Getting Botox and Filler? What’s actually in that medspa fridge?

Dr. Furnas (00:12):
You walk into Best Price Med Spa for some Botox, for those frown lines and a touch of filler for your lips. You get your injections and you're all set, right? Maybe. Welcome to Skin Tuition. I'm Heather Furnas.

Dr. Korman (00:28):
And I'm Josh Korman. As two plastic surgeons, we lay aside our scalpels and explore the nonsurgical world to bring you what's new, what's safe, and what to look for when you're ready to hit refresh.

Dr. Furnas (00:43):
So we've talked a lot about neurotoxin on this podcast with previous episodes, but so far we haven't really talked about the logistics, how to make sure you're getting the real stuff, the full potency. Is it legitimate? So Josh, why don't you tell us a little bit about what we're going to discuss?

Dr. Korman (01:02):
Well, it's good to understand what things matter, what things don't matter and what things may matter. So we're going to talk about everything from dilution. We'll talk about that. We'll talk about where it comes from. Botox or Dysport, neurotoxins, all that stuff. The fillers, sterility, shelf life, does it matter if you get it priced by unit, by area, by treatment, and also safety. If there's what we call in the medical biz an adverse event, meaning something goes wrong, is there something that needs to be done kind of quickly and is it ready?

Dr. Furnas (01:38):
Yeah. Adverse event is sort of our secret way of saying complication. Is there really something that we want to correct that we need to correct? So if we start out with dilution, so when Botox comes to the office, it comes directly to physician's office in California and we get it from the company and it comes on dry ice. It's cold, so we put it in the freezer and it's actually a powder. There are a hundred units of Botox in that powder, and we need to actually put sterile refrigerated saline into that to reconstitute it is what we call it. And the dilution can vary. Typically we put 2.5 milliliters of saline or you can put 4.0 milliliters of saline into that vial. And so if somebody says, I'm going to give you one syringe, well that doesn't tell you anything about the number of units because you could have just one unit in a full syringe of saline.

Dr. Korman (02:41):
Well, I think it's good to know units in general, units, that's all they are units. Somebody decides they're called a unit. If you have a milliliter or you kind of know what that is, if it's an ounce, if you're making a cake or you're doing something in the kitchen, you know what measurements are. When it's units you don't really know. And the units, the concept of units are, they're not artificial, but they are for specific to the product. So with Botox for example, or Dysport, it is units, but units are reconstituted with this fluid that's generally it's saline, it's still the same number of units, but it can be in different amount of liquid based on how much liquid the practitioner decides to add. So you think, well what does it matter? Well, if you put more saline in, like if you put four milliliters in, and again, there's these vials, and if there's a hundred units in the vial and you add four milliliters, that in general when you get your treatment, you'll probably be more likely to have more bumps where the injections are because it's just more liquid. If you use less, then it might be less. And you go, okay, well why would I want to use two and a half? Why would you want to use four? And I think sometimes some people feel like it's practitioners for more precision, but also it's liquid. So it's not a perfectly exact science because it is units in a measurement and how much comes out of the little syringe in the skin. It's not a perfect setup, but everyone tries to make it as good as possible.

Dr. Furnas (04:26):
And there can be a reason to have a more dilute or more concentrated solution. For example, some people will have these salivary glands called submandibular salivary glands that you can see as a shadow underneath the jawbone and they can be distracting. And so you can put a little bit of Botox, but you want to put your reconstitution would be one cc one milliliter in the vial for the proper constitution because you don't want the Botox to travel and affect the swallowing muscles or the speaking muscles. On the other hand, there may be another area, the forehead where you want it more diffuse, you might use more of a dilution. So it really depends. It depends on what the practitioner is used to as well. It's better to be standard than continuously changing 2.5 to 4.0. So that's something you could just ask your practitioner what their rationale is just to make sure that they know what that dilution is.

Dr. Korman (05:28):
And it's also sometimes the difference with Dysport and Botox, Dysport tends to spread out a little more than Botox does, and so you might want to use less or more depending on what you're really trying to do. So I think it's not like one size fits all and a lot of the finesse comes from the practitioner. So it's important to realize that it's not just anybody you find online, just by price is necessarily the right person to go to because technique is really important.

Dr. Furnas (06:02):
And then the source is really important because you can get veterinary grade Botox or neuromodulator and there have been people who ended up in the I C U because of that or they'll get some neuromodulator from another country and that's not been vetted, not been approved by the F D A and there've been serious complications with that. So you want to make sure that you go to a legitimate med spa where they're really getting their source from the company. Why would you get veterinary grade? Well, it's a lot more expensive. So better business plan for the med spa, but not good for you is the patient.

Dr. Korman (06:45):
You mean more inexpensive?

Dr. Furnas (06:47):
More inexpensive, if I said the reverse, sorry about that. Yeah, you want, yeah, cheap for the med spa is not necessarily great for you. Now there will be some people who will run their med spa in areas where they really aren't licensed to do so, and so they will get their Botox from a physician who is willing to buy the Botox, him or herself and then sell it to somebody else. You don't know what the refrigeration history is, you don't know a lot of things about how potent that is or what the actual source of that Botox was.

Dr. Korman (07:31):
It's also important to understand that in the big picture, the companies that manufacture the neurotoxins, for example, if use Botox, the Botox that you find in a meds spouse called Botox cosmetic. And while it's the same product, there is a whole world that's used for functional reasons. And so it's really important to understand what it is. It's all the same product, but there are a lot of things you can learn about and read about. But ultimately it's really about finding a practitioner you can trust and then ask them the questions to satisfy your interest of what is being injected into you.

Dr. Furnas (08:13):
Yeah, you could say, let me see the box. Let me see. You withdraw the Botox from the vial, from the actual Botox vial. You could ask for the expiration date. The hope is that you find somebody that you trust so that you don't have to go through that every time.

Dr. Korman (08:30):
Yeah, so that comes to the next question a little bit about sterility. And the Botox that comes in the box is generally sterile. It's made under what they say G M P, good manufacturing practices and it's sterile. But then when the box is opened for delivery to where the vial is located inside, and then as we talked about, it's reconstituted with saline. So how's it reconstituted? Well, a sterile needle is put through either through the stopper or some practitioners may decide to remove the rubber stopper and inject directly in there, but it's sterilely reconstituted. So then it comes to the point of, okay, so what happens when it's removed from the bottle to the person? Well, it's removed in a sterile needle and then the needle is changed for the injection and then it is a new needle for another patient because these are, as they call them, multi-dose vials.

(09:40)
It is not one vial for one patient if there's a hundred units, generally the acceptable or heard about number for let's say injection in one area is let's say 20 units of Botox, which is the equivalent of about 50 units of Dysport. But let's use the Botox example. So we have 20 units of Botox, so that means there's five of those in a hundred unit vial. So it's not going to be necessarily only for one person. Now obviously if one person's having multiple areas, and it can be more, but just it is a multi-dose vial, so it needs to be sterilely injected and removed from the vial each time. Well, you have to be careful to make sure that it's done sterilely because otherwise you can see how bacteria could be introduced if it's not done sterilely.

Dr. Furnas (10:30):
Now Botox is supposed to be refrigerated, as I said, it comes on dry ice and we immediately put it in our freezer and refrigerate the reconstituted form of it, the vials. Now one thing to ask about is what does the med spa do in the event of a power outage? And for example, we live where we occasionally have wildfires and the power can go out. We have a backup generator, so we know that the Botox is still being refrigerated, but if there's no way of monitoring it, nothing that tracks the temperature and their power outages that could impact the effectiveness of the Botox. And you can keep Botox. There's actually a study that showed that you can keep it as long as four weeks as long as it is refrigerated. Oftentimes people say five hours, but there is a study that looked at Botox and found that it could be effective for four weeks, but it has to be refrigerated.

Dr. Korman (11:33):
But that means after it's reconstituted.

Dr. Furnas (11:36):
After it's reconstituted, not when it's just powder and a vial, yeah, four weeks of reconstituted Botox or any of these other toxins.

Dr. Korman (11:46):
So now that gets to the next question of well price. So these, as I'm sure everybody knows, the price is kind of all over the map and there's a lot of, you can go find who's having the Botox special of the day, and there's important ways to understand that in that price. In some ways, if it's actually too low, then you need to be a little concerned because then there is a high chance that the product may be being obtained in a way that may not be correct. Now the retail price for Botox for example, is it is at a number that is then translated by the practitioner. And also there is two different kinds of pricing. There is pricing by the unit, there is pricing by the area, and there's pricing by the treatment. Now I have some patients who will walk in and say, I only need four units in this area.

(12:52)
And how do they know that? Well, they had it before, but just because you had four units and it works, as I mentioned before, 20 units is the recommended amount for a certain area like the forehead. So that's obviously, different areas need different amounts and different people need different amounts. But what you have one time, if you have it may be a year or two later, your body gets a little used to it and you might need a little more, or it's not necessarily because your friend had this many units. It means that you'd have this many units. This is again, something you have to work out with the provider, but there is the unit part, as we mentioned. Some places offer by the unit, then there is by the area like forehead or other areas. And then there is the treatment. And you can say, well, that's a little confusing treatment area, unit.

(13:46)
Well unit is a obviously will be different for different people when you do it by the area, it may be that it gives a little bit of a bandwidth, a range because people need different amounts. And then some people will do a treatment and then say, come back in a couple of weeks and if you need a little more, we can do that. And the pricing often varies, but it's important to understand that you're comparing apples and apples and be a good consumer and an educated consumer realize what is the offer and what is the price.

Dr. Furnas (14:24):
If we were to expect Botox or any neurotoxin is to be sold based on units. If you get a lip flip, which is an injection just along the upper lip, just four units, 1, 2, 3, 4 along the lip to allow it to roll out and to get that sort of pouty look along the border of the upper lip, well four units for a practitioner to take the time to put that in is just not going to pencil out. So you're actually paying for the person putting the Botox in. So an area like forehead and crow's feet might be 65 units total. Somebody who is getting older may find that Botox isn't working as well anymore. Well, that's actually not the case. It's that you're aging and we tend to need more Botox with time. There are different areas that will vary from person to person. Some people have very, very deep frown lines, so their muscle's going to be very thick, so they're going to be somebody who needs more Botox more. So it all varies and it's not a science, it is an art. It's a combination of science and art.

Dr. Korman (15:44):
So let's move a little bit from Botox and neurotoxins to fillers. So those obviously are different and those come in pre-made syringes. So that is with their own needle, their own syringes. So Heather, what do we know about fillers?

Dr. Furnas (16:06):
Well, generally there are different types of fillers. The most common that we'll sort of focus on are the hyaluronic acid fillers like R H A or Juvederm. And they are basically a naturally occurring type of sugar that we have in our own tissues and they attract, it attracts many times its weight in water, so it fills out, and that's what allows us to fill the crease between the corner of your nose to the side of your mouth, or it allows us to fill out lips and so we can inject that, but it is essentially like a foreign substance. And so we really need a good skin prep because it's possible to introduce bacteria and then you have bacteria with this foreign substance that can set you up for an infection. So it's really important that the people that you choose to inject filler in are doing a really good skin prep before they inject that needle.

Dr. Korman (17:18):
Yeah, I think fillers are, like you said, they come in a lot of different kinds, but it is still the same kind of concept that you want to have a clean skin. And also to recognize that whenever you inject anything into the body, whenever we take anything in the body, whenever clean it, there's always chances that you're introducing new things. So you have to be as careful as possible. And primarily in a lot of ways we rely on our own immune systems to make sure that we don't get sick from things that we are exposed to in the area. So one thing that's unique to it, but it is something to think about with fillers, is that they have certain molecular weights and they take up a certain amount of space and the needles are being placed under the skin. Well, what supplies the blood and the oxygen to our skin and to all of our bodies is blood through blood vessels.

(18:18)
And so the needles go in and out of the little blood vessels, which is why sometimes it's not unusual in certain cases to bruise. And I know some people kind of think, oh, I got a bruise from my practitioner, so therefore my practitioner is bad. No, that's not really true. It is that the blood vessels that are supplying to the skin and oxygen to the skin and nutrients have blood in them. So if the needle pierces the blood vessel, even if it's really little and even just for a second or a millisecond, it is still potentially can bleed as the blood seeps out. Well, what is important to understand is that the filler not very often can get an inadvertently put into a blood vessel, and usually even that's not such a problem. But there are some blood vessels in the face that are connected to other blood vessels that go to important parts of the skin and important structures.

(19:19)
And so it is important for the practitioner to be familiar with recognizing when there is a potential for the little material to get stuck and then block blood flow coming to a certain area. And so it is important for offices to have a protocol if that happens and what to do about it at an emergency kit. Like I said, it's really pretty unusual, but it is forewarned is forearmed and it is important to understand the anatomy and the mechanism is obviously not so much for the patient, but is obviously for the practitioner, but it's also good to be an informed patient. So you too can understand if something happens that you can make sure you after you've left the office and make sure you notify your practitioner.

Dr. Furnas (20:12):
And you can just ask, do you have a protocol? And it's called an inclusion where the blood vessel is blocked and that's an occlusion protocol, and do they have an emergency kit for that to be able to inject a reversal agent, that type of thing. One other thing I'd like to mention, some med spas will save syringes of filler because it's such a bargain. If you just use half a syringe, maybe you use a syringe in half total and the practitioner may say, we'll save this half syringe for you for the next time you come back. Well, you have taken a sterile connection, you've got the syringe with a sterile needle and injected that into the skin, which is not sterile even despite the prep. There will be some bacteria seeding the needle and that can go back up. And basically you no longer have a sterile syringe and needle. So when you come back to have that injected, you are not getting a sterile injection of hyaluronic acid. And most med spas don't keep their syringes in the same manner that a blood bank keeps different bags of people's blood. So it is much more likely to mix up syringes, and so you could get somebody else's syringe. So it's not a practice that is in the long run beneficial for the patient, even though it sounds like a great bargain to begin with.

Dr. Korman (21:53):
So I think it is important to recognize that fillers and Botox and Dysport, neurotoxins and fillers, they're very popular for all the reasons that we know and we encourage you to learn about them and have them as you see fit. But it is super important to ask the questions of yourself and of your practitioner so that you can be as efficient a consumer as possible and a smart consumer. And as I've said, and we've said multiple times, find someone you can trust, find someone that is good, that give you comfort, will give you support, and we'll be there in case something happens.

Dr. Furnas (22:43):
So we're going to sort of wind up with bargains, Groupon, guess what we're going to say? That's not going to be the best thing for you. Yes, you can get cheap filler and cheap Botox, but for all the reasons we've discussed, you may not be getting the best deal for yourself as far as safety and quality and the person having the knowledge. And then last, something that we see more and more on social media are injectors doing their injections in their kitchen. And it may be a very homey, comfortable situation, but these injections, as we've discussed, are medical procedures. And you can ask, what is their sterility like? How sterile is their kitchen and what sort of protocol did they have? Where's their emergency kit? And they probably are not going to check off all the proper boxes. This is a, like I said, Josh has said a medical procedure and it needs to be taken seriously.

Dr. Korman (23:50):
Thank you for listening to this episode of Skintuition. Join us every two weeks as we tackle topics from hair loss to hormones and pimples to wrinkles, discovering new ways to feel better about ourselves.

Dr. Furnas (24:04):
Follow us, comment, ask questions, and keep in touch. We'd love to hear from you. Thank you very much. This is Heather Furnas.

Dr. Korman (24:13):
And this is Josh Korman. See you next time.