BOTOX COSMETIC INJECTIONS By Joshua Zuckerman, MD, FACS in New York City

Botox treatment to the forehead by Dr. Zuckerman at Zuckerman Plastic Surgery in New York City. This patient will not form transverse (horizontal) forehead lines even when raising the brows. Patient pictured before and seven days after.

Botox Cosmetic, or Botox as it is often known, is an injectable neuromodulator product from pharmaceutical company Allergan. Its active ingredient is a form of a toxin from the bacterium Clostridium botulinum. When injected into targeted muscles, modest amounts of this toxin causes controlled relaxation temporarily, usually lasting from three to four months. Botox injections are the most common non-surgical aesthetic treatment at Zuckerman Plastic Surgery and in the United States. Over seven million Botox injections treatments were performed in the United States alone last year, and many of Dr. Zuckerman’s patients come regularly a few times per year to maintain the effects as part of their regular beauty regimen. Botox was approved by the FDA for the treatment of lines and wrinkles between the brows in 2002 although its first FDA-approval came in 1989, and it is one of the longest publicly available injectable products. It is now approved to treat facial aging in several areas of the face.

Botox is Preventative: Future Wrinkles Be Gone

Botox Cosmetic fully relaxes targeted areas which a patient can not do through conscious effort, and it therefore eliminates existing fine lines while active. Lines and wrinkles are formed by repeated animation and muscle contraction of certain facial muscles, which Botox temporarily prevents. As a result, it can be used to prevent or delay future fine lines and wrinkles. An interesting scientific study was published on this phenomenon in 2006, where researchers followed two identical twins for 13 years. One twin underwent Botox treatment regularly, while the other received Botox injections just twice in 13 years. Untreated areas showed comparable aging in both twins, but forehead lines and vertical lines between the eyebrows had not developed in the treated twin but had in the other twin. Study: “Long-term effects of botulinum toxin type A (Botox) on facial lines: a comparison in identical twins”, Journal of Facial Plastic Surgery (2006).

Long-term Effects of Botox

Botox is broken down relatively quickly after treatment and does not remain in the tissues. Its effect are also temporary due to the body’s regenerative capabilities. Furthermore, Botox treatment actually becomes more effective over time at diminishing the appearance of lines and wrinkles as targeted facial muscles weaken. A medical study published at the end of 2016 demonstrated that after multiple Botox treatments, lines and wrinkles may appear less severe even after the effects of treatment have worn off. In other words, even though Botox only relaxes facial muscles, and therefore lines and wrinkles, while it is active in the three to four months after treatment, repeated applications may lead to a more permanent improvement. The study measured the severity of vertical lines between the eyebrows after the effects of Botox treatment had dissipated. Measurements were taken after each of three consecutive treatments each spaced four months apart. 45% of study participants who previously had lines at rest – while not under the effects of Botox – before the study no longer did. This effect was most pronounced for those with mild lines and older patients. Consequently, starting Botox earlier helps patients stay in the mild category and as patients age, the product has the potential to be even more effective. Individual results may vary. Study: “Repeated OnabotulinumtoxinA Treatment of Glabellar Lines at Rest Over Three Treatment Cycles”, Journal of Dermatologic Surgery (2016).

Botox Treatment Mechanism

This diagram demonstrates approximately how Botox works at a cellular level to prevent muscle contraction and therefore the formation of lines and wrinkles. For educational use only.

The active ingredient in Botox Cosmetic modulates the release of neurotransmitters, which would otherwise cause muscle fibers to contract during facial animation. Hence, Botox and similar products are often called neuromodulators. Nerves induce muscle fibers to contract in response to stimuli. As the diagram demonstrates, at the junction of nerve and muscle cells, Botox’s active ingredient prevents the structures carrying neurotransmitters inside the neuron from delivering them into the space between neuron and muscle cell, where they would otherwise bind to receptors on the muscle cell and cause contraction. The protein complex that Botox disrupts are broken down into their basic components, amino acids, and recycled by the body or may be excreted via the kidneys. The muscle relaxation effect due to Botox is temporary, because the body regenerates these areas of the neuron within a few months. Botox does not stay in tissues or build up over time, because it broken down by the body relatively quickly after cleaving the protein complex in the neuron.

Possible Treatment Areas of the Face & Neck with Botox

Botox can be used in several areas of the face and neck to treat fine lines and wrinkles. Outside of the forehead and between the eyebrows, most of these treatments are advanced injection techniques best performed by a board-certified plastic surgeon like Dr. Zuckerman.

As seen in the diagram at right and in the treatment pages linked below, Botox injections can be used to treat a variety of the signs of aging in the face and neck. However, outside of the forehead and between the eyebrows, most of these treatment areas require advanced injection techniques, which may be near sensitive areas such as the eyes. As a result, it is best to visit a board-certified plastic surgeon who has surgical knowledge of the anatomy in these areas. Neuromodulators like Botox can migrate slightly from the injection site, which may be influenced as well by the level of dilution of the product. Inexperienced injectors or non-surgeons are more likely to overly dilute Botox when preparing it for treatment as it is easier to inject. Consequently, Dr. Zuckerman does again recommend visiting a board-certified plastic surgeon for treatment.

Which Botox (Neuromodulator) Product to Choose

Patients most often ask for “Botox”, but there are actually three FDA-approved neuromodulator products available.

“Botox” has become so popular that most patients refer to it by name when asking for the treatment. However like Coca-Cola, Botox is a brand, not a type of treatment, and there are actually three products now available using a similar form of the botulinum toxin to treat facial wrinkling: Botox Cosmetic, Dysport, and Xeomin. These products are very similar, and to some extent, Dr. Zuckerman uses them interchangeably although the measurement of treatment amounts, also called units, may vary per product. If patients prefer a certain product, please request it during treatment with Dr. Zuckerman. There may be small variations as to how an individual may react to each product, but product choice is largely a matter of patient preference. For first or second-time Botox patients, Dr. Zuckerman likes to ask patients to come back in to the office for a follow-up seven to ten days after treatment. This follow-up is optional, but for new patients, it helps Dr. Zuckerman to more precisely measure the effects of treatment and to deliver the proper Botox dosage. Facial muscle strength varies, and a result, certain patients may be best treated with slightly more product than others. After initial visits, Dr. Zuckerman will base treatment off the patient history, and over the years, he may recommend expanded dosages or treatment areas depending on each individual’s pattern and progression of aging.

Xeomin versus Botox Cosmetic: New Kid on the Block

Xeomin is the newest of the three neuromodulator products. Approved in 2011, it has recently gained attention with the appointment of Christie Brinkley as a spokesperson. It is very similar to the other products but is a slightly more purified form of the toxin. This may lower the already remote risk of allergy, but it may also shorten its effective duration. Scientific research is still being conducted on the subject. Dr. Zuckerman typically recommends one of the other two products as they have been FDA-Approved longer and are proven safe. However, he is happy to use Xeomin for treatment if a patient prefers.

Treatments & Uses of Botox Cosmetic

As a board-certified plastic surgeon, Dr. Zuckerman has hundreds of hours of injectables experience andis an expert injector of Botox Cosmetic. In his practice in New York City, the most commonly requested treatments using this injectable include:

Forehead Wrinkle Treatment with Botox

Dr. Zuckerman performs injections on the upper portion of the forehead to treat the transverse (horizontal) lines and wrinkles. This is one of the top two most common treatments involving neuromodulators like Bostox Cosmetic.
Learn more about Dr. Zuckerman’s Forehead Wrinkle Treatment.

Glabella “11’s” Treatment (Vertical Lines between the Eyebrows) with Botox

The second most common use for Botox, and the application for which it was first FDA-approved, is to treat vertical lines between the eybrows formed by the Glabella muscles. These are often formed due to concentration or stress, and Dr. Zuckerman has some patients who wish to eliminate these lines for professional reasons.
Learn more about Dr. Zuckerman’s Glabella “11’s” (Vertical Lines between the Eyebrows) Treatment.

Crow’s Feet Treatment with Botox

From squinting, sun damage, or general aging, some patients develop lines that radiate outward from the eyes and worsen over time. Dr. Zuckerman can effectively treat the crow’s feet with Botox Cosmetic injections or another neuromodulator. This treatment involves injections around the sensitive anatomy of the eyes, so Dr. Zuckerman recommends that you seek an experienced, board-certified plastic surgeon like himself as your injector.
Learn more about Dr. Zuckerman’s Crow’s Feet Treatment.

Non-Surgical Brow Lift with Botox

The non-surgical brow lift using Botox is an advanced injection technique that Dr. Zuckerman performs. He injects Botox Cosmetic in the vertical fibers of a muscle around the eye to decrease the force pulling downward on the lateral portion of the brow.
Learn more about Dr. Zuckerman’s Non-Surgical Brow Lift.

Bunny Lines Treatment with Botox

Some patients develop standing lines on the bridge of the nose due to aging or sun damage. Dr. Zuckerman can effectively address these lines with strategically placed Botox injections.
Learn more about Dr. Zuckerman’s Bunny Lines Treatment.

Facial Slimming Treatment with Botox

Dr. Zuckerman can inject Botox into targeted cheek muscles to reduce their prominence and to help patients with a square or angular jaw who desire a slimmer, more feminine jawline. This is also an advanced injection technique, and Dr. Zuckerman recommends you visit an experienced, board-certified plastic surgeon like himself for treatment. Facial slimming via Botox injection often becomes more effective over time with multiple sequential treatments, and it is among the techniques increasing in popularity in Dr. Zuckerman’s practice in Manhattan.
Learn more about Dr. Zuckerman’s Facial Slimming Treatment.

Neck Rejuvenation with Botox

Another advanced Botox injection technique that Dr. Zuckerman performs is done in the neck to address horizontal lines. Again, the anatomy in the neck is sensitive, and Dr. Zuckerman recommends that you visit an experienced, board-certified plastic surgeon like himself for treatment. Surgical training in the anatomy of the area is a great asset for this treatment.
Learn more about Dr. Zuckerman’s Neck Rejuvenation.

Important Aspects of Treatment

Botox treatment to the glabella muscles by Dr. Zuckerman at Zuckerman Plastic Surgery in Manhattan. The patient will not form vertical lines between the eybrows even when squinting. Patient pictured before and seven days after treatment.

Botox Cosmetic Injections Treatment Longevity

Treatment takes approximately one week to set in and lasts three to four months.

Botox Cosmetic Injections Recovery (Downtime)

Botox Cosmetic injections involve very little downtime, and most patients return to work immediately after a daytime treatment. Patients with sensitive skin may experience mild redness or minor bleeding at the injection sites, but this will resolve within minutes to hours. If needed, Dr. Zuckerman advises patients that it is reasonable to reapply makeup after treatment, although avoiding makeup products for the skin on the day of treatment is best.

Botox Cosmetic Injections Pretreatment Guidelines

To minimize the possibility of bruising or bleeding, Dr. Zuckerman recommends that patients refrain from consuming aspirin or ibuprofen within a few days before and after treatment. In addition, he advises that patients don’t drink alcohol to excess for twenty-four hours before and after treatment. Skipping a physical workout the day of treatment is also recommended. However, most patients are able to undergo treatment even if not all of these recommendations are fulfilled. Please inquire to Dr. Zuckerman is you have questions about your ability to undergo treatment.

Dr. Zuckerman performs Botox Cosmetic injections on a patient’s forehead to treat transverse forehead lines and between her brows (her glabella muscles) to treat vertical lines, the “11’s”.

Frequently Asked Questions About Botox Cosmetic

How safe are Botox Cosmetic Injections?

Botox Cosmetic is extremely safe. It was initially approved by the FDA in 2002 and has since become widespread and been approved for additional uses. While rare complications due to allergy have been reported, the most common risk involved with Botox is an unintended drooping of the brows, or worst case the eyelid, or appearing “frozen” due to poor injection technique. You can avoid these minor risks by visiting Dr. Zuckerman, an expert injector and a board-certified plastic surgeon. Due to the popularity of Botox and other injectable treatments, Dr. Zuckerman is often asked to provide corrective treatment for low quality injectable treatments performed by other practitioners.

Does the body build up resistance to Botox over time?

No, if anything the opposite. A research study from 2016 actually showed that after three Botox treatments, fine lines and wrinkles were improved in appearance even after treatment had worn off. Your body does not build up “resistance” to Botox. In fact, over successive treatments, the targeted muscles that would otherwise form wrinkles become weaker. This leads to a slightly longer lasting treatment and helps prevent wrinkle formation long-term.

Can I go back to work same day after a daytime Botox treatment appointment?

Yes, many of Dr. Zuckerman’s patients do return to work immediately post-treatment. You may experience slight redness at the injection sites in your forehead, but this will resolve within one to two hours. In addition, these sites are very small and overall level of redness or irritation will be minor. Many of Dr. Zuckerman’s patients do cover any redness at the injection sites with makeup post-treatment. The needle Dr. Zuckerman uses for Botox injections is a 32 gauge needle, the smallest gauge needle on the market for medical use.

Can I wear makeup before and after treatment after Botox treatment?

Dr. Zuckerman will clean the treatment area, removing any makeup, pretreatment. You are free to reapply makeup immediately after treatment. Many of Dr. Zuckerman’s patients do cover any redness at the injection sites with makeup post-treatment.

How do I avoid looking completely overdone or “frozen” after Botox injections?

It is important that your injector understand facial anatomy to avoid overdosing or injecting in suboptimal locations. Dr. Zuckerman often has first-time or second-time Botox patients visit the office for a small follow-up treatment 8-14 days after the initial treatment for a touch up, so he can very accurately determine how many units a patient requires in a particular area. Especially for younger patients in their twenties or thirties, Dr. Zuckerman will also limit forehead injections to high up on the forehead, well away from the brows. This technique will result in the patient still being able to move their brows and be expressive.

I’m afraid of needles. Can I still undergo Botox?

Unfortunately, Botox is only made in an injectable form (via a needle). However, this needle is extremely small: a 32 gauge, which is the finest needle available for medical use. Dr. Zuckerman is able to perform the treatment within a couple of minutes, and most patients only feel small pinpricks during. If needed, he is happy to apply numbing cream to the targeted areas. Finally, patients do not see the needle generally as the injections are being performed given the targeted locations on the face.

Isn’t the active ingredient in Botox the same toxin that causes botulism?

Yes, it is, but the clinical dose is much lower than that which would be needed to have a systemic effect on the body: perhaps 20x – 50x less. Botox treatment is highly safe and very common.

Should I visit a doctor for Botox injectable treatments in New York City?

Botox is the most popular non-surgical aesthetic treatment nationwide, and as a result, there are many practitioners attempting to perform injections. With Dr. Zuckerman, you can be certain that your treatment will be performed in a sterile, medical environment by someone with detailed surgical knowledge of the affected anatomy. As a note, if you are considering visiting a non-doctor for treatment, know that these injectors are required by law to be overseen by a physician, but often that supervision seems to be lacking. Dr. Zuckerman has been asked to provide corrective treatment for side effects of poorly performed Botox treatments including drooping eyelids or eyebrows. While these complications are extremely rare when injections are performed properly, improper Botox injections may be difficult to address.

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