All posts by Calvin Lee

About Calvin Lee

Surgeon in Modesto, California specializing in Botox, Juvederm, Veins, and Acupuncture. Worked in the past as a trauma surgeon. Grew up in New York, went to college and medical school at Brown University. Surgical Residencies in Cleveland and Springfield, Illinois. Now lives in Modesto, CA with his wife, Dr. Tammy Wu - Plastic Surgeon. They have a practice together: Surgical Artistry. Office telephone is (209) 551-1888. Website for the practice is www.SurgeryToday.com

Muscles, Nerves and Vasculature of the face for the Botox and Juvederm injector

Botox Anatomy, , ,

These are just some notes – this is by no means complete.  Just sporadic notes to supplement other sources.

Lip elevator muscles

  • Levator labii superioris alaeque nasi – gummy smile muscle.
  • Levator labii superioris
  • Levator anguli oris
  • Zygomaticus Major/minor

Lower Lip depressor muscles

  • Depressor anguli oris
  • Mentalis
  • Depressor labi inferioris

The Frontalis Muscle

  • Creates the transverse rhytids
  • Only elevator of the brow – don’t want to entirely weaken this muscle with neuromodulators (ie. Botox).  Consider limiting the injections to the upper 2/3 of this muscle.
  • Wrinkles are perpendicular to the movement of the muscle.

Agonist/Antagonist action of muscles on the Brow

  • Obicularis Oculi, Procerus, and corrugators depresses the brow vs. Frontalis.  Tug-a-war.  Can change the shape and location of the brow with Botox/neuromodulators.

Parts of the Obiclaris Oculi Muscle

  • Palpebral portion= Pretarsal (lies on tarsal plate) and Preseptal = responsible for passive closure of the eye
  • Orbital portion – further out laterally.  Responsible for forceful closure of the palpebral fissue of eye.  Accessory muscle to smiling.

Nerves of the superior orbit

  • Supratrochlear nerve – runs through the belly of the corrugator supercilii.  This nerve provides sensation to the medial 1/3 of the forehead and is a nerve that can be responsible/trigger for migraine headaches.
  • Supraorbital nerve – just lateral to the supratrochlear nerve.  Sensation for the lateral 2/3 of the forehead.

 

There is much more, but this is a start.

I have made this super webpage a few years ago with BOTOX muscles of the FACE

That link above may be of interest to you.

 

Meanwhile feel free to visit our self-made Botox home page:  Modesto Botox by Dr. Calvin Lee, Surgeon.  Thank you for visiting.

Facial Fat Compartment Anatomy for Botox and Juvederm injections

Uncategorized

Notes regarding Facial Fat Compartment Anatomy

  • Orbital retaining ligament separates the orbital fat compartments from the rest of the face:  Superior, Inferior, and Lateral orbital fat compartments.
  • Cheek fat compartments:  Most medial is the Nasolabial fat compartment (the medial border is the actual nasolabial fold), then there is the medial cheek fat compartment, middle cheek, lateral cheek fat compartment
  • The Jowl is a fat compartment
  • See below for deeper fat compartments.

What does this mean for a cosmetic Botox and Juvederm injector?

  • Looking at the whole face as a continuum
  • Temporal wasting is also something we should start to address – hollowness from temple area to neck – the lateral projection.
  • Many patients start by noting nasolabial fold and jowel fat compartments.  But this is a symptom, not an actual problem.  It may be a symptom of other fat compartments becoming deflated, such as the medial cheek fat compartment.
  • As we age, we lose these volume in these fat compartments, and in addition to face lifts to tighten the skin, we have to consider filling these areas again to regain some of our youthful appearance.

There is fat superficial and deep to muscle which are compartmentalized

  • SOOF – Suborbicularis Oculi Fat – underneath the obicularis muscles.  There is the medial SOOF and the Laterial SOOF.
  • SMAS – Superficial Musculo-aponeurotic System
  • The fat is compartimentalized
  • Deep fat in the cheek – below the musculature.  Can cause a pseudo ptosis of the superficial fat.  Over the Maxilla.  Medial and Lateral aspect to the deep medial cheek fat.  Refilling the deep fat in some patients can create a lift in this area of the mid cheek.

juvederm

There is no medical advice here.  Read more: Why choose Dr. Calvin Lee for your Botox injections.

More information at our personally designed Botox page:  Modesto Botox by a Surgeon-Violinist, Calvin Lee, MD.  We are located in the heart of Stanislaus County, California.

After Botox, I have a headache

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Headache after Botox

About once a month, I’ll hear someone tell me about this experience.  I myself get this problem when I have Botox, Dysport, or Xeomin injected for my wrinkles lines on my face.  I also have heard of this phenomenon after facial rejuvenation acupuncture.  I think with acupuncture this may be related to the qi which is brought to the face and scalp for facial rejuvenation acupuncture.  And I have also heard of this problem after mole removal from the facial area – a procedure I also do often.  Thus I’m not always sure that the cause of the headache after Botox is entirely caused by the Botox.  It may be from the placement of needles or the stress of having the procedure.  Regardless, the headache after Botox should resolve with the use of routine headache medications, such as advil, aleve, and tylenol.

What happens if the after-Botox headache lasts longer than a few days?

It may be possible that a nerve was irritated by the proximity of the needle used to inject Botox.  This also should resolve with time.

Most of my patients who get headaches after Botox still feel that the procedure is entirely worth repeating every 3-4 months.

Disclaimer

The information here is for informational purposes and should not be considered medical advice.  We would recommend that you see your doctor in person.  If you want to see me in person:  More information about my Modesto based Botox practice.  And here’s a link to other emergencies and complications due to cosmetic injections.

Our Botox Home Page:  Modesto Botox.  Thank you for visiting!

Allergan and Valeant – Letters against the possible “Vallergant” merger

Allergan, Botox, Juvederm, Modesto, Valeant

On April 24, 2014, Dr. Tammy Wu wrote a letter against the idea of the possible merger of the Allergan Botox giant along with the skin care / cosmetic giant Valeant.  This was 2 days after Valeant had proposed a merger with Allergan – or possibly a hostile takeover?

While this merger may make some sense since there is many crossover items – basically competition could be eliminated with this type of corporate merger.  But we have been afraid that customer service will be hurt as will future research and development.  Esepcially with our beloved Botox.

Allergan just published on their website about 100 of the 500 letters they have received from their physician customers.  This is the link to the letters from physician customers to Allergan – all of these are against the idea of the “Vallergant merger”.  I figured it’s a cute name for combining the companies.

Dr. Tammy Wu’s letter is among those 100 published.  In fact, I think in reading them, she was the first one to write.  Perhaps she sparked a flurry of letters to Allergan.

This is her letter:

Dear Mr. Schaison:

As a physician who has experienced the “Valeant” service, I have to say that I am not impressed with them.  Specifically, our office had enjoyed a great relationship with Obagi Medical Products (OMP) and have done business with them for many years. As you may be aware, Obagi was acquired by Valeant last year.

Since the merger/ acquisition, every aspect of OMP has gone down the tubes. Customer service, billing service, product quality control (we receive leaking products and broken products almost with every order – which had never happened before when Obagi was independent), shipping control, timing of delivery of products, etc. have all been negatively affected. The poor OBagi representative has to backtrack and apologize almost on a regular basis for all the mishaps that have happened since the merger.

Allergan has been a leader in aesthetic products and more, and I hope that Allergan will stay independent and have no affiliations with Valeant. I respect Allergan for its research and development aspects, and I believe the future is quite bright for Allergan as an independent company.

I hope that the Board of Directors will take into consideration as much as possible the implications of this merger and what it will do to the reputation of Allergan – in my opinion, if it’s the same as Obagi and Medicis, it will only be negatively affected. We stopped using Medicis products as a result of bad customer service, and we are currently considering eliminating Obagi from our office as a result of all the mishaps.

Thank you for reaching out to us physicians. I know that I am not the only physician hoping for a positive outcome from this, which would be Allergan Independence, no Valeant involvement.  Thank you for listening.

Sincerely,

Tammy Wu, MD

Diplomate, American Board of Plastic Surgery

Surgical Artistry, Inc.

2336 Sylvan Avenue, Suite C

Modesto, CA 95355

Some Background info:  Allergan has the products that we carry: Latisse, Juvederm, and Botox.  It also has SkinMedica.  Valeant has Obagi, Restylane, Perlane, and many other dermatologically related items.

I would like to mention that Obagi has tried to improve on it’s customer service since we had initially complained, but it is a different culture, it seems at Valeant, and I do think that some change is unavoidable.  But we hope to adapt and get used to the new culture.  And we’ll probably adapt too, if Allergan and Valeant were to become combined.

Visit our Modesto Botox home page.

Actavis update

UPDATE: Valeant didn’t end up merging with Allergan.  Actavis ended up being the company which merged with Allergan.

Radiesse is back at Surgical Artistry

Juvederm, Modesto, Radiesse

Radiesse is available again at Surgical Artistry, Modesto, CA

I took a brief break from Radiesse to become excellent with injecting Juvederm, but I’ve come to realize the unique niches filled by having Radiesse, a demal filler.  Radiesse acts as a scaffolding, providing structure for your own natural collagen to grow.  Radiesse is comprised of Calcium Hydroxylapatite (CaHA).

I know many of you have requested Radiesse by name and now I have it back in stock and ready to go.  I have both the 0.8cc and the 1.5cc syringes available to inject.

Feel free to call us to set up an appointment with me:  209-551-1888, Modesto, CA.

For more information about Radiesse, volumizing dermal filler, please visit www.radiesse.com.

Visit our semi-personalized Radiesse website on www.radiesse.com

Of note, the makers of Radiesse also makes Belotero.

Radiesse Brochure says:

  • Get better results from your filler.
  • Clinical studies of Radiesse patients show that they were more staisfied with the results they received from treatment with RADIESSE than with other leading dermal fillers.
  • 33% more Juvederm injectable gel may be needed to achieve full correction compared to RADIESSE volumizing Filler.
  • RADIESSE Volume Advantage syringe contains 50% more product vs. Juvederm injectable gel syringes.

 

Modesto Radiesse Injections
Modesto Radiesse Injections
Visit our Modesto Radiesse and Botox home page.

Calvin Lee, MD Modesto Botox Surgeon Stats as a Botox Injector

Botox, Botox Injectors, statistics,
Calvin Lee
Calvin Lee

Updates:

2013 Background in general for Calvin Lee, MD

written by Calvin Lee, MD

  • I have a degree from Brown University in Neurosciences.
  • I have a medical degree from Brown University.
  • I am a Board Certified General Surgeon
  • I am an acupuncturist
  • I am a violinist
  • I also play the piano to help develop my dexterity and artistry
  • My main focus now is minimally invasive type procedures done with needles such as Vein Sclerotherapy, Acupuncture, Botox and Dermal Fillers in our office in Modesto – Surgical Artistry.

5 year patients choice

2013 Botox / Allergan Background for Calvin Lee, MD

  • I founded Surgical Artistry with my wife in 2006.
  • I have participated in cosmetic surgeries by assisting my wife (Dr. Tammy Wu) in plastic surgeries since 2006.  I mainly assist with almost all tummy tucks and face lifts which are done by Dr. Tammy Wu, Board Certified Plastic Surgeon in Modesto.
  • Dr. Tammy Wu gave me my initial certification to inject Botox, via instruction, guidance, and critique.  The certification was approved by California’s Cooperative of American Physicians.  I have since developed my own style of injections.  This was not required for me.  But something I wanted to do.
  • I started officially injecting Botox in the year 2008 with approval from the Cooperative of American Physicians.  I had to submit my trial cases of Botox and get a letter of recommendation.
  • Eventually, I became a speaker for the Allergan company (makers of Latisse, Botox, and Juvederm)
  • I have participated actively in learning all I can about the rest of the world’s knowledge about Botox at the Las Vegas Cosmetic Surgery meeting in 2013.
  • I have also received personal tips from one of the original injectors of Botox and Dermal Fillers, Dr. Steve Yoelin in 2013.  I attended one of his lectures in 2013 and have kept in touch due to his kindness and generosity.

surgical artistry full page ad never boring

Summarized 2013 Statistics for Calvin Lee, MD regarding Botox in Modesto, CA

  • I wrote a separate website here with even more details on my Modesto Botox practice statistics for 2013
  • 724 Botox patient visits in 2013.
  • 374 Different patients seen for Botox in 2013.
  • I definitely hope to continue to grow and I am very thankful to those who trust me with their cosmetic Botox injections.
  • For fun, I queried our database for the number of Botox visits I had in 2008 when I first officially started with Botox injections (May – after getting a self imposed formal certification to perform the procedure).  I had 103 Botox patient visits in the year of 2008.  In contrast, 724 patient visits for Botox for 2013 is a nice improvement.
Calvin Lee, MD (209) 551-1888
Calvin Lee, MD
(209) 551-1888

Modesto Botox 2013 in review

Botox, Botox Injectors, Brilliant Distinctions, Juvederm, Modesto, statistics, year in review, ,

Some Fun Statistics about my Modesto Botox Practice

by Calvin Lee, MD

I love to share information, and I wanted to be transparent about my Botox experience.  I’ve been injecting Botox since around 2006.  We started having more detailed tracking available to us starting in 2010 by having patients enroll in Brilliant Distinctions.

How the Botox statistics were obtained

The Botox statistics were obtained from Brilliant Distinctions Analytics.  This is a free service included with our participation in Allergan‘s Brilliant Distinctions program which is a “frequent flyer rewards” type program.  It is a free program for our patients to enroll.  I’ve been keeping simple statistics of my Modesto Botox practice before by looking at total number of patients enrolled and looking at the total amount of coupons redeemed.  Most of our Botox patients are enrolled in the Brilliant Distinctions patients.  As are our Juvederm and Latisse patients.  We do not currently have SkinMedica which is part of the Allergan family.  But feel free to call us to see if we have encorporated SkinMedica into our collection of skin care products.  (209) 551-1888.

Possible faults of the data collection

  • Not all of our patients are enrolled in the Brilliant Distinctions program.
  • More and more existing patients enrolled in Brilliant Distinctions as the program became more familiar to us.  This means that any increases in the number of patients “seen” for Botox, may actually be lower than the reported number because the numbers we have reflect Botox patient enrollment into Brilliant Distinctions, not necessarily patients who have received Botox.  Thus we are using Brilliant Distinctions registered visits as a surrogate for actual Botox visits.  But i think the estimate is pretty close because we try to enroll all Botox patients into Brilliant Distinctions.

Here are the Botox Related Statistics of my Modesto based Practice which I have with my wife Dr. Tammy Wu, Plastic Surgeon

  • 724 separate patient visits over the year for 2013.  This represents a 43% increase over 2012 where I had 505 separate patient visits.  In 2011 we had 270 patients registered.  But I think this number might be “artificially” lower because many of our patients at the time weren’t signed up for Brilliant Distinctions.  How is this calculated?  I went through the Analytics part of Brilliant Distinctions and had the computer program extract out the patient data one month at a time.
  • Averaging 60.3 Botox Visits per month.  60.3 Botox visits per month is the average number of visits per month for 2013.
  • 374 unique patients seen for Botox Cosmetic injections who are registered in Brilliant Distinctions in 2013.  In 2012 we had 278 unique patients seen for Botox injections.  In 2011 we had 180 Botox different patients.  Unique, or different, patients means that these patients were counted only once even if they came to the office several times over the year.
  • I couldn’t seem to find too many monthly trends with our Botox Visits.  But from what I can see over three years of data, it seems that there is a consistent increase in patients in March and November.  I’m not sure about these seasonal changes, but this may be specific to our town of Modesto, CA.
  • We grew to have about 245 new Brilliant Distinctions Signups in the last year.  This also includes Juvederm-only and Latisse-only-patients.  This averages about .67 new Botox/Juvederm/Latisse patients per day (365 days per year).
  • We reached 702 unique patients on Brilliant distinctions.  This growth in the number of unique patients is very steady – it doesn’t seem to be increasing exponentially, just a direct increase which is steady.

Financial analysis and comparison with the other components of my medical and surgical practice.

I have many medical colleagues and students who ask is a profession of doing Botox worth it?  They mainly ask from a standpoint of does Botox make money?

Without going into gory details.  I can say that  the other parts of my medical practice was more profitable than the Botox part of the practice.

As with any other medical practice there’s the personal satisfaction aspect.  For me is very satisfying to be injecting Botox.  I enjoy the process and having wonderful patients who value appearance and beauty.  And most of all, I enjoy working with my wife who is a plastic surgeon.  I have been working with her since we moved to Modesto in 2003.  However, it became an every-day work experience together since 2006 after we founded Surgical Artistry in Modesto, CA.

Another financial rewards related Botox question:  How much overhead does one have when injecting?  I guess one way to answer this question would be to look at my Botox and Dermal Filler practice in a vacuum.  Botox and Fillers (ie. Juvederm Voluma, Juvederm Ultra, Juvederm Ultra Plus XC, Belotero Balance, etc) are expensive for the practice to buy.  These are the most expensive products I have ever had for my surgical practice.  Expensive in terms of price for size of product.  In my estimation, I think a Cosmetic Injectible practice’s overhead with lasers (I have one laser) would be about 75%.  Meaning there’s a 25% profit margin.  This is without a surgical practice, vein practice or acupuncture practice.   I don’t use our laser all that much, and this figure of a 25% profit margin on a Botox/Filler/Laser non-invasive cosmetic practice is for my practice.  I’m sure it would vary.  I’m factoring in the cost of the products and the overhead costs of the office – staffing, malpractice insurance, rent, utilities, supplies (syringes, etc).  And this figure would be before tax – which will of course, take out another chunk!  I hope this information helps.  I’m thinking that most of the people reading up to this point are Botox injectors of sorts or interested in becoming one.

Graphical Representations of Botox Data

Modesto Botox Monthly Statistics
Number of Unique Botox Visits to my Modesto Botox Practice broken down by Month
Botox patients per month with actual numbers
The graph shows the Botox Patient Visits for the past consecutive 35 months. It is missing December 2013’s data. But for 35 months before December, it is shown above.

Conclusions and predictions.

Botox is growing at our practice in Modesto.  There is definitely room for even more growth for my practice.   724 separate Botox visits is certainly a good “start.”  I think my practice could handle twice that.  I guess we shall see what 2014 holds – this is hard for me to predict.  I think our growth will slow percentage-wise for 2014, I think it will be lower than  the 43% growth we achieved this year.  I think I would be happy with a 15% growth in the amount of Botox appointments.  A 15% growth for next year will reveal 833 patients.  So perhaps that’s my prediction for 2014.

We currently have 702 different patients signed up for Brilliant distinctions.  If I were to be ambitious, I would hope to break 1000 new patients in our Modesto Practice’s Brilliant Distinctions program.  But a conservative estimate based on calculations over the past 3 years would be 947 members signed up.

Good luck and Merry Christmas!

Please visit our main Modesto Botox home page

Update: Please see a new Blog entry:  Botox Charting of 2011-November 2014: BOTOX patients per month

Juvederm before and after picture for cheeks

Belotero, Botox, Botox Injectors, Brilliant Distinctions, Crows Feet, FDA, Juvederm, Modesto, , , , , , ,
Juvederm and Belotero Before and After
Juvederm ultra plus xc and Belotero injected via Cannula Technique by Dr. Calvin Lee

This is not done with Juvederm Voluma.  As of November 2013, I do not have experience with Juvederm Voluma.  Juvederm Voluma, however, is on it’s way to the office in Modesto, CA and I will soon have experience with this new dermal filler.  [update: I’ve used my first syringe of Juvederm Voluma on 12/24/13.  It was a very satisfying and positive experience.   I look forward to having even more experience with Juvederm Voluma.  I was able to use my 27g 1.5 inch cannula for Juvederm Voluma injections].

To improve my cosmetic dermal filler craft, I’m analyzing my past week. 95% of this result was performed with CANNULAS as an instrument of liquid implant delivery and a whole bunch of other secrets. There’s more that I would like to do with fillers for her, but my instructions were only to work on under eyes (tear troughs) and cheeks.

Background info:

Patient had lost a good deal of weight and it is showing in her face.  Options include face lift.  However, she chose to use Juvederm, Belotero, and Botox.  In the before picture she had Botox and Juvederm expertly done at another plastic surgery practice in our town of Modesto, CA.  I added upon that work to get the 13 day “after” picture using only Belotero and Juvederm.

Info about Brilliant Distinctions in our Modesto Cosmetic Injections practice.

Picture used with permission.  Thank you very much for letting me share this experience.  This is an off Label, FDA usage of Juvederm ultra plus XC for cheek fillers.

Axillary Hyperhidrosis Botox (excessive sweating) treatments in Modesto by Calvin Lee, MD

Botox, hyperhidrosis, sweating, , , , , , ,

Hyperhidrosis – sweating under arms

I perform Botox injections for Axillary Hyperhidrosis (excessive sweating – underarm). However, I’m always in the interest of getting the patients the best value. I don’t take any forms of medical insurance, and the procedure with me costs $1000 (price as of 11/15/13, subject to change), and the results last about 9-12 months when injected in a focused pattern after localizing testing with starch (otherwise it’s probably more like 6 months). I’ve heard that medical insurance might cover this procedure, have you found a good place to get this procedure done under insurance? Is the doctor good at it and does the insurance really cover the procedure adequately where the doctor feels that he is getting paid for the Botox used? Botox is an expensive product to acquire. I would like to send patients to a insurance provider who will do a great job. So far, I personally haven’t found this. So for now, many people are stuck with me for the $1000 procedure.

Feel free to email me if you have further thoughts:   staff [at] surgerytoday.com

Visit our Botox home page:  Sweating and Botox in Modesto, CA.  Thank you!

What to do in case of Dermal Filler Emergency

Belotero, Botox Complications, Juvederm, vascular occlusion, , , ,

In case of Dermal Filler Complication of Vascular Occlusion

Emergency

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.