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The Changing Face of Botox: Patient Customization

Rarely do we see true paradigm shifts in cosmetic surgery.  Neurotoxins are certainly a prime example of a new technology that replaced previous treatments with increased safety and less recovery.

When Botox arrived in the early 1990’s the “pretty poison” caught on like wildfire and soon became the most commonly requested cosmetic treatment internationally.  In the early days, patients wanted paralysis.  It was not uncommon for patients to complain or return for touch up if even a slight amount of movement was present.  It got so you could walk down a busy street or turn on TV and tell exactly who was “Botoxed” and what areas were treated.  At that time, the most common areas requested for treatment were the glabella, frontalis and lateral canthus, in that order.

Over the past decade, much has changed in how patients desire animation.  Gone is the overt reated paralyzed mask look.  It is a rare patient that does not want some remnant of normal animation.  This is especially true for the frontalis (forehead) region.  Not being able to frown is rarely a problem as we can communicate anger or displeasure in so many ways.  Not being able to use the eyebrows to communicate, however, is a bigger problem.  The average patient desires the ability to raise the brows as we communicate so much (often silently) with the upper face.  Not being able to convey surprise, interest, skepticism (raising one brow), etc. is a setback for the contemporary patient.  Adding to this problem are females with dermatochalasis (baggy upper eyelid skin).  Many females are habitual brow raisers.  They raise their brows from the time they wake up till the time they fall asleep.  This is done in part to lessen the effect of the excess upper lid skin.  A patient with excess upper lid skin will look younger (less skin) when they elevate their brows.  If Botox or Dysport takes away the ability to elevate the brow, then the excess upper eyelid skin is much more obvious.  Getting a neurotoxin in the forehead (or neuromodulator, to be more contemporary) does not make extra skin, it merely prevents brow elevation thus causing the already excess skin to be more evident.  Herein lies the problem.  Experienced injectors know how to spread the injections and neuromodulator out across the forehead to prevent the bothersome horizontal forehead wrinkles in the center of the forehead, but still maintain enough muscle activity laterally to enable brow elevation.  Inexperienced injectors may frequently over treat a patient with upper lid skin excess and this leads to a very unhappy patient.  Due to the fact that some patients are more sensitive or more resistant to Botox or Dysport, a normal dose on one patient may knock out all forehead movement on another patient.  So….even experienced injectors occasionally may see upper eyelid skin excess from conservative treatment.  When injecting a patient who has never had Botox treatment or has never been treated by me, I always recommend 1/2 the normal dose in the forehead.  This allows me to evaluate the patients sensitivity and response to the treatment.  If the 1/2 dose is not adequate, they can always return for a touch up, but if the 1/2 dose is adequate then the full dose may have caused over treatment.  You can always add more Botox, but you cannot reverse it.  Good rule to practice by!  This is even more important in patients that have low hair lines or short foreheads and are having the glabella and frontalis simultaneously treated.  In these patients, the glabellar dose can be enough to effect the frontalis movement and it is easier to over treat this population.

Although this “relative skin excess phenomenon” is temporary, these patients can be more unhappy that a patient with a permanent surgical complication.  This group can be disproportionately unhappy about a temporary problem.  The best treatment is prevention and conservative injecting.  Sometimes these patients will mistakenly confuse the inability to elevate the brow and related skin excess with true ptosis.  True ptosis after neuromodulator injection occurs when the toxin diffuse to the muscles that open the upper lid, which is fortunately a very rare problem.  Injecting at least 10 mm above the superior orbital rim will prevent this complication.  A related problem is the “Mr. Spock” eyebrow.  This devil brow situation occurs when the medial brow does not move but the lateral brow is untreated.  This is a very unesthetic look and is easily fixed by simply injecting several units of drug into the lateral frontalis region.

Due to overtreatment, the desire to look natural and the “Botox upper lid skin excess” problem, the frontalis region has dropped from the second most requested facial area to the third.  The most commonly requested facial regions in my practice are the glabella (still king) the lateral canthus (Crow’s Feet) regions and finally the frontalis.

Another phenomenon that I more commonly see is “patient customization” of neuromodulators.  I am an Allergan Diamond level Botox provider and the largest solo injector in my state, so I have been treating some patients for over 12 years.  As time has passed, many of these patients request “a la carte” Botox treatment.  By this I mean that they desire smaller doses and come to the office with a “map” of their face and where they want the injections.  At first I thought that this was related to the economic recession and to some circumstance it may be.  What has become clear is that many patients don’t want to look over treated and like what Botox or Dysport does, they just don’t want as much of it.  Alternately, many astute patients have learned by trial and error, what doses and patterns produce the most aesthetic effects on their face.  They want do duplicate this injection dose and pattern and therefore it is important for the surgeon to record the area and dosages of the injections at each appointment.  This way, when a patient returns and says, “do exactly what you did last time”, the surgeon has a map.

Some of my colleagues become miffed when patients attempt to direct their treatment, but I think it is overwhelmingly a positive thing.  We are giving the patient what they want and the customer is always right.  In addition, they may save some money, making them even happier.

To find out more about Botox or Dysport by Dr. Joe Niamtu, III DMD in Richmond, Virginia visit

Joe Niamtu, III DMD


Botox, Dysport


Blog, Botox, Dysport

Office Address

Joe Niamtu III, DMD
11319 Polo Place
Midlothian, VA 23113

Office Hours

Monday - Friday
8:00am - 5:00pm

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