Part 1 of our interview with Marc Scheiner MD, an Allergan Certified Botox Cosmetic Trainer and the physician instructor on Botox Training MD.
In this three part series we're discussing Botox and fillers with Marc Scheiner MD who trains clinicians through 14 credit CME two-day hand's on seminars with the American Society of Aesthetic Medical Professionals and Botox Training MD, an online botox training site for clinicians.
In part 1 we discuss Botox indications, complications and some treatment techniques.
Let's talk a little bit about differentiation between Botox and fillers. Can you give me a kind of a overarching framework of how it is that you decide which is going to be better treatment for an individual patient?
Well, certainly, to determine whether or not you're going to treat someone with Botox versus fillers really requires that you have an understanding of facial ageing right from the beginning. So typically when you evaluate the face, you notice several different age-related changes that occur in a predictable fashion.
The first thing we notice is that the surface of the face changes whereas we once had a very nice homogenous color to our face and a nice turgor to it, it now becomes maybe a little like crate-like in areas, and the color and the tone is different so we'll have maybe some spotchiness, some brown spots, some visible underlying vasculature. So that's the first thing we notice or the surface changes.
The second thing we begin to notice are actual lines, rytids, or wrinkles that again occur in predictable areas of the face. For instance, we see this on the forehead, we see them between the eyebrows, and we see them surrounding the eyes--the crow's feet. So, in addition to the surface changes we then develop lines.
And the third aspect of ageing that we see are furrows or depressions that occur as the result of the loss of volume. For instance you begin to develop some smile lines or the nasolabial folds as a deepening furrow adjacent to the nose. You begin to develop some marionette lines down on the chin, some are jowling. You begin to lose volume under the eyes, and you develop tear troughs. So that's the third area of ageing that happens.
So, if you take off three of these areas, the surface changes--the wrinkles and the loss of volume. And then you target those areas with all the various products that are available. Botox and fillers are able to target the wrinkles and the loss of volume. They are not able to treat the surface changes that we see with ageing. Those changes--again the change in color and tone, are treated with resurfacing modalities such as cosmetic lasers or chemical peels.
So, back to the initial question, you know, when do we use Botox versus fillers? Well, Botox blocks the transmission of nerve impulses to the musculature or the magnetic muscles of the face. Understanding that, and understanding the fact that muscles are actually responsible for the wrinkling of the skin, we can then understand that Botox is used for wrinkles. For instance, the forehead wrinkles, the frown lines, around the eyes, perhaps around the lips. So by paralyzing these muscles, they're unable to contract and wrinkle the overlying skin which is the etiology of the wrinkling. So, the Botox, again, is for the wrinkles and the fillers are just fat. They fill up areas that have lost volume from ageing. So, we use fillers to fill up areas under the eyes, for instance the tear troughs or the area adjacent to the nose, the nasolabial fold. We also use it to augment the lips. So, in it's basic form, Botox and fillers are used in that regard and there are instances where you actually use them both together. Two very common areas that we use this in combination are the glabella--which is the area between the eyebrows or the frown lines and the lips or the smoker's lines.
So let me just go a little bit more in depth into what I mean by the combination of those. If somebody is to have the development of the frown lines or the number 11, that's what it's commonly called, the initial treatment is the injection of Botox. And the Botox is used to paralyze the muscles producing that crease or wrinkles specifically the corrugator or the procerus muscles. So, we add over the Botox to that area and we paralyze the muscle. And in most instances, there's a softening or an improvement of those muscles, of those lines. However, in a certain percentage of people, Botox will be unable to completely correct that area or give a degree of correction that is acceptable to the client. In those instances, you can then add some filler to the crease or the depression of the frown line. So that's one common area where we combine Botox and fillers.
Another common area of the combination treatment is the periorbital area. Typically when we begin to develop a of the upper lip, often known as the smoker's line, there's really many different ways to treat it but one is to inject a small aliquot of Botox into the orbicularis oris. Maybe just one or two units at two separate injection points right above the vermillion border of the lip. And that will soften the appearance of those lines. But to add a greater degree of improvement, one can add a filler to the upper lip. That volume that you add actually stretches out the upper lip so that combination also causes some improvement in that area. Okay, so that's basically the indications for those 2 products.
How do you talk to patients about static vs. dynamic wrinkles. Is there a nomenclature that you typically use to describe to a client how these wrinkles are formed and which ones you're going to treat and why?
Well, typically,the clients come to you with specific concerns regarding their ageing and quite frankly, it's usually the same areas over and over. And with that said, you know, most people are complaining that they've developed some lines around their eyes or the crow's feet. And they don't like the fact that they appear either tired or angry. And that is because of the development of the frown lines between the medial eyebrows. In addition, some people complain of the forehead wrinkling as well. My discussion with them always goes over the etiology of their issues. It's pretty easy to understand. The skin as we age loses its elasticity as a result of the age-related loss of collagen. The loss of the collagen and the subsequent loss of the elasticity allows the underlying muscles that we use everyday to produce emotion to wrinkle the overlying skin. For instance you know, when we're teenager or young adult and we frown, you notice a small, little area between our eyebrows that indicates we're angry. But as we age, the skin loses its turgor or elasticity, so when we frown and contract those muscles, a much greater degree of wrinkling is observed. And that's the typical discussion I have with them. And I go and tell them how can that be very easily corrected with small injections of Botox. I'm sure that... I mean that I am always careful to explain to them... so that they have a realistic expectations with regards with the treatment. You know, I always explain that I don't have a paint brush and I can't just erase the lines but I say we can certainly improve them and soften them. I think it's really important to understand people's expectations so that they're happy after the treatment. So once we have that discussion and then review the risks that are associated with the injections themselves and have a consent signed, we are ready to begin... and most people are pretty satisfied with Botox.
So in looking at each individual treatment area, both with Botox and fillers, some have potential issues. I mean injecting Botox around the mouth has some real potential for unwanted effects. Many physicians wouldn't even attempt it. How would you rank the difficulty in treating an area? Where's the hierarchy there?
The face as we initially discussed really ages in a predictable fashion. And the importance of that is most people are going to present to the physician wanting correction of, thankfully, the most easily, correctible part of ageing and that's the frown line. So without question, the forehead and the frown line are the easiest to treat and the most forgiving with result...with complications. And the reason for that is the initial treatment with Botox began in the glabella or the frown line so there's a lot of experience in that area, and a lot has been written on that but it's simply 5 small injections into that area and it can be done with 3 injections but the most conventional treating recommendation for 5 small injections into the muscle. So the reason is easy standing right in front of you. All you really need to do is isolate the muscle between your fingers and place the small needle between your thumb and index finger which is grasping the muscle and you put a small aliquot into each area. So that's why that's easy. The forehead is easy because the wrinkles are quite visible, the tissue itself is very forgiving when you inject. And what I mean by that is if you are to compare the tissue of the forehead or the skin, with the tissue or the skin of the crow's feet, which is the area surrounding the eye, it's completely different. If you'll just appreciate that the skin right around your eye, it's very thin. The skin on your forehead is very thick. The reason that's important is one of the common complications of injecting the crow's feet is bruising. And that's because the skin is so thin, and right underneath that skin are veins very commonly. So whereas in the forehead it's almost, I say, unheard of but pretty rare to get bruising in the forehead because it's such a thick skin that if there is to be some bleeding underneath it, it's usually not visible.
So, I would say to begin injecting for someone who hasn't started, we always begin with the glabella, with the forehead, we move to the crow's feet. And from there it gets a little more advanced and you need to have a larger comfort level and the complications can be a little more unnerving. And what I mean is the complications around the forehead or the eyes,are typically bruising, and there's persistent redness this just resolves. There is an occasional person who will develop some ptosis or droopiness of the eyebrow or eyelid. But in general, complications are isolated to some bruising. We move further down the face and start treating areas around the mouth with Botox and fillers. There's a risk of making asymmetrical smile, perhaps, some drooling if you use a little too much of Botox to correct for instance perhaps the gummy smile or you're treating the smoker's line with Botox and you make an uneven smile, you risk maybe having some drooling or a very awkward appearing smile which is very unnerving for the patient. So that's kind of, you know, the degree of difficulty in injecting the products.
Getting started through Botox Training MD, an online video training course.
Botox Training MD is an online course for clinicians that teaches you everything you need to know to begin offering Botox and filler injections inside your medical practice. It's exactly the same course and content that is taught in Dr. Marc Scheiner's two day course but comes packed with extra information and bonuses. Best of all, better than trying to remember everything you saw and learned during an in-person course, this course is taught via video and delivered online so you can review each module as often as you wish to. Oh, and by the way, you'll save more than $1,400 off of the two day course tuition.
Here's a very short excerpt from module 5 on using Botox for periorbital rhytids (crows feet).
Module 5: Periorbital Rhytids (Crows Feet)
NOTICE: This course is offered exclusively to physicians and clinicians who are licensed to perform these treatments in their geographic location.