Monthly Archives: September 2013

What to do in case of Dermal Filler Emergency

In case of Dermal Filler Complication of Vascular Occlusion


This “essay” shows depth of knowledge. Proud of Surgical Artistry Team member, Karla, for her answer to this question when a student nurse from San Jose called asking for advice on a school project, “What should one do and have available in the event of a dermal filler emergency where vessels get occluded.” This is her expert response:

I am the Patient Care Coordinator for Surgical Artistry, Dr. Tammy Wu and Dr. Calvin Lee‘s office in Modesto, CA. You contacted our office regarding information for a nursing program project. I wanted to take this opportunity to answer any other questions you may have regarding the “mini-crash cart for injectables” for your project. I am very sorry for the delay in response and I hope this information is still helpful. We would include the following: a butterfly needle, a towel for warm compresses, nitro paste to dilate the vessels, and Hylenex to dissolve the filler. I can provide you with a little bit of background information.

Juvederm, Restylane, Perlane, Belotero, Prevelle Silk are HA fillers

juvederm boxBelotero Box

We use hyaluronic acid fillers, commonly referred to as HA fillers. The brand names of the fillers we use are Juvederm and Belotero. One of the benefits an HA filler is that they are dissolvable. There are two main products used for this purpose. They are Hylenex (hyaluronidase human injection) and Vitrase (hyaluronidase Ovine). Vitrase has an animal source; Hylenex has a bacterial source and is synthetic. Therefore, Vitrase sometimes requires a skin test/allergy testing. This would not be ideal in an emergency situation.

belotoro balance shelf

Emergency Kit: Butterfly needle with tubing, Hylenex 150 units, and Nitropaste

220px-Butterfly_needle hylenex(image)

If you had a vascular occlusion complication while injecting filler, you would use a butterfly needle to attempt to get into the occluded vessel by aspirating for a “flash”. If you get the “flash” then you are within the vessel and Dr. Lee would inject Hylenex – perhaps even up to 150 units of Hylenex. Even without a “flash”, Dr. Lee would still consider injecting the Hylenex. Then Dr. Lee might apply 2% nitropaste (for vasodilation) or a warm compress to this area with some massaging of the area to keep the blood flowing through the area.  The patient would then apply nitropaste at home 2-3 times per day if patients didn’t get severe headaches or light headedness from the nitropaste.

He would do the same even if a HA filler wasn’t used – such as Radiesse. He thinks that the Hylenex would dissove some of the body’s native HA and thus make more room for the vessel and hopefully un-occlude the obstruction.

Dr. Lee asked me to tell you that this is an excellent project idea, especially if you are an aspiring nurse injector. He says that filler emergencies are rare but it’s good to be prepared. Please do not hesitate to call me at (209) 551-1888. Also feel free to read Dr. Lee’s Botox blog.

Feel free to visit our main Modesto Botox home page.

BOTOX is now approved by the FDA to treat Crows Feet

It’s official:  Botox approved by FDA for the cosmetic treatment of crows feet

Hot off the press:  Today:  9/11/13.  These are my views as a Botox injector in Modesto, CA.

Botox for Crows Feet? No, crows do not stop walking after treatment, and No, it’s not something that veterinarians can do for your pet bird.

Crows feet are those wrinkles around the corners of the eyes.  Sometimes these are even called “fish tail”.  Medical folks are somewhat inclined to call this area lateral canthal lines.  The original cosmetic approval of Botox was in 2002 for the treatment of glabellar lines which are cause by a complex of muscles involved in frowning between the eyebrow area.  Botox now has FDA approval for effectiveness and safety in the crows feet area after studying over 800 patients.


But haven’t doctors been treating crows feet for awhile?

Yes, doctors have been using Botox to treat crows feet wrinkles for many years.  This is called using it off-label FDA usage of Botox – and based on a doctor’s professional discretion.  FDA website.

How Long does Botox last in the Crows Feet?

Botox typically has an effect in my experience and Modesto based practice from 1 to 6 months.  But the results are usually dose dependent.  Meaning that the higher the dose, the longer it lasts.  But there are some minor factors which depend on Botox injection technique and patient factors – but for the most part it is dependent on the amount of Botox injected.

What’s all this about eyelid swelling after Botox?

There’s the risk of eyelid droop.  Then there’s the well known risk of eyebrow droop.  And there’s another complication of eyelid swelling.  The periorbital muscle is the muscle which causes most of the crows feet.  It has the function of closing the eye shut which also serves to squeeze fluid and edema out of the area.  Theoretically if too much Botox was injected into the periorbital muscle – obicularis oculi, it can hamper this mechanical function of squeezing out excess fluid and thus swelling can dwell in the eye area.  However, this is not to be confused with a temporary (few minutes) swelling that appears with the injection site of Botox.  These are small temporary blebs/bulges in the skin which appears as the Botox is injected in a liquid under the skin.  Confusing?  Yes, but these risks are unusual and injectors worry about them so the patients don’t have to worry about them as much.

How about competitors to Botox?  Do they have Crows Feet Approval?

Not yet, the other neuromodulators, which are Xeomin and Dysport do not yet have approval for crows feet.  It is up to the manufacturers whether they want to obtain this type of approval from the FDA.

How will this new FDA approval change my Botox practice?

  1. I think it gives the patients a greater feeling of safety for this product.  Thus I think it is useful.
  2. It becomes easier to pick a product which is FDA approved for the desired effect.  ie.  When deciding between the different neuromodulators available to the Modesto, CA, USA market:  Dysport, Xeomin and Dysport.
  3. I think we would see more advertisements coming from the Allergan company regarding crows feet Botox.  Allergan has historically been very good at advertising directly to the public.


Other Botox related links

Botox Development built into Brilliant Distinctions

The Best of Brilliant Distinctions for the practitioner

Calvin Lee happy with computer
I’m the kind of guy that gets frustated easily with computers, but I’ve found some great features from Brilliant Distinctions which is a computer driven program which brings Botox customers back with coupons and rebates.

Please feel free to view our Modesto statistics with Botox and the Brilliant Distinctions Program.

I like how Brilliant Distinctions emails the patients reminders

  • After a certain period of time, and from time to time, Brilliant Distinctions emails customers reminders regarding Botox, Juvederm, Latisse, and other Allergan products.
  • They will sometimes mail reminders when a patient is about due for their Botox cycle.
  • They will sometimes mail special rebates.  This, I know our Botox / Juvederm / Latisse patients enjoy getting.    These rebates are somewhat intelligent and can target a population who hasn’t tried a particular product.
  • They also sometimes mail reminders if they have coupons or points which are about to expire.
  • In a way, Brilliant Distinctions, keeps the patients connected with these products which I carry in my office.

I like the discounts Brilliant Distinctions gives patients

I sometimes tell patients that BD stands for “Botox Discounts”.  But as we know BD stands for Brilliant Distinctions.  As the owner of a medical office, I personally dislike sporadic discounts because I think our prices should be a great value all the time.  But BD takes that work out of my hands and gives discounts to the patients for me.  The patients love discounts.

I like how it ties one product to another

When someone likes the results of Botox, they would most likely like the results of other aesthetic related products such as Juvederm and Latisse.  The coupons from Brilliant Distinctions act as a bridge introducing other products we carry in our office.  The coupons are the bridge, the products are the gateway to other excellent products which make our patients happy and confident.

My favorite part: BD Analytics

With analytics, we can easily see which patients might benefit from a nudge from our practice.  I personally appreciate nudges from coaches.  In many ways, we are the beauty coaches for our patients.  Using the analytics section, we can identify patients who have “slacked” off from a routine maintenance program of restoring youthful appearaces at our office.  Once identified, we consider giving the patients a phone call to see if we can help.  Or perhaps we need to find out about some things we need to improve upon.  It’s a diligent disciplined approach to life that yields the best results – the same can be said for achieving and maintaining health and beauty.  BD analytics is very customizable, and allows one to find patients who have expiring coupons, or who haven’t been to the office in a certain period of time.   Calling these patients will improve our retention rate, and by contacting these patients, we will improve their outcomes from having a disciplined approach to Botox, Juvederm, Latisse, and skin care.

If you have basic spreadsheet (ie. Excel) skills you can manipuate the data to further assist you in your practice.  For example, I wanted to show my staff how we grew, we were able to use BD analytics to show how many unique patients we see per year for Botox and for Juvederm:

Growth of my Botox and Juvederm practice over the last three years since we started with Brilliant Distinctions, a program for coupons developed by the Botox company - Allergan.
Growth of my Botox and Juvederm practice over the last three years since we started with Brilliant Distinctions (BD).  These graphs were drawn in Excel using data from Brilliant Distinctions Analytics.  Click to see a larger version of the graph.

Overall, Brilliant Distinctions can grow our practices.

There’s automatic growth by using Brilliant distinction, and there’s purposeful growth by putting energy into the program and using BD analytics.  Once you start building up patients in the program, BD analytics eventually becomes one of the most valuable parts.  The more you put into Brilliant Distinctions, the more you’ll get out.  You need staff training, time, and the opportunity to sharpen your spreadsheet skills.  All is worthwhile.

My patients love the coupons, they love crossing over into other products in the Allergan family, and we have become better practitioners for allowing them to get a lower cost, giving them chances to try other excellent products, and with this tool, we can also monitor patients who might become “lost to follow up.”

Calvin Lee, MD
Modesto, California.

a use for calvin lee  profile picture DSC08729 -brighter

Calvin Lee, MD is a graduate of Brown University Medical School.  He is a General Surgeon who works with his Plastic Surgeon wife, Dr. Tammy Wu in a practice called Surgical Artistry in Modesto, CA.

Links related to Brilliant Distinctions by Calvin Lee, MD

  1. Please feel free to view our statistics with Botox and the Brilliant Distinctions Program.
  2. Add Allergan’s Brilliant Distinctions Program to your Website’s Social Media Buttons – an article about Brilliant Distinctions written by Calvin Lee, MD for MedicalSpaMD publication.  Brilliant Distinctions program created the custom sized logos found in that article.
  3. Modesto Botox Home Page

Botox in Modesto – Consider having it done by Calvin Lee, MD

Botox in Modesto:  I hope you will consider me for your injections

botox picture with arrows
Locations for potential Botox use. Some of these injections are considered off-label FDA usage of Botox.


THE BASICS of my Modesto Botox practice:  

I created Surgical Artistry with my wife, Dr. Tzuying Tammy Wu, Modesto Plastic Surgeon.  I am a surgeon & violinist.  I have enjoyed playing my violin at Carnegie Hall in New York twice thus far.  Originally from New York City, I moved to Modesto, CA in the year 2003.  Highlights of my educational life are getting accepted to all the universities which I applied:  Harvard, Stanford, MIT, Yale, and much more.  After careful decision, I felt Brown University was best for me and that was where I met my wife, Dr. Tammy Wu.  She eventually graduated with a #1 designation from our class at Brown .  Surgical Artistry is proud to be founders of the  Surgical Artistry Modesto MarathonModesto Symphony Pops Series, and the Gallo Center for the Arts.


I would like to think of all my patients as my friends. Friends should be honest to each other.


My staff counted once, and I use up about 500 needles per day. I use needles for acupuncture, vein injections, Botox, Juvederm, Belotero, and DermaPen. Doing surgery with needles is what I do at Surgical Artistry. So if you need medical procedures which involves needles, please consider me.


For my music with the violin, I understand the creation of art which appeals to one’s positive emotions. This artistry is the same for the subtle changes that I need to make when injecting Botox and dermal fillers (Restylane, Radiesse, Perlane, Juvederm, Belotero, etc).


I think at least 50% of creating a great result is based on understanding the patient’s goals and vision, and then also communicating expectations and trade-offs.  The final result is the result of teamwork with me, my office and my patient.  This type of communicative teamwork requires time and patience to achieve the desired result.


I am a surgeon and an instrumental musician – these are two things which improve my dexterity every day. Having precision is a high priority in my life.

Doria Bybee  - Audrey Saint-Gil Copy - Copy


Why? Because my plastic surgeon wife will kill me otherwise. Well, kidding aside, I am dedicated to great results for all the modalities I offer at Surgical Artistry: Acupuncture, Botox, Dermal Fillers, and Veins. Great results and happy patients are what fuels my enthusiasm and purpose on this planet.

a use for calvin lee  profile picture DSC08729 -brighter

Calvin Lee, MD
(209) 551-1888 (office in Modesto, CA)

Growth of my Botox and Juvederm practice over the last three years since we started with Brilliant Distinctions, a program for coupons developed by the Botox company - Allergan.
Growth of my Botox and Juvederm practice over the last three years since we started with Brilliant Distinctions, a program for coupons developed by the Botox company – Allergan.



Here are some reviews found on my Yelp page:

These are the filtered out reviews which I think are very valid and thank you to those who took the time to write and I’m sorry they got filtered out on Yelp.  I have no control over that

This kind review is about my acupuncture practice

Review Yelp by Nancy

“Dr. Lee is great!  I’ve been going to him for years for various health issues, especially stress.  It leaves me so relaxed with a lasting effect and is very healing.  I am unable to go longer than a month without seeing Dr. Lee because it keeps me healthy like nothing else does.
Dr. Lee has even given me acupuncture for wounds and the flu that have healed much faster than usual.  He’s easygoing and really good at what he does.  It’s very important to be calm, so the energy blockages can be released and your chi can flow again and bring healing.  Before acupuncture, I could not feel the energy at all because I was so blocked.  Now I can feel it as soon as the first needle goes in and my feet vibrate with all the energy that flows.  I highly recommend Dr. Lee.”

This other very nice review is regarding my Botox practice

Review Yelp by Debra


“Dr Lee is amazing with botox/juviderm injections. He is extremely people oriented and has a fantasic bedside manner. His results for getting rid of unwanted wrinkles  are fantastic and almost painless I will continue to go to him in the future and hightly reccomend his services if you are looking for injections !!”

I would love to get more Yelp Reviews:

I would love to hear more review (hopefully positive feedback? – if you feel I deserve it).

Review Dr. Calvin Lee, MD Botox and Acupuncture on Yelp

Thank you.

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