Botox Injections 101: 10 Minutes to Look 10 Years Younger with James Zins, MD

Podcast Transcript

John Horton:

Hey there, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

It seems we love using cute little phrases to describe the wrinkles time etches on our face — laugh lines and crow's feet, for instance — or those adorable sounding “bunny lines.” Funny names, though, don't make age-defining creases a more welcome site. That's why millions of people a year look to erase wrinkles through Botox® injections. A 10-minute procedure that can make you look 10 years younger. So, how does this time machine work? That's what we're going to find out today from Dr. James Zins, Emeritus Chair and Section Head of Cosmetic Surgery at Cleveland Clinic. He's one of the many healthcare experts who visit our weekly podcast to help demystify the world of medicine. So, let's get started. After all, we're not getting any younger here, as those wrinkles clearly show. Dr. Zins, thanks for joining us on the podcast today.

Dr. James Zins:

Well, John, thanks for having me. It looks like we're going to have some fun.

John Horton:

I think we're going to.

Obviously, we're talking about treating facial wrinkles today. Clearly, that's something that bothers a lot of people as they age. Is this just a beauty thing or is there something deeper going on?

Dr. James Zins:

Well, I'll tell you … it's interesting, John — usually, the maximum in plastic surgery is mini effects, mini results. With Botox, it's very different. Here, it's mini effort, but maximum results. So this is really a divergence from many other treatments that we have. Really, an office procedure, which takes just a few minutes, really can have a very significant effect on appearance. Now, that being said, also we should realize that Botox has hundreds and hundreds of uses. It's not just for wrinkles. It's used for bladder problems, it's used for migraine headaches, it's used for a wide variety of other issues. The dosage that we use for Botox is extremely small, so the risks involved are really infinitesimal.

John Horton:

Well, we're already just a few minutes into the podcast and I feel like there's already been a huge amount of information shared. So we are going to learn a lot today.

Dr. James Zins:

Right.

John Horton:

I read where Botox injections — and Botox refers to a specific brand — which is something I learned in looking at this, but these injections rank as the most common cosmetic surgical procedure performed globally. Can you walk us through how this treatment works its magic?

Dr. James Zins:

It's very interesting. Just a little background — there was actually a dermatology ophthalmology couple from Canada — which, back in the 70s — the ophthalmologist's wife was using Botox for what's called blepharospasm, benign blepharospasm, which is an unconscious squinching of the eyes. Her husband, a dermatologist, realized, "Well, maybe if this can affect unconscious blinking of the eyes, maybe this could help wrinkles." So that's really how Botox started being used for wrinkles. Also, Botox was used “off-label” for decades. By that we mean, it was approved for benign blepharospasm, but was being utilized by hundreds of thousands of physicians and surgeons for wrinkles. So it's really a very interesting past history.

John Horton:

So with wrinkles then, how does it work?

Dr. James Zins:

Well, very interesting. It can get very simple and it can be very complex. From a simplistic situation, what we do is, we're using a drug, which actually causes some weakening of the muscle, or paralysis of the muscle, in very, very low dosage. It actually blocks the neural communication between the nerve and the muscle, causing weakening or paralysis of that muscle. Now, the Botox will travel about one centimeter on injection. So, you do need to understand the anatomy when you're using the drug to have maximum benefit. Now, that being said, there are other ways to use Botox, for example, in the forehead. Brow position can be altered by the use of Botox, by weakening depressor muscles and allowing elevator muscles to work unopposed. By that I mean, depressor muscles are the muscles which close your eyes. The forehead muscle raises the brow, and those cause the horizontal wrinkles. If we weaken the muscles that close the eye, the brow can then elevate, and that is a very youthful appearance.

So there are intricacies of Botox, besides just injecting the muscle. Botox, interestingly enough, if it's used for a prolonged period of time, it can actually cause some muscle atrophy — that is, wasting of the muscle. So it's been used in the calves, for example, in patients who have big calves and they want to slim down their calves. Now, that being said, Botox is temporary. So once the treatments have stopped, then the effect goes away.

John Horton:

Now, Botox — it's described as a neurotoxin, correct? And it's one of many different brands that are on the market?

Dr. James Zins:

Yeah, Botox is really one commercial name. There are others, Myobloc®, Dysport®, a number of other botulinum toxins. That's a scary term when you hear “toxin.” But again, John, we're using this in such a minute dosage that there is no risk from overdosing.

John Horton:

Well, I was going to ask you that, ‘cause you do hear “neurotoxin,” and that doesn't sound like something you just want injected in your head.

Dr. James Zins:

Scary.

John Horton:

It does sound a little scary. Are there any risks with it?

Dr. James Zins:

The risks are resulted to inadvertent injection, poor understanding of the anatomy. The muscles of the face ... Botox is mostly predominantly used in the upper face or around the eyes and the forehead. The muscles are very integrally related. So if we inject the Botox into an unwanted muscle, a muscle that we don't want to inject, we can have some untoward effects.

Again, for example, if we inject the forehead too low, we can actually drop the brow so the brow looks lower and that makes patients look older or angry. Similarly, if we miss a diagnosis, upper eyelid ptosis, or drooping of the upper eye, what patients call lazy eye — can be very subtle. If the doctor doesn't realize that the patient has a little bit of an upper eyelid ptosis, drooping of the eye, and it can be subtle, injecting the forehead muscles, which elevate the brow, takes away the compensation. So what I'm saying is, if the eye is droopy, then the patient tends to use the forehead like I'm doing now to raise the brow. If you weaken that attempt, that effort to raise the brow, by injecting the forehead, the brow can drop, and the ptosis looks worse. Again, you need to go to someone who understands the anatomy of the face.

John Horton:

Now, it seems like you started touching on this a little bit, but let's go over some of the most common issues in areas addressed by Botox treatment. I'm pretty sure I can model a few of those wrinkly areas if you need it, too.

Dr. James Zins:

I think you look pretty handsome myself, John.

John Horton:

I've got the crow's feet and the lines coming in. I spend a lot of time laughing.

Dr. James Zins:

Again, if we talk about the most simplistic way, the easiest way, and the most common ways of using Botox, that's to get wrinkles. Probably the most common one is the “elevens,” the vertical lines between the eyes, right here.

John Horton:

When you look concerned.

Dr. James Zins:

Yeah. "Why are you angry? You look sad. You look angry." So those muscles can be injected, and then that weakens or makes those lines go away. The laugh lines … another very common use of Botox is to get the laugh lines in the lateral eyelid area. That's another common use. The horizontal lines in the forehead that we talked about, another common use, but again, injecting those forehead lines, the surgeon/physicians got to be careful because you could have the untoward effect of inadvertently dropping the brow when that's used. So, those are probably the most common uses.

Another common use is to get the wrinkles around the mouth, the vertical lines in the upper lip, and that can often be combined with a filler so that we fill the wrinkle and also address the wrinkle with Botox. Then, finally, another common use is to get the corners of the mouth to come up. As you get older, those corners tend to drop a little bit, mine dropped a little bit. Botox can actually elevate that corner again by weakening the depressor. So the muscle that pulls down the lip is weakened, allowing the elevators to work relatively unopposed.

So those are probably the most common uses. Other uses … you can use it to shrink, or make the masseter muscle not as prominent. Very common in Asian patients. It's called benign masseteric hypertrophy. So that muscle, or the very wide face, lower face, can be slimmed down by injections of Botox. So lots and lots of uses. As I said, that just touches it. There are hundreds and hundreds of other applications of Botox — medical indications, headache, bladder problems, TMJ problems — just hundreds and hundreds of uses.

John Horton:

Wow. Everyone just focuses on the cosmetic ones, right?

Dr. James Zins:

Sure. I think what you do, when you think about Botox, they are the cosmetic uses and then there's the medical uses.

John Horton:

When you get the cosmetic treatment, what happens afterward? Is there a long recovery? You talk about paralysis of the muscles — you feel like there might be a little bit of time that you need to recover there — but is it as quick as the procedure?

Dr. James Zins:

Yeah. Again, we say “mini effect, mini result.” This, again, “minimal effort, maximum result,” it really is just a very fine needle stick that we do in the office, which just takes minutes, and there's basically no recovery. The side effects that can happen are really quite mild, but patients should be aware. Especially in the laugh line area where the skin is very vascular, you can get a bruise, there can be a little bit of discomfort. Occasionally, patients get a headache. Headache is a very multifactorial thing, but some patients report headaches after Botox injection. But these effects are mild. Again, the one thing that I mentioned earlier is, inadvertent injection into a muscle we don't want to inject, we can get some untoward effects that I mentioned before.

John Horton:

Now, as somebody who doesn't like needles, I noticed you said, "A very fine needle." Are we talking ... is it like a flu shot needle or less than that? Is it that hair thin?

Dr. James Zins:

Well, what we do is, we really try to ... if you hurt the patient, they're not going to come back. So we do everything we can to minimize discomfort. There are a number of things that we can do. You can use ice to reduce discomfort. I use a spray called Pain Ease, which we spray on the area before we inject the patient, so that the needle discomfort is really minimized. That, and there's also topical medicines we can rub on to lead to anesthesia. So really, the discomfort is really minimal, and the needle is finer than a flu shot needle.

John Horton:

OK, well, that's good to know. As anyone who was listening to this podcast knows, I am a very big baby when it comes to anything like that. So I always ask the question.

If you come in and you get a Botox treatment, how long can you expect this magic spell to last?

Dr. James Zins:

Well, the Botox — it's not like the faucet, you turn it on and you turn it off. You will gradually lose the effect, and it lasts approximately three to four months. Again, it's temporary. Also, if there's any adverse effect, you realize that's temporary as well. So again, three to four months. So patients do have to return to maintain the effect. The other thing to realize is, it's interesting, I don't know if it's behavior modification or if it's actually atrophy of the muscle, but with repeated injections, I find that patients really don't frown as much. Why that is, I'm not exactly sure. But I think you break that habit by behavior modification.

John Horton:

That's an interesting bit of insight there. Now, when you say you can come back for it, if it lasts a few months, can you just keep coming back every couple months and keep erasing those lines?

Dr. James Zins:

Sure. Yeah. Again, I find that patients are usually coming back. They're not coming back periodically at three months, but they'll come back at four months, six months for a second injection. There's really no downside to doing that. Again, perhaps what we will see is atrophy of that muscle, so that time sequence maybe even lasts a little bit longer.

John Horton:

Now I know most people view Botox as a way to resolve wrinkles, but I read where it's also being used as a preventative tool. How does that work?

Dr. James Zins:

Well, again, I think that's more theoretic than operational. But the concept there is that what we're doing is — one, maybe breaking the habit of frowning. That may be one issue. Also, of training that muscle, weakening that muscle, or making that muscle atrophy so it's not as active. Again, I think more of a theoretic thing. I don't think we have hard data to support that, but I think it's a reasonable assumption.

John Horton:

Well, it's a good thing I'm always smiling doing these podcasts, 'cause then, I don't think I'm going to have to come in and get that frown taken care of anytime soon. When you look at people coming in, are there some folks who are good candidates for Botox?

Dr. James Zins:

Absolutely. Again, like everything else, the older we get, the more difficult it becomes to rejuvenate the face, to make the face look younger. So those patients that come in, they're 70 years old and they have, actually, have excess skin, and that frown is deeply ingrained in their skin. Those patients are not going to respond as well as someone whose frown is present only with action. So that patient who comes in where the frown is deep can best be handled by a combination of Botox and a filler. So we're going to inject a filler in that area, a synthetic filler, to plump up the skin, as well as to weaken the muscle. So those patients will definitely need additional treatment besides Botox alone. So the older the individual, the more difficult the problem. The younger the individual, once the problem is present, the most effective. So I would say the patient between about 30 and maybe up to 55, 60 are ideal patients.

John Horton:

Well, it sounds like I'm right in the zone now.

Dr. James Zins:

You're right there. We'll tighten you right up. I actually have my bottle here. We can do this right after the show.

John Horton:

But if you are interested in Botox, what should you do? What's the process to follow?

Dr. James Zins:

Well, you see your doctor, your plastic surgeon, your dermatologist. Like everything else, going to someone who does an awful lot of it, you tend to get the best results. So query the doctor, or friends who've gone to other doctors who've had good experience. But I would stick with the so-called core specialties, plastic surgery, dermatology, rather than going to an internist, a general practitioner or gynecologist. We tend to have been trained not only in Botox, but also alternative to Botox. Like I mentioned, certain patients really aren't going to benefit, or need combination therapy.

John Horton:

All right. Well, we've covered a lot of info here, Dr. Zins. But before we part ways, is there anything else you'd like to add for someone who's considering Botox treatments?

Dr. James Zins:

Visiting a doctor, talking to the doctor about it, perhaps. If you have concerns or if you're hesitant, then just going in and just having a consultation, rather than planning on having Botox injected. Speak with the doctor, answer the questions, answer the concerns. Make sure you're comfortable before you have the procedure. But again, this is a procedure where the risk is quite low.

John Horton:

Always good to hear. So I'm going to take a little closer look at some of these lines, and maybe we'll be talking again here soon.

Dr. James Zins:

Sounds good, John. Thanks very much. It was a pleasure talking with you.

John Horton:

Thank you. Millions of people a year turn to Botox treatments to smooth out wrinkles and get a more youthful appearance. Know this going in, though, it's a temporary fix, not a permanent return to youth. If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. 'Till next time, be well.

Speaker 3:

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