How long do I have to wait for Botox to work?

It takes a few days for Botox to work.

This is what I’ve told my patients regarding Botox’s ability to resist wrinkles – regarding onset:
  • It takes 4 days to reach 90% activity.
  • It takes 2 weeks to reach 100% activity.

Thus if you feel like you need more Botox, I usually recommend waiting 2 weeks before adding more Botox.  This way we see the full effect of Botox before adding more.  I do believe in using Botox efficiently (without wasting it on the patient).

How many sessions of acupuncture?

I wrote this email in October 2018 to my Botox / Acupuncture office staff regarding “How many sessions of Acupuncture is necesssary”

Hi Office,

This is one of my most common questions that we get.

How often and how many acupuncture sessions?

How often?

once or twice a week.

How many?

Usually takes 8-12 sessions of acupuncture (once or twice a week) to maximize the treatment results.  After that some sort of maintenance needs to be done whether it is different habits like stretching or perhaps acupuncture sessions once a month.

How do I know if acupuncture is worth it?

Dr. Lee has a 4 session test of acupuncture.  If there is no improvement at all after 4 sessions of acupuncture, then it is probably not worth it to go to 8-12 sessions of acupuncture.
Thank you for rebooking the patients for acupuncture.  For acupuncture to work, it depends on rebooking appointments for our treatments to have lasting effect – I guess that goes for Botox as well.
Take home items from this email:
1. When does the patient come back? As soon as 2 days from now to 2 weeks from now is ok (that sorta is 1-2 times per week – although I prefer in general within 1 week).
2. How many acupuncture sessions does one need? It’s a patient preference, but most will need 8-12 sessions and then after that to change their habits (more sleep, more stretching, more vegetables, less TV, etc).
3. Can a patient stop after 4 sessions of acupuncture? Yes, if they are completely cured of their problem, but most patients use the 4 sessions as a test of worthiness of acupuncture and they usually do 8-12 sessions of acupuncture.
4. How many sessions do I need if I am a new back pain patient?  Most likely 8-12 sessions of acupuncture with the sessions about 1-2 times per week.  Use the first 4 sessions as a test to see if acupuncture is working.
Like Botox, a disciplined, habitual approach to rescheduling (rebooking) helps more than just one “mega-botox” or “mega-acupuncture” session.
Thanks!

Modesto Cosmetic Surgeon injecting Botox

I wrote a little blurb about myself recently.

🌱I am a Cosmetic Surgeon and Acupuncturist with a history in General Surgery and Trauma Surgery. I have a neuroscience and MD degree from Brown University. I was honored to have been accepted for college by all the Ivy League schools including the great Harvard University. But self-descriptively, I have been quite the slacker and I hope to make up for lost time and opportunity in the present and future. I slacked so much as a child that I was fired by my piano teacher around age 7. I took up the violin after that point. Now, I am mostly trying to teach myself piano. I respect my piano teacher’s decision for parting ways.

🌱In 2006, I started Surgical Artistry, a plastic surgery and acupuncture medical office in Modesto, CA with my wife, Dr. Tammy Wu, Plastic Surgeon. In 2019, we expect to finish building from the ground up, a new state of the art Plastic Surgical Center residing on 2 acres of land in our home town of Modesto, California. I spend my days working on my craft of injecting Botox, Fillers, and Kybella; treating veins, acne, back pain, fertility, stress; discussing nutrition, skincare and anti-aging strategies; performing acupuncture, cosmetic injections, surgeries, chemical peels, microneedling and threadlifts. My wife specializes in Breast Augmentation and Tummy Tuck surgeries and is a vice-principal of a K-12 school in Sacramento.

🌱
My wife and I have been vegan since 2011. We love to run and we helped start the Modesto Marathon and Ripon’s Run Half Marathon.

What’s new with Botox for 2017

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My 2016 Botox Statistics

I reached the Diamond level injection status – which is top 4% of Allergan accounts.  I’m happy to report that I injected 66,597 units of Botox for the year and almost 900 syringes of filler – I guess I should have just worked harder.  I pledge to continue to work harder to improve my skills.  Thank you to all those who trusted me with my surgical skills to inject Botox.  As expected, Allergan is going to raise their prices on the purchase of Botox for 2017.  This is an annual price increase which I’ve come to anticipate.

Botox Bottle Photography Art

Empty Botox Bottle

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I had this used bottle of Botox laying around.  I used to put little flowers inside this bottle just for fun.  It was a particularly sunny day outside in my backyard and I decided to take this photo of the empty Botox bottle.  It looks pretty – to me anyway – probably because injecting Botox is such an art form for me in Modesto, CA.  The table is a stained teak patio table which needs to be stained again, but the weathering is actually quite beautiful in a way.  This picture of the Botox bottle was done with a Canon 80D camera which I still haven’t learned how to use.

Pimples after Botox

I attempt to answer another public forum question about Botox.  This question comes closer to my office in Modesto, California – it is from San Jose, California!

Why do I break out since having Botox?

In the exact same area where the injection was; is where i break out. As if causing a “man made pore” from the needle which then does not close up and gets filled causing an ongoing blemish effect. I ONLY break out now where I’ve had the injections. But why??

My Pimples and Botox Answer:

Wonderful question.  I’ve encountered this question about having breakouts in the area of Botox injections in my own practice in Modesto, California about 3 times.  So this is rare.  The world of medicine is complex, and sometimes it seems strange.  I have not had a case of the “man made pore” – so I can’t address that question except to speculate that it may be a scar of sorts or somehow related to a cyst?   I’ve had an experience where there was a reddish – pimple like reaction to only one of my needle pokes.  I suspect in that patient that there was an underlying infection in that area – such a pimple – which then got exacerbated when I decided to inject Botox too close to that area.  Botox injections are tricky, we want our injections to be in strategic places, but sometimes in our patients, blemishes and veins get in the way of an ideal placement – and thus I have to compromise in my decision and Botox strategy.

​Regarding the break-outs in the Botox areas.  For some of my patients, I’ve come to realize that they are sensitive to some of the antiseptic methods I use to help prevent infections from the Botox procedure.  Sometimes they are allergic to the antiseptic.  There are various ones available out there and perhaps switching to a different antiseptic could help.  Meaning, having your injector/surgeon/doctor/nurse switch to a different agent.  And there’s the possibility that the actual needle poke – which is a very mild form of skin trauma – could incite a inflammatory process.

​Ironically (to your question of why does Botox cause more blemishes), I’ve found most of the time that Botox helps calm down inflammation in an area of skin. This may be due to reduced sweating or a direct effect on rashes and pimples by Botox.  Also, Botox sometimes shrinks pores as with what we’ve seen with meso-Botox.

​Thank you for your question, I’m just answer from my own personal experience as a Botox injector. 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.

​I hope this discussion is somewhat helpful.

​Calvin Lee, MD – Botox Surgeon
Botox injections ​Modesto, California

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Botox doesn’t work as well anymore – what to do?

I’ve decided to tackle on another question in a public forum about Botox.

I’m a Botox user but over the last 3 – 4 times I’ve had Botox it hasn’t worked as well. What unit of Botox would I ideally want?

I’ve been getting Botox for a few years,recently its not worked as well ,getting top ups is a hassel, especially when it doesn’t work again.i asked my doctor what units he used, what type and the dilution solution , ‘ Azzalure which is the same as Dysport. Diluted with bacteriostatic saline solution to produce 200 Speywood units per ml. ‘frown 50-60units’ is this good? I’m thinking of changing doctors, what would the best thing to ask them?how many units do i want injected if this didnt work?

My Answer:

There are so many different ways to inject a neuromodulator and there are so many possibilities for a neuromodulator injection to work less effectively.  I’m going to use the word neuromodulator to describe Botox, Dysport, or Xeomin.  I agree that Dysport is sometimes called Azzalure.

​WHAT CAUSES VARIANCES IN OUR RESULTS?

​Patient factors

  • ​Is the patient Zinc deficient?  Zinc seems to play a role in neuromodulator
  • Did the patient develop antibodies to the product?
  • How long ago was the patients previous neuromodulator treatment.  Often, when the treatments are close enough together, there’s a synergistic effect of the previous injection along with the new injection.  Thus don’t wait too long between injections where to facial muscles have gained back all their strength.

Product factors

  • ​Dilution of the product.  Was it diluted appropriately.
  • Age of product.  How long has it been on the shelf?  Shelf life can matter.
  • Which product?  I feel that the neuromodulators are somewhat different from each other.  The units cannot be interchanged very easily.  It’s sort of like asking – how many tangerines does it take to make a washing navel orange?  Similar, yet different for the discriminating injector/patient.

Injector factors

  • ​Where were the injections made?
  • Was there waste of product?
  • Was the measurements accurate?
  • Three dimensional injection, was the neuromodulator placed within the muscle or right under the skin, or right above the bone?
  • How many injection points were chosen?

​I’m probably forgetting a few variables.  But you can see that there’s so much going on here.

THE ANTIBODY QUESTION:  Try more Dysport and/or go back to Botox.

​Consider going back to your injector and asking for a higher dose of Dysport.  If that still doesn’t work, then consider asking your injector to switch back to your original – Botox – which seemed to work for you.  If both the higher dose and switching back to Botox – this might point to an antibody problem.  This will degrade the product faster.  This is a very rare possibility.  I think in the past, this happened more because of the higher percentage of albumin mixed in with the Botox.  But it’s a much lower amount of albumin used now and thus the antibody reactions are much rarer.  If antibody reactions occur, I believe that you’d be forming reactions to all Botulinum Toxin Type A’s:  Xeomin, Dysport, and Botox.  These are the ones available in the USA.

​SWITCHING INJECTORS​

​But if you have doubt about your injector.  You can switch.  Neuromodulator injection styles are incredibly different – this might be what you’re looking for – something different.  And hopefully better results.  I think you have a good idea on this one.


OR SPEND MORE TIME DISCUSSING THE PROBLEM
​​
​Consider spending even more time talking to your injector.  Perhaps he/she will come up with a comprehensive plan of figuring out what’s happening with your new dissatisfaction.  Above is just my own plan of what I do with my patients who present with such a scenario.  But most of the time, it’s because I’ve gotten patients who have decided to switch to me due to dissatisfaction with results from another injector.

IDEAL BOTOX UNITS FOR THE GLABELLA:

​How many units of Botox for frown lines?  I call these lines glabellar lines.  I usually inject anywhere from 10-36 units of Botox for this one area.  Every person is different, but usually I am sticking to the same general amount of units for each treatment session.  Thus if a patient is a 36 unit user – they tend to be a 36 unit user for a few years.  I have found that they can usually space the treatments further apart though as they keep using Botox.

​On average, I use 20 units of Botox for the glabellar complex.  The numbers written above in the question are probably Dysport units which could be about 3 times more than the Botox units to achieve a similar (not same) result.  I’m not entirely sure because I am nearly 100% Botox in my own practice.  My experience with Dysport spans only about 3 months in my practice.  I was pretty happy with the Dysport results, but my patients seem to want Botox more, so I caved into consumer demand.  I am happy with both products.  But I do not use the terms Botox, Xeomin, and Dysport interchangeably.  They are different products and have different effects and require different care.
​​​
​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.

​Calvin Lee, MD
​Botox injections Modesto, California

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Plumped up Cheeks with Botox or Filler?

Another Botox question in a public forum:

Fluffy cheeks with botox or filler?

Hello i am 37 years of age. I want my cheeks become fluffly as i was used to look in young age. Which treatment would b better botox or filler ? And how much is cost? Thanks.

My Botox Answer:

I get this type of question of Botox or Fillers every single day – so it’s a great question.

​BOTOX IS MORE PREVALENT

​Last month I had the honor of treating 127 patients with Botox, and 31 patients with a dermal filler.  I think 1/4 of these patients wondered about the differences between Botox and Fillers.  And in my practice, the usage of Botox is a lot more than the usage of fillers.

​BOTOX AND FILLERS EXPLAINED AS MOUNTAINS AND VALLEYS.

​I came up with this explanation for my patients and perhaps it will help others.  First imagine our face as having a landscape.  We have mountains and valleys in our face.  The valleys being the wrinkles which are usually surrounded by mountains on either side.  I have told my patients that Botox weakens muscles and thus it will give the appears of lowering the mountains on our face.  But Fillers, will help to fill up the valleys.  Thus if we want an even surface – a combination approach might be needed: we might have to lower the mountains with Botox (those bulging muscles!) and we might have to raise the level of the valleys/wrinkles with Fillers.

​WHAT IF WE WANT TO RAISE A CHEEK?

The filling/raising of a structure on the face requires a Filler.  Thus for bigger, fluffier cheeks, we need a filler.

​WHAT CHOICES OF FILLERS DO WE HAVE?

​There are many fillers.  The filler that is very popular in the cheek is Juvederm Voluma.  But I still consider off-label FDA choices of other fillers in the cheeks for my desired appearance or a combination of fillers.  I use Belotero, Juvederm ultra plus XC, Juvederm ultra XC​, and Radiesse in the cheeks.  I also use thinned out versions of Juvederm by purposely diluting the products.  All this is considered off-label FDA, but this helps me get the results I envision along with my patient’s goals.

​OTHER POSSIBILITIES – PERMANENT IMPLANTS:
​My plastic surgeon wife who is in practice with me has certain permanent implants which she can use in surgery.  But that would be a totally different topic which I’ll let her explain.

​SUMMARY:

​What is used for making bigger cheeks Filler or Botox? The answer is Filler.  I try to explain that Botox actually shaves down the appearance of bumps in the face, and filler raises lowered areas on the face.  But if we want to raise a bump (mountain) on the face – that would also be fillers.  Naturally the next question might be which filler would we choose.  I think my go-to filler right now is Voluma for the cheek.

​DISCLAIMER:
​​
​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.

​Calvin Lee, MD
​Botox and Juvederm in Modesto, California

Modesto Surgeons at work

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​

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​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.

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.

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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.

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