Botox for slimming the jaw

Another Botox question on a public forum:

Botox for reduction of masseter. How many units are required for a noticeable difference?

How many units is required for a noticeable difference? Or is it entirely dependent on the individual? I’ve visited a few clinics and I’ve been quoted either 15 or 25 units. I was told by one doctor that with Botox, only a small amount is needed for a difference to be seen. But some clinics recommended a higher dosage as the cost was paid for per unit. Could anyone provide some information on this and what dosage they recommend?

An excellent question. I’ve wondered this myself and I continue to wonder about what others think about jaw slimming with Botox. The masseter is the main muscle which can give us a square-ish box-like face.

I don’t get this opportunity to do this procedure very much. I’ve only had about 20 patients come in for this issue. And about 16 patients who come in repeatedly for this feature of Botox at this time. But I’ve had many more (probably 60 patients) who have had TMJ dysfunction/pain issues which required Botox in the Masseter muscle.

My worst case scenario is a male patient who had TMJ pain which eventually resolved when we eventually came to the conclusion that 50 Units of Botox on each side helped. I usually like to do my Botox procedures in a staged fashion where we do a little bit at a time and thus we eventually find the lowest dose that does the right job for us. He did get jaw slimming features, but that actually was more evident after his third round of 50U of Botox on each side.

My experience with TMJ masseter muscle Botox helped me come to the realization that masseter/jaw muscle slimming Botox usually has it’s most dramatic effect after the 3rd Botox treatment – assuming no large gaps between treatments. So this is almost 10 months later.

Thus for patients coming directly to me for Jaw slimming Botox (cosmetic only). I try to assess how much of a “rush” patients are in for this to happen. If they are OK with best results in 10 months. I usually suggest about 16U-20U on each side to start. And repeat this process in 3-4 months. If a person is in a “rush” to get this result, I might start with a higher dose – such as 24-30U and then gradually lower this dose with each subsequent treatment – so I don’t over-correct and get a sunken in jaw look – which in my opinion is not a youthful appearance at all.

Summary: Quick answer: 12-50 units per masseter muscle. Long answer: It’s not the number of units per session – it might be the number of units done over time that matters most. I’ve come to realize that the best appearances for masseter muscle slimming is obtained after repeated treatments to this area. I tell my patients to be patient and wait for the appearance after the 3rd Botox treatment to the masseter area. Everything in medicine should be individualized – especially Botox!

Calvin Lee, MD
Botox injections in Modesto, California

Thank you for your question. Without having seen you in person, I’m answering the best I can without physical examination info. My comments are meant for a general public discussion to help others who may have similar concerns. I’m also using my answers to build up library of information for my own patients and also to see how my answers compare with other doctors. There is always much for us to learn from each other. My answers are generalized medical information only, not directed medical advice. For medical advice please see your doctor/surgeon in person.

Botox for changing eye size

Here’s another public forum cosmetic Botox question.

Can I use Botox for my cheek pushing up on eye when I smile, making it look smaller than other?

I have had 2 ptosis surgeries On my upper eyelid it has been about 4 weeks since my 2nd. the 1st 1 was an over-correction. Now I don’t think it is so much my top eyelid. It is raised a little more than before any surgeries. I’m still not happy with my eyes. If you notice when I smile it really goes to one side. And I’m okay with that. But when I smile only 1 cheek pushes up on my eye and makes it look smaller. i don’t want to do anymore surgeries. Could Botox fix my check from coming up?

My Answer:

What a great question! I have to break up my answer into several parts

BOTOX FOR CROWS FEET

Botox is FDA approved for treatment lateral canthus lines (crows feet). These are the lines on the side of the eyes which become more pronounced when we smile. Through our experience treating these crows feet, we’ve found that we can affect eye size, brow lifting, and even cheek elevation.

FULL vs. PARTIAL TREATMENT of CROWS FEET

In a situation where one just wants the cheek to elevate less with smiling, a full treat of crows feet might be too much. However, if one is bothered by the potential of crows feet (meaning that BOTOX can prevent crows feet as well as treat crows feet), the a full treatment could work on both sides, and may even out the appearance. I can envision a possible treatment of the lower crows feet on the side with the cheek elevation “problem.” I can also see a potential patient of mine benefiting from full treatment on both sides and with added Botox to the “problem” side.

TREATING THIS PROBLEM IN STAGES

If I had a patient coming in for this issue, I would consider treating this issue in stages. Starting with a low dose targeting the lower crows feet area (obicularis oculi muscle) and bringing the dose higher perhaps separated by about 2 weeks. And maybe even considering treatment on both sides to keep up with symmetry issues. With good note taking, we could figure out the optimum solution if possible.

MOUTH MUSCLES MIGHT GET IN THE WAY

Cheek elevation is also caused by muscles that affect the smile of your mouth – Zygomaticus Major and Zygomaticus Minor muscles. These muscles, if targeted too strongly with Botox will affect the symmetry of your mouth. Thus if the bulk of your cheek is formed from these muscles, Botox may not be able to give you your 100% desired result. But I still think that your desired effect is possible without injecting Botox into muscles that affect your mouth. Fortunately with a gradual staged approach, you might gradually find a solution. If a solution isn’t possible, I would say that it’s because of the mouth muscles and the amount of natural fat pads we have on each side of the face which can compress and change shape on animation of our face (ie. smiling).

THE QUEST FOR SYMMETRY

I understand that symmetry is important. However, we should keep in mind that it isn’t human to be exact mirror images of our selves on each side. We are usually strong on one side – for example, being right handed. This contributes somewhat to our facial muscles as well. The natural asymmetries in a person’s face can be considered a strength and add flair. Thus, sometimes, it’s ok to go with the idea that the sides of our faces are like siblings, not genetic clones.

IN SUMMARY

Botox can possibly solve this problem of smaller-eye, higher-cheek. If one is interested in wrinkle treatment or prevention – it makes using Botox even better. Consider partial or full treatment of crows feet or even heavier application on the elevated-cheek side. But keep in mind that Botox can make other parts of our face appear asymmetrical – like the mouth or the eyebrows – so be careful, and good luck!

Calvin Lee, MD
Botox injections in Modesto, California

Thank you for your question. Without having seen you in person, I’m answering the best I can without physical examination info and a one-on-one dialogue. My comments are meant for a general public discussion to help others who may have similar concerns. I’m also using my answers to build up library of information for my own patients and also to see how my answers compare with other doctors. There is always much for us to learn from each other. My answers are generalized medical information only, not directed medical advice. For medical advice please see your doctor/surgeon in person.

How to dissolve Belotero?

Another public forum question which I attempt to answer for fun.

Blue puffy bags after Belotero in tear trough + older Juviderm on inner orbit rim. Will Vitrase dissolve both at the same time?? Had bad reaction to Vitrase 2 years ago but can’t wait it out…it’s appalling.

Thank you for asking your question. My answer is just an academic exercise in producing a discussion regarding a hypothetical situation. My answer is not directed medical advice. Please see your doctor in person for medical advice.

So how do we dissolve Belotero and Juvederm which caused blue puffy bags in the tear trough under the eyes?

About the sensitivity to Vitrase issue:

Vitrase isn’t the only hyaluronidase available in the USA. I believe that other formulations are Hydase, Wydase, Amphadase and Hylenex. All of them are animal derived hyaluronidase products except for Hylenex which is derived synthetically from recombinant human product produced by genetically engineered Hamster Ovary cells in a laboratory. Because it is not derived from an animal and it is the human form of hyluronidase, there would be less reactions from it. Consider using Hylenex. This is what is available in my office. For a patient with previous Vitrase reaction, I would try Hylenex.

About dissolving both Juvederm and Belotero at the same time:

Yes, Juvederm and Belotero are both hyaluronic acid fillers and will be affected by Vitrase, Hylenex, or other hyaluronidase products. However, Juvederm will be a bit more resistant to dissolving. Thus if a very small amount of hyaluronidase is use, the Belotero would dissolve first.

Regarding the Bluish tint = Tyndall effect:

That is probably from the Juvederm. I have had the same problem before when using Juvederm in the tear trough. But I still use Juvederm in that location but only for patients with thicker skin or darker skin. I had to learn from some of these problems which I’ve also had. I have only had one patient who reported a Tyndall effect with Belotero and thus I consider the Tyndall effect to be very rare with Belotero.

Another possible suggestion – using dilute Hylenex:

Much of what we do as doctors are considered off-label FDA use. Much of what we are discussing here is off-label FDA use. For some of my Hylenex cases, I dilute the Hylenex with Saline. My formula varies with the application, and thus I have been able to thin out the problem to an appropriate degree and thus have a happy outcome without having to reinject filler or to have a complete loss of filler in a particular area. This is a tricky process, and I sometimes manage this in a staged approach – meaning multiple sessions.

Calvin Lee, MD
Modesto, California Belotero Injector

Voluma Disappeared over a Month?

Another public forum question which I will attempt to answer.

Almost total Voluma absorption after only 5 weeks? What caused and does that mean hyaluronic products a no-go for me?

I had 1 vial of voluma–split between both facial cheeks and eye areas, and one perlayne split between both marionette areas 5 weeks ago and already the sunkeness around my eyes is returning–voluma should last at least a year–any suggestions as to why this happened? Does this mean I’m not a good candidate for any hyaluronic acid products? My injections performed by a very experienced plastic surgeon–little bruising, redness or after discomfort; immediate happy results. )-: thank you!

My Voluma Answer:

I will attempt to answer your question from a community discussion standpoint. Please see your own doctors in person for personalized medical advice.

Much of what an injector does with fillers is an art, thus the amount, the products, the location, and the method of placement is all different.

I am currently mostly a cannula injector when it comes to Juvederm Voluma and I still prefer the threading methods. And for me, Voluma is not the only filler I use in the cheek. I have found myself layering with Juvederm Ultra Plus XC, and also Belotero when needed for additional superficial shaping. I used to inject this differently – using droplets of filler. But my style changes from time to time and from patient to patient. Thus I am speaking only from my experience, and my methods and thought process could be completely different from your plastic surgeon. Please keep in contact with your plastic surgeon. I think he/she would appreciate an open dialogue. I am answering this question as a public academic exercise for myself to see how my answer compares to others and to personally build up information sheets for my own patients. Thank you for giving me the opportunity to participate.

Your comment about Voluma disappearing in about a month’s period of time is a comment I hear from my own patients in my practice. Much of the time, it isn’t because they were fast metabolizers of Juvederm Voluma. But most of the time it is due to at least these four factors:

1. The Juvederm Voluma softened over that time and lost some of it’s original projection. This almost always happens in what I’ve seen. Then the Voluma spreads out and becomes more of a diffuse appearance – more rounded / less angular. this is what I mean from the title – the Juvederm Voluma evolves over the first few weeks.

2. The Juvederm Voluma, with gravity, sometimes shifts downwards. Thus, it might get somewhat “lost” in the hollows of the cheek. This is what I also mean from the title – the Juvederm Voluma evolves over the first few weeks.

3. Some of the original swelling has gone down from the procedure itself (needles/cannulas/massaging), and thus it appears that some of the material is lost – but in fact the only thing lost is the swelling.

4. Our patients sometimes gets used to the new look and had pleasantly “forgotten” the “before” look. Thus the changes don’t seem as dramatic.

With all those four factors, additional Juvederm Voluma injections might solve the problem. I have found that one syringe is useful in youthful patients with tight skin over their cheek bones. But for most of my other patients, two syringes of Voluma helps me achieve the look (and duration) I want for my patients. It is not uncommon for me to consider 3 or 4 syringes.

You also mentioned in your question about Perlane. The active ingredient in both Voluma and Perlane is hyaluronic acid. If the Perlane results are still evident, this means that you are unlikely to be a rapid metabolizer of hyaluronic acid. It sounds like from your question that you are satisfied with your Perlane results. This means to me, even more so, that another syringe of Voluma might be your best solution before thinking of switching to a different material such as Radiesse or giving up on future Voluma injections.

Calvin Lee, MD
Modesto, California Juvederm Voluma Injections

Disclaimer: some of the discussion above involves off-label FDA usage of fillers. And none of what I mentioned above is meant to be personalized medical advice. I am just discussing a hypothetical situation posed by a person I have not examined. Without a personalized examination, I am only guessing at possible solutions which I present above. I am also assuming that the mention of 1 “vial” = 1 syringe.

Bulging Vein after Voluma Injections

I copied this question from Real Self. I think it would be a good intellectual exercise to pretend that these questions come from my own patients and I try to formulate my own answers then compare to the answers of other doctors. Of course, I’ll probably be biased and think that my own answer is the best.

Disclaimer: This is just generalized medical information. Any medical discussion here is not meant to be medical advice. Please see your doctor in person.

Here’s the Voluma question:

I had Voluma a week ago and I have this bulging vein/artery on the side of my temple now that has two branches stemming from it. It is ugly and really noticeable. I really don’t know how to correct it or who to go to next. Can more fill disguise it or will that just make it worse? Is it dangerous to get it ligated? Or should I just get the filler dissolved?

Here’s my Voluma Problem answer:

Thank you for your question. Without a personal examination of the problem, my thoughts will only be a generalized discussion.

I have to make the assumption that your question regarding Voluma is an injection at the side of the face by the cheek. There are off-label FDA injections of Voluma elsewhere but the FDA indication is for the cheeks. Thus, the problem described is bulging vessels in the temple (probably a vein) 1 week after Voluma injections in the cheek.

It is possible that the venous outflow is somewhat limited due to the mass-effect created by the added volume of the filler (Voluma) and the very likely added swelling from the physical nature of the procedure. (Meaning that the flow of blood is a bit squished from the filler itself and swelling due to the procedure.) When the swelling subsides, the venous outflow would become less obstructed. In my opinion it may take 3 weeks for the swelling to disappear. Perhaps at that time, the veins would become less distended.

During this time, if you were my patient, I would appreciate knowing about your situation and concerns. Together we could discuss further therapy – such as those that you mentioned such as dissolving the filler or ligation of the vein. Ligation of a facial vein is possible but it would be an extreme measure in my opinion. Sometimes the hardest therapy to endure is a tincture of time. But many times, that is the best option along with watchful expertise from your injector.

If you haven’t contacted your injector, please do so as your top priority. You mentioned “who to go to next.” Your injector should help guide you in that decision if you feel another level of expertise is needed. Best of luck to you.

Calvin Lee, MD
Modesto Voluma Injections, California

Dysport vs. BOTOX comment on FaceBook

Personally in my hands, I like BOTOX

Today, I received on FaceBook, a question regarding a comment regarding Dysport vs. Botox. I was invited to give my personal thoughts and I would like to share them. For the most part, I disagree with what’s written in the screen capture below:

My response to the question:

I like all of them! Botox, Dysport, and Xeomin

Dysport is excellent. So is Xeomin. Dysport, Xeomin, and Botox are neuromodulators. In my opinion they work very similarly. I have personally injected all three products and have personally received injections of Botox and Dysport. I have come to the conclusion when using the products, much of the differences come down to four things:

1. How much was used.

2. Who is the injector.

3. What precise 3-D location was it injected (muscle/fascia all have depth).

4. How was it injected.

How to Compare? pound for pound?

I’m not certain that you can convert one unit of one product to another unit of another product. For example, how many Hondas equal one Toyota? Would it be 1.5 Hondas is the equivalent of 1 Toyota because of horse power rating or based on gas mileage – or the other way around. I have owned both Hondas and Toyotas – and I like both.

So that’s the first problem when comparing neuromodulator. Do we really know if we have equivalency? Is 2.5U of Dysport really the same as 1U of Botox? Or have we now changed it to 2.9U of Dysport to equal 1 U of Botox. I jumped at the chance to try Dysport in January 2013. I think the results were great. But I think that in my own hands, the results of Botox was better.

I agree that Dysport spreads more. But for me, I see that as a disadvantage. The way I inject, I like a bit more pin-point accuracy. But then again, that’s my personal way of injecting. I like planning my injection sites whenever possible – thus I’m not looking for a wide diffusion pattern of the neuromodulator.

There will be people who say that a Toyota is better than Honda – or the other way around. I think both are good car companies. But I would say that currently for me, I drive my own Honda a lot better than I would drive a Toyota because that’s what I drive every day.

Botox is my Violin

Schindler’s List Played by Calvin Lee, MD, guest concertmaster Taipei, Taiwan

Yep, that’s me and my violin.

I have been a violinist most of my life. I frequently say that Botox is my violin. When I’m using my violin, I can create results more predictably. My Violin is what I prefer when I concertize. I would be a bit timid when using a different violin. But this is not to say that other violins are inferior. But I have confidence to say that I would make other violins sound quite good!

Thus said in a different way. I prefer to inject BOTOX because I’m comfortable with it and I can predict the outcome better. But if I had to use Dysport or Xeomin, I would still get great outcomes, but I would have some uncertainties with it because I don’t use it every day.

Many of my patients and my entire staff prefer their BOTOX results over other products.

Their reasons are multifactorial. Perhaps in another entry of my BOTOX blog, they can chime in.

I leave you with one more thought: The injector plays the biggest role in the outcome.

It’s the violinist that makes the sound, not the violin. Just like it’s the surgeon that makes the surgery, not the scalpel. Thus we can debate on and on regarding which violin to use or which scalpel to use. As long as the violin is of high quality and the scalpel is too, then the results lay on the shoulders of the artist.

Here’s a quote from master violinist, Jascha Heifetz:

After a concert, a member of the audience went up to Jascha Heifetz. He said, “Wow, your violin sounds really great.” Heifetz then held the violin up close to his ear and replied, “Funny, I don’t hear anything.”

What size / kind of Botox refrigerator would you recommend?

I like to help other Botox injectors and I just got this question on my email today. I thought I’d share and hopefully help others

Question: How big of a fridge will I need for Botox? Which one do you recommend?

Answer that I emailed back:

Fridge Size: I use a dorm room sized fridge. It’s half height fridge which comes up to my waist. You don’t really need anything big at all for Botox. Small works just fine.

You could even get a square shaped mini fridge. But I don’t want to bend down all the way to the ground.

You don’t need a freezer for Botox. They make refrigerators without a freezer. This could potentially save electricity and some hassle of freezer issues. I think if I were to do it differently, I would get a refrigerator without a freezer. The ice in there messes up the temperature sometimes.

Regarding temperature regulation. I have two thermometers – one is digital (uses batteries) and broadcasts the temperature, and the other is just a plain analog thermometer (no batteries). It’s important to keep the temperature of the Botox within the guidelines suggested by the manufacturer. But sometimes, it’s nice to have a freezer section for the ice packs. These would be ice packs to hand out to patients for bruising.

I hope this info helps.

www.InjectionArtistry.com – my homepage for my Modesto Botox Practice.

Does BOTOX freeze sensation?

Botox freezes the action of muscles but does it freeze feeling?

I got this question in my Modesto Botox practice about three times this past week. This gave me the spark to write about it a bit in my blog of Botox Topics.

surgical artistry full page ad never boring — Our ad in a Modesto Magazine back in 2013.

Botox does not freeze sensation – it does not make you “numb.”

As you can probably tell from many of the questions I’ve received before, that answers are not always that simple. If I had to summarize/simplify the answer to the question of Botox making you numb – would be “no” – Botox does not make you numb. Numb in the sense of getting of numbing shot at the dentist, etc. However, it is believed that Botox may play a role in diminishing pain sensation – such as those felt in migraines. Thus Botox most likely doesn’t change your normal sensations, but it may diminish excruciating pain sensations. As we know from our studies of neuroscience, different sensations such as fine touch, coarse touch, temperature and pain have different pathways in our nervous system.

Botox does not make you numb.

I hope this answers the question.

Please see your doctor in person for a detailed explanation. There is no medical advice intended here, just a general discussion.

Restylane or Belotero under the eyes

A tear trough filler question (under the eyes)

A patient recently called me (who lives relatively far away from Modesto) to see if I can give her a second opinion regarding restylane under the eyes. She has a local injector (local to her) who wants to inject restylane under her eyes and she wanted to know why we don’t do restylane under the eyes. Here are some thoughts I had.

I would tell her that I think that any product could work well under the eye in the tear trough region with a skillful injection artist. The more important factor is the artist who injects under the eye. There are so many things you can do with a filler (off-label FDA) – such as dilute the filler or add lidocaine/epinephrine or inject deep or use a cannula, etc.

The filler product is like the violin without the violinist.

Restylane in my hands is excellent under the eyes – I have even used it before quite frequently and was very happy with the results. I personally prefer Belotero because in my hands currently because it results in a smoother contour. The edges are not as aparent to me if I have some superficial injections. My technique is usually to inject deep. But some patients need a thicker fill under the eyes, and thus they would be better served with Restylane – which also lasts longer than belotero under the eyes.

Because of the smoother contours, I prefer belotero under the eyes rather than Restylane. This is only a personal preference and it is my current preference which can/will change with time and further experience and further feedback from patients.

The reason I don’t carry Restylane, it’s because it’s a product that is very similar to Belotero and Juvederm. Similar enough that I don’t really see a point in having it in my practice, and I have received poor customer service from the Restylane company in the past, and thus I chose not to carry their products for the past 6 years.

Juvederm under the eyes, in my opinion causes a bluish hue (tyndall effect) in the hands of many surgeons/doctors/injectors including myself. I have rarely experienced this problem, but because other surgeons have reported this more often than I’d like to hear. Thus I tend to stay away from Juvederm for under the eyes.

The under eye filling with any filler is consider off-label FDA usage, and thus there won’t be a ton of information about this because companies are technically prohibited from advertising off-label FDA uses of products.

I think she would be fine getting Restylane if she trusts her injector. I am not able to comment on the skills of other injectors because I don’t know how they inject. Please continue to see your injector in person for detailed information. I would welcome another visit to our office to continue the conversation if that were convenient.

Disclaimer: The above is medical information. It’s not intended to be advice. Please see your doctor/injector in person for personalized advice.

Botox Experience

855 Botox Patients, 2594 Botox Visits

855 different Botox patients seen as of 1/30/15. 2594 Botox visits.

How much Botox Experience does Dr. Calvin Lee have?

Dr. Calvin Lee is a board certified surgeon who has been focusing on Botox injections since 2009. We have made a few pages which shows some of our detailed Botox statistics at our Botox practice. However in this Botox blog, we present even more Botox metrics.

It’s not my goal to be a super busy practice. I like to spend a good amount of time and attention for each patient. Quality over quantity!

Previous pages with our Modesto Botox Statistics

Botox usage summary 2014: 34,234 units of Botox used in 2014 by Dr. Calvin Lee
Amount of Botox purchased by Surgical Artistry in 2014 – 365 vials of Botox.
My personal Modesto Botox injection statistics 2014: 503 different patients were seen for Botox in 2014. This is up from 374 botox patients seen in 2013.

Starting from 2011, we can track statistics through the Botox company

Fortunately, the Botox company has decided to form a frequent-flyer type program which gives coupons directly to the patients in the form of discounts for future Botox injections (or Juvederm or Latisse). This program is called “Brilliant Distinctions.” With brilliant distinctions, there is a computer portal which our Modesto Botox practice can access. We have been a member of Brilliant Distinctions since 2011. With these statistics, we found that Dr. Lee has seen 855 different Botox patients. These patients have visited the office 2594 times for Botox. Botox Touch-Up visits are not counted in this figure.

Return to Modesto Botox Topics