Botox: Common Misconceptions

Foreign.

I'm here with Dr. Moak. We're going to go over some of the misconceptions of Botox. I'm going to ask them a couple questions here. So what can you not do after Botox? Injections.

Okay. You can do anything after Botox injection. So you'll hear a lot of myths that you're not supposed to lie down, not supposed to exercise, not supposed to push on, you're not supposed to get hot. It's all. It's all BS. So Botox has actually been around for about 60 years. It's been FDA approved for wrinkles for about 20 years. So the common things you might hear about would be don't push on the area or don't massage the area. After Botox, actually, theoretically, it would have faster uptake by moving the air. Massage the area or exercising the area. So we're doing large areas like muscle spasm. We like to inject in. Why the muscles under spasm? Because the uptake will be faster. The uptake of Botox takes roughly 12 to 17 minutes. So when we inject the Botox into the muscle, there's basically a push of those fluid into the muscle is getting pulled up by the muscle end plate, and a half minute is done at about 10 minutes. In about 17 minutes, it's all taken up. Now what makes it uptake faster? There's a few things. One is heat. Now, we don't need to heat the area up, but I'll hear don't get no sauna afterwards and don't get exposed heat. Heat would actually make it work faster. Now, cold, on the other hand, would make it work slower, but it would be immaterial. So if you ice the area down, theoretically might take 20 minutes for it to be taken up, but it doesn't really matter. So temperature has no effect on the clinical outcome. Motion does. Motion arguably would make it take up faster and get a little better response. So that could have a benefit. In medical Botox, we're doing large units in the big muscle. We do have an exercise muscle. For cosmetic Botox, it probably doesn't really matter.

Motion. You mean by exercising the muscles?

Yeah, probably only for the first few minutes. Let's say you do the Botox. I can usually have the patient squinch a couple times. It might take up faster, but again, it's not clinically important.

Okay, so talk again about the heat. Can you go into a sauna? Can you go into a hot tub?

So let's say you did your Botox and immediately you got no Sauna, it would arguably uptake faster. Okay. Since you're probably not going to sauna for half an hour, you have. You'll have no clinical issues for sure. You can sauna after Botox. You can blow dry your hair, you can get hot, you can go out in the sun. I'd hear don't go in the sun after Botox. That's all nonsense. The Botox drink now, it hasn't kicked in yet. Okay. But it's been already taken up. It's no longer floating around. So that there's no issues with that.

What about lying down?

Yes, that one a lot. Yeah. So really, when they originally did the Botox, FDA study was in the 80s and 90s and they had people not lie down just for a reference point. Okay. Turns out it makes no difference. It cannot affect the outcome of Botox, the complication of Botox, the effectiveness of Botox. You can lay down after your Botox.

What about working out?

So working out, Arguably it would work faster only if you did within minutes after the Botox. So it was a half an hour afterwards. No positive, no positive or negative impact on the Botox. If you worked out your muscles immediately after Botox, arguably it'll kick in a little faster, a little bit more effective, but in general, no impact, showing you no contraindication. You work out immediately after Botox.

So why do you think there's so much misconception out there about what you can and can't do with Botox?

Yeah, great question. What happens is when people are not scientists, they look for the nose, they look for things that people should not do. They go to conference, they start hearing stuff. I Additionally, when you look at the product labeling Botox was first came out, it was actually oculinum. It was for the eye for a muscle spasm. Interesting. This is an interesting tidbit, if you don't know much about Botox, is Botox was bought by Allergan, the current maker of Botox, for $9 million in 1990, something that generates billions of dollars in revenue. They basically bought the patent back then. But when they did their study, they had certain criteria. First off, they used preservative free saline, which we never do because it hurts like hell. Okay, so that doesn't. But it says it in the labeling also it says use it within four hours. It is unchanged in a refrigerator for one year. So that may be used to me went to mix it up and use it. You can mix it up and sit in the refrigerator for a day. Don't pop it with that. But they did say things like inject it in certain spots which are not the appropriate spots. Not too late out four hours afterwards. They put that in the labeling. But as time goes out, we do studies and we find out it doesn't really matter. So it's something that those legacy just carry on. And I think from a scarcity standpoint, people want to scare you about stuff. So when a person has Botox and let's say they didn't get the result they wanted, usually that's from not enough units or not proper injections. The provider wants to blame you inside your phone. Okay. So it's either not enough units or wasn't put in the same product. And rarely you are immune to Botox. Now what can happen? There's really no true allergies to Botox. There's been one reported case in Turkey in about 2015. You'll get allergic to it, but people can make antibodies to the Botox, usually from very high number of units being done very often starting at a young age. Doesn't occur as even with Botox or Dysport or Jeuveau. And the Botox has a little protein tail on it that some people make antibodies to where eventually it's not working as good. We see that in less than one out of a thousand cosmetic patients. So it's really not a big risk. Another thing that can impact Botox's outcome is zinc. Now Botox is zinc metal peroxidase and requires zinc to work. And healthy people are usually depleted in the zinc. The reason is healthy people typically eat a lot of fiber. And fiber is an anti nutrient extracts nutrients from your body. That's why they put zinc in different elements in cereal. That's why they required to do that, why they put in cattle feed. So if you want your Botox to work longer, studies have shown that if you avoid on grains a day or so beforehand or day or so after, it takes a think it might work a little bit better. Generally it's not material, but somebody's not working as well. That's one thing you can do. So let's just summarize what can make Botox not work as well. Not enough units, not quite in the right spot. I mean, that's it. Occasionally neutralizing antibodies, very rare, rare. What can make it work worse Instead of not working, work worse. Not having enough zinc may not last long enough. In addition, things I said before, not enough units working make it work better. Having plenty of zinc on your body, putting it in the right spot, having adequate number of units, move it immediately afterwards for about maybe 30 seconds to a minute and actually heat. And I'm not recommending using fine necessity, but theoretically it uptake faster. But the things regarding not laying out afterwards, don't exercise, don't get sauna, don't pant. This is all nonsense designed to scare people or maybe blame them when they're Botox and getting results they wanted to. So very, very safe. Botox is very, very safe. When I say Botox, I'm generically referring to Xeomid, you know, Dysport, Daxify, Juveau and Xeomin. They all have the same characteristics. There are slight differences between the different neurotoxins, but those answers apply to all of them.

What about like facials or getting laser treatments done directly after? Is there a certain amount of time that you wait to have something like that done?

That's a great question. It's something I missed when you asked my first question. One thing that can occur if you do Botox, and we do, we call tummessing the face. We put a lot of water in the face to do aggressive laser procedure. It can spread into areas we don't want it to spread. So that's one of the times we won't do Botox and say laser resurfacing, aggressive laser refurbishing the same day. Usually we wait a day between them or a few hours between them. That's one thing that can cause unwanted spread. But you can get facial afterwards, a facial massage afterwards, IPL afterwards, a vagus peel afterwards, ulce therapy afterwards, microneedling afterwards, or even frequency microneedling afterwards. Something where we're putting a lot of volume in the face. We want to give it a few hours just because if you do the Botox and you have a bunch of volume in the face, it does make that 12 minutes of uptake last a little bit longer than the Botox can displace. Yeah, that's a good one.

Okay, and how long does it take for it to kick in?

Actually? Okay, so if we look at the three major toxins that we're seeing right now, which is Xeomin, Botox and Dysport. Okay, now there's two other ones I'm not going to talk about because they haven't studied head to head. Xeomin has the fastest onset, about two to three days in women and three to five in men. Botox in between about three to five days. It would have been five to seven days of men in this part. It's a little bit longer about five to seven days in women and a little bit longer in men. Now in terms of how long they last, Eczema's got a little edge, lasts about a week or 11 days longer. Botox rating between and dysport probably the shortest. If you're using equal clinical doses, the Dysport dosing is not matching up with Botox and Xeomin. But there's a ratio we use to get them the same. So we're using equal clinical doses. Go faster onset, large ratio, Xeomin, Botox, you know, the Bumbleberry in the middle and then the Dysport a little shorter, long lasting and a little longer onset. And Dysport spreads the most zeum and the least Botox rate and twins, you have subtle differences.

So I would say we're probably on the higher end of dosing. Is there too many units a person could ever get? Would you ever get too many units?

Yes. So the unit is defined by the LD50 lethal dole50 in the sprog daily mouse. And there's a, there's actually, to test for Botox sensitivity, you actually got to sacrifice a mouse or the units are based on some mouse model. However, we know that the lethal dose 50% for humans is 3,000 units. So if you did say a thousand units, you are using potentially close to dangerous dose, 3000. It is risky. Generally stopped at 300 mutas and below for all humans is okay. Up to about 1,000 in adults is okay. And typically we're not using 1,000 or 300 in the face. We're using those unsafe muscle spasms in the leg. Neck and neck is typically 300 units. So for cosmetic dosing, there's really no dosage window because you really can't do enough that could be dangerous. The FDA dose is 64 units of Botox and that's just the only dose you can use more than less than that. So FDA is what they have approval to market for as physicians, we're typically about 57 units in our average female patient. Average male patient, roughly 100 units. As for typical treatments and we're doing the neck and the lower face more like, you know, 100 to 150 units of women and 200 units of men.

So what happens if you use more units less longer?

So there's a dose duration curve, let's say the glabella, which is between the eyes. The first Approved dose was 20 units by Botox in 2003. Lewis Light. So at that time it was the newest thing for neurotoxin warning Competitors, you only had to get a certain percent. They expect 100% response rate. 20 units, you'll have about two thirds of people getting a decent response. It'll last about three months. However, if you do 30 units, you respond about 95% of people for about three and a half months. If you Xeomin lasts just a little bit longer, but we're seeing it about three and a half to four months now. If you double the dose of neurotoxin, you go from 30 to 60. Doesn't last twice as long, but it'll last about 50% longer. More so with Xeomin than with Botox, Duciport, they're not quite as linear. If I have somebody that's traveling away, they're going to Europe for six months. I'm putting 100 units there. Go Bella. There's no risk to it spreading into other areas from that. For that modded units, it'll just last longer. There's a new product out called Daxify. Now the Daxify is billed as the six month toxic. Okay, There's a problem with that. So if you say your toxin lasts six months, you expect this will last six months. It does it 47% of people, okay. And you have to use twice as many units as you would at Botox or Xeomid. So now you use twice as many units for product that costs more to begin with for something that only 47% of people, less than half and will get a longer duration. If you use twice as many use as Xeomin, you're gonna get an average of five or six months that are toxic for almost everybody. So the there is a dose distribution or dose duration curve, but it's not linear. Typically what we want the dose to last approximately four months because that's the best bang for your buck. You do it three times in a year, maybe three times. The second year, the third year, don't need it so much because the muscle has been at rest so long, it has reversed its age, it's atrophied. So typically after about two years, these muscles have gone back in time. It's just not necessary to doing it either as often or as, or maybe once a year now.

Well, thank you very much, that was great information.