Monthly Archives: November 2014

Medical Botox vs Cosmetic Botox, differences?

BOTOX® Medical and BOTOX® Cosmetic

The BOTOX formulations are the same.  But the uses are different.  As the terms say, BOTOX medical is used for Medical purposes.  And BOTOX Cosmetic is used for cosmetic purposes.  There are many OFF-LABEL FDA uses of BOTOX, but here we explore the ON-LABEL uses for medical problems and cosmetic problems.

Medical uses of BOTOX
Sometimes called BOTOX THERAPEUTIC

More specifically, medical uses of BOTOX which are ON-LABEL FDA:

  • BOTOX for Overactive bladder symptoms
  • BOTOX for Urine Incontinence due to neurological disease
  • BOTOX for Headaches, specifically chronic migraines (15 or more days each month, longer than 4 hours each day)
  • BOTOX for upper limb spasticity
  • BOTOX for cervical dystonia
  • BOTOX for strabismus: an eye muscle problem
  • BOTOX for blepharospasm: an abnormal spasm of eyelids.
  • BOTOX for axillary hyperhidrosis
BOTOX Injection sites for Blepharospasm

The BOTOX injection site picture from Allergan.  BOTOX has been the main blepharospasm treatment since FDA approval in 1989.

BOTOX injection sites for Blepharospasm treatment.  Picture from Allergan.  BOTOX has been the main blepharospasm treatment since FDA approval in 1989.
BOTOX injection sites for Blepharospasm treatment.

Cosmetic uses for BOTOX

  • Glabellar lines = Frown lines between the eyebrows.  Botox was approved for usage for cosmetically reducing the appearance of wrinkles, temporarily between the eyebrows in patients between the age of 18 to 65 years old.  This was approved by the FDA in 2002.
  • Crows feet = Lines on the side of the eyes.  In September 2013, the FDA approved Botox for use in the crows feet area.  Botox for the Crows Feet – a entry in my Modesto Botox Blog

Again all the above mentions are FDA approved – ON LABEL usage.  There are other medical and cosmetic uses of BOTOX but they require a physician to determine the possibility of OFF LABEL-FDA use.

Differences in Dosages in Medical Botox vs. Cosmetic Botox

Usually many more Botox units are needed for medical indications than for cosmetic indications.

Disclaimer for this BOTOX webpage:

Unless you are directly looking at my actual crows feet and my glabellar lines, there is no establishment of a doctor-patient relationship.  Please see your own doctor’s wrinkles in person so that you can get medical advice.  Above is for information only – not to be considered any sort of medical advice.  Furthermore, looking at a picture or video of my crows feet and glabellar wrinkles does not count – it has to be a live and in-person viewing.


Monthly Botox Chart – November 2014 update

Botox Patient Charting

Background info

For fun, I like to see trends.  And I like to use the functionality of an old Excel spreadsheet.  I use Excel 2003 – it just seems most comfortable to me.  I have updated version of Excel which I use but I still always seem to go back to the 2003 version.  Just my preference.  I make these charts based on data from Allergan’s Brilliant Distinctions – I also keep track of other Botox Statistics related to our Modesto Botox Practice.  I also have 2013 Modesto Botox Statistics.  I’m getting ready for 2014 Botox Statistics, but 2014 isn’t completely over yet.  In fact November isn’t over yet either, but the next working day is Dec 1, 2014.

The Botox Patient Monthly Chart

Botox Patients Per Month
Botox Patients Per Month.  Click larger.
  • The dip in September 2014 for Botox patients is due to a two week vacation away from the office.  The much of the vacation was work related.  With visits to other Botox practitioners, Acupuncture centers, and Qi-Gong lessons.
  • The orange arrow was drawn in by hand; there was no mathematical method done for the rendering of that line.
  • December 2014 is missing from the chart because December hasn’t come about yet.
  • It’s interesting to see that the growth so far seems to be linear.
  • The chart starts with the very beginning of 2011 where a large part of my practice included General Surgery, Veins, and Acupuncture.

Some generalizations from the BOTOX chart

Regarding our Modesto Botox – Plastic Surgery Practice:

  • In 2011, the average number of BOTOX patients per month was 22.5
  • In 2012, the average number of BOTOX patients per month was 42
  • In 2013, the average number of BOTOX patients per month was 60
  • In 2014, the average number of BOTOX patients per month is 82.9
  • We await December to finalize the 2014 number above.

BOTOX Predictions

This linear growth will start to level off in 2015.  Why?  Because I am totally running out of appointment slots.  That’s fine with me.  I’ve made peace with the idea that I’m not aiming to be busier.  I just am just aiming for higher quality with each visit.  I’m looking forward to December 2014, and a New Year 2015!


Botox Report: Number of Patients for the Month

Brilliant Distinctions Analytics Section

I’ ve been playing around with Botox’s Brilliant Distinctions reporting.  Brilliant Distinctions is a rebate/coupon type program run by the Allergan company for our Botox patients.  I pulled up a custom report with the dates in November 2014, and selected it to produce a list of Botox patients.  This is in the analytics section.  Then I look at the reports on an excel spreadsheet.  I also keep my own Modesto Botox and Juvederm Brilliant Distinctions Statistics.

November’s Botox Numbers: 96

The results reveal a grand total of 96 patients seen for the month of November, 2014.  November has typically been a busy month for Botox at our Modesto Botox Practice: Surgical Artistry (Injections by me: Calvin Lee, MD).

96 Patients – well, this hasn’t been our busiest month this year.

I did hit over 100 patients last month.  A while back, I wrote a blog regarding the elusive 100 Botox patients per month goal for my Botox practice.  Botox and Fillers takes up half of my practice; meaning it takes up half of the practice when using time as a measure.  So it takes up half the time – stated more simply.

123 Patients seen in the month of October, 2014

October, which is last month, revealed a large surge of Botox patients into our office with 123 patients seen.  Overall, I think the Botox trend is an upward one.  Perhaps this is a reflection of the overall economy.

Excuses for not hitting 100 Botox patients this month? (with Thanksgiving in it).

Well, there aren’t much excuses except that it isn’t that big of a goal for me anyway.  My main goal is excellent results with Botox – not huge numbers of Botox patients.  But Allergan’s Brilliant Distinctions Analytics does make it fun to extract these numbers.  And… December is another month to look forward to.

Does Botox Hurt?

Do BOTOX shots hurt?

That’s a better rephrasing of the question of “Does Botox Hurt?”

This is a question I get in my Modesto Botox Practice – Surgical Artistry – almost every single day.  It’s a difficult one to answer because everyone is different.  But I’m going to attempt to answer it in this blog.

The quick answers from me:

It is sometimes tempting to answer with: “Let’s try it and see.”

Or, sometimes I’m tempted to say “It doesn’t hurt me one bit when I’m injecting it.

EMR frustrations Calvin Lee
Not to worry, I don’t use a hammer when injecting BOTOX.

OK, some serious thoughts on the topic of BOTOX pain:

In general, most people think that BOTOX shots hurt a little bit but is bearable.  I would venture and say that perhaps people even look forward to coming back for BOTOX shots.  Perhaps they forget how painful the shots could be.  I get BOTOX injections myself, and I would say that they hurt a little bit but not enough for me to complain about it.  But I also think that there are variables to what causes pain with BOTOX injections:

What are some causes of pain with BOTOX shots?

I’ve divided these into Injector and Patient factors

– Injector factors

  • Injection technique  – “hands of a woman, heart of a lion, eyes of an eagle” – a strange mantra passed on to me by a surgery mentor while I was a Surgeon-in-training.   There is so much to this topic – it wouldn’t all fit here.
  • Size of the needle.  Smaller is usually better.
  • Did we hit bone? ouch!  But sometimes this is part of the technique to gauge depth.  Not usually necessary though – in my humble opinion.
  • Is the needle dull? – a dull needle causes more pain.  I have found that needles – even from the same batch might be sharper or duller when brand new out of the box.
  • Did the needle become dull?  It could become dull after a few shots (same patient of course!).  The Botox injector could change the needle after a few shots to start “fresh.”  Or the needle could become dull if it was purposefully or inadvertently “banged” against certain anatomic structures such as bone, or it could have been used to extract the Botox from the sterile bottle (not my practice – though).
  • How often are we going to change the needle?  Changing it often is a good thing, especially with the smaller needles.  Smaller needles dull pretty quickly.
  • Did we hit a nerve?  This would hurt.
  • Did we hit a blood vessel?  This would hurt too.

– Patient factors

These are just my thoughts from my experience of injecting Botox patients:

  • Nervous patients usually feel more pain.
  • Tensed muscles usually get more pain.
  • Patients who squirm around during injections usually suffer more pain.
  • Patients who haven’t experienced raising children (or birthing them) usually experience more pain.

Summary about pain with BOTOX shots

Pain is a very individual experience.  But I’m glad to report that lots of patients like their BOTOX visits and come back regularly for more BOTOX visits.  I think that tells me that it isn’t a really terrible pain.  And I consider myself to be the biggest CHICKEN in the world (just ask my wife the Plastic Surgeon), and I think that BOTOX shots are just fine for myself.

My wife, Dr. Tammy Wu, by the way, won the Best Cosmetic Surgeon award this year.


I’m vegan, I need to find a different word for “CHICKEN.” – perhaps a future blog.  Please see your own injector regarding Botox Pain Perception questions.  Reading this blog does not automatically make me your doctor.  Read at your own risk.  Do not try this at home.  The FDA has nothing to do with this web page.

Please visit my Modesto Botox Home Page for more important information.

Modesto Botox Home Page

Botox Delivery – what it looks like in a box.

Ever wonder what it looks like when BOTOX is delivered to an office?

Here’s what the boxes look like.  Inside these shipping boxes are styrofoam containers with dry ice on one side and individual BOTOX boxes on the other side.  These three BOTOX containers added up to a shipment of 50 vials of 100U Botox.   I have delivery of this amount of BOTOX before and it came in one large container – so I think it varies from time to time.   I don’t see any obvious advantage to breaking up the BOTOX shipment.  But perhaps Allergan decided that it was better that way – or they just simply ran out of larger BOTOX shipment boxes.

A tower of Botox!  Delivered to our door.

Botox Delivery.  No, it's not Pizza Delivery.  It's better than Pizza!
Botox Delivery. No, it’s not pizza delivery. It’s much better than pizza!

This is a picture at our Modesto Botox Office of Botox delivery boxes ready to be stocked and recorded (lot numbers).  It needs to stay refrigerated.

Botox WiFi?

How is BOTOX and Wi-Fi related?

Basically BOTOX shuts down the signal (this signal can be thought of as “WiFi” for your phone) between nerve and muscle.  There is no alteration of the muscle – just like when the WiFi signal is shut off, there is no alteration to your cell phone.

I’ve come up with this original analogy one day when talking to a patient who was cellular phone sales person.   WiFi is a trademark name and is considered at this point, any wireless local area network for computers.


First, in general, how does BOTOX work?

What’s the mechanism of action for Botox?  Botox prevents the tensing up of muscles.  The word “tensing” could be also be considered “contracting.”

Medical professionals consider BOTOX to be one of the most effective ways to maintain youthful beauty.

botox mechanism  botox mechanism 2

In more detail:  how is Acetylcholine involved with BOTOX?

Acetylcholine is the signal for muscle contraction.

Botox reduces the release of acetylcholine from the nerve endings.  It is the acetylcholine, which is a neutrotransmitter messenger, which tells the muscles to contract.  Without the acetylcholine released, the muscles stay in a more relaxed configuration because it doesn’t get that signal for contraction.

Thus, the real analogy is that Acetylcholine is the Wi-Fi signal

Acetylcholine carries the signal for muscle contraction.  Just like WiFi carries the signal for my internet connection.  Botox works on reducing the signal.

Anyway, that analogy is a fun one, and I’ve enjoyed using it in my explanations in my Botox Consultations at my Modesto Botox Center: Surgical Artistry.

So, muscles cause wrinkes?

Yes and No.  Yes, muscle CONTRACTION causes wrinkles.  Thus if we cut the signal for muscle CONTRACTION, the wrinkle isn’t crinkled.  But the muscle by itself in a relaxed state does not cause wrinkles.  So the key word here is contraction.

Disclaimer:  I am by no means trying to say that Botox gives you a better WiFi signal.

That would be interesting and probably very useful – but it doesn’t work that way.   I was just trying to use some real life examples to explain Botox to my patients.  Please see your Botox doctor, nurse, or aesthetician in person for a personalized discussion.  There is no patient-doctor relationship set up by reading this article.  Nothing here is medical advice.  This is just generalized information.

What is Botox FDA approved for cosmetically?

Glabella and Crows Feet

As of the writing of this Botox blog which is November, 23, 2014.  Cosmetic Botox on the face is FDA approved for use in the glabellar complex and the crows feet.  The glabellar complex is sometimes known as the “11’s” or the frown lines between the eyes.  It is made up of more than one muscle – thus it’s a complex of muscles.  And the crows feet, sometimes called fish tail, area of the eyes is the lateral wrinkles to the sides of the eyes.

How about other areas of the face for Botox Injections?

These two areas constitute the FDA approved areas for facial Botox in a cosmetic sense.  There are other areas on the face – in fact many other areas – which have not received FDA approval, but these have been commonly done for the past decade.  And Botox injections in these other areas of the face is considered off label FDA for Botox usage.

Getting Botox in Modesto, CA

Please consider visiting your Botox injector for one-on-one discussions.  If you are near us, consider visiting our Botox practice in Modesto, CA.  And if not us (Surgical Artistry), then there are these other places in Modesto to get Botox.  The Botox listing of injectors is not an endorsement; it is just a courtesy listing of other practices in Modesto who offer Botox.

Belotero Balance Injection Technique – a unique method

Belotero Serial Puncture or Serial Killer?

Belotero offers a dual cross-linking process of the hyaluronic acid which offers a natural-even integration into the dermis.

This Belotero page is for Botox/Belotero injectors.  And I’ve decided to call this Belotero injection method the “aerial dive bombing technique.”

I have my own version of this technique, but it’s more of a “submarine missile attack” (more on this someother day).  Actually I personally think that my idea is superior – well at least in my small hands.

Injection technique with BELOTERO BALANCE is simple and accurate

When injecting using the serial puncture technique, it is important to remember the following:

  • Penetrate the dermis just until the bevel of the needle is hidden.10
  • The needle’s bevel measures 0.75 mm in length.*
  • Typically, the dermis measures approximately 1.8 mm in depth.
  • Once the bevel is buried, filler can then be deposited accurately within the dermis.
  • Then repeat the process multiple times per wrinkle line.

*Bevel measurement based on the needle included with the BELOTERO BALANCE syringe kit.

Superficial injection of Belotero works!
Superficial injection of Belotero works!

For Killer results, consider the techniques above

and consider visiting us at our Modesto Surgical Artistry Botox Injection Center by Calvin Lee, MD

Lowest price Botox?

Lowest Botox Price matching?

We get this question from time to time regarding matching the lowest price of Botox or Juvederm.  It isn’t a common question, but it comes up perhaps once per month or so.  I figure it’s worth addressing.

This is not a blog about different Botox-like substances or Botox from other countries.  We receive our Botox directly from Allergan USA, that ensures that it is genuine.  So back to the topic of “Lowest Price for Botox?”

So, do we price match or compete on pricing?

The quick answer is “No.”

But we like to compete on “value”.  But in the end, we don’t see this as a competition.  We have a lot of respect for everyone.  We have set prices that make sense to us.

So the long answer is that we hope that we are considered the “best value.”  But all this depends on what patients value.  It might be different than what I might value.  So I can definitely understand different definitions of value when it comes to Botox injections.

Surgical Artistry doesn’t emphasize or compete with “cheapest” prices.

Our Botox Surgeons (mainly Calvin Lee, MD) value a high level of

  • results
  • safety
  • and comfort.

And the Office values a high level of

  • customer service
  • positive attitude
  • and communication

We hope to win with BEST VALUE.  I think we would lose the battle if we were going for price wars on Botox.

But hopefully we might win with best value – that’s our attempt.

Here’s a link to another topic of Botox Wars – The fight for Allergan Ownership.


Botox didn’t work for my “11s”

Botox didn’t work.  I still have those creases between the eyes!

I hear this problem from time to time.  Botox has a hard time with certain creases in the glabellar complex – and also in the crows feet.  Why?  because for me, it doesn’t seem to work very well on static lines.

Static lines vs. Dynamic lines:  this is the reason

Dynamic lines are wrinkles that are created with movement.  Static lines are wrinkles which are present even when the muscle is at rest – relaxed.  Botox main mechanism is to relax the muscle.  Although, I have seen Botox’s effect on possibly tightening skin – but that’s a different topic.

Botox works best on Dynamic lines

By relaxing the muscles, the dynamic lines diminish.  However, Botox has a harder time relaxing static lines.

Dynamic Lines eventually become Static Lines

It seems to me that most dynamic lines eventually becomes static lines.  Thus Botox works amazingly well in my opinion in preventing static lines.  This effect of Botox is one of it’s best uses.

So what can we do about these stubborn Static Lines?  More Botox?

I also believe that with some patience static lines can diminish over regular usage of Botox – perhaps after the 3rd or 4th time of getting Botox over 1 year.  I wouldn’t let too much time lapse between botox treatments.   I don’t think necessarily MORE botox per session is the answer – but perhaps more diligent usage of Botox – or perhaps a more “disciplined” approach to Botox scheduling.  Don’t forget to schedule your Botox Appointment with us in Modesto, CA.

Consider fillers or more time to help with these stubborn wrinkles.

So if time is on your side, and you can wait it out – consider waiting a bit to see if Botox will assist your body in repairing these deep static wrinkles.  However, if there’s a deadline (special event coming up), some of our patients would consider dermal fillers such as Belotero or Juvederm.  Much of this use would be considered off-Label-FDA usage.  Dermal fillers within the wrinkles will help smooth them out!

Disclaimer: please see your physician in person for personalized recommendations.  Above is just an academic discussion of wrinkles, Botox, and Fillers.  I have also encountered lines which just didn’t seem to be helped much with either Botox or Fillers – the human body is certainly very challenging, and keeps our jobs as Botox injectors very interesting.  Here’s a list of Modesto Botox Injectors – but of course, I hope you choose our practice (Surgical Artistry in Modesto).