Published August 18, 2008 By Dr. Adam Lowenstein

Today I had a call from the concierge at the Four Seasons Resort here in Santa Barbara. One of their guests wanted a Botox® treatment and was curious if we were available today, Sunday. I spoke with the concierge and explained that I would of course love to provide services to their guests. This woman decided that she wanted to have her injection later in the week, and so I’ll look forward to seeing her then. It did get me thinking, however, about who, what, and where patients are getting their Botox® done.

Injectable substances such as Botox®, Restylane®, and Perlane®, as well as less invasive procedures such as microdermabrasion all fall under the term of “cosmetic medicine”. These more superficial treatments of the skin fall naturally under the purview of both plastic surgeons and dermatologists. That being said, because of their elective nature, other medical specialists, as well as some “medical spas” are getting into this business. Too often, however, these procedures are done by nurses or other non-physician staff members who are “physician supervised”. Often, this physician is not even on the premises, and often, this physician is not one of the specialists with intimate knowledge of the skin and facial anatomy that may be being treated.

How does Botox® work? Botox® paralyzes muscles underneath the skin. When these muscles naturally contract, they bunch up the skin around them causing folds and wrinkles. When Botox® is injected into the muscle, that muscle is paralyzed and therefore the overlying skin does not manifest these folds and wrinkles. But which muscles should be injected? Below the skin are layers of relatively thin muscles, and the injections need to be placed rather precisely in order to affect the correct ones. Poor positioning or migration of the Botox® can cause the desired wrinkles to remain unaffected, or it can give patients adverse effects such as the inability to open the eye, or a droopy eyebrow that is asymmetric and distorted.

For these reasons, both Dr. Sheffield and myself insist on performing all of the medical injectables that our patients receive ourselves. In facial plastic surgery, not to mention the dissections that we have performed during our training, we directly manipulate many of the same muscles that are treated with Botox® . The familiarity that a plastic surgeon has with the layering, positioning, and effects of these facial muscles allows an excellence in understanding how to get the best and safest result from a Botox® injection. In actuality, facial sculpting can be performed with Botox® in manners not commonly utilized by non-plastic surgery personnel. Eyes can be widened, lips can be made thicker, and eyebrows can be lifted and shaped. While all of these things are of a temporary nature, as are all Botox® effects, many patients use these initial steps to evaluate the appearance of the new facial form instead of or before having a more invasive and permanent procedure.

Now that’s not to say adverse effects can’t happen when a physician is providing the treatment. Although I have never personally had a poor outcome from any of my injections, I’m certain it can happen and quite possibly will happen eventually. Botox® can migrate into tissue planes where it doesn’t belong, and someone with aberrant facial anatomy may get some unexpected result. That being said, I would hope that my patients appreciate the anatomic knowledge and concern for safety that I bring to the table. Or to the needle, you could say.

And so, the next time you or a friend are going to get your Botox® injection, ask yourself whether it is being done in the safest environment, and by someone who can elicit all of the manifestations that this fantastic modern therapy can provide you.

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