Favorite part of owning your own Plastic Surgical practice

“What’s your favorite part of owning this practice?” I got this question today from an employee. I think it’s a great question!

Here’s my response and I thought I’d just share:
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It’s OUR plastic surgical practice.

First, I don’t really feel that I “own” the practice alone. I hope the employees can see that they own a piece of this too through their hard work.

I feel that this is all of ours together. I would love to share the successes of the practice. But I would take all the blame.

I work for the “employees” of the practice.

There is so much that I love about this practice so one favorite is hard to pin down.

I like the FREEDOM to do what I think is BEST for our patients

I love what we do for our patients. I like having our own practice so that we can go beyond the “standard of care.” Others might strive to achieve the standards of care. For us – the standards are the minimum level. I like being able to go the extra mile and not have someone tell me that I’m wasting time.

And I love to be generous with my time with the patients when possible.
I like being able to make my own decisions that would result in outcomes which would be the very best for our patients.

I like to GIVE BACK to those who believe in us.

And for the employees and our representatives who believe in us, I are very grateful for having them put their trust in us, and spending time with us. I hope to give back. I personally take a lot of pride in watching our team grow. And sometimes I do take pride in watching our team move on. Although sometimes sad for me on one level, but happy for me on another. I do want to prepare the team to be able to move on beyond what we do if they choose to do so – like become a nurse or doctor or work at another office. It is important for me to be able to give back to those who choose to believe in what we do.

Surgical Artistry is a reflection of WHO I AM.

I also have a lot of growing to do, and as I improve, I like watching the practice improve as well.

Botox Drift Question

Hi office,

Hannah asked this Botox eye-droop question on email which I’d like to share with the rest of the office.

In the case of an eye droop due to the Botox drifting, why is it that the eye droop only lasts for 2 weeks if the Botox is active in the system for 3-4 months?

It’s because the Botox wasn’t injected directly into the eyelid. When a Botox droplet drifts into the eyelid muscle (Levator palpebrae superioris muscle) from the corrugator glabellar muscle it would only be a tiny droplet and wouldn’t last very long because it wouldn’t be a full dose. The lower the dose of Botox, the shorter the duration. Sometimes when I inject (with the patient’s urging) with a very high dose of Botox, I’ve notice that Botox can last 5-6 months! I’ve found in my own Botox practice that Botox duration of action is dose dependent.

Avoiding this shifting of Botox is why we have our patients refrain from rubbing or pressing on the Botox injected areas for about 4 days after the Botox injection.

I hope my explanation is clear.

Great Botox question!

What is it like to be a doctor?

I was recently asked to answer these questions as part of a student’s assignment for school. She wanted a surgeon to interview. I have elected to answer these questions as the surgeon that I am today which is different from a decade ago when I was a trauma/general surgeon. Now I am a surgeon who does acupuncture and cosmetic injections (Botox, Fillers, Kybella – neck, Asclera – veins). For more information, consider visiting my other webpages www.InjectionArtistry.com and www.SurgeryToday.com

Describe your work environment.

I am a surgeon with additional training with acupuncture and cosmetic injections. I have worked as a general surgeon and trauma surgeon. In 2006, I decided that I was going to dedicate my surgical skills to working with needles for the majority of my work as a doctor. I became an acupuncturist and learned cosmetic surgery from my wife, Dr. Tammy Wu, who is a plastic surgeon. Our practice is Surgical Artistry, and one of the main focuses of the practice is cosmetic surgery. About once or twice a month, I have days where I assist the entire day in surgeries with Dr. Wu or other surgeons in our area. For the most part, I am now mostly an office based doctor – as opposed to one who sees patients in the hospital. I use three different acupuncture rooms to see patients with varying problems ranging from back pain, neck pain, headaches, athletic injuries to fertility acupuncture. And then I have one large procedure room where I see my cosmetic injection patients. The lighting and space design is different in each of these rooms based on the procedure intended for the room. Surgical Artistry has two physicians – myself and my wife, and at this time 4 full time employees. We like to keep our work environment clean and neat and be a sanctuary for health and wellness. It has an open feel to the environment for our employees as we want to foster good communication with our team. We believe in having our patients be beautiful both with health and appearance.

What’s a typical day at work like?

As a surgeon who focuses on acupuncture and cosmetic injections, I see patients from 8am-5pm. I try to start on time as much as possible and I try to stick to the schedule. I dislike having patients wait. Half of my usual day is dedicated to acupuncture and the other half to cosmetic injections. I go from room to room with no break in between. I find time for my “breaks” when patients don’t show up or are late to the office. That is when I prepare a batch of Botox, catch up on emails, enjoy some facebook (my facebook page), maybe even grab a quick bite. I don’t take a formal lunch break. I usually work till about 5:05pm. That’s when I start to have time to write my office medical charts which are important to document the day’s work. This allows me to record for future medical use when the patients come back, and thus, I can improve on their care. The medical charting usually takes me about 1-3 hours. Then I go home. But sometimes I have to take care of business matters especially since Surgical Artistry is my business. Sometimes there are employee matters, bills that need to be paid, or leaking roof issues. So at times I don’t go home till 1am in the morning. This is pretty much most of my days Monday-Friday. There are a few days per month which I reserve for surgery assisting where I give my staff a break from my daily grind; I am not at the office on that day, I would spend my day at the hospital going from surgery to surgery. And my staff spends that day catching up on their paperwork in the office. The hospital and my office are not connected. I think there are some lucky doctors who have an office inside a hospital. Or maybe they consider themselves unlucky because they never get out of that work environment. Regardless, I have to drive to the hospital from my office and I work at a handful of hospitals such as Stanislaus Surgical Hospital, Doctors Medical Center in Modesto, and Sutter Memorial Hospital in Memorial. on Stanislaus Surgical Hospital’s home page, they actually have a picture of me as the operating surgeon on their header!

What are the three most important responsibilities of your job?

First most important responsibility is getting the patient the best results that I can. Second most important responsibility is to do this as safely as I can. This involves good technique and good knowledge. The third most important responsibility is managing patient expectations – which means that I should spend the time communicating well with the patient and letting the patient ask questions, and I should try to think of questions that the patient might not have thought of himself/herself.

What technical skills do you need to do your job?

A tremendous amount of technical skills are required. Skills involved in navigating around anatomy so that needles are placed accurate. Steady hands are involved to insure precise delivery of Botox or filler. Plus there is technique involved which help prevent injury to the patient if the patient were to flinch. And there are techniques involved which ensures a sense of 3D space and tactile feedback at the tip of each finger. These are skills which I think take many years to develop and I’m still trying each day to get better. I became a surgeon because I am attracted to technical skills with my hands. I received my MD degree in 1997 and every day since then, I’ve been continually trying to improve.

What people skills do you need to do your job?

To be a surgeon, acupuncturist, or cosmetic physician. One has to love people and have a passion for other people’s health. We are teachers to begin with and we need to teach patients about their current state of health and teach them how to improve upon it. We have to be convincing as well to help steer them in paths which may not be apparent or easy to them – such as quitting smoking or eating more veggies. We have to have people skills to communicate well. And we have to have people skills to not only manage expectations, we have to manage our complications. Surgeons are only as good as the complications that we’ve managed. But those complications doesn’t just involve technical skill, they involve all sorts of people skills; We have to listen, empathize, have compassion, instill confidence, communicate effectively, and most of all have patience.

Describe a recent problem on the job and how you solved it.

There are always problems, but by being a cosmetic physician and acupuncturist, my problems may not be as life threatening as a trauma surgeon’s problems. I realize that it is somewhat less stressful for me since 2006. But I have the same passion for making sure I focus completely on patient problems. I’ll just describe something from yesterday’s line of work. I had a patient come into the office for what seemed to be a routine cosmetic mole removal. However, on examination and further questioning, it was revealed to me that it was a vascular type of lesion which had a history of bleeding. The patient was worried that it was going to bleed further because when it did bleed, it was very severe. I decided that I had to postpone some of my patients for a bit of time and take care of this bleeding mole like structure right away. I first fired a vascular laser at the base of this lesion and then removed it like a mole and found the bleeding artery – which continued to bleed – but I was able to place an old fashioned figure of eight stitch around the bleeding artery and closed the skin incision which I purposely made. We sent the mole like structure to pathology to rule out the possibility of cancer. I discussed with the patient that if this lesion continues to bleed at home that he was to call me on my cell phone and I would meet him immediately at my office even if it was the middle of the night. It bled more than the usual skin lesion removal because this lesion was in my opinion mostly vascular in nature.

I had anticipated this problem and thought the laser would stop the bleeding before I even began, made a decision to act on it right away, and encountered more bleeding which I had a plan which was my old fashioned stitching. Then, I made plans for aftercare and in case other problems arise after he leaves (having the patient contact me and meet me at the office). I’m glad I have a background in trauma surgery and bleeding is really not a big deal to me.

What kinds of information do you need use, analyze, and/or stay up to date on how to do your job efficiently?

There are medical journals pertaining to acupuncture and cosmetic injections which I read from time to time. There are also national/international meetings on acupuncture and cosmetic surgery which I attend regularly. There’s the collective wisdom of many doctors who can share experiences and ideas which will help my patients in Modesto. Having the latest info helps me with another aspect of being a doctor – advising my patients on alternatives, even alternatives which I do not have.

How do you think your job will change over the next 10 years? Why?

I think for the most part the acupuncture will stay the same and perhaps become more popular with patients. More and more people in the world seem to be exposed to acupuncture and the idea of healing with less side effects. The art of acupuncture began about 5000 years ago, and I think much of the practice of acupuncture will stay the same. But I do think that more points will be discovered as physicians are now more open about sharing. Regarding cosmetic injections. I think they will become more popular in the next 10 years as patients are looking for quicker procedures, less invasive and less downtime.

What technology and special tools are used by you and others at your workplace?

As a acupuncturist, I don’t think I have any special tools except my hands and a collection of acupuncture needles. For the cosmetic side, there are many tools such as lasers which help with little red veins on the face, etc. However, in my own preference of what I do at work, I try to rely mostly on my hands connected to instruments which do not require too much technology, except for the technology which rendered the instruments. I like special needles for all of my work in acupuncture and cosmetic injections. There is a lot to the property of a needle. It is very much like a violin bow. Needles may all look alike, but they have different characteristics – weight, flexibility, length, angle, sharpness, consistency from one batch to another, and the ability to stay sharp throughout the procedure.

What written materials are used at the workplace?

We have written materials on the safety of chemicals at the workplace. We also have written protocols which I follow for some of the procedures that I perform. Plus we like checklists.

What impact dose the workplace have on the local and global communities?

I particularly like it when I get patients who come from other cities and then get to spend some time enjoying our local economy here in Modesto. For example, I had a patient from San Francisco, who said that she did all her Christmas shopping in Modesto and got to enjoy our lower sales tax rate.

In general, I think I am here to mainly help our patients in Modesto get the best care that they can. Globally, I don’t think I’ll have much of an impact unless others want to learn my techniques.

What academic skills do you need for your job?

The most important academic skill is the ability to keep learning and improving. My knowledge of the human body and experience with operating on the human body are at play every day in my work.

What are at least two ways you apply mathematics at the workplace?

One way is when I have to calculate the cost and dosage of Botox every day. This is simple addition and subtraction. But it is in play all the time. Even when drawing Botox out of the bottle. Then there’s the mathematics of injecting it out of the syringe. You have to make sure you push and stop your thumb at the right moment and that’s math. Botox arrives as a powder and precise but simple math skills are used to convert that powder into a liquid. I also use math skills to determine how to best use 1 syringe of filler in a patients face. The filler is a limited resource and we have a job to do which involves symmetry. Then there’s more abstract and intuitive math which involves angles – especially when using a long needle. Then there’s the mathematics of getting the procedures done under the price budget laid out by the cosmetic patient.

What are at least two ways you apply communication skills at the work place?

I like to have a detailed conversation with the patient in trying to understand their vision of beauty. I have my vision, and many times the patient has their beauty. I need to spend time understanding if my vision and their vision align. If not, I need to really try harder to understand. Then I have to communicate what I am capable of doing – which sometimes may not be enough for the patient. And if I get the feeling that I can’t get my message across, or I can’t understand the patient, then I need to communicate that I am not the right person for the job.

What are at least two ways you apply scientific principles or social studies concepts in your work?

In cosmetic medicine, there’s the economical social studies concept of meeting the patient’s budget, and dealing with the supply and demand of Botox/fillers. We also have to deal with the history of the patients responses to various treatments. In the end, I want to have high yielding efficient results for the patients which they can afford.

We live in a world of science. And medicine is the artful application of that science. So I would say that all that I do as a doctor has a foundation in science which ultimately is an explanation of how things are in the universe. However what we know of science at this point is just small window into how things are in the universe and sometimes we are misled of what we know of science. But I would say that science is the best of what we know at this time. As a surgeon, our main science disciplines is the science of anatomy, the science of physiology, and the science of physics. The anatomy is the science of having identified body parts. Naming these parts allows us to communicate efficiently with others. physiology is the science of how these body parts function. And as for physics, it is the nature of the interaction between surgeon, instrument, anatomy, and its impact on physiology.

What opportunities are there to use creativity or art in your job?

There is always creativity and art in my world of acupuncture, surgery, and cosmetic injections. Every human being is different and every problem is somewhat unique. Thus almost every solution for a patient requires creativity and art. This is why I’ve called my medical practice: “Surgical Artistry.” There are so many different instruments to use, so many different fillers, different needles, different angles, different locations. Plus with limited budgets for cosmetic procedures, we have to think creatively to get the work done. Compromises need to be thought of, but always without sacrificing safety.

As for Acupuncture. There are creativity needed in picking effective points for the patient. Each problem has a unique set of problems. Back pain patients sometimes even have the problem of not being able to lay on the table a certain way. So we have to think of ways to get the patient comfortable – perhaps in a chair or perhaps with rolls under their knees, etc.

How long were you in school?

First 12 years got me past high school. Then I did 4 years of college. Then I did 4 years of medical school. At this point I got my MD degree – but that’s without any formal surgery training. Thus to continue on to become a surgeon, I did 1 year of surgery internship, then I did 5 additional years of surgery residency. At this point I became a board-eligible Surgeon. As for acupuncture, I did 1 additional year after all the surgery training. I think I took the short route compared to other surgeons. There are many surgeons who spent more years in school. I consider all those years to be formal schooling for me. But in many ways I am still in “school” as my patients are my teachers.

How does your job affect your life?

My job is my life. I think I don’t really have much of a life outside of my job. It was much more this way when I was doing trauma surgery, but I got in the habit of living the job – always. I married a surgeon too and we love what we do. I initially picked surgery because I wanted to live that way of life. Surgery isn’t a job, it’s a way of life. But I think I need to start learning to live my life in a different way. Perhaps it isn’t the healthiest way of life for me – I’m starting to realize that and I’m almost 50 years old. In fact, I don’t really respond to my first name – which is really part of a person’s normal life. I respond more to “Dr. Lee.” As that’s who I am and the majority of my life I’ve been called “Dr. Lee.” I know many people go through customer service and say that people feel comfortable when they hear their first names. Not so much in my case… it’s usually my parents or my wife who call me by my first name, and usually if they are using my name, it might mean that I was in trouble. But hopefully as I change my lifestyle and have a life outside of the medical world, I’ll regain my recognition for my first name again.

Why did you want this job?

I was drawn to the world of surgery. I believe it was some sort of calling. I think I liked it because it requires great responsibility and the capacity to make others happy. Perhaps also, it was the ability to fix a problem rather quickly. I also feel that I have a gift of using my hands and wanted to use my gift. In addition, I was drawn to the world of acupuncture because I wanted to have medical solutions with low cost in terms of side effects – I wasn’t happy with some of the side effects created by medications. But in the end, I came to realize that acupuncture is just another branch of Surgery. Blade or needle, either way, we heal with steel.

Will Botox Help lift my inner eyelid? (public forum question)

Will Botox help lift my inner eyelid?

Another public forum question I attempted to answer. This question comes from Corona, California. A photo was attached, but it isn’t entirely clear from the non-moving 2D photo – the goals and wishes of the patient. But I did my best to try to answer the question.

Here’s my answer which all the other doctors don’t seem to understand what I’m writing:

Lateral and Medial Pretarsal Obicularis Botox micro injections

What we’re discussing is consider off-label FDA use of Botox. In my experience, I have treated only 3 patients for eye lid raising with Botox. The injections are extremely tricky.

I would inject the lateral and/or medial aspects of the pretarsal obicularis (which is the eyelid muscle) – taking extreme care to avoid the middle part of that muscle which is connected to the levator (which lifts the eyelid). I would inject about 0.5 to 1 unit with each shot. I don’t want to go into too much detail because this is a discussion you need to have with your injector. The basic theory is that if we weaken a depressor (which are the sides of the eyelid), we help the levator become more dominant.

For mild imbalances in appearance, I would leave it alone. It’s possible for us to make things worse with our decisions and injections. With my only 3 patient trial of this method – this doesn’t make me the expert on this topic. It’s a very rare request.

Basically if your question was an academic style question, I would say that it could be done if I understood your question correctly. But in reality – check with your Botox injector!

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.

Best wishes.

Calvin Lee, MD
Modesto Botox Injector, California

Lip swelling after Juvederm Question

Another public forum question that I attempted to answer:

I had Juvederm 2 wks ago and my top lip is protruding like a duck bill. Will it go away or should I have it dissolved?

I had juvederm ultra plus done 2 weeks ago in my lips and the top is still protruding outward like a duck bill. Will this go away or should I get Hyaluronidase to dissolve it and if I do use Hyaluronidase in the lips will it dissolve it completely and evenly?

My Answer:

Perhaps more filler for the bottom lip but first consider waiting 3 weeks?

It is sometimes possible that the upper lip swells more than the lower lip with Juvederm. In my hands – that happens often because there are just so many more components in the upper lip – thus I have to manipulate the needle and filler in that area more.

Sometimes the swelling could be present for a month after injections, but that is somewhat unusual in my humble opinion. But consider waiting till 3 weeks before deciding to do something different. And if that’s the case – you may just need more filler on the bottom and then you could have the results you wanted in the first place.

Lip fillers are a difficult project for me. I do it every day, but I am still humbled by the artistry and difficulty of the procedure. Best of luck to you.

Here’s my disclaimer:
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.

Thanks for reading.

Calvin Lee, MD
Cosmetic Injections in Modesto, California

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

BOTOX for Hyperhidrosis

A pubic forum questions which I decided to answer using my own experience in Modesto, California as an injector of Botox for this problem of excessive sweating in the axilla (arpits). The question comes from Kansas City, MO.

Is it uncommon for botox for hyperhidrosis to not work the first time?

I’ve had hyperhidrosis since age 13. I finally had botox treatments about three weeks ago, and was sure that this would be my answer. The sweating has improved some, but I still get sweat marks. Which, for the price I had to pay, is incredibly disappointing. I don’t know if it’s worth it to try again or not. My dermatologist’s office said insurance wouldn’t even allow me to get another treatment until it had been 4-6 months. They also said nobody had ever had the botox NOT work for them. Help!

My Botox and Hyperhidrosis Answer

A great question. I can only speak from my own experience as an injector of Botox for my Modesto hyperhidrosis patients. I have had a few patients where the sweating has reduced somewhat after 50U of Botox injected in each axilla (arm pit area). But then they needed more. A carefully planned approach to the remaining excessive sweat areas by using a starch test or even just observation, could help direct perhaps another 25 units of Botox into each side. That’s what I’ve done with some success in my own practice in Modesto California where it does get over 100 degrees F in the summers. I think that 1 in 5 of my patients would benefit from a higher amount. I’ve also worked with excessive sweating in the palms/feet which can be a lot higher in Botox dose.

You’ve shown that it works with the reduction you noticed, and now it just needs more – probably because everyone is different. And perhaps if you had to wait 6 months – it might work even better because I think there would be some overlap of the Botox injections.

My practice doesn’t accept insurances, so I totally understand that the cost can be a concern. But many of my patients think that it is “a new lease on life” as some of my patients claim.

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.

I hope my own experience as an injector helps.

Calvin Lee, MD

two surgeons working at the same time - Crop — Dr. Tammy Wu and Dr. Calvin Lee operating together in Oakdale, California

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

How much is the Unit of Botox?

I got this great question today: “how much is the unit” of Botox?

I guess I get this question every day. For some reason – I have trouble answering it with just one sentence. Maybe I could say that the unit of Botox is free! Wow! But we charge a certain price to have the units injected by our Surgeons, etc. Thus we charge a certain price per injected-unit. So I really think the question is how much does it cost per unit to have the Botox injected. I guess it’s obvious that the Botox by itself doesn’t do anything except take up space in my refrigerator.

Here’s the answer I gave today:

Botox in a catalog for Medical Doctors to buy.

Hi! Thank you for asking! I always wonder how to best answer that question of “how much is the unit.” I guess it’s a question on price! But I need to explain that the price per unit and the price-per-unit-which-is-injected are different. I get my Botox from Allergan USA directly. They charge me about $6 per unit. It is shipped to me on dry ice in 100 unit vials which is stored in my strictly monitored refrigerator. I could also get it from an official Botox medical supplier such as McKesson Medical or Moore Medical and they charge about $7 per unit. There is also a 50 Unit vial which is available and I believe that it costs more per unit.

These vials of 50U or 100U Botox is only at maximal strength for a few hours once reconstituted. After that, I feel that it weakens in power. When injected at full strength, we charge $12/unit when injected by me as of the writing of this blog. I try to be as efficient as possible with my injection; I like to use the freshest Botox and the least amount possible for maximum effect and duration. Precision placement helps in achieving this goal. Prices vary, even in our office, depending on who’s injecting it. Each practitioner has a different reason for their injection charges. But I’m the main injector at Surgical Artistry. I hope this answer helps! Please contact us for more info or current info: www.InjectionArtistry.com

To confuse issue even more:

I have received ugly looking faxes – almost every week in fact – which advertise illegal black market Botox from foreign countries which offer Botox at less than $3.50 per unit for “Botox”-injectors to buy. And to confuse issues even more, there’s Dysport and Xeomin in the USA with Botox-like effects. And one needs about 3 times the amount of Dysport Units for a similar (not same) result.

Botox is my Violin!

Violin is my Botox — Dr. Calvin Lee on the Violin.

Dr. Calvin Lee as Guest Concertmaster in Taipei, Taiwan

I allude to my post about Dysport vs. Botox. In the end, I conclude that the injector makes the biggest difference – not the product itself. Botox is like my violin. I paraphrase the last part of that link here:

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 or surgeon.

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.”

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