Category Archives: Botox

How does Botox Work?

Botox, Modesto, , , , ,

The Biology of Botox

I was a neuroscience concentrator at Brown University.  So I might just call this blog the Neuroscience of Botox instead.  My wife, while at Brown, studied Biochemistry, so I might also call it the Biochemistry of Botox.  Regardless…

botox mechanism 2 botox mechanism

The main gist of what Botox does is a relaxation of muscles.  At least that’s how we view it on a grand scale.  On a more minute scale, we might see it as the prevention of release of neurotransmitters and peptides from the axon of neurons.

Mechanism of action for Botox, sequentially:

  1. Biochemical activity occurs at the neuron side (rather than the muscle) of the neuromuscular junction (NMJ)
  2. Two chain polypeptide with a heavy chain and light chain.
  3. Heavy chain of Botox targets axon terminals of neurons.
  4. After the heavy chain of Botox attaches to the surface of axon terminals, the toxin is taken into the neurons by endocytosis.
  5. The light chain is released inside the neuron cytoplasm.
  6. The light chain has protease activity and degrades the SNAP-25 protein (Synaptosomal-associated protein 25).  SNAP-25 is normally required for vesicle fusion which releases neurotransmitters from the axonal endings – usually acetylcholine (ACH).  Without the intact SNAP-25 protein, ACH is not released as a signal for muscle contraction.

 More Botox Biochemistry Notes

  • SNAP-25 is a type of SNARE protein.  SNARE stands for Soluble N-ethylmaleimide-sensitive factor attachment Protein Receptor.  SNAP 25 stands for Synaptosomal-associated protein 25.
  • Without SNAREs there is no fusion and thus no synaptic signal transfer.
  • Without acetylcholine being released the muscles no longer have their signal for contraction.  Acetylcholine is an excitatory neurotransmitter at the neuromuscular junction in skeletal muscle.

YouTube Video demonstrating the Biology of Botox

Botox on a molecular level is shown in the video above.  I did not make this video.

Visit us for Botox in Modesto

Other Botox info links

Disclaimer:  There is no medical advice here.  Medical facts change from time to time, please double check these facts.

Calvin Lee, MD
Calvin Lee, MD

Can Botox Cause Botulism?

Botox, Botox Complications, Botox Injectors

Botox cause Botulism?

Yes, when injected incorrectly and with certain patient factors.  But please read on.

Botox from Allergan is a highly purified protein derived in the laboratory from a bacteria which can cause botulism.

What Bacteria does Botox come from?

Botox is purified in the lab from a bacteria known as Clostridium botulinum.  It is a gram-positive, rod-shaped, anaerobic, spore-forming bacterium.

Botulism and the Bacterial cause

Botulism is a rare illness that causes paralysis of the body including breathing muscles.  It can be caused by several different strains of Clostridium: Clostridium botulinum, Clostridium butyricum, and Clostridium baratii.

Various forms of Botulism

There are about 5 various forms of botulism, but the three main forms are  foodborne botulism, wound botulism, and infant botulism (which can be caused by honey ingestion in infants).  The bacterial spores from clostridium botulinum are common in soil and water.

Various forms of Botulinum Toxin

The Botulinum toxin are a varied group and consist of 8 types.  Botulinum toxin types A, B, E, F, and H affect humans.  The other types affect other mammals.  Botox is Botulinum toxin type A.  There are three forms of Botulinum toxin type A used medically:  Botox, Dysport, and Xeomin, and there is a botulinum toxin type B called MyoBloc which is also used medically.

Iatrogenic = accidental overdose.  Another form of Botulism.

An iatrogenic form of botulism (in addition to the three main types described above) can occur from accidental overdose of these botulinum toxins.  How can an overdose occur?  Too high of a dosage, injected into blood vessels or accidental spread from intended medical targets.

“Botox is to Botulism as Penicillin is to Mold”

But one elegant way to think about Botox is this analogy:  “Botox is to Botulism as Penicillin is to Mold.”  That statement is trying to say that Botox is harnessing the good powers of something considered harmful; just like how penicillin was derived from mold.

With cosmetic dosing and usage, the chance of overdose related (iatrogenic) Botulism is small.

“Good Medicine given in dangerously high doses is a Bad Poison”

Medicine can become a poison when given in supra-physiologic amounts.  That goes for just about every medicine.  This is my own quote, but in many ways, this can be considered common sense and applicable to many facets of life.  The common quote is “too much of a good thing is bad.”

In my opinion, when genuine cosmetic Botox is injected properly, it is one of the safest drugs I’ve used.

The risk of Botulism from Botox is extremely small

Hopefully this discussion isn’t too scary.  What I mean to say is that if Botox is injected in huge amounts and incorrectly, there is a risk of Botulism.  There may also be risks when patients inadvertently push the Botox away from their intended targets.  But when injected in small amounts (ie. for cosmetic use) and carefully (and with experience), the risk of Botulism is extremely small.   Medical Botox usually is a higher dose of Botox than Cosmetic Botox.  Medical Botox is frequently 10 times higher dosage than Cosmetic Botox.  But even so, the risk of iatrogenic Botulism is miniscule.   As with any potential risk, we should be aware and treat Botox with respect.

Treat Botox with respect – a message to myself as a Botox injector.  Here are some tips to avoid Botox complications

As injectors we should continue to watch out for high doses of Botox.  Perhaps we should break up those doses into a staged approach, meaning that the patient could come back a few days later for more Botox instead of cramming it all in at once.

We need to watch out for blood vessels.  We should aggressively seek out vessels that we can see or feel with our hands and avoid them, and consider taking notes of offending vessels when repeated Botox is anticipated.

We should take care to think of Botox as a three-dimentional injection.   The depth of injection matters to me.

And it goes without saying, that we should use the proper Botulinum toxin for the indication.  No shortcuts here.

As for patient factors, I continue to warn my patients to avoid large amounts of pressure on the injected spots and avoid rattling the area with devices such as clarisonic for a few days after the injections.  This is just my own thoughts on the topic of Botox migration.

Please visit us in person for more of your concerns and questions about Botox.

Calvin Lee, MD

More info on Botox and Botulism

Our website: Modesto Botox – www.InjectionArtistry.com  or visit the home page of our Modesto Botox Blog or visit our Plastic Surgery page.

Please see your own doctor or Botox injector for a personalized discussion.  There is no medical advice here, just medical information.  This is just my own opinion for this blog.  Allergan has nothing to do with this blog.  In fact Allergan sales people have said things to me before which make me believe that they wouldn’t agree with this blog.  Please double check facts in this blog which may change with time.

www.InjectionArtistry.com

botox-bottles-botox-blog-2.jpg

Spending too much money on internet webpages?

Advertising, Botox, Botox Injectors, , , ,

Spending too much money on BOTOX advertising – a bad thing?

“If they spend THAT MUCH money on webpages, they obviously aren’t good enough”

Maybe I need to cool it with websites (but it’s fun!). Overheard on the streets of Modesto, “Don’t go to Surgical Artistry because they spend way too much money on advertising with webpages. If someone needs to spend THAT MUCH money on webpages, they obviously aren’t good enough.”

Whoa! Wow! I know I’m frequently misunderstood. I think it comes out to a penny a webpage.

Give me a chance to clarify before judging my BOTOX skill to be inversely proportional to the amount of money I spend on WEBPAGE ADVERTISING (which I think is close to nothing, and I don’t consider all of this advertising – just a strange hobby). I spend a prepaid amount which is $95 per year for hosting, and about $1-$15 per year per website – for example www.InjectionArtistry.com and www.ModestoAcupuncture.com (These are $11 each per year). Each website could have a ton of webpages without additional cost. I don’t consider this spending a lot on webpages – plus, it’s a hobby!

Proof: this is what my internet webhosting account looks like today 12/13/14.
Proof: this is what my internet webhosting account looks like today 12/13/14.

$95 a year for my BOTOX website hosting

Every year, I think I spend much more on paper (to write on and print/copy) than I do on websites. Sorry for the misunderstanding.  I will rethink my plethora of webpages.  Thank you for the indirect feedback!  I appreciate it all.

How big is your BOTOX needle?

Allergan, Botox, Juvederm, Modesto,

Different Sizes for BOTOX Cosmetic needles

When I first trained to perform BOTOX injections.  I used 30 gauge needles.  I think these are still the most popular needles used for BOTOX Cosmetic made by Allergan.  But as I got into vein sclerotherapy with Asclera, I started using smaller needles and one day I thought, why not use the smaller needle for BOTOX.  My wife at the time was skeptical, and I gave it a try and it worked very very well.  This was back in 2006.  Now I think the use of smaller than 30 gauge needles for BOTOX has caught on.  The smaller needles tend to be much more expensive, but I think it’s worthwhile.

That is not a small BOTOX needle. No real needles were injected in the making of this photo.
That is not a small BOTOX needle. No real needles were injected in the making of this photo.

Disclaimer:  Photo above is of a model, not a real patient.  The doctor in the picture above is Calvin Lee, but not Calvin Lee, MD.  (Both people in the picture have the same name).

Smaller is usually better

A smaller needle used for Botox is usually better.   Smaller needles hurt less, bruise less, and cause less damage to surrounding tissues such as nerves and blood vessels.  But there’s a point where a smaller needle might blunt more quickly or bend.  So in my mind there’s a sweet spot for picking the right sized BOTOX needle.

32 gauge needle

For me, the right sized BOTOX needle is a 32 gauge needle (smaller than a 30 gauge).  I am also currently trying out the possibility of 33 gauge needles.  The larger the gauge, the smaller the needle.  a 32 gauge needle roughly .23 mm in outer diameter.  a 33 gauge needle is .21 mm in outer diameter.  Compare that to a standard 30 gauge needle which is .31 mm in outer diameter.

I’m slightly concerned that the 33 gauge needle will dull quicker, but I still need more experience with the 33 gauge needle.

Wikipedia has a needle gauge comparison chart for diameters.

The manufacturer of the needle matters

The different brands of needles have vastly different needles in my mind.  Some are sharper, the bevel is different, and the ability to stay sharp is different among the brands.  I have also found that needles will be slightly different from one to another – even in the same box.  If you are reading this and wondering which brand, I would recommend trying a few different ones yourself.   If you need to know which one I use, feel free to call our Modesto Botox Practice – Surgical Artistry.

I tend to be very picky with needles – I value fine craftsmanship

I am an acupuncturist so I am probably a bit strange with my attitude toward needles.  I frequently use needles that are smaller than a 34 gauge needle for acupuncture.  So I value fine craftsmanship when it comes to needles.  For acupuncture, I routinely use Seirin needles.  They have extremely fine needles for facial rejuvenation acupuncture.

facial rejuvenation acupuncture needles
facial rejuvenation acupuncture needles

I have learned, that like sutures, the smaller the needle or the smaller the suture, the more expensive the product.  But it’s understandable due to the challenges of manufacturing.

Visit us in Modesto, California for BOTOX injections

I also like to use small needles for Juvederm injections – smaller than the ones that come in the box.  But that’s another discussion and needles need to be FDA approved, and thus, this would be considered an off-Label-FDA usage.

Our website is www.InjectionArtistry.com

 

 

Who is Allergan?

Actavis, Allergan, Botox, Brilliant Distinctions, eyes, Juvederm, Latisse, Modesto, Valeant, Voluma, ,

Allergan is the Company who makes BOTOX

Allergan is the company who makes BOTOX, Latisse, and Juvederm.  These are three popular products offered at Surgical Artistry.  Latisse is a take-home product, unlike BOTOX and Juvederm which are injected (by Dr. Calvin Lee).

logo_allergan

Allergan cosmetic products

Allergan is also regarded as an ophthalmic (eye) pharmaceutical specialty company

Allergan makes many other pharmaceutical products – many of them are for the eye – conditions such as dry eye.

Eye Products include:

  • Restasis
  • Lumigan
  • Acuvail

How many Billions in sales for Allergan?

  • It is estimated that Allergan has $7 billion in sales in 2014

Advertising spending for Allergan?

  • In 2012, it is estimated that Allergan spent 162 million in advertising.

Allergan Location?

Headquarter is in Irvine, California

Allergan Merger?

Allergan plans to merge with Actavis.  The battle for Allergan started in April 2014 when Valeant made a bid for Allergan.  Actavis plans to pay $66 billion for Allergan.  Brent Saunders is the CEO and president of Actavis.

For more information about Allergan including the CEO’s BLOG.

  • Allergan home page – this is a great place to start learning about Allergan.
  • AllerganViews: The CEO of Allergan has a blog.  “Our Pursuit, Life’s Potential.” That is Allergan’s vision, and every day, around the globe, our more than 11,000 employees work to deliver on this vision.  David Pyott is the current CEO, as of the writing of this blog which is Dec 10, 2014.
  • Allergan on Twitter
  • Allergan also runs the Brilliant Distinctions program.  Click here to log in direction to Brilliant Distinctions.

Links For Physicians and Nurses who inject Botox and perform Breast Augmentation

Visit Surgical Artistry in Modesto, CA

That’s our BOTOX and Plastic Surgical Practice in Modesto, CA

Latisse as an adjunct to BOTOX eye treatments

Actavis, Allergan, Botox, Brilliant Distinctions, Latisse, Modesto, Valeant

How to use Latisse – scroll to video

BOTOX around the eyes

BOTOX can be used to accentuate the eyes by lessening the wrinkles around the eyes.  Two areas of FDA approved usage of Botox around the eyes would be for the Glabellar complex and for the crows feet.

What if the eyelashes were accentuated?

Enter Latisse!

Latisse would make the eyes really stand out beautifully by allowing the lashes to grow longer, thicker and darker.  There’s much discussion to Latisse.  Consider visting the official Latisse website.   Or one of our Modesto Latisse webpages.   And there’s more information about us at our Modesto Botox webpage.

Picture from Allergan. She is not an actual patient of Surgical Artistry's.
Picture from Allergan. She is not an actual patient of Surgical Artistry’s.

If the eyes are windows to the soul.  Eyelashes are some pretty impressive window treatments.

Latisse comes in a 3ML or 5ML kit.  But Latisse kits are usually not sold at your local Hunter Douglas window covering dealers.  You can find them in doctor’s offices, such as ours in Modesto, CA.

Please visit our Botox practice in Modesto, California and we’ll show you some of our own personal tips regarding Latisse.

Here’s a Video regarding applying Latisse – the video is made by Allergan.  Allergan is currently in the process of merging with Actavis.  Valeant apparently is no longer in pursuit.

Credits and Disclaimers:  Latisse picture is not from an actual patient of ours.  Please visit your doctor in person for medical advice and for personalized details regarding Latisse and BOTOX.

Skin Aging Infographic from Colorescience

Botox, Botox Injectors, Crows Feet, Modesto, Obagi, , ,

Skin Aging Explained – and how to fight it

I got this infographic about Skin Aging from Colorescience.  It was sent over in an email.  I posted it to our facebook accounts and it started getting some shares.  I think that’s an indication that skin aging is a pretty populr topic.

infographic on Skin Aging - need Botox
Skin Aging Explained and what to do about it. Click to enlarge.

 

Highlights from the infographic on Skin Aging from Colorescience:

  • Sun Damage – more than 90% of age-related skin changes are caused by the sun.  Use sunscreen – in particular it says, use their product called Sunforgettable.  And we carry that product at Surgical Artistry, Modesto.
  • Dehydration – use hyaluronic acid.  We have many products with hyaluronic acid made by Obagi and SkinCeuticals.
  • Acne Treament – spot treatments dry out the skin.  Use products for the whole face.
  • Food – sugars, sweets and saturated fats increase the likelihood of a wrinkled appearance.  Solution:  avoid processed food, eat plenty of fresh fruits and veggies.
  • Exercise: only 18% of women meet the recommended amounts of exercise
  • Sleep: Getting insufficient sleep ages the skin prematurely and fosters eye area puffiness.  Solution:  ban bright electronics at least 90 minutes before bed to improve quality of sleep.
  • Makeup Removal.

What is Sunforgettable?

It is a powdered mineral sunscreen with Zinc and Titanium dispensed with a brush, and it comes in 3 different skin tints.

sunforgettable sunprotection

What? No mention of BOTOX wrinkle prevention?

BOTOX, to me is one of the most effective treatments to receive to help prevent wrinkles.  It has received FDA approval for the Glabella area and Crows Feet areas.   Botox has also received approval for cosmetic use in wrinkle prevention in other areas of the face.   I guess BOTOX wasn’t mentioned in this article because Colorescience isn’t the manufacturer of Botox.  Otherwise, of course they would have included Botox in this discussion of skin aging.

And Smoking? even more important than BOTOX or Sunscreen.

It’s tops on my list to quit smoking – as a top thing to do to slow down skin aging.

My top three for Anti-Aging skin?

  1. Stop smoking
  2. Use Sunscreen with ZINC
  3. Consider BOTOX use

Slowing down the aging skin is a passion of ours at our Modesto Botox Practice:  Surgical Artistry.

Visit my blog from a few years ago about Zinc and Sunscreen

Hawaii picture by Calvin Lee, MD
Hawaii picture by Calvin Lee, MD

Disclaimer:

I didn’t write this infographic.  Please visit us: Modesto Botox, Plastic Surgery, Veins, and Acupuncture.  Please verify all ideas presented here with your doctor.  I am not your doctor unless you have seen me in person.  We carry Colorescience skin care products in addition to NIA 24, Obagi, and SkinCeuticals.

BOTOX Terminology: Glabella

Allergan, Botox, Botox Injectors, BOTOX Questions, Modesto

What is the glabella?

Glabella has very little to do “gorilla” or “umbrella”.  Although they rhyme.  And if you got a gorilla angry, he/she would have a furrowed glabella.  And if you were caught in the a rain storm without an umbrella.  I think you would also be furrowing your glabella.  And for some patients they look like gorillas if they have very strong muscles in the glabella.

It is the area between the eyebrows above the nose.  Interestingly, it is derived from the latin word “glabellus” which means smooth.  And a smooth glabella is the goal of a BOTOX treatment for the glabella.  We sometimes consider the wrinkles that form in this are the “frown lines” between the eyes or eyebrows.

I'm activating my glabellar complex of muscles here (between the eye brows).
I’m activating my glabellar complex of muscles here (between the eye brows).

Is Glabellar Botox FDA approved?

Yes, BOTOX is FDA approved for cosmetic use in the glabellar complex

How many BOTOX Units are used in the Glabella?

Usually around 20.  But ranges from 12-40 units have been used in my Modesto Botox practice.  Men and younger patients, with their stronger muscles, usually need a higher dose of BOTOX units.  However some younger patients are looking for prevention, and thus may not need as high of a dose.  Customization is key.

What muscles comprise the Glabella?

The procerus muscle in the middle, surrounded by a pair of corrugator/depressor supercilii.  Everyone has different presentations of this muscle.  The anatomy is slightly different for each individual, and the strength of these muscles differ as well.  This leads to individualization of each BOTOX injection.

So basically three muscles:
  • Procerus in the middle
  • Depressor supercilii
  • Corrugator supercilii

Botox 111

If BOTOX doesn’t work for glabellar creases, what’s next?

Consider fillers for the static lines of the glabella.  BOTOX may work somewhat for the glabellar static lines; however, BOTOX is mainly a treatment for dynamic lines.  Dynamic lines (wrinkles) are formed when the muscle contracts.  Static lines (wrinkles) are present even when the muscles are relaxed.  Many dynamic lines are on their way to static lines – it’s just a matter of time.  However BOTOX can prevent the progression.

What is the best filler for glabellar static lines?

I think this question depends on the injector and how they use the fillers.  This would be an  off-label FDA use of fillers.  I personally prefer Belotero for filling Glabellar creases if it becomes a desired option.   The reason I like Belotero to complement BOTOX treatments in the glabellar region is that it is a light-weight filler which doesn’t easily show up as bumps in the glabellar region.  However if the glabellar lines are very deep and the skin is lax, sometimes a thicker filler such as Juvederm would work better.

More questions about the Glabellar BOTOX injections?

Feel free to make an appointment at our office.  Home page here: Modesto Botox Injections.  Botox injections in the glabella is the most popular use of Botox Cosmetic.

BOTOX Award from Allergan

Allergan, Botox, Botox Injectors,

Allergan APP Levels

APP – stands for Allergan Partner Privileges

It’s a program which offers rebates around 4% to 8% regarding on level of purchases.  It’s somewhat complex and involves additional rebates known as Portfolion Bonus Rebates (PBR’s).   I haven’t exactly figured it all out.  But it’s a program that rewards the big purchasers and the practices who buy more than just BOTOX;  Breast implants, Juvederm, Voluma, Latisse, and SkinMedica are involved in the rebate program as well, and combinations of purchases apply.  For me, most of the points I needed to earn “Platinum” status was from BOTOX purchases.  You would log in through this Allergan APP webpage.  And this is a link to more Allergan APP info.

The Certificate to Display

They even give you a certificate to show off your level.  We can display this in our Modesto Botox Practice.

Most of my points to get this "Award" was from BOTOX purchases.
Most of my points to get this “Award” was from BOTOX purchases.

APP levels from Allergan

  • Silver – 20 points needed
  • Gold – top 12% of members, 200 points
  • Platinum – top 6% of members, 400 points
  • Platinum Plus – top 3% of members, 650 points
  • Diamond – top 2% of members, 1000 points
  • Black Diamond – top 1% of members, 1500 points
  • Top 50

How much dollar value is a point worth?

I think a point is about $550 worth of products give or take $100.  This probably changes from year to year.

  • One vial of Botox = 1 point.
  • One box of Juvederm (2 syringes) = 1 point.
  • 1 case of Latisse 5 ML = 3 points.
  • Other products such as Natrelle breast implants and SkinMedical have point values, but I’m not entirely familiar with those values.

Friendly Competition to fuel BOTOX injections

Allergan possibly has this setup because they probably think the Botox practices like to have a little bit of friendly competition to see where they stand.

Here’s a listing of places to get Botox injections in Modesto, California.

What level will I be at in 2015

I think I will probably be in the Platinum Plus level in 2015.  Not a high priority for me but, I think that’s how I will naturally fall into that category with my usual BOTOX growth rate.

Dexterity for Botox Injections – Chopin?

Belotero, Botox, Botox Injectors, dermapen, Juvederm, Modesto, Piano for Dexterity, Radiesse, surgical dexterity, Voluma, ,

Dexterity for Surgery, Piano, and Botox Injections

Surgery depends a lot of dexterity.  So does playing the piano.  And so should Botox injections.

LogoR4_3

I have some unique ideas of developing and maintaining my Botox dexterity with Piano Practice.

  • As with piano playing, I like to keep my wrist supple and flexible when injecting Botox.
  • When injecting fillers, there are times where I have to do finger stretches to be able to maintain tension on the skin with my non-dominant hand, and then I also sometimes have to reach for the plunger which may be in slightly awkward positions for my dominant hand – it depends on the style of the plunger.  Radiesse Volume Advantage is one of the larger syringes due to it’s 1.5 cc volume which is more than some of the other syringes of dermal filler.
  • Timing is also key in Botox injections.  Timing is a big deal in music and performing piano.
  • Then there’s the grace in lifting off from the actual Botox injection.  It would be a shame to waste Botox with a heavy handed lift-off – in that case, the Botox isn’t injected into the muscle – it might even be injected into the air.  Thus a light lift-off is key.  It’s akin to musical phrasing with the tapering that occurs and the lifting off of each note too.

Chopin Etude Op. 25, No. 1 (Aeolian Harp) as Botox Dexterity Practice

Here’s a piano piece which is dedicated to finger dexterity building.  It is also one of the most beautiful melodies I have ever encountered in an finger dexterity etude.  This piece is also known as the Aeolian Harp Etude.

Yes, that’s me.  Recorded at my home in Modesto, California.  Yes, this is one of the great things you can do in Modesto – practice piano!  And record piano for YouTube!  And write this blog… ok, the list goes on and on regarding great things  in Modesto, CA.

Quoted from the wikipedia entry on this piece:

“Technically, the piece requires both dexterity and velocity, good balance and weighting of the arms coupled with flexible finger stretches”.

For me my dexterity and musical challenges are: evenness, flexibility in the wrist, and flexibility with finger stretches, light touch, and musical line phrasing. I hope to continue to work on this to make it even better.

Light touch?

And a light touch is very very important in lightening the sensation of any pain from Botox shots.

Consider getting Botox from us in Modesto, CA

Please visit my Modesto Botox injections home page.  We offer other Cosmetic procedures besides Botox.

Our other Procedures include: