Fine Arts Skin & Laser Facial Plastic Surgery exists today because of a unique blend of experiences and events in the life of Dr. David Hartman. He received his Bachelor of Science degree from Ohio University, graduating with high honors – summa cum laude, Phi Beta Kappa, and the National Dean’s List. He was one of only two college students in the state that year to receive the Governor’s Award for Exceptional Volunteer Service. Dr. Hartman is board-certified by both the American Board of Facial Plastic & Reconstructive Surgery, and the American Board of Otolaryngology-Head & Neck Surgery. He is a fellow of the American College of Surgeons (FACS). Haute Beauty expert Dr. Hartman goes over what not to do before an injectable treatment and highlights injectable do’s and don’t’s.

Photo Credit: ShutterstockThere are 10 million injectable treatments in the US every year. For many clients, their very first experience in receiving any type of minimally invasive cosmetic treatment will be an injectable treatment. Therefore, many people considering Botox/filler will have lots of questions about how to get started.

Many of the questions and concerns that are discussed by some injectors before injections simply mirror the label warnings handed down by the manufacturers of the injectables. Those label warnings have minimal practical importance compared to the important discussion questions that actually do make a difference. The important questions will help determine 1) if an injectable treatment should happen in the first place, 2) exactly what that treatment should be, and then 3) precisely where the injectable will be placed and 4) exactly how much in each location. First, I will discuss these conversation questions that are important. I will then circle back to the “label warnings“ afterward.

First and foremost, before having an injectable treatment, my strongest advice is that the client has a comprehensive conversation with that treating physician. This is not the same as sitting down with your dental hygienist to have your teeth cleaned. Before having an injectable, there are important choices and details which must be hashed out. Even with those individuals whom I’ve treated dozens of times, I still open the treatment session with at least a brief conversation that discusses the following questions.

1. What are the specific concerns that bring you in today? Is it angry frown lines? Crow’s feet lines? A desire for fuller, sexier lips? Attention must be given to the relative likelihood that an injectable treatment will satisfactorily accomplish the client’s vision or expectations. Certainly, injectables can’t do all things. For instance, neuromodulators like Botox don’t cause an appreciable “lift” of the brow – despite the trendy, gimmicky assertions made by some injectors, Botox temporarily softens muscle contraction, Botox doesn’t lift.
2. With Botox, it’s entirely possible to be both over-treated and under-treated in the same treatment. So, it’s very important to discuss priorities – from most important to least important. Treating the horizontal lines in the forehead may inadvertently contribute to a temporary drop or heaviness in the brow. That possibility should be mentioned so that if brow heaviness is a large concern for a particular client, the Botox injections should only be placed towards the top of the forehead. The priority between a more elevated brow and a smoother forehead can then be discerned and decided.
3. Is there a specific event (such as a wedding) in the near future for which you’re choosing to have a given treatment today? It’s important to communicate this because some treatments have an onset delay (Botox needs 2-7+ days lead time) and some treatments have specific risks that may show up only in the first several days (bruising, swelling, and asymmetries) – so treatment timing may be critical when an important event is in the near future.
4. The costs and expected duration of the treatment results should also be discussed. Botox lasts 3-5 months. Average treatment costs are $300-$600. Depending on the type of filler used and the location of treatment, fillers last between six and 24 months. The average cost for a syringe of filler is $500-$800.
5. Is an injectable actually the best treatment choice for the concern at hand? In some cases, resurfacing laser treatment would better address fine lines and wrinkles and skin looseness than an injectable. In other cases, a more comprehensive approach such as surgical eyelid rejuvenation, brow lift, or facelift would be indicated to successfully address a client’s concerns.
6. So those previous problems aren’t repeated, it’s important to discuss if you have ever had a reaction to an injectable, and what was it? Have you ever felt like you were over-treated? Undertreated? Was treatment discomfort a concern? Would the client like to use a pre-numbing cream or try nitrous oxide (laughing gas) to make for a more enjoyable experience?

As mentioned above, the manufacturer’s label warnings are far less important in 99% of injectable treatments. As for “clients using blood thinners,” my experience is 50% of my skin cancer reconstruction patients are on a blood thinner, but, fewer than 1% of my clientele seeking injectables is on a blood thinner. What’s more, blood thinner patients already understand they bruise more easily, and it would never be my advice that a client goes off of their Coumadin or Plavix in an order to get Dysport injections – the inherent risk of going off of blood thinners far outweighs the risks of a bruise from the Dysport.

I’ve seen it mentioned that recent consumption of alcohol “thins the blood.” The minuscule impact that recent alcohol consumption has on platelet function is irrelevant to the consideration of getting injectables. Vitamin and supplement consumption likewise is irrelevant.

Once someone understands how Botox works, they realize that Botox is safe during pregnancy, especially after the first trimester. Botox is simply a peptide strand – a string of amino acids. Strings of peptides strands are what proteins are made of. In other words, there is nothing inherently toxic in Botox the way we think of toxins such as lead, cyanide, or arsenic. We have tens of thousands of “motor endplates” that trigger muscle contractions in our forehead, for instance. The Botox peptide fits like a key into a lock to disable motor endplates – thereby softening affected frown muscles. Strategically disabled frown muscles cause us to look more relaxed, rested, young, and attractive. The disabled Botox-motor-end-plate complexes are then removed from the nerve endings by our bodies and taken by our lymphatics to our liver where they are broken down and used to build other proteins or used for fuel. Consequently, over the next 3 to 5 months, the treated nerve endings must sprout and grow new motor endplates to bring those corresponding muscles back online. It’s that lag time that determines the duration of the effectiveness of the Botox. So, consequently, within a week or so after the Dysport/Botox is placed in the forehead, there is no longer even a trace of it in the forehead anymore – or for that matter in the body anymore – but, what does remain is a sparsity of functioning motor endplates in the treated area until those nerve endings sprout and grow new ones. Therefore, the “active” form of Botox never leaves the forehead. So, it is completely safe to use during pregnancy or infant nursing. Having said that, because the first trimester is inherently fraught with concern, I nevertheless will wait until the first trimester is over. Thereafter, I believe it is entirely safe – this also goes for nursing moms.