Got Lines? Relax with Botox—and More!

You've heard about Botox for wrinkles. Well, there's a new kid in town and it's the most innovative neuromodulator in three decades. Welcome to Skintuition. I'm Heather Furnas.

And I'm Josh Korman. From pimples to Wrinkles, our skin affects how we feel about ourselves. As two plastic surgeons, we discuss what's new, what's safe, and what to look for when you're ready to hit refresh.

So Botox is a neuromodulator and

That's a big word.

<laugh>. It is. How would you define it?

I don't know, I just, a neuromodulator is just the technical term, but it's so confusing. So maybe we can just break it down to like what it really is and what does it do.

Yeah. So I'd say neuro means nerve and modulate, like you modulate your voice. You control your voice. So it's a way of controlling the nerves that go into the muscles of, and usually we think of muscles of the face. Can you improve on that?

Well the thing that's confusing is that, so if Botox or Dysport or Jeuveau or Daxxify, we'll talk about in a second, all these things they, they get injected into muscle. So what does that do? I guess that just, it goes into the muscle but then it accesses the nerves that supply the muscle? So then it doesn't move the muscle so much?

Yeah, the way I think about it is, it's like the nerve is like the electric current, electric cord that's plugged into the muscle. I mean when you, we put in a neuromodulator, we just unplug that cord. So the electricity, the electric currents, the sort of signal saying contract, contract has just been disrupted for about, for most neuromodulators, three to four months.

Yeah. So, and maybe that's why people like to call it just Botox because neuromodulators like at least four syllables, whereas Botox is two syllables. But I think we get the point. So, okay, so what's new?

So Daxxify. Daxxify just came out and a lot of people are talking about it. We're using it in our practice and we're loving it and it's because it distinguishes itself in one big way. And I'll let you say that Josh.

Well I guess it's supposed to last longer, like six months or something. So the question is, have you been using it for more than six months?

Well, we are not at six months yet, but we have our follow-ups and so far, the follow-ups have been looking really good. But we're not at the six months yet and we're excited. We're really excited to see this happen because we get, a lot of people are either busy or they live two, three even four hours from us and for them to have to come in every three to four months when they could come in every six months, twice a year, that's a big deal.

Yeah. I don't know. In my office I think we're a little bit on the slower adopters cause we haven't started it yet because we kind of want to see if it really is gonna last six months. We don't want to overpromise. And also what happens if it doesn't look the way you want and then you have to wait till six months goes by. So that's why we're a little hesitant about it.

Well that's a really good point. And if you're new to neuromodulators then I think one of the shorter acting products would be the way to go just to make sure that you're really happy with what it does. Sometimes people will have their forehead injected and they feel like they can't move it and it's not a very comfortable feeling. Other people love it. So if you love it then, you know, okay great, I can have Daxxify now. Any new area, same thing, you just wanna test it out, then why don't you go for the three to four months? But once you really, you know that that's what you want, then every six months, that's the way to go. At least for my schedule, that's the way to go.

Yeah, I think that obviously, uh, makes sense and that's what's the current disruptor in the market. There are several besides Botox and Daxxify, there's Xeomin, Jeuveau, Dysport and Botox and those have all been uh, around for a long time and, and those tend to last three to four months. But I have some patients that even though it's supposed to be three to four months, they'll say, you know, after a while it's only two months. And sometimes people say, well the first time it lasted a lot longer. So it's a little hard to know how to, as a consumer, how do you know which one to choose?

Yeah. And I, I think that's something that just all these products are being injected into humans and humans vary hugely in their physiology. So you're absolutely right. We get patients who say Botox doesn't last very long for me. And others will say, you know, I get Botox that last six months. So I think we're gonna see the same thing with Daxxify. Maybe not everyone's gonna see that they last six months, that's sort of a average point, but they're gonna be some who find that they get benefits for longer than six months. You know, we'll wait to see. We're excited.

Yeah, so I think it's good that there's a new thing on the market and it's, it is good to know and it's also good to have options and I think that's really good for as a consumer. So I think the question is, you know, there are lots of people who've never had Botox or Dysport or Daxxify any of these things and sometimes a little freaky the first time like, oh what am I doing? Am I getting like botulinum toxin injected into my face? What does that do? And yet it's been a proof for cosmetic reasons for more than 20 years. But it's still a little bit confusing like how much to put in and as a consumer, like where it should get put in should it, you know, there's the upper part of the face and the lower part of the face and you hear about Botox being used for kind of just about everything these days. And I heard even that now it's, we know it's been used a lot for to help with migraines, but now there is like a study that it helps to reduce anxiety.

Yeah, that's pretty cool. You know, because we think about if you're tense, you know, your muscles are tense, your furrowing, maybe your shoulder muscles are, you know, pulling your shoulders up and people are saying, relax, relax. And so it's an interesting finding that people who have not just one, but several areas injected, that they are more relaxed than people who don't have Botox injected. Not that it's a treatment for anxiety, you know, it's, that's gonna be therapy and medications that are really geared towards anxiety, but it's actually a really nice sort of side effect.

Yeah, I think that's interesting. I think part of it though that's a little bit confusing is that sometimes, you know, late night television hosts and, who probably have had all, all have had Botox too, they sometimes come out with these lines about, oh, that I want my face to still move. There's so many muscles in the face, it's doesn't stop your face from moving. I think that's really giving too much credit to any of these neuromodulators. They just don't do that.

No, they're dose dependent too. So if you want to weaken a muscle but not take away all of its function, you can do that by controlling the dose. And then you may find that first time around people will come back say the Botox didn't work, we take photos of pre-treatment and post-treatment and we can show the patient, well actually it did work. It's just that your muscle isn't paralyzed, it's just weakened. And if somebody wants a stronger effect then they can just have a higher dose, more units injected.

Yeah. The thing though, there's still a certain area, like what I've found even for myself, is that when, one of the big popular places for Botox to get put in and is in the crow's feet, and it's interesting about crow's feet because there are the wrinkles that people see when they don't smile and they're the wrinkles you see when you do smile. And I think there's no matter really how much of any of these products you stick in the crow's feet when you do smile, you have so many muscles interacting. It's not like you can, oh it didn't work, I need more, I need more, I need more. I think the reality is as we age, there's more and more muscles that are recruited when you smile and we wanna look as good as we can for the age that we are, but you're not gonna suddenly look like a teenager and have no wrinkles when you smile. And I think it's important not to put too much, uh, hope is a strong word, but <laugh> to realize that when you, it's, wrinkles when you smile are different than wrinkles when you don't smile. But that's different than in the glabella, meaning in the frown lines of the forehead, because Botox really does work well in reducing the frown lines when you frown. But that's different than in the crow's feet. Why? Why do you think that is?

Well I think when you're, you mentioned the glabella, so you've got a couple muscles that act in that area and uh, one causes the up and down furrows and the other causes little wrinkles across the bridge of the nose. And so they're just two muscles that you're dealing with. And so that's, you can knock those out. Same with the forehead. You've got one muscle that raises your eyebrows and creates those horizontal lines and so you can knock that out. But if you look at your crow's feet, you've got the muscle that the Botox weakens, but you also have your cheeks pushing up when you smile. You've got a lot of other effects going on other than that one muscle that you're targeting. And so when people say, I want the crow's feet completely gone, you know, I say, well we can completely paralyze all muscles of the face and you're not gonna get any movement there. But that is, I say that in jest because of course then it would look like you had a stroke and you would have trouble speaking, and so it would not look natural. So we need some animation or we look funny, we look unnatural, we can look if there's asymmetry, like we had a stroke and we can look a little scary. So it's important to accept the limitations of what we can do with neuromodulators and also to accept that a natural look is much better than, than a look that is distracting because it's been overdone.

Yeah, that word natural, that's a, a, a word for us to talk about at another time because there's so much, like what's natural? Is the electric light natural? So we'll talk about that another time. But back to this Botox on the forehead, one of the things that that I think does happen if you put too much, and for some people it's the right amount to get all the wrinkles in the forehead to go away, sometimes that can drop the eyebrows and that's then you sort of feel like you have a window shade on you. And so the question really is, is that you know, you want all the wrinkles gone, but you don't want the potential side effects of having so much in your injected. So what's the best way to figure out what the right amount is?

Well I think first of all you start on a, in a more conservative range. There are dosages that are recommended, dosages for men, dosages for women. Somebody who is younger may not need as much as somebody who's older. And sometimes as people get older and they keep on coming, coming more for Botox, they are shocked that the same amount of Botox is not working for them anymore. And we say, well you need some more. And they think that it's because the Botox isn't working, but it's in fact because they're getting older and they need more Botox. And so there can be what we would call some titration where the person injecting tries a certain recommended dose and if somebody needs more, sometimes you have one side that's overactive, that side needs more than the other. And with experience, the person doing the injecting will have a sense of where something needs more, something needs less. How about you?

Well first of all, older. Who's getting older? <laugh>, What do you mean? What are you talking about? I have a question is now, you know the, Botox started for cosmetic purposes in the upper third of the face. So the forehead, the glabella, the the crow's feet. But Botox is getting injected all kinds of places in the face now, like in the neck and in things called the lip flip. So what's a lip flip?

Oh I love the lip flip. You put a little bit of Botox in the upper lip, not so much that you can't eat, speak, or suck in a straw, but enough so that you relax the muscle, the of the upper lip that can pull an older lip down and also kind of flatten the lip and draw the pink part down so it can rotate that pink part up plump up the lip line. And so you see that cupids bow and it looks younger, the lines themselves are softened, not erased, but softened. It's wonderful.

And what about like to get the corners of the mouth up?

Oh that is I think a two-pronged thing cuz there's depressor anguli oris, a big mouthful so to speak, for a muscle that pulls the corners of the mouth down and so you just put a little bit of neuromodulator right there. And also filler. Yeah, just filler, right? It's so cool to inject the filler and you see that downward corner kind of going up. So a lot of what we do in, you know, all of this lines and shadows and whatnot, is a combination of neuromodulator with filler. But targeting that the right muscles that you need to know the anatomy and be of a bit of an artist as well.

So that's also interesting, like how do you figure out how much you should pay for Botox? You mentioned a good point. It's good to go to someone who's, I would say a little more than a little bit of an artist, and somebody who has a lot of experience. So as a consumer it's a little bit of a question like why wouldn't I just go for the cheapest price?

Well you are paying not just for the stuff in the bottle, but the person putting the stuff in the bottle into you. And that's really the trick. And so if you don't think that that person is something that you really care about as far as background, experience, knowledge of anatomy, sterility, quality control and all of that, then you can go for the $7 unit Botox. But if you really care about the results and the quality, then you want somebody who really knows what they're doing and not over do, then that's where you're gonna pay a little bit more.

I think the other thing is that sometimes it's a little bit of a shell game. Cause a lot of places you go, they'll charge by the unit because Botox and a lot of these other neuromodulators are in units and some are by the area. So that's a little confusing. And then there's also, there's some places where the units are low, but then there's an injection fee. So if you actually look at the numbers altogether, it's kind of all the same. And then the other thing that happens in the part of the shell game is what happens if you need a little more? So do you pay for the little more or not? So these are, and also what is the dilution and when was the Botox reconstituted? These are all things that need to be, you have to be an educated consumer and it's really important just like if when you buy a car, you're trying to be an educated consumer.

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The difference here is that in addition to all the things about buying a car, when you buy a car, the cars were all made in the license factory of the car manufacturer. With these neuromodulator, Botox, Jeuveau, Dysport, Daxxify, all these other ones, the most important thing is who's putting in you. And as you said, you know, who knows how to put it in the best. So it is a little confusing, but it's why it's really good to be such an educated consumer and realize that there are a lot of options. A lot of good options.

Yeah. And so you want to, bottom line is you want to trust the person who's putting it in, and this is not an area to go cheap on. You can buy cheap toilet paper and cheap paper towels, but don't cheap out on your medical care whether it's aesthetic or otherwise. One question I have is what age would you say people should or shouldn't consider neuromodulators?

Well, I think it depends for what area, but I personally think, and people age different rates and a lot of different things. My gut feeling is somewhere around 30. I'm sure there are people that wanna do it earlier and that's fine. I think if you think about how, if you start when you're 20, you'll be doing it for a long time. And I don't think there's anything wrong with doing it sooner, I just think that wrinkles start to form for the most part in their thirties. Although full disclosure, I've had wrinkles on my forehead since I was a teenager and I don't think that they really bothered me that much. They haven't changed that much over the years. So I guess that's what I would answer. Late twenties or early thirties. How about you?

Yeah, we, we will do, particularly frown lines, if there's somebody who is young in their twenties with lines that you can see at rest, that line's just gonna get deeper and deeper and will start to distort the contours of the skin and the muscle. So that's an area. And forehead lines, as you mentioned, Josh, you know, you can, some people get forehead lines at an early age and it really depends on the genetics, how your forehead muscle inserts onto the skin. And so if you are someone who is developing lines at an early age that are visible at rest, in other words, you never completely relax those lines, then that's when Botox can be preventative in preventing that line from being permanent. And so those are the areas that I would consider. But otherwise for the most part we do see most of our patients coming in and 30 and then increasingly as they get older and notice those, those lines. But it's a wonderful product because as you started out saying, Josh, it's, you know, it's scary, it's a toxin, it can terrify people. But it's controlled and, and that's really the whole point of it. You take something that you harness and and make it work for you rather than against you.

And at the end of the day, what you're really trying to do is, you know, as that famous line goes, you're never fully dressed without a smile. So you know it's something you want to do. Things that make you happy and give you comfort, give you confidence, and not be afraid.

Thank you so much for joining us. This is Skintuition.