That said, there are a few things I'd make sure everyone knows before trying it. For one thing, it can be pretty painful. I have a pretty high pain tolerance, but getting 30 to 40 shots every three months is pretty rough — it feels a bit like getting tattooed with a bee's stinger, but once the needle is out of your skin, the pain goes away, and if it works for you, it's worth it. It's also important to know that it can take some time to work. The first treatment barely worked at all for me, and the second round took a few weeks. If you're going to try it out, be patient.

Spread of toxin effects.The effect of botulinum toxin may affect areas away from the injection site and cause serious symptoms including: loss of strength and all-over muscle weakness, double vision, blurred vision and drooping eyelids, hoarseness or change or loss of voice, trouble saying words clearly, loss of bladder control, trouble breathing, trouble swallowing.

Serious and/or immediate hypersensitivity reactions have been reported. These reactions include anaphylaxis, serum sickness, urticaria, soft-tissue edema, and dyspnea. If such a reaction occurs, further injection of BOTOX® should be discontinued and appropriate medical therapy immediately instituted. One fatal case of anaphylaxis has been reported in which lidocaine was used as the diluent, and consequently the causal agent cannot be reliably determined.
BOTOX® Cosmetic targets one of the underlying causes of frown lines, crow’s feet and forehead lines — the repeated muscle contractions from frowning, squinting, smiling and raising the eyebrows over the years. Your specialist will inject these muscles with BOTOX® Cosmetic to temporarily reduce muscle activity. You will begin to notice a visible smoothing of the frown lines between your brows, your crow’s feet lines and your forehead lines.
Focal Spasticity is a condition in which certain muscles in your body become stiff or tight. It is caused by damage to parts of the central nervous system that control voluntary movements. When this happens, your nerves send continuous messages to your muscles telling them to contract, or tighten. If you or someone you care for has stiffness in the muscles of the elbow, wrist, fingers, thumb, ankle, or toes, it could be Focal Spasticity.1
Dermal fillers, as we’ve discussed in our previous post, vary on what you’re looking for and how long you’d like to see those results. According to the Plastic Surgeons Portal, the minimum you’ll pay for dermal fillers, like Juvederm and Restylane, is going to $1500, while the maximum you’re looking at is $2,500. It’s a small price to pay for radiance and confidence!
Sharona Hoffman, professor of law and bioethics at Case Western Reserve University School of Law, says that step therapy is driven by a single motivator: saving costs. Hoffman, who’s written about the legal and ethical implications of step therapy, says that sometimes step therapy can have sensible outcomes, like pushing patients to take generics instead of brand-name drugs. But these policies can also keep doctors from prescribing the more expensive drugs of choice, forcing patients to take medications that are less effective or have worse side effects.

Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis (ALS), or neuromuscular junction disorders (eg, myasthenia gravis or Lambert-Eaton syndrome) should be monitored when given botulinum toxin. Patients with known or unrecognized neuromuscular disorders or neuromuscular junction disorders may be at increased risk of clinically significant effects including generalized muscle weakness, diplopia, ptosis, dysphonia, dysarthria, severe dysphagia, and respiratory compromise from therapeutic doses of BOTOX® (see Warnings and Precautions).


Jump up ^ Mangera A, Andersson KE, Apostolidis A, Chapple C, Dasgupta P, Giannantoni A, Gravas S, Madersbacher S (October 2011). "Contemporary management of lower urinary tract disease with botulinum toxin A: a systematic review of botox (onabotulinumtoxinA) and dysport (abobotulinumtoxinA)". European Urology. 60 (4): 784–95. doi:10.1016/j.eururo.2011.07.001. PMID 21782318.
So people told me I looked tired, overlooking the grape-size purple bruise smack dab in the center of my forehead. As one RealSelf reviewer wrote: “My head feels too tight, my eyebrow position has dropped enough to lose my nice pretty arch and my eyelids seem hooded. My eyes look smaller.” Now, if it works, looking a bit tired is a small price to pay for a few more days each month of migraine freedom and function. And bruises can be covered with makeup.

I’ve had migraines since I was 12, but in 2015 my attacks got much worse. Without migraine-specific painkillers, my migraines make me queasy and tired, forcing me to go to bed with a freezing wet towel on my head. For the last two years, I’ve tried different medications, switched birth control pills, made lifestyle changes (less stress, more swimming, no alcohol) — to little avail. My migraines would improve for a while, but then they came back, worse than ever. Then this year, I finally discovered a treatment that works — Botox.


Ophthalmologists specializing in eye muscle disorders (strabismus) had developed the method of EMG-guided injection (using the electromyogram, the electrical signal from an activated muscle, to guide injection) of local anesthetics as a diagnostic technique for evaluating an individual muscle’s contribution to an eye movement.[44] Because strabismus surgery frequently needed repeating, a search was undertaken for non-surgical, injection treatments using various anesthetics, alcohols, enzymes, enzyme blockers, and snake neurotoxins. Finally, inspired by Daniel Drachman’s work with chicks at Johns Hopkins,[45] Alan B Scott and colleagues injected botulinum toxin into monkey extraocular muscles.[46] The result was remarkable: a few picograms induced paralysis that was confined to the target muscle, long in duration, and without side-effects.
Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis or neuromuscular junction disorders (e. g., myasthenia gravis or Lambert-Eaton syndrome) should be monitored when given botulinum toxin. Patients with neuromuscular disorders may be at increased risk of clinically significant effects including generalized muscle weakness, diplopia, ptosis, dysphonia, dysarthria, severe dysphagia and respiratory compromise from therapeutic doses of BOTOX [see Dysphagia And Breathing Difficulties].
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BOTOX® increases the incidence of urinary tract infection. Clinical trials for overactive bladder excluded patients with more than 2 UTIs in the past 6 months and those taking antibiotics chronically due to recurrent UTIs. Use of BOTOX® for the treatment of overactive bladder in such patients and in patients with multiple recurrent UTIs during treatment should only be considered when the benefit is likely to outweigh the potential risk.
Botulinum toxin produced by Clostridium botulinum is the cause of botulism.[9] Humans most commonly ingest the toxin from eating improperly-canned foods in which C. botulinum has grown. However, the toxin can also be introduced through an infected wound. In infants, the bacteria can sometimes grow in the intestines and produce botulinum toxin within the intestine and can cause a condition known as floppy baby syndrome.[32] In all cases, the toxin can then spread, blocking nerves and muscle function. In severe cases, the toxin can block nerves controlling the respiratory system or heart, resulting in death.[1] Botulism can be difficult to diagnose, as it may appear similar to diseases such as Guillain–Barré syndrome, myasthenia gravis, and stroke. Other tests, such as brain scan and spinal fluid examination, may help to rule out other causes. If the symptoms of botulism are diagnosed early, various treatments can be administered. In an effort to remove contaminated food which remains in the gut, enemas or induced vomiting may be used.[33] For wound infections, infected material may be removed surgically.[33] Botulinum antitoxin is available and may be used to prevent the worsening of symptoms, though it will not reverse existing nerve damage. In severe cases, mechanical respiration may be used to support patients suffering from respiratory failure.[33] The nerve damage heals over time, generally over weeks to months.[4] With proper treatment, the case fatality rate for botulinum poisoning can be greatly reduced.[33]
Dr. Starling says the FDA approval indicates that the anti-CGRP treatments are ideal for individuals with episodic migraine who have four to 14 headache days per month, and people with chronic migraine who have 15 or more headache days per month. Clinical trials are also being conducted to see if anti-CGRP antibodies are effective for the treatment of cluster headache. “The initial studies have demonstrated that it’s likely effective for cluster headache patients,” Dr. Starling says. The FDA’s approval of these medications has been incredibly meaningful for the migraine community. “The migraine community is feeling like they’re relevant—that they’re being seen, heard and taken seriously,” Dr. Starling says. “There are many people who are working hard to develop more treatment options until we can address every patient who has migraine, and eventually find a cure.”
During a recent therapy session, one of Dr. Norman Rosenthal's regulars said he was considering suicide. It wasn't the first time the patient had entertained the thought, and even though he was on antidepressants and always kept up with his appointments, Rosenthal, a licensed psychiatrist with a private practice in North Bethesda, Md., wanted to offer his patient something else.
Autonomic dysreflexia associated with intradetrusor injections of BOTOX® could occur in patients treated for detrusor overactivity associated with a neurologic condition and may require prompt medical therapy. In clinical trials, the incidence of autonomic dysreflexia was greater in patients treated with BOTOX® 200 Units compared with placebo (1.5% versus 0.4%, respectively).
Some doctors and dermatologists recommend lying down and resting after a treatment, but Ravitz says she doesn't think there's any need for downtime unless a patient experiences pain. It can take about two weeks to work, though some patients start to feel relief from chronic migraines sooner than that. Ravitz tells me, "If it’s going to work for a patient, one round of the treatment typically lasts for around three months." Though everybody metabolizes it at a different rate, getting it done every three months or so has been found to be effective.
In May, hedge fund Appaloosa Management, run by David Tepper, received antitrust clearance from the Federal Trade Commission to potentially increase its stake in the Botox-maker. This means that Appaloosa now has more flexibility to push for further changes at Allergan. It remains to be seen if that happens, but if so, it could mean more changes are ahead for the drugmaker.
Dr. Engelman says preventative is legit. “Most certainly! I do micro-injections on patients who are just starting to show the finest expression lines in order to prevent them from ever making the wrinkle." NYC-based board-certified plastic surgeon Norman Rowe, MD, is also a fan. "While Botox has a fundamental use in treating wrinkles that are already formed, it has a role in the prophylactic, or prevention, of wrinkles. So, don't think that you don't need Botox because you don't have wrinkles. If you want to keep that smooth skin, start with Botox before they form."
Formation of neutralizing antibodies to botulinum toxin type A may reduce the effectiveness of BOTOX treatment by inactivating the biological activity of the toxin. The critical factors for neutralizing antibody formation have not been well characterized. The results from some studies suggest that BOTOX injections at more frequent intervals or at higher doses may lead to greater incidence of antibody formation. The potential for antibody formation may be minimized by injecting with the lowest effective dose given at the longest feasible intervals between injections.
Prior to injection, reconstitute each vacuum-dried vial of BOTOX with only sterile, preservative-free 0.9% Sodium Chloride Injection USP. Draw up the proper amount of diluent in the appropriate size syringe (see Table 1, or for specific instructions for detr usor overactivity associated with a neurologic condition see Section 2.3), and slowly inject the diluent into the vial. Discard the vial if a vacuum does not pull the diluent into the vial. Gently mix BOTOX with the saline by rotating the vial. Record the date and time of reconstitution on the space on the label. BOTOX should be administered within 24 hours after reconstitution. During this time period, reconstituted BOTOX should be stored in a refrigerator (2° to 8°C).
Extraocular muscles adjacent to the injection site can be affected, causing vertical deviation, especially with higher do ses of BOTOX. The incidence rates of these adverse effects in 2058 adults who received a total of 3650 injections for horizontal strabismus was 17%. The incidence of ptosis has been reported to be dependent on the location of the injected muscles, 1% after inferior rectus injections, 16% after horizontal rectus injections and 38% after superior rectus injections.
BOTOX® increases the incidence of urinary tract infection. Clinical trials for overactive bladder excluded patients with more than 2 UTIs in the past 6 months and those taking antibiotics chronically due to recurrent UTIs. Use of BOTOX® for the treatment of overactive bladder in such patients and in patients with multiple recurrent UTIs during treatment should only be considered when the benefit is likely to outweigh the potential risk.

Preventative Botox has been getting lots of buzz. “It can potentially have a preventive effect on dynamic wrinkles, which are caused by underlying muscle movement,” Shah explains. “That being said, muscle movement is only one factor that contributes to the development of wrinkles, so Botox may not be completely preventive.” (Some other wrinkle causes: sun exposure, smoking, and diet.)
How does BOTOX work in migraines? The current theory is that BOTOX disrupts the trigeminal nerve terminal end. This leads to down-regulation of the trigeminal nerve cells and suppression of neurotransmitter release in two critical areas: central neuronal glutamate release and peripheral nerve inflammatory-inducing compounds such as CGRP in the cerebral blood vessels.
I’ve had migraines since I was 12, but in 2015 my attacks got much worse. Without migraine-specific painkillers, my migraines make me queasy and tired, forcing me to go to bed with a freezing wet towel on my head. For the last two years, I’ve tried different medications, switched birth control pills, made lifestyle changes (less stress, more swimming, no alcohol) — to little avail. My migraines would improve for a while, but then they came back, worse than ever. Then this year, I finally discovered a treatment that works — Botox.
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Unopened vials of BOTOX should be stored in a refrigerator (2° to 8°C) for up to 36 months. Do not use after the expiration d ate on the vial. Administer BOTOX within 24 hours of reconstitution; during this period reconstituted BOTOX should be stored in a refrigerator (2° to 8°C). Reconstituted BOTOX should be clear, colorless, and free of particulate matter.
Co-administration of BOTOX® or other agents interfering with neuromuscular transmission (eg, aminoglycosides, curare-like compounds) should only be performed with caution as the effect of the toxin may be potentiated. Use of anticholinergic drugs after administration of BOTOX® may potentiate systemic anticholinergic effects. The effect of administering different botulinum neurotoxin products at the same time or within several months of each other is unknown. Excessive neuromuscular weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin. Excessive weakness may also be exaggerated by administration of a muscle relaxant before or after administration of BOTOX®.
As the only Facial Plastic Surgeon in North Texas to have Diamond status with Allergan, we have found that in today's economic environment, patients want value as well as quality. Understand that when you go to a non-physician med-spa for injectible treatments, there are more hands in the "cookie jar" diluting the price for your treatment. For example, the med-spa that is owned by a non-physician, with a nurse injector, is the hardest model to stay competitive in today's world. In that scenario, the patient is paying for the cost of the Botox; PLUS the cost of the nurse to inject the product; PLUS the fee for the medical director to sign off on the nurse doing the injections; AND the profit for the medspa. By going to a physician, the patient can cut out 2 of the middle-people. The chances of getting more product for the same price is greater by going to a doctor's office for your treatment.
BOTOX is administered about every three months, and must be injected at the site of each nerve trigger, relaxing the surrounding muscles so that they won’t compress the nerve and trigger a migraine. It is a potent drug, and we only recommend using it if other preventative treatment options haven’t helped you. It is generally only administered to patients who have at least 14 headaches a month, or don’t respond to other treatments.
There are eight types of botulinum toxin, named type A–H. Types A and B are capable of causing disease in humans, and are also used commercially and medically.[3] Types C–G are less common; types E and F can cause disease in humans, while the other types cause disease in other animals.[4] Type H is considered the deadliest substance in the world – an injection of only 2 ng can cause death to an adult.[5] Botulinum toxin types A and B are used in medicine to treat various muscle spasms and diseases characterized by overactive muscle. Commercial forms are marketed under the brand names Botox and Dysport, among others.[6][7]
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