By Pamela Jacobs
We’ve all heard of Botox by now, and we think we know what it does…or do we? What exactly is it? What’s the difference between Botox and some of the other names we’ve been hearing? And are there any alternatives? Being an educated patient means being a happy one, but it’s often hard to know what is real, and what is simply advertising. Resident sat down with Dr. David Rapaport, a renowned Fifth Avenue plastic surgeon, to find out everything we’ve ever wanted to know about Botox, and more.
NY Resident: What exactly is Botox?
Dr. Rapaport: Botox, which has been FDA approved for cosmetic use for nearly ten years, refers to botulinum toxin, a toxin made by a bacteria, which, when attached to a muscle, essentially relaxes or paralyzes that muscle for a limited period of time. Botox Cosmetic, its trademark name, is made by a company named Allergan, the makers of a commonly used breast implant, and Juvaderm, one of the most commonly used fillers. Botox is a highly purified form of botulinum toxin, which contains absolutely no bacteria, and has been used millions of times worldwide without causing infection or serious adverse effects. A very small amount is injected and once it touches the muscle, it makes that muscle go to sleep for three to four months. What Botox is all about is easing dynamic wrinkles, which are wrinkles that appear with muscle activity, and that’s key to understand. Botox is not a filler. Many times I have patients who come to me with deep nasolabial folds, the smile line folds, and say ‘I need Botox.’ But what they’re really saying is ‘I need an injection,’ thinking every injection is Botox, which of course, is not the case. There are two general types of injections for your face, one is Botox, which is a neuromuscular toxin, and the other is a filler.
NYR: So Botox is different than a filler?
DR: Botox isn’t a filler. If you have a line on your face that looks the same while you’re asleep, while you’re relaxed, and while you’re animating your face, then that line will not be improved by Botox. Botox will only improve a line or wrinkle that is caused by the activity of a muscle.
NYR: Where on the face is Botox typically used?
DR: The classic area is what we call the glabella, which refers to the area between your eyebrows. This area is commonly referred to as the ‘eleven’ and is caused by a scowling motion, or a look of surprise or curiosity. This qualifies as a dynamic wrinkle—when you’re sleeping there’s no ‘eleven’ there. So I inject Botox, and then typically within about 5-7 days that muscle gradually relaxes. Afterwards you think you’re scowling, but if you look at your face, you look entirely relaxed and you have a more relaxed look between your eyes. That, according to the FDA, is the only officially approved cosmetic use for Botox, and every other use is considered an off-label use; those off-label uses are extraordinarily common. The other two most commonly injected areas for Botox are the forehead, or the frontalis muscle, and the crows’ feet, which is the orbicularis oculis muscle, the muscle that goes around the eyes.
Botox is also used for the gummy smile. With two tiny injections on the side of your nose, that specific muscle can be relaxed and the gummy smile is gone. There’s also a muscle that brings the corners of your mouth downward, and that muscle can be injected. Another use is for sweating. If you are an excessive sweater, getting Botox injected in that area will greatly reduce the sweating for nine months, sometimes even a year. It’s pretty amazing. Patients that I treat for excessive sweating come back every 9-12 months.
NYR: Once you inject Botox, is it a permanent decision? Do you have to continue using it forever, and does it make the area worse?
DR: Once I inject Botox into those lines, they gradually go away, and then they return as gradually as they went away, meaning they don’t come back worse. In no way do these injections make things worse—there’s no revenge or punishment for using them. This is also true for fillers. The only change later on is that you are older, but unlike dyeing your hair, you don’t get ‘roots.’ You just go back to the way you looked before. The only addictiveness is psychological.
In fact, when people use Botox regularly, the muscle itself will atrophy and become weaker due to lack of activity, and so the amount of product needed per treatment may actually go down.
NYR: How do you, or I, determine whether I need Botox or a filler?
DR: During the consultation I will hand you a mirror and ask you to point out what bothers you. We need to communicate properly to ensure that I inject you with exactly what it is you need and fix what bothers you. So the patient needs to communicate what bothers him or her; if it is that scowling, that “eleven” area, then ask to fix that. If it’s the crows’ feet that bothers you then ask for that.
Because of the wild success of Botox—Botox is the Kleenex of injections, it’s a household name—most people, when asking for an injection or a filler, ask specifically for Botox, not knowing the difference. As you age, you are losing fat in your face and essentially your face is melting away. So actually, fillers probably deserve a bigger role than muscle relaxers, and it will just take time for people to understand this. During the aging process, it’s fillers that are key. I like to tell patients to think of their face as a mountain with snow on it, and as they age, that snow melts. The cheeks become more empty, the smile lines become more evident, and that’s the melting of the snow, and this is addressed by fillers, of which we have many excellent options.
NYR: How do you actually apply the Botox, and what should a patient expect? Are there side effects?
DR: Before administering the injection I make markings where I will be putting the product and I place a little ice on the area, which is typically enough because it’s a very fine needle and the material doesn’t burn. Since I’m making the injection under a very strong light, I can see if there’s a vein, so bruising is very uncommon in my hands. Then just leave it alone. Don’t massage it, don’t work out for a few hours after, and you shouldn’t take aspirin or motrin for a few days before in order to minimize the risk of bruising. And just think ahead—while the risk of bruising is low, plan to go to your doctor a few days before a special event. Don’t go to your doctor on Friday if the party is on Saturday.
The only time you hear of the really scary stories of side effects is when practitioners have no idea what they are doing or are buying counterfeit products and are really doing it wrong. When they are buying the right product—meaning the real Botox, and administering it correctly, adverse effects should be exceedingly rare. It’s extremely safe.
NYR: Are there any alternatives to Botox?
DR: For nearly ten years, Botox was the only product on the market, and you could set your watch by the fact that every year they would increase their price. Then approximately two years ago, a product called Dysport came on the market, and it’s almost identical to Botox—only one molecule is different—it’s the same toxin, just made by a different company. Dysport is made by Medicis, the company that manufactures the most popular filler in the world, Restylane, my personal favorite filler. It’s a very smart, solid company. Dysport is virtually identical to Botox, but there are three major differences: Dysport starts to work a little sooner (2-5 days), yet lasts the same amount of time. Its more rapid action is definitely a benefit if you are in need of results in less than 5 days; it spreads a little bit better, which is almost always an advantage, and therefore you’re less likely to need a touch-up; and finally, the company’s strategy is an advantageous difference. They are pricing it much more competitively, and they are selling it to doctors for less money, which means the doctors can sell it to patients for less. Typically a vial of Botox costs the doctor about $550, and can be used on maybe three people. Dysport’s more aggressive pricing allows me to pass that savings on to the patient.
The most recent development in this market is the recent FDA approval of a product called Xeomin, which is made by Merz, who manufactures a filler called Radiesse. This product is expected to be released for cosmetic use in the U.S. around March 2012. What’s unique about Xeomin is that, unlike Botox and Dysport, which both have proteins attached to them, Xeomin is like pure Botox with no proteins. If in the rare case somebody develops antibodies to the proteins in the Botox, it will no longer be a problem with Xeomin. Perhaps the biggest advantage of Xeomin coming along is that these three products can compete with each other and bring the prices down even more.
NYR: Speaking of prices, what should someone expect to pay for one of these products?
DR: Botox for one area typically costs between $400-$500; when you do more than one area at a time, the price becomes more attractive. If you do the three most common areas at once, it will run $800-$1100 or $1200, at high-end practices, with the treatment delivered by a physician.
For the exact same treatment with Dysport, the price should be 20-30% lower, so it can be a real advantage. And this is a truly great product, it’s just a company being smart. I’d say, in my practice, right now, about 80% of the muscle relaxers I inject are Dysport.
NYR: How do you feel about the now-common practice of Botox parties and store-front Botox injections?
DR: I don’t believe that medical decision making should be mixed with intoxication. If you are making a decision about needles going into your face, this decision should not be made while you and your friends are sitting around drinking wine. I don’t think it’s good for sound decision making, so I don’t like the idea of Botox parties. Additionally, when you’re drinking alcohol your veins dilate and there’s a higher chance of getting bruises.
As far as med-spas, etc., I am not saying at all that only doctors should be administering these products, but what I do strenuously believe is that only very experienced practitioners should be administering them. What you want to know is that the person injecting you is ethical and very experienced. You have to be very careful of a med-spa that has a different person there every time you go. When the staff is turning over very frequently, there could be a problem. It becomes an art to know how much to inject and where to inject it. I keep detailed records, so I know what works best for every individual patient. You want continuity, and you want someone who does it frequently. A person who does it well is justifiably getting a higher price, and you are trusting their ethics, experience, knowledge, and skill. The smart consumer knows to go to the experienced professional who has devoted time to this practice and will be there tomorrow for you.
David Rapaport, M.D. is a board certified plastic surgeon on Fifth Avenue in Manhattan who has been practicing for over twenty years. Dr. Rapaport will be serving as the monthly cosmetic surgery consultant for NY Resident. For more information visit