two distinct effects…to either dampen down an overactive or spastic muscle or to weaken a normal acting one to help balance out certain facial expressions. It can be used to open a narrowed eye, soften the smile, and relieve the pulling sensation in the neck. It requires a careful assessment of the facial movements to determine the proper injection points so as to not cause additional facial asymmetry problems. This is of paramount importance around the eye area and injecting the orbicularis muscle.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What I most dislike about my face at this time are the bags/creases under my eyes that make me look tired and old. There are also some fairly “deep” lines in my forehead. I am turning 35 next month, so I don’t think I want any type of surgery yet. I am interested to find out what types of options there are for me and what it might cost. Likely, I would do this in the spring time over school break. Thanks!
A: The earliest signs of facial aging always with exactly what you are seeing. Wrinkle lines on the forehead and/or around the eyes and the development of bags (herniated fat ) on the lower eyelids. Botox injections work well for forehead wrinkle lines. Lower eyelid bags are really best treated by removal. (transconjunctival blepharoplasty) But to those adverse to surgery, injectable fillers can be used to fill in the tear troughs created by the bags. Such injection treatments in my experience are a mixed ‘bag’ since they have a not rare problem of lumps and unevenness due to the thin skin of the eyelids. When they work well they are great but when irregularities develop the filler often has to be dissolved away by hyaluronidase injections.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had jaw surgery two times and now have lip damage. Bottom lip seems paralyzed or damaged. (lower lip asymmetry) I saw online and seems others have had the same problem. I have seen it may be hyperplasia of depressor orbis lip muscle or paralysis of lower lip nerve. I don’t know what it is. Do you think it is nerve damage or muscle damage? Is it likely to be permanent damage after jaw surgery or temporary? I has been one year now and still no change. It is less obvious when relaxed but when make ‘O’ shape with lips or kiss shape with lips or smile it pulls down to one side on my right. The left side doesn’t pull down. I did think it was the right side which shows lower teeth when smile which is the problem side but actually I think after research it is the left side which doesn’t show any teeth when smile which is the problem side. I have seen certain solutions are to use Botox but are there any other options? I want something permanent. Can a surgeon correct it with more invasive surgery? Can they maybe correct the problem side or maybe damage the other side so both don’t show lower teeth when smile because personally I think that looks better to only show upper teeth. I really need your help doctor. Please help thanks.
A: What you have is paralysis of the left marginal mandibular branch of the facial nerve. This tiny nerve branch supplies movement to the depressor muscle of the lower lip. With the nerve being paralyzed that side of the lip does not move down normally while the opposite right side does. With no lower lip movement on the left, the normal righth lower lip retraction looks exaggerated and overly pulled down. This lower lip appearance can make one think the side of the lip that moves is the problem when in fact the th higher lower lip side is the culprit of the lower lip asymmetry.
At one year from the injury with no movement, there is no reason for optimism that the paralyzed nerve will start working again. I wouldn’t say it is impossible but very unlikely. There is no method to make the nerve work again other than natural healing. Thus the treatment for lower lip asymmetry from permanent marginal mandibular nerve paralysis is to weaken the opposite side whose muscular movements are exaggerated. This can be done by Botox injections (temporary) or by partial resection of the depressor muscle from an intraoral approach. (permanent)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I received Botox injections for migraine headaches once and they did not give me relief, If the injections did not give me relief…then would migraine surgery not give me relief as well?
A: Botox is usually used as an indicator of success for the actual migraine surgery. When the Botox test is positive, there usually is a near 100% success with surgery. But when the Botox test is not positive, I have seen a few patients still have success with surgery. The other questions is how and where were the Botox injections done. I have seen quite a few patients who have had Botox for migraines where the injections were not done properly. As a result they had a negative test when, in fact, it might have been a positive test result if the injections were properly placed near the nerves.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have facial tics from Tourette’s syndrome. The facial signs that I have are that I blink frequently and occasionally will wrinkle my nose. I have researched Botox for facial tics and would like to know what you’re experience is with this. I can get past the social awkwardness the tics cause at times, but there are flare ups and I would like to stop them. I do not like the long term side effects of medication so I’m looking at this option.
A: Botox can be effective for facial tics as facial tics come from the muscles of facial expression. However, Botox injections for facial tics are done somewhat differently than when it is used to treated overactive muscles from undesired facial expressions and the wrinkles and folds that result.
The location of the facial tics must be precisely located and a superb understanding of the facial musculature is needed. However, many patients with facial tics can not always reproduce them in the office and a description alone is not sufficient for accurate muscular placement. What I like patients to do is to take pictures, or even better a video, of their facial tics in action and bring it into the office. That is the best way to see where the injections should be placed.
Unlike cosmetic use of Botox, injecting for facial tics is a fine balance in getting just the right amount of Botox to control the tic but not causing too much surrounding facial weakness. There is always a trial and error period to find the exact injection location and the right number of units (dose) for the facial tic problem. It is always best to start conservatively with a few injection locations and a small number of units in the first treatment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 37 yrs old and I have some wrinkles under and around my eyes I would like to get rid of and not sure if I should just do Botox or try and have surgery to remove them. I have attached some pictures for your review.
A: There are basically three treatments for aging eye issues, Botox, blepharoplasty surgery and skin resurfacing. (chemical peels vs. lasers) Botox is the only treatment for wrinkles that occur OUTSIDE of the eyelid area. (e.g. crow’s feet area) Blepharoplasty (eyelid) surgery is the only treatment that can remove excess skin and fat of or ON the eyelids. Skin resurfacing using either chemical peels or fractional laser resurfacing can be used for fine wrinkles ON and OUTSIDE of the eyelids. Given the nature of aging around the eyes, many people need a combination of these approaches to get the best result…not to mention the need for maintenance therapies such as Botox injections, topical skin creams and the avoidance of smoking and extreme sun exposure.
What I see in your pictures is hooding of upper eyelid skin and a roll of skin underneath the lashline of the lower eyelid. These are definitely surgical (blepharoplasty) issues. I suspect there is wrinkling beyond these areas but the quality of the pictures does not permit that assessment. These pictures are also only smiling which creates animated rolls of skin on the lower eyelid which may or may not be present when not smiling.
The short story is that you are likely in need of surgery for major improvement but I would not use the term ‘remove’ when it comes to eyelid aging changes as that is not realistic. You need to think improvement of them that is not going to be a permanent cure to them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had TMJ problems for years and have had just about everything under the sun to treat the condition with no success. I read Botox might be a solution to the symptoms. What type of success have you had in this area and should I come in for consult?
A: When it comes to the term ‘TMJ’, that is a highly variable and diverse term. I would need to know specifically what are your exact symptoms. Botox may be able to help with certain masticatory problems that are primarily muscular in origin. But true intracapsular joint issues require other treatments than muscle modulation.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I was treated by a “#1 Migraine Specialist” in my state. I had been seeing this Dr. for 1 yr. and 4 months before he suggested Botox and I finally did the treatment because my insurance paid for it! YAY! I finally did the treatment in November 2012 and it was so painful! There was no spot left untouched. It helped the headache I had then so I was sure it was going to prevent the future ones! And low and behold just days later I get a Migraine and been having them as usual! I never had migraines until I had my stroke on May 10, 2010. When I get them they stay until i have to go to the emergency room for relief. Ten dr.’s later and I still have no relief. I have taken over 50 different types of meds and STILL NO RELIEF! I am so disappointed! I cannot live like this anymore! What can I do???
A: I am so sorry to hear about your terrible migraine history and current condition. Just based on your description I comment on your Botox experience. First, it should not have been that painful. When skillfully done wirth a small 30 gauge needle, it is at best of minimal discomfort. Secondly, when Botox is used for migraines it is not done ‘all over the head’. It needs to be placed specifically into known trigger point areas of which there are three very specific locations. This does not sound like what was done. Whether you have the type of migraine headaches that may be improved by Botox is unknown…as of yet. I would suggest that you have the Botox injections repeated at the identified trigger points based on your headache pattern. This will the tell you if you may be a good candidate for surgical decompression which is what, as a plastic surgeon, I can offer for your potential migraine headache relief.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Specifically I have had a problem with “marionette lines” since my early thirties, I am now 41. I had Juvaderm twice about five years ago and I had Restylane this past October. I definitely prefer the Juvaderm and I was going to do that again. Maybe with some Botox as well because I also have smokers lines around my lips. I am not a smoker but I have a habit of constantly chewing on the sides of my mouth and that, along with genetics, appears to be a big contributor. I have not actually tried any Botox yet but research indicates the two treatments together could get me a nice result.
The reason I am inquiring about the Thermage is because my face is aging just like my mother’s, she had Thermage done in 2009 and had a great result. She has not had any follow up treatments and her face is looking very saggy again but I do think if she had kept up treatments she would be looking pretty good right now.
I am wanting to know which treatments would give the best long term results. The Thermage appeals to me more than injecting things into my face and it appears that it is something I could maybe do around once a year, where as the injections would need to be done more often. I am not opposed to injections and pain is not a factor. It is more about what is being injected into my face.
I currently get microdermabrasion every two weeks and I use vitamin C and lots of sunscreen because I am very pale.
I have been doing research on line for years about procedures. Now that I have some background information on what seems like a million options, I need to know what would work best for me and still be in my comfort zone. I have a big fear of looking plastic and unnatural, but now my fear of looking older than I really am is becoming bigger.
A: Thank for clarifying your problems. While the options for your concerns may seem endless, they really are not. The reason it seems there are so many is that none of the non-surgical approaches have any lasting effect and the differences in the results many of them produce are negligible. Hence, many things exists when none of them really work that well…at least compared to surgery.
For marionette lines, injectable fillers are the only real effective non-surgical option as you already know. Botox is not going to help the marionette lines because that it is not a muscular/animation problem. Botox can be effective for helping reduce some vertical lines in the lips and may help turn up the corners of the mouth a bit but it is a deanimator not a filler.
The use of Thermage is for the treatment of jowls and for some mild facial skin tightening. While once state-of-the-art in its day, it has largely been surpassed by many other ‘tissue heating’ technologies such as Ulthera or Exilis. They all work the same even though the energies that cause their effects are different. (ultrasound vs radiofrequency) While they do some good facial effects for some patients, they don’t really make new collagen that is sustainable and thus their effects are short-term. It takes a lot of maintenance treatments to keep their effects and that can quickly surpass the effects of surgery which is much longer-lasting. Face and neck treatments like Exilis when combined with overlay treatments of light fractional laser resurfacing skin treatments is a very fine combination that for the right patient can produce some really good effects.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am sending you some pictures of my lower eyes so please let me know what you think. I have bags and many wrinkles under my eyes even though I am only 29 years old! It’s so much worse when I smile because the wrinkles show much more!! I’m really excited to do something about it but scared of surgery!!
A: Thank you for sending your pictures. What I see is not really much infraorbital fat herniation. Rather I see some infraorbital rim hollowing and a lot of skin wrinkles when you smile. The infraorbital hollowing could be treated by fat injections and perhaps a little lower eyelid skin removal. But many of those lower eyelid wrinkles are impossible to treat surgically because they mainly appear when you smile, thus they are dynamic wrinkles. Much of your lower eyelid wrinkling needs to be treated by Botox injections to stop the muscle action.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Is there a permanent solution for treatment of the hyperactive mentalis muscle? It manifests in a very subtle way, just on the right lower part of my chin, and instead of repeating injections on a semi-regular basis, I’m much more interested in finding a permanent method of altering this very slight irregularity. Thank you for your time.
A: The use of Botox is the easiest and most effective method for treating a hyperactive mentalis muscle. While it is not permanent, a few units skillfully placed works very well. It is possible to do a partial transection of the mentalis muscle through an intraoral approach and this may provide a more permanent solution.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am curious to the cost of Botox in specific areas on my face. My biggest issue is my eyes as I am only 31 and am very attractive and often to I don’t look my age but I’m feeling as though I’m beginning to these days :-(. Also, am interested in the cost of breast augmentation. Thank you
A: Thank you for your inquiry. When it comes to Botox, the cost is completely related to the number of units delivered. Such units are usually very consistent for the area treated and so the cost can be well estimated. For between the eyes (glabella), which is the most popular area on the face for Botox injections that will take 20 units with a cost of around $300. For the crow’s feet area (beside the eyes) the number of units usually needed is 16 with a cost of around $225. When the two are done together, the total units can be reduced to 30 with a cost of around $425. For breast augmentation the cost is completely related to the type of implant used. Total surgical costs for saline breast implants is around $4700 while that of silicone implants is around $5800.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 42 year-old white female who has the beginnings of lip lines. I don’t smoke and have never tanned excessively. I have fairly pale skin. While my lips have never been really big they have never been thin either and have always had good shape. I have noticed over the past few years that I am getting several noticeable lines in my upper lip. My lipstick now is starting to bleed into the upper lip along these lines. My lips still have some shape but they are beginning to lose their shapes. What can I do to get rid of these lines and get some plumpness back to my lips?
A: Vertical lip lines or wrinkles are one of the peskiest facial aging problems. They are not easy to treat and they are relentless…always fighting to come back no matter what is done. Lips lines, like all wrinkles, appear because of underlying muscle action. The mouth is encircled by a ring of muscle known as the orbicularis oris. Anytime you pucker your lips or suck on a straw, this muscle is activated and contracts. Wrinkles appear on the overlying lip skin perpendicular to the direction of the muscle movement, thus the appearance of vertical lip lines. The thinner the lips one has (most common in Caucasian females), the more likely that lip lines will appear. Since it is impossible and impractical to completely stop moving your mouth (although not sucking on a cigarette or water bottle helps), treatments must be directed toward either inducing some muscle weakness (dilute Botox injections) and/or plumping up the lips by injectable fillers. In more advanced lip aging with a greater number and deeper lines, laser resurfacing or dermabrasion must be considered.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, you have done some Botox for me in the past. We discussed that I was one of the few people who didn't respond very well to the Botox. You said maybe because my forehead muscles are too strong or some other reason. Whatever the case may be, I would like to know what option I have to get rid of the deep “angry eyebrow” wrinkle. Is the only option to go under the knife?? Thanks.
A: To review your forehead/glabellar furrow issue, it is not that Botox didn't work. Botox always works but its mechanism of action (muscle weakening) was unlikely to correct what is now the main problem with your furrow, it is so deeply indented from years of muscle overactiivty that the skin is now permanently etched or grooved. This is beyond being ideally treated by muscle weakening (although it was worth seeing how much of a difference that could make) but now requires some form of skin management for improvement. For patients with these very deep grooves or furrows in which Botox fails to provide any significant improvement, the furrow can be treated by a variety of options. The simplest and most common is an injectable filler (e.g., Juvederm) to plump it out and soften its depth. This is often done either after Botox has 'failed' or in combination with it. (the filler lasts longer if it is not pounded on by the muscle movement that caused the problem in the first place) All current injectible fillers are temporary and do not create a permanent filling result. Another filler approach is to place a small tubed implant under the skin to create a permanent filler. The tubed implant, Permalip, is the same type of permanent implant that is used in the lips, nasolabial or labiomental folds. Another permanent option is to excise the furrow and treat it like a geometric scar revision. By cutting it out and putting the skin back together in an irregular fashion, the furrow is made smooth. All of these treatment options can be done in the office under local anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had upper and lower eyelid surgery and a muscle needed to be stitched in my eyebrow where a cut injury once existed. I have just had Botox for frown lines. The doctor (different doctor) hurt me when injecting into that muscle. Within a few hours my eyelid is heavy, dropped eyebrow and when I raise my cheek in a winking jesture the whole of my cheek quivers very badly. Will the effect of the Botox go away and the lid raise? Does this sound permanent? Has the muscle been damaged by the Botox as it was scared tissue and stitched in 2008 in order to raise the eyelid? I would be so comforted by your response as I need reassurance before i return to my doctor for correction.
A: The workings of Botox is based on two fundamental principles, it affects the neuromuscular junction of the muscle causing weakness or paralysis and its effects are TEMPORARY. The biggest advantage and disadvantage to Botox is that its effects are not permanent. Patients who get good results with its use wish it was permanent while few patients who develop an undesired aesthetic effect are happy that it is only temporary. In addition, Botox has no adverse effect on long-term muscle function regardless of whether it has had prior surgery on it or not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello, I am interested in non-surgical rhinoplasty as well as a small amount of Botox. What is the cost per unit of Botox and the approximate cost of non-surgical rhinoplasty for a dorsal hump. Thanks!
A: My assumption is that you are inquiring about 12 to 16 units of Botox for the glabellar area and about .3cc of Radiesse above a dorsal hump. (non-surgical rhinoplasty) You could expect to pay about $200 for the Botox and about $400 for the Radiesse injections. Expect that the Botox will last about four months and the Radiesse to last close to one year after injection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, do you offer Dysport injections? If so, what is the cost per unit? Do you think Dysport is better than Botox? And if so, why?
A: I do both Botox and Dysport injections for aesthetic facial wrinkle treatments. In my opinion, they are essentially equivalent and Dysport has no significant advantages over Botox. The cost per Dysport unit ($5.00/unit) may be substantially less than Botox but it also takes 2.5 units of Dysport to equal the effects of 1 unit of Botox. Thus one does not choose Dysport because it costs less which is a common misconception. The only real value of Dysport is if one has developed a ‘resistance’ to Botox, Dysport offers a very slight molecular structure variation that may make it more effective. In addition, because Dysport has a greater zone of diffusion it may be more effective in the crow’s feet area This is because the orbicularis oculi muscle is spread out and requires a broader zone of drug spread to get a maximal aesthetic effect.
Perhaps the greatest advantage of Dysport is that it offers competition to Botox which had been the sole provider of this aesthetic treatment for over a decade. (and that only includes the time when it become formally FDA-approved for wrinkles and not the decade before when it was used off-label) Unfortunately, competition for Botox has done little to affect its cost. This is probably because Dysport has just a small fraction of the aesthetic injectable wrinkle market in the U.S.. Dysport at this point can not even claim the analogy that it is Pepsi compared to Coke.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Is Xeomin used in masseter hypertrophy? If it is, is the amount of diluent used the same as Botox. Thanks.
A: Xeomin will work the same as Botox for masseter muscle hypertrophy. It is just as potent and has the same onset of action as a full week after the injections. Like Botox’s other competitor Dysport, the unit dosing may be somewhat different from Botox and an exact replicative dose is not well established. For a cosmetic effect in the frown lines, reports indicate that Xeomin has similar dosing to that of Botox on a 1:1 unit basis. Whether such a dosing method works the same in the masseter muscle is completely unknown. If I was a patient knowing what I know, I would not switch from Botox for massteric hypertrophy if it is working. It will take a lot more clinical experience to determine what dosing comparisons are between Xeomin and Botox. For now, there is no known advantageous reason to make that switch and there is the risk of less effectiveness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had Botox for the first time a year and a half ago for free. A local doctor was training a woman on it and he did one side and instructed her on the other side. It was just okay, one side felt heavier than the other and one eye brow was higher than the other.
Then an anesthesiologist friend offered to give me Botox injections as she does a small group of women from time to time and I wanted to try again. This was like eight months after my first try. Long story short, I had a furrowed left brow for a while which was not cool. Plus she diluted it big time which in hindsight was a blessing because of the furrowed brow. I was starting to think that there is definitely an “art” to this injection thing.
Then I was out of town visiting friends and a local doctor introduced me to Dysport. At the time I was totally feeling ugly and wanting to try anything to reduce the fine wrinkles in my forehead, just look fresh. Well he did a first rate job so I loved it! No heavy feeling in the forehead and it took almost immediately and looked great! I’m sold on Dysport for no other reason than it was my best experience to date. You will have to educate me on the cost vs Botox as I have no idea.
So here I am today, looking online for a reputable guy to help me out…I’m due for something, but will not go the route of using anybody but a professional ever again!
A: The apparent simplicity of facial injections does belie that there is actually some art to it. There is also an obvious benefit to knowing the underlying facial muscles and how their movement contributes to facial expression. It is slightly more sophisticated that just throwing darts at the side of the wall so to speak.
The actual differences between Botox and Dysport are very slight and there is no real evidence that one is more effective than another. Dysport may ‘kick in’ a day or two earlier than Botox but otherwise lasts and costs about the same as Botox. The differences you have had with two negative experiences with Botox and the favorable one with Dysport undoubtably reflects technique (injection location) and doses used. I have not seen any differences in my experience with either one. There is some evidence that Dysport may be slightly more effective than Dysport (because it spreads out better) but in the forehead there is no appreciable difference in effect.
All of that being said, you should continue with Dysport because you have had a good experience and there is no change what isn’t broken.
Dr. Barry Eppley
Indianapolis, Indiana
Aging is inevitable and it begins to appear first around the eyes. While eyelid and brow lifts provide immediate and significant improvements, many would prefer to lessen these eye flaws without the costs and recovery of an operation.
There are a variety of non-surgical eye treatments combining neurotoxins, fillers, lasers devices and topical products. Which ones are used often follows the age of the person. Those in their 30s and 40s usually just need Botox to control their frowning and squinting wrinkles. Fillers and light and laser treatments are added for those in their 40s and 50s. At age 50 and beyond, surgery is needed to remove extra upper eyelid skin and lower eyelid bags. But these non-surgical treatments are still needed to preserve one’s surgical investment.
Botox is the most known name when it comes to facial wrinkle reduction by injection. But it is not alone as two other injection drugs, Dysport and Xeomin, are also available. While there are some that believe one is better than the other, they all are really comparable. They all take a few days to a week to start working and their effects will last from three to four months. One is not more powerful than the other nor does one cost less. These injections are given by the unit and the cost per unit varies for each one but so does how they are prepared. As such their treatment costs are all about the same.
While Botox is the most common non-surgical eye treatments, injectable fillers can also play a role. Many people will develop shadowing and tear troughs under the lower eyelid, sometimes as early as the late 30s. This can be treated with fillers to plump the area out. While they are over a dozen types of injectable fillers, the hyaluronic acid-based fillers (e.g., Restylane and Juvederm) are preferred. They can be delivered under the thin tissues of the lower eyelids with a low risk of lumps and irregularities.
While eye wrinkles can be held in check with Botox and fillers, they can not reverse certain skin problems. Blood vessels and brown spots can be removed with pulsed light treatments. These are often confused with lasers which they are not. When it comes to improving skin texture and reducing fine lines and wrinkles, laser resurfacing can provide improvements beyond what an eyelid lift can do.
Topical skin care products complement eye the benefits of injectable and energy treatments. The skin around the eyes is so thin that it responds well to many Vitamin C, retinoid and antioxidant-containing products. A new topical product, Latisse, is great for thinning eyelashes and eyebrows and it works like nothing else. Eyelashes and eyebrows can become one-third longer and thicker in a few months.
While surgery may be needed or inevitable for some, younger and less tired looking eyes may be just a few injections or the wave of a laser wand away.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had Botox injected into my lips to help treat my lip lines. I was not pleased with the results at all. Besides not getting rid of any of the wrinkles it also gave me the unhappy effect of making my upper lip look funny (not in a good way) when I smile. I happened to have heard on my way out when paying my bill that this was the first time the doctor had ever injected Botox into a lip. I am upset that I paid for not only no result but that it may me look worse. On my own investigation I read on the internet that Botox is only approved for use in the forehead. I think I should get my money back and maybe even sue the doctor. What do you think?
A: Botox is used for a wide variety of aesthetic facial applications. It was initiallystudied and subsequently cleared by the FDA for glabellar (between the eyebrows) wrinkles and is known as an ‘on-label’ use. Despite this one approved cosmetic use in the face, it is a perfectly acceptable medical practice to use Botox for numerous other expression-reducing/wrinkle reduction indications. This is known as ‘off-label’ use and is commonly done with many drugs. It is neither wrong nor malpractice to do so. The use of Botox in the upper lip can be effective at wrinkle reduction but is technique and dose sensitive. Unfortunately for you, this effort did not turn out to produce the desired effect. The good news is that your Botox will wear off in a few months and you will return completely to normal. I would discuss your dissatisfaction with the treating doctor and see what accommodations they may be willing to do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking into working for the Medicis company and was wondering what you could tell me about their two aesthetic products, Restylane and Dysport.
A: All I can say about the company’s products is that Restylane is one of the most popular and well known names in injectable fillers The injectable filler market, however, is a crowded one with nearly a dozen other competitors. The name recognition in the market is not only because it is product that works well with very few complications but also because they were the first to enter the modern-day injectable filler era as a hyaluron-based material. Dysport lags far behind Botox as an injectable facial expression reducer and probably has less than 10% of the U.S. market. They just don’t don’t have the advertising and name recognition that Botox does and as a late entry into the field never established any clinical advantages over Botox. For all intent and purposes, it works the same and has very similar patient costs. As a result, it has had a tough time finding widespread traction in the market place. One day, at best, it may become Pepsi compared to Coke…but it is far from even that now.
Dr. Barry Eppley
Indianapolis, Indiana
Botox is commonly recognized as an injection treatment to either turn back or slow down the hands of time. By reducing the wrinkle lines of the forehead and around the eyes, a more relaxed and often a less scowling appearance is achieved. But the use of Botox continues to find new medical problems for which it is effective. Allergan, Botox’a manufacturer, is already a multibillion company which continues to experience record revenue and earnings growth.
The newest FDA-approved indication is in the treatment of migraines. Approved last year it works for migraines just like it does for wrinkles, by relaxing muscles. But it is injected around those nerves in the head which are being squeezed by muscles and thus serve as the trigger for the migraine headache. These are commonly in the eyebrow, temple and at the base of the skull in the back of the head. For some patients the temporary relief is a near-miracle which will last about four months. Botox in migraines is also a test which proves that doing surgery by removing this muscle around the nerve can have a more permanent effect.
Botox has long been approved for halting severe underarm sweating, an embarrassing condition known as hyperhidrosis. This disorder causes so much perspiration that some sufferers are forced to carry several changes of clothing to make it through the day. The excessive sweating is caused by over stimulation of the sweat glands by the nerves of the autonomic system. Botox interferes with the nerves responsible for this drenching. It has a similar benefit to those who also suffer excessive sweating in the palm of their hands. (palmar hidrosis)
Botox is effective for cervical dystonia, a condition that causes the neck to twitch, twist, and go though repetitive movements and carry the head in abnormal postures. This happens because of involuntary muscle contractions which the injections directly weaken. It is similarly effective in cerebral palsy in which patients have stiff spastic arms and legs caused by abnormal signals from the brain to the muscles. Botox interrupts this communication between the nerves and the spinal cord which then causes the muscles to relax.
Overactive bladders are also benefiting by these injections. Caused by muscle spasms of the bladder muscles, urinary incontinence can make it difficult for some patients to undergo even short car trips. Some patients end up wearing adult diapers. Botox overcomes bladder incontinence by weakening or paralyzing those muscles which contract inappropriately and squeeze out the urine involuntarily.
Botox can also stop chronic pelvic pain which can make it difficult to have sexual intercourse or undergo an examination or a pap smear test. This type of pelvic pain is caused by tight over-contracted pelvic muscles.
While often perceived as a drug of beauty, the many medical benefits of Botox makes its few precious drops life-changing for more just a better look in the mirror.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Will massage make my Botox go away more quickly? I got Botox to my forehead several weeks ago and love the results! I regularly get facials and massages and am worried that putting pressure on my forehead or rubbing bit too much will make the Botox wear off. I have read that this can happen. Is is true?
A: I have heard that question many times from numerous patients and I can tell you emphatically that it is not true. When you understand how Botox actually works, and more importantly, how it wears off you will see that rubbing or massage has no bearing on the length of its effectiveness.
Current understanding of how Botox works is that it goes into the nerve endings and blocks the release of the neurotransmitter, acetycholine, from the mitohondria where it is produced. This is why it takes days for Botox to work. The nerve ending must use up the acetycholine that still exists (has been released) into the nerve ending. Once depleted (and it is not making anymore) the nerve ending can no longer send its chemical signal to the motor end plate of the muscle and make it move. Conversely, Botox wears off by growing new sprouts or axons from the nerve around its non-working ending to attach to the muscle to start working again. To the best of our knowledge, massage or any other manipulation does not increase the growth rate of these axons. Thus, you can’t really make the muscle start working by pushing around on it.
Dr. Barry Eppley
Indianapolis, Indiana
Plastic surgery, unlike some medical specialties, seems to always find its way into the news. 2010 was no exception in this regard. As a plastic surgeon, most of the items that become newsworthy were an incredible mix of the freaky, incredulous and even fantastic events.
Breasts always seem to make the news and the more freaky seems to be better. Whether it is basketball-size implants of quadruple FFFF proportions, dancers subject to IRS scrutiny trying to write off their surgery, or breast augmentation as part of a marathon makeover (aka Heidi Montag), women who seek their ten minutes of fame marr the perception of an otherwise highly successful body contouring surgery. While the real breast augmentation news this coming year will be the introduction of a new form-stable (gummy bear) implants, this will likely be overshadowed by the media’s never-ending focus on celebrities, their breasts and Hollywood’s version of silicone valley.
There is always the continued incredulous news of patients suffering complications and even death at the hands of so-called cosmetic surgeons. This seems to be most evidenced with liposuction, largely due to its popularity and the larger body surface areas that it treats. There is an obvious difference in the size of the trauma to the body from abdominal and thigh liposuction from that of a nosejob or eyelid surgery for example. Liposuction attracts a large number of inexperienced and often unscrupulous practitioners because of the relative ‘simplicity’ of the procedure and easy access to new liposuction devices. It only takes a medical license and a credit card to buy the newer laser liposuction machines. Equipment manufacturers are more interested in sales than safety as evidenced by their marketing and selling behavior. Patients died last year from one coast to the other at the hands of doctors with dubious credentials. The public would think that better regulations would exist but they would be wrong. Doing your homework is your best protection.
Botox continues to show its fantastic benefits and those are not only in those worried about their frown lines or crow’s feet. Last year Botox was approved by the FDA for the treatment of migraines. For some migraine sufferers, Botox injections can be a miracle even if its effects are only temporary. The benefits of Botox have translated into an actual migraine surgery procedure developed by plastic surgeons. If Botox injections relieve one’s migraines, a relatively simple muscular decompression around the nerve trigger points can provide a more permanent amelioration of one’s migraine pain and frequency of attacks. It’s a rare example of a cosmetic treatment turning into a really useful medical or reconstructive surgery, usually that works in reverse.
One other piece of fantastic plastic surgery news from last year has been the emergence of face transplants. While once thought impossible and something more akin to a movie or science fiction, more and more partial or complete face transplants are being done around the world. While the patients who need them are last resort problems of massive facial deformities and tissue loss, that is the history also of all organ transplants which are commonplace today. From the extreme technical advances of today come spinoffs that will benefit many more facial reconstruction patients in the future.
No telling what this coming year will bring, but if past history is any predictor of future events, plastic surgery will continue to make the headlines…let us hope it is largely in the fantastic category.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have read on the internet an articlce that stated that Botox can cause permanent muscle weakening over time. Since I get Botox fairly regularly should I be concerned that it might eventually affect other facial muscles as well?
A: I think the article that you are referring to and has been reported in different internet venues was the one in the Journal of Biomechanics that appeared last year. I am familiar with that study and have read it. In this animal study, they examined the effects of Botox on not only the muscles that were injected but on the surrounding muscles as well. They found that Botox did lead to local muscle wasting as well as weakness of other untreated muscles in the region.
This study has caused a little bit of hullaboo about Botox but, in my opinion, it has no relevance to the cosmetic use of Botox. Beyond the fact that this was done in animals (rabbits), the doses were very high compared to what we use in humans. By my calculation, they were giving the equivalent of 200 to 300 units of Botox every six months. Given that the normal cosmetic dose of Botox is around 24 to 36 units, their dosing was nearly 10X that of a cosmetic facial treatment. The muscles that they injecting were voluntary motor muscles as opposed to involuntary muscles of facial expression. These are quite different types of muscles. Motor muscle are well known to atrophy from simple disuse, muscles of facial expression do not display this atrophy phenomenon. Most of our cosmetic patients would welcome that if it happened but there has been no evidence that it occurs.
This article is an interesting piece of science but its findings do not hold a candle to the 25 years of human Botox use in which this permanent muscle weakening effect has never been seen in a low-dose cosmetic application.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am 36 years old and have had fairly deep forehead lines for quite a few years now, which appear to be getting worse. Is there something other than plastic surgery or Botox that I can do to help my problem? I am desperate!
A: The simple answer is…no. But let me explain why. Wrinkles on the face form perpendicular to the direction that the underlying muscles move with facial expression. The well known horizontal lines on the forehead are a result of the large frontalis forehead muscle that attaches to our eyebrows and goes across our forehead the whole way to the back of our head. As you move your forehead with expression, the muscle lifts the eyebrows and creates the horizontal lines. The only way to stop them from forming, therefore, is to stop moving your forehead. Notice the difference in the depth of the forehead wrinkles when your forehead is still and not moving versus when you are lifting your eyebrows. (that difference is important for treatment considerations below)
There are only two non-Botox and non-plastic surgery options that can reduce your forehead wrinkles. A state of permanent facial paralysis is one option, otherwise known as death. Very effective but not appealing. The other option is to retrain your facial expressions so you don’t move your forehead anymore. Theoretically possible but if you are successful you will be the first human to have successfully done so.
I tell you this so in your desparate state so you don’t chase worthless treatment options and throw away money…or actually transfer your assets to the benefit of someone else. So do not chase the illusion of innumerable skin lotions, potions and facial exercises that promises a miracle wrinkle cure.
That leaves you with exactly what you want to avoid, Botox and forehead surgery, Unappealing but actually the only things that will work. Back to the depth of your forehead wrinkles when they are still versus moving. If the depth of the forehead wrinkles is acceptable when your forehead is still, then Botox would be the preferred treatment. If the depth of the forehead wrinkles at rest is still not acceptable, then a forehead lift with muscle removal would be the better treatment.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have read that there is a cosmetic procedure that cures migraine headaches. I have had migraines for years and sometimes they are so bad I can’t leave the house. If there is an operation to cure this migraine problem, I would sign up for it in a minute! Can you tell what they are talking about?
A: The use of Botox for the treatment of glabellar furrows (wrinkles between the eyes) has been done for decades. One of the very interesting findings from that cosmetic treatment was that plastic surgeons discovered that some patients with frontal migraines got a temporary cure, as long as the Botox lasted. The now proven theory is that in those patients with a focus of their migraines that starts above their eyes in the brow area are caused by the muscles squeezing the sensory nerves that exit from the bone there. This is why Botox relieves those migraines…it stops those muscles from working.
If you take that one step further, a browlift (of any type) can create the same effect as Botox except that its results will last much longer and maybe even permanently. That is because during a browlift some of the muscles are removed to prevent that type of wrinkling action. Recent studies and publications in the journal Plastic and Reconstructive Surgery has shown that certain types of migraines can be cured by performing a modified forehead/brow lift. Therefore, the type of forehead lift used to cure migraines could also lead to one looking younger as well. This type of cosmetic operation has been shown to be safe, effective and can lead to a tremendous improvement in the quality of some migraine patient’s lives.
Dr. Barry Eppley
Indianapolis Indiana