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

Update on Month of May 2015 Botox Statistics

Botox Statistics per Month (May 2015)

For the entire month of May 2015:
110 patients seen for Botox this month, 28 Patients seen for Juvederm,
121 patients getting Botox OR Juvederm. 17 patients getting Botox AND Juvederm.

Using my own data, I can derive that 35.4 units of Botox is the average number of units per patient.

I know quality counts for much more than quantity. But it is always tempting to look at the numbers provided by the Botox company. This is what you can derive from their computer analysis about my Botox/Juvederm practice. I am also big on injecting Radiesse and Belotero which don’t show up in these numbers. I’m not sure if these numbers include Juvederm Voluma. Sometimes Allergan calls Voluma a separate product.

Botox in Modesto.

More about me, Calvin Lee, Botox injector

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

Botox for slimming the jaw

Another Botox question on a public forum:

Botox for reduction of masseter. How many units are required for a noticeable difference?

How many units is required for a noticeable difference? Or is it entirely dependent on the individual? I’ve visited a few clinics and I’ve been quoted either 15 or 25 units. I was told by one doctor that with Botox, only a small amount is needed for a difference to be seen. But some clinics recommended a higher dosage as the cost was paid for per unit. Could anyone provide some information on this and what dosage they recommend?

An excellent question. I’ve wondered this myself and I continue to wonder about what others think about jaw slimming with Botox. The masseter is the main muscle which can give us a square-ish box-like face.

I don’t get this opportunity to do this procedure very much. I’ve only had about 20 patients come in for this issue. And about 16 patients who come in repeatedly for this feature of Botox at this time. But I’ve had many more (probably 60 patients) who have had TMJ dysfunction/pain issues which required Botox in the Masseter muscle.

My worst case scenario is a male patient who had TMJ pain which eventually resolved when we eventually came to the conclusion that 50 Units of Botox on each side helped. I usually like to do my Botox procedures in a staged fashion where we do a little bit at a time and thus we eventually find the lowest dose that does the right job for us. He did get jaw slimming features, but that actually was more evident after his third round of 50U of Botox on each side.

My experience with TMJ masseter muscle Botox helped me come to the realization that masseter/jaw muscle slimming Botox usually has it’s most dramatic effect after the 3rd Botox treatment – assuming no large gaps between treatments. So this is almost 10 months later.

Thus for patients coming directly to me for Jaw slimming Botox (cosmetic only). I try to assess how much of a “rush” patients are in for this to happen. If they are OK with best results in 10 months. I usually suggest about 16U-20U on each side to start. And repeat this process in 3-4 months. If a person is in a “rush” to get this result, I might start with a higher dose – such as 24-30U and then gradually lower this dose with each subsequent treatment – so I don’t over-correct and get a sunken in jaw look – which in my opinion is not a youthful appearance at all.

Summary: Quick answer: 12-50 units per masseter muscle. Long answer: It’s not the number of units per session – it might be the number of units done over time that matters most. I’ve come to realize that the best appearances for masseter muscle slimming is obtained after repeated treatments to this area. I tell my patients to be patient and wait for the appearance after the 3rd Botox treatment to the masseter area. Everything in medicine should be individualized – especially Botox!

Calvin Lee, MD
Botox injections in Modesto, California

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.

Botox for changing eye size

Here’s another public forum cosmetic Botox question.

Can I use Botox for my cheek pushing up on eye when I smile, making it look smaller than other?

I have had 2 ptosis surgeries On my upper eyelid it has been about 4 weeks since my 2nd. the 1st 1 was an over-correction. Now I don’t think it is so much my top eyelid. It is raised a little more than before any surgeries. I’m still not happy with my eyes. If you notice when I smile it really goes to one side. And I’m okay with that. But when I smile only 1 cheek pushes up on my eye and makes it look smaller. i don’t want to do anymore surgeries. Could Botox fix my check from coming up?

My Answer:

What a great question! I have to break up my answer into several parts

BOTOX FOR CROWS FEET

Botox is FDA approved for treatment lateral canthus lines (crows feet). These are the lines on the side of the eyes which become more pronounced when we smile. Through our experience treating these crows feet, we’ve found that we can affect eye size, brow lifting, and even cheek elevation.

FULL vs. PARTIAL TREATMENT of CROWS FEET

In a situation where one just wants the cheek to elevate less with smiling, a full treat of crows feet might be too much. However, if one is bothered by the potential of crows feet (meaning that BOTOX can prevent crows feet as well as treat crows feet), the a full treatment could work on both sides, and may even out the appearance. I can envision a possible treatment of the lower crows feet on the side with the cheek elevation “problem.” I can also see a potential patient of mine benefiting from full treatment on both sides and with added Botox to the “problem” side.

TREATING THIS PROBLEM IN STAGES

If I had a patient coming in for this issue, I would consider treating this issue in stages. Starting with a low dose targeting the lower crows feet area (obicularis oculi muscle) and bringing the dose higher perhaps separated by about 2 weeks. And maybe even considering treatment on both sides to keep up with symmetry issues. With good note taking, we could figure out the optimum solution if possible.

MOUTH MUSCLES MIGHT GET IN THE WAY

Cheek elevation is also caused by muscles that affect the smile of your mouth – Zygomaticus Major and Zygomaticus Minor muscles. These muscles, if targeted too strongly with Botox will affect the symmetry of your mouth. Thus if the bulk of your cheek is formed from these muscles, Botox may not be able to give you your 100% desired result. But I still think that your desired effect is possible without injecting Botox into muscles that affect your mouth. Fortunately with a gradual staged approach, you might gradually find a solution. If a solution isn’t possible, I would say that it’s because of the mouth muscles and the amount of natural fat pads we have on each side of the face which can compress and change shape on animation of our face (ie. smiling).

THE QUEST FOR SYMMETRY

I understand that symmetry is important. However, we should keep in mind that it isn’t human to be exact mirror images of our selves on each side. We are usually strong on one side – for example, being right handed. This contributes somewhat to our facial muscles as well. The natural asymmetries in a person’s face can be considered a strength and add flair. Thus, sometimes, it’s ok to go with the idea that the sides of our faces are like siblings, not genetic clones.

IN SUMMARY

Botox can possibly solve this problem of smaller-eye, higher-cheek. If one is interested in wrinkle treatment or prevention – it makes using Botox even better. Consider partial or full treatment of crows feet or even heavier application on the elevated-cheek side. But keep in mind that Botox can make other parts of our face appear asymmetrical – like the mouth or the eyebrows – so be careful, and good luck!

Calvin Lee, MD
Botox injections in Modesto, California

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.

Reviewing Dr. Tammy Wu and Dr. Calvin Lee

Review us if you get a chance.

Calvin Lee, MD

Tammy Wu, MD

My Disclaimer for Real Self Question and Answers

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I hope to be answering many Botox, Voluma, Juvederm, Radiesse, Asclera, Vein questions as I can.

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