Botox

How does Botox work?

Botox cosmetic is a dilute neurotoxin that is injected in minute quantities into the facial muscles that cause wrinkles. Within three to seven days the muscles relax and the results are impressive. The effect diminishes after three to four months. Clinical studies show that with routine treatments every 3 months, smaller amounts of Botox may reproduce continued desired results. 

I alway look "mad", will Botox work for me?

In situations where the patient is a chronic frowner, behavior modification (known as muscle training) may be suggested.  Muscle training is simple, place a strip of scotch tape horizontally between the eyes and above each brow, and place a strip vertically above each brow and in the middle of the forehead (you will form inverted T's).  Now whenever an unwanted expression is displayed (frown) you will hear the scotch tape crinkle and you will feel it pull.  This auditory and tactile stimulus will allow you to consciously decide whether the facial expression (frown) you just expressed is consistent with your anti-aging desires.  "Turn a frown into a smile :)"

Where does Dr. Steven Dominguez inject Botox?

Dr. Steven Dominguez began using Botulinum A and B (before Allergan developed Botox) in 1984 to treat patients with surgical conditions such as laryngeal spasms and excessive muscle contractions after Facial Reconstructive surgery due to either cancer or trauma.

Dr. Steven Dominguez teaches other physicians to inject cosmetic Botox into the muscles of facial expression for wrinkle alleviation. Specifically, Dr. Steven Dominguez is a recognized expert in reducing wrinkles of the forehead, between the brow, crows’ feet, chin, and the depressor angular oris (sad clown lips). 

How much Botox is injected?

Dr. Steven Dominguez advises injecting a conservative amount in each region depending on the patients need (which may not be what the patient is demanding or has previously received at some other facility): Forehead - up to 25 units, Between the brow - up to 25 units, Crow's Feet - up to 10 units per, Raising outer brow - up to 2.5 units per, Chin - up to 5 units per muscle belly, Sad Clown - up to 5 units per side, cheek up to 25 units per side.

The muscle thickness and strength is different among men and women.  Typically a man will require more Botox than a woman.  However, there are women with well defined "bossy" or genetically masculine glabellar complex or forehead muscles (strong and thick) that requires repeated Botox doses to achieve a satisfactory result.

 Dr. Steven Dominguez advises against injecting into the lip edge or naso-labial region which is known to cause a long, flat upper lip. Dr. Steven Dominguez does not inject for Migraine or sweat related conditions.

What is the treatment like?

 Dr. Steven Dominguez uses a small 31 gauge diabetic type needle. There may be a slight sting and maybe a mild bruise at the injection site, but this is uncommon. Bruising appears to be more common in patients taking aspirin, ibuprofen, or blood thinners.

Are Botox treatments safe?

Botox is safe in skilled surgical hands, like Dr. Steven Dominguez. Malpractice literature reviews show that untrained practitioners (Family Practice, Pediatrics, Ob-Gyn, RN’s) have the highest rate of adverse events (eye muscle or eyelid paralysis).

Dr. Steven Dominguez teaches other physicians to only inject the minimum amount necessary to produce a softening of the muscles, thus resulting in a younger, smooth and natural appearing face.  Dr. Steven Dominguez does not endorse complete paralysis of  the facial muscles, and he says "facial muscle animation is our means of non-verbal communication, Botox is intended to reduce contractility for anti-aging purposes. When complete paralysis occurs, the Porcelain Doll face inhibits communication and is viewed by the observer as freakish."

Dr. Steven Dominguez says “instead of injecting more volume of Botox and risking an adverse event, physicians should instruct their patients to return after 2 weeks for a “touch-up” if more Botox is desired.”

Botox is contraindicated and should not be injected in pregnant women, or those with known neurological diseases.

What is the primary adverse event seen with Botox treatments?

Dr. Steven Dominguez says that an academic literature review reveals that the most frequently observed adverse event of Botox is unwanted decreased or uneven facial muscle contraction or complete paralysis.  Unwanted decreased facial muscle contraction is usually due to an injection of Botox that exceeds the upper limits of volume per region.  This is usually a result of the practitioner yielding to the overzealous demands of the patient resulting in migration of Botox into an unwanted region.  Many urban myths abound to avoid this phenomenon: "don't lay down for 4 hours otherwise your forehead and brow will be lopsided..."  Dr. Steven Dominguez says "If you don't exceed the upper limits for Botox injection there is no need for urban legends."

Dr. Steven Dominguez published in the Emergency Medicine literature the following peer reviewed medical journal article which described "a 68-year-old woman presented with diminished ability to raise her head, difficulty swallowing, and intermittent stridor 5 days after receiving 225 IU of onabotulinumtoxin A."

Why do I need more Botox now than I did 2 years ago?

Dr. Steven Dominguez Botox lecture includes Botox Resistance.  Botox resistance is a known event that occurs normally as a result of the body recognizing Botox as a foreign substance.  Dr. Steven Dominguez states that Botox resistance is known in patients who require high doses of Botox for treatment of neuro-muscular disorders, and is known to occur in cosmetic patients after one dose and in those who have been receiving Botox regularly. 

Dr. Steven Dominguez says "Botox resistance was presented as a de novo phenomenon in an Italian study in 2010, and this study described patients who had never received any Botulinum  injections, but yet were resistant to  Botox - Dysport - Xeomin at upto 200 units per injection site."

Dr. Steven Dominguez advises patients who are requiring more Botox than usual to "take a break and let your antibodies to Botox diminish, they will never go away but maybe with time you can resume Botox injections for that special occasion."

References:

[1]   Dominguez S, Dobke M, Dominguez S Jr: Too Much Of A Good Thing: Weakness, Dysphagia, and Stridor After Botulinum Toxin Injections. Emergency Medicine 48:551-556, 2016

[2]   Dressler D, Adib Saberi F. New formulation of Botox: complete antibody-induced treatment failure in cervical dystonia. J Neurol Neurosurg Psychiatry. 2007;78:108Y109.

[3]   Borodic G. Immunologic resistance after repeated botulinum toxin type A injections for facial rhytides. Ophthal Plast Reconstr Surg. 2006;22:239Y240.

[4]   Goschel H, Wohlfarth K, Frevert J, Dengler R, Bigalke H. Botulinum A toxin therapy: neutralizing and non-neutralizing Abs – therapeutic consequences. Exp Neurol 1997;147:96–102.

[5]   Hatheway CL. Toxigenic clostridia. Clin Microbiol Rev 1990;3:66–98.

[6]    Smith LA. Development of recombinant vaccines for botulinum neurotoxin. Toxicon 1998;36:1539–48.

[7]   Houser MK, Sheehan GL, Lees AJ. Further studies using higher doses of botulinum toxin type F for torticollis resistant to botu­linum toxin type A. J Neurol Neurosurg Psychiatry 1998;64:577–80.

[8]   Dressler, D (et al); Antibody-Induced Failure of Botulinum Toxin A in Cosmetic Indications; Dermatol Surg 2010; Vol 36, No 4: 2182-2187

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