BOTOX® can be used on the forehead lines, frown lines, crow’s feet, bunny lines (lines in the nose), chin (for dimpling), skin bands on the neck, and around the mouth (for smoker’s lines and down-turned corners of the mouth). Wrinkles caused by sun damage and gravity often will not respond to BOTOX®. It is important to re-emphasize that BOTOX® is NOT a facial filler (that is, it does not fill existing wrinkles) – it merely relaxes the muscles that are creating those wrinkles.
Overall, with the exception of Overactive Bladder (see below), clinical studies of BOTOX did not include sufficient numbers o f subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. There were too few patients over the age of 75 to enable any comparisons. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease o r other drug therapy.
The cost of a Botox treatment is usually communicated as a flat cost, but can also be measured in individual injectable units. Each unit usually costs somewhere in the neighborhood of $15, but prices vary between geographic areas and between individual clinics. How many units are needed per treatment will depend on which areas of your face are being treated, and on your individual facial anatomy.
Autonomic dysreflexia in patients treated for overactive bladder due to neurologic disease. 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).
So what exactly are you putting into your face? John Paul Tutela, MD, a board certified plastic surgeon, explains, “Botox is a cosmetic injectable neurotoxin that is a very diluted form of Botulinum Toxin, which is found in the bacteria Clostridium botulinum. In this diluted format, it is used to relax your muscles—typically in your forehead, in between your eyebrows, and around your eyes.” The idea is that if you temporarily block local nerve impulses to specific muscles within your face, you won’t make certain facial expressions, so you won’t form the wrinkles that come with them, explains dermatologist Tsippora Shainhouse, MD, FAAD. These are the 7 signs you’re ready for Botox? (And 6 signs you aren’t.)
If the musculature of the oropharynx and esophagus are affected, aspiration may occur which may lead to development of aspira tion pneumonia. If the respiratory muscles become paralyzed or sufficiently weakened, intubation and assisted respiration may be necessary until recovery takes place. Supportive care could involve the need for a tracheostomy and/or prolonged mechanical ventilation, in addition to other general supportive care.
A migraine requires only two of the following headache features: a unilateral distribution (one-sided), pulsatile quality (throbbing), moderate or severe pain (more than 5 out of 10), and aggravation by physical activity (such as bending over). In addition, to diagnose migraine, only one of the following is required: nausea or vomiting or sensitivity to light and noise.
As compared to standard-size injections, Baby Botox lowers the risk of your features appearing to be frozen. Take the forehead, for example: "The risk is that you weaken your frontalis muscle, which causes your eyebrows to drop," Darren Smith, a board-certified plastic surgeon in New York City, tells Allure. "If you're getting micro doses of Botox, that's a lot less likely to happen."

The recommended dilution is 200 Units/2 mL, 200 Units/4 mL, 100 Units/1 mL, or 100 Units/2 mL with preservative-free 0.9% Sodium Chloride Injection, USP, depending on volume and number of injection sites desired to achieve treatment objectives (see Table 1). In general, no more than 50 Units per site should be administered using a sterile needle (e.g., 25-30 gauge) of an appropriate length. Localization of the involved muscles with electromyographic guidance may be useful.

Treatment with botulinum toxins may weaken neck muscles that serve as accessory muscles of ventilation. This may result in a critical loss of breathing capacity in patients with respiratory disorders who may have become dependent upon these accessory muscles. There have been postmarketing reports of serious breathing difficulties, including respiratory failure.
So when I first propositioned my husband about the idea of me getting a bit of Botox for the furrowed brow I've earned from a decade of writing and editing behind a computer screen, he was adamantly against it. And frankly, I was a bit scared too. I mean, isn't Botox poison? As an idealistic 21 year old, it was easy to say that I'd never put that stuff in my body, that "poison." Now, I'm not so sure.
Currently, there are several anti-CGRP treatments undergoing clinical trials. Some of these treatments involve monoclonal antibodies, which reduce the activity of CGRP, potentially leading to fewer migraine attacks. One of these anti-CGRP monoclonal antibodies, erenumab (Aimovig™), has been approved by the Federal Drug Administration (FDA) and is now available for patients. A second agent, fremanezumab (Ajovy™), was approved in September 2018. A week later, the FDA approved galcanezumab (Emgality™), making it the third anti-CGRP treatment currently on the market. Results from the clinical trials involving anti-CGRP antibodies have shown that about 50 percent of patients will have at least a 50 percent reduction in migraine days. “If you think about someone who has 20 migraine days per month, they have a 50 percent chance of having 10 or less migraine days,” Dr. Starling says. “We think that there are even these super-responders who have a 75 percent response rate, as well as super-super-responders who actually go into remission.” The results from these clinical trials are very promising, Dr. Starling adds. “The adverse events have been very minimal and the efficacy has been very good. It’s all looking up.” Dr. Starling says that although these medications are available, what really needs to be looked at is how to make them truly accessible for patients. Erenumab can cost about $7,000 per year without insurance coverage. “Insurance coverage is very, very key for the majority of our patient population,” she says. “Because the medications just came out on the market, there are still a lot of unknowns about insurance coverage.”
Unlike some resurfacing or surgical procedures, after which there is possible pigmentation or scarring, when Botox is done correctly, it can be done on all skin tones. “This is a procedure [and] product that crosses all divides,” says Dr. Matarasso. “Men, women, Caucasian, African-American, Asian, Indian. I don’t think there is a demographic that has not enjoyed the benefit of this product.”

The FDA approved such usage in the late 1980s upon the discovery that Botox could stop ailments like blepharospasm (uncontrolled blinking) and strabismus (lazy eye). Doctors have been using Botox for years to successfully treat wrinkles and facial creases. In April 2002, Botox gained FDA approval for treatment of moderate-to-severe frown lines between the eyebrows - called glabellar lines. However, Botox is often used for other areas of the face as well.

“Most people in their twenties decide to try Botox simply because they want to enhance their appearance, such as relaxing the muscles in their forehead, or because they want to keep their skin looking fresh and young,” Shah says. “Starting earlier is better than later because as the lines get more and more embedded into the skin, Botox is not as effective in eliminating the lines.”
After Hoffman’s husband was diagnosed with Parkinson’s at 55, his health insurance decided to stop paying for the drug he had taken successfully unless he tried cheaper alternatives. She appealed on behalf of her husband and was eventually able to get approval for the drug, which would have cost them $8,000 a year otherwise. “I felt terrible and I had to fight and it took a long time,” Hoffman tells The Verge. “It caused a lot of anxiety and a lot of these patients don’t have a law professor wife to fight for them.”
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).
Ptosis generally occurs from injecting the frontalis incorrectly. The worst mistake is for the injector to move the procerus and corrugator injection points higher, where they will place more onabotulinumtoxinA into the frontalis. It is important to examine patients to determine their preexisting conditions prior to treatment administration. In particular, patients should be examined for pre-existing eyelid ptosis or pseudoptosis. With pseudoptosis, the lid strength is normal, but soft tissue covers part of the upper lid. With lid ptosis, the lid strength is weak. For both lid ptosis and pseudoptosis, patients will have frontalis compensatory activity, resulting in upgoing eyebrows (reverse Babinski sign). With brow ptosis, the frontalis is weak, and the eyebrow is depressed downward leading to tissue resting on the upper lid. To avoid this, the frontalis should be injected in the upper third of the forehead. The corrugator muscle attaches to bone at the medial end of the superciliary arch. The muscle fibers travel laterally and upward inserting into the skin in the middle of the supraorbital margin. The corrugator muscle is partially blended with the orbicularis oculi and occipitofrontalis. The supraorbital and supratrochlear nerves pass through the corrugator muscle. The corrugator muscle acts to pull the eyebrows downward and medially, which causes vertical wrinkle lines in the skin between the brows.
Can you use Botox under your eyes? Botox is often used to treat lines and wrinkles around the eyes and mouth. Can it also reduce dark circles or bags under the eyes? Using Botox under the eyes is not approved in the U.S. and researchers are unsure how well it may work and what side effects may occur. Here, learn about the procedure and its alternatives. Read now
The drug has come a long way since its ability to smooth facial wrinkles was first discovered, by accident. In the 1970s, ophthalmologist Dr. Alan B. Scott started studying the toxin as a therapy for people with a medical condition that rendered them cross-eyed. "Some of these patients that would come would kind of joke and say, 'Oh, Doctor, I've come to get the lines out.' And I would laugh, but I really wasn't tuned in to the practical, and valuable, aspect of that," Scott told CBS in 2012. Scott named the drug Oculinum and formed a company of the same name in 1978. In 1989 he received FDA approval for the treatment of strabismus (the crossed-eye disorder) and abnormal eyelid spasms.
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Botox for migraines has been something that has flown under the radar, as many people know Botox as a procedure simply aimed at hiding fine lines. We turned to Matthew S. Robbins, MD, director of inpatient services at Montefiore Headache Center and the chief of neurology at the Jack D. Weiler Hospital, Montefiore, to break down the procedure for us. Scroll down to see what he has to say.
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“Most people in their twenties decide to try Botox simply because they want to enhance their appearance, such as relaxing the muscles in their forehead, or because they want to keep their skin looking fresh and young,” Shah says. “Starting earlier is better than later because as the lines get more and more embedded into the skin, Botox is not as effective in eliminating the lines.”

A follow-up visit is most often scheduled at around three months after injection. The team will determine if it was helpful and if the effect is wearing off. The effect on muscle spasticity by botulinum toxin is temporary and can last for up to three to five months. This also varies with the amount of toxin injected, the size of the muscle, the degree of spasticity in the muscle, and treatment such as therapy and bracing.
Intradetrusor injection of BOTOX is contraindicated in patients with overactive bladder or detrusor overactivity associated with a neurologic condition who have a urinary tract infection. Intradetrusor injection of BOTOX is also contraindicated in patients with urinary retention and in patients with post-void residual (PVR) urine volume >200 mL, who are not routinely performing clean intermittent self-catheterization (CIC).
But in a recent Fat Mascara podcast, NYC dermatologist Pat Wexler, MD, said this is a myth. And Dr. Matarasso falls somewhere in-between. “For aesthetic or cosmetic reasons, does a 19-year-old need this? No. Does a 26-year-old need this for aesthetic purposes? Highly doubtful. But, hey, listen, if you are like, ‘I am looking at my parents, I am looking at my genes, and I want to stay proactive,’ it is not unreasonable to introduce it in small amounts.”
Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.

What are Botox costs and benefits? Hands down, one of the most exciting cosmetic procedures in dermatology is Botox. It’s been over a decade that this miracle injectable has been approved for cosmetic use and the effects have been amazing. With one injection, Botox has the ability to iron out wrinkles and even prevent new ones from forming. Botox is completely safe and the perfect alternative to plastic surgery. Botox has even been shown to lift moods. A recent study showed that Botox had the ability to improve symptoms of depression when injected in the area in between and directly above the eyebrows. Other areas that can be treated with Botox are the crow’s feet, the upper forehead and around the hairline, to give the entire top half of the face a lift. Plus even more good news for Botox users! A new study shows that Botox injections not only get rid of wrinkles, but also make the overlying skin look and feel younger. So that means the overall appearance of your skin will look rejuvenated thanks to Botox injections. While the cost of Botox injections is certainly not cheap, it’s a sure thing and will produce real results that you can be happy with .
Two double-blind, placebo-controlled, randomized, multi-center clinical studies were conducted in patients with urinary incontinence due to detrusor overactivity associated with a neurologic condition who were either spontaneously voiding or using catheterization (Studies NDO-1 and NDO-2). A total of 691 spinal cord injury (T1 or below) or multiple sclerosis patients, who had an inadequate response to or were intolerant of at least one anticholinergic medication, were enrolled. These patients were randomized to receive either 200 Units of BOTOX (n=227), 300 Units of BOTOX (n=223), or placebo (n=241).
Most insurance companies require patients to try at least two oral medications first. Botox is expensive, so if you respond well to oral medications, it makes sense to stick with the more-affordable option. If you don’t respond to medications or if the side effects are intolerable, however, your insurer may cover Botox. You’ll need to check with your plan for your specific coverage requirements.

"The difference between using a cannula and a 'needle injection' technique is cannulas are a blunt tip needle that lets us place filler on a plane that allows it to last longer," explains Goodman. "They look better and preserve the 'untouched look' we're known for. Also, it's a more advanced technique that ensures the patient will not leave the office bruised."


Twenty two adult patients, enrolled in double-blind placebo controlled studies, received 400 Units or higher of BOTOX for treatment of upper limb spasticity. In addition, 44 adults received 400 Units of BOTOX or higher for four consecutive treatments over approximately one year for treatment of upper limb spasticity. The type and frequency of ad verse reactions observed in patients treated with 400 Units of BOTOX were similar to those reported in patients treated for upper limb spasticity with 360 Units of BOTOX.
BTX-A has also been used in the treatment of gummy smiles,[80][81] the material is injected into the hyperactive muscles of upper lip, which causes a reduction in the upward movement of lip thus resulting in a smile with a less exposure of gingiva.[82] Botox is usually injected in the three lip elevator muscles that converge on the lateral side of the ala of the nose; the levator labii superioris (LLS), the levator labii superioris alaeque nasi muscle (LLSAN), and the zygomaticus minor (ZMi).[83][84]
Treatment with botulinum toxins may weaken neck muscles that serve as accessory muscles of ventilation. This may result in a critical loss of breathing capacity in patients with respiratory disorders who may have become dependent upon these accessory muscles. There have been postmarketing reports of serious breathing difficulties, including respiratory failure.
In 2005, the national average cost of a BOTOX® injection was just over $375. However, the cost of BOTOX® treatment varies from area to area. In 2005, the northeastern United States had the highest BOTOX® average cost, at just over $500, while the western states had the lowest average, at under $370. It is important to keep in mind that these statistics may be somewhat misleading, as the cost of BOTOX® injections in Los Angeles will almost certainly be higher than BOTOX® treatment price in say, a rural area of Pennsylvania.
BOTOX injections for migraines is a preventative treatment, rather than treating the condition with pain medication. It was FDA-approved in 2010 and is considered an appropriate treatment for adults who experience migraine headaches more than 15 days per month, for more than three months. The product blocks the release of certain brain chemicals, and it is believed that blocking these chemicals limits the nerve signals causing pain.
Receiving Botox injections for migraines is a straightforward outpatient procedure. The skin in the area to be injected is cleaned. Most injections are administered in the forehead area, usually above the eyes or where “worry lines” might occur. Because this area may be sensitive or patients may be experiencing hypersensitivity to pain, a topical anesthetic may be applied before the injection.

In the United States, botulinum toxin products are manufactured by a variety of companies, for both therapeutic and cosmetic use. A U.S. supplier reported in its company materials in 2011 that it could "supply the world's requirements for 25 indications approved by Government agencies around the world" with less than one gram of raw botulinum toxin.[66] Myobloc or Neurobloc, a botulinum toxin type B product, is produced by Solstice Neurosciences, a subsidiary of US WorldMeds. AbobotulinumtoxinA), a therapeutic formulation of the type A toxin manufactured by Galderma in the United Kingdom, is licensed for the treatment of focal dystonias and certain cosmetic uses in the U.S. and other countries.[30]
"There is a difference in pricing based on the duration of the results," says L.A.-based injection specialist Lisa Goodman. (FYI: She's incredible, and I emphatically recommend seeing her if you're in L.A. or Dara Liotta, MD, if you're in NYC.) "The longer-lasting formulas cost more upfront. Shorter-term fillers can last from six to 11 months based on the patient's rate of aging (i.e., smoking, drinking, sun exposure, genetics), while the longer-term fillers last about one to two years."
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.
In 2016, the stock price of Tobira Pharmaceuticals stumbled on the release of the top-line data of the Phase 2b CENTAUR study of CVC therapy in NASH because the clinical trial missed its primary clinical outcome of improvement in NASH resolution without worsening of liver fibrosis. However, CVC therapy achieved its secondary clinical outcome of improvement in liver fibrosis without worsening of NASH resolution. The clinical efficacy of CVC on NASH liver fibrosis is currently being further researched in the ongoing Phase 3 AURORA clinical trial.
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.
The frontalis muscle attaches to the skin of the lower forehead and ascends to join the fronto-occipital aponeurosis. The action of the frontalis muscle involves elevation of the eyebrows to produce expressions such as surprise, and can cause deep transverse wrinkles on the forehead. The antagonists for brow depression are the corrugators, procerus, and orbicularis oculi muscles.

The recommended dilution is 200 Units/4 mL or 100 Units/2 mL, with a final concentration of 5 Units per 0.1 mL (see Table 1). The recommended dose for treating chronic migraine is 155 Units ad ministered intramuscularly using a sterile 30-gauge, 0.5 inch needle as 0.1 mL (5 Units) injections per each site. Injections should be divided across 7 specific head/neck muscle areas as specified in the diagrams and Table 2 below. A one inch needle may be needed in the neck region for patients with thick neck muscles. With the exception of the procerus muscle, which should be injected at one site (midline), all muscles should be injected bilaterally with half the number of injection sites administered to the left, and half to the right side of the head and neck. The recommended re-treatment schedule is every 12 weeks.

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Botulinum toxin is a purified substance that's derived from bacteria. Injections of botulinum toxin block the nerve signals to the muscle in which it was injected. Without a signal, the muscle is not able to contract. The end result is diminished unwanted facial wrinkles or appearance. Commonly known types of botulinum toxin type A injections include Botox®, Dysport® and Xeomin®.
Tell your doctor about all your medical conditions, including if you: have or have had bleeding problems; have plans to have surgery; had surgery on your face; weakness of forehead muscles; trouble raising your eyebrows; drooping eyelids; any other abnormal facial change; have symptoms of a urinary tract infection (UTI) and are being treated for urinary incontinence (symptoms of a urinary tract infection may include pain or burning with urination, frequent urination, or fever); have problems emptying your bladder on your own and are being treated for urinary incontinence; are pregnant or plan to become pregnant (it is not known if BOTOX® or BOTOX® Cosmetic can harm your unborn baby); are breastfeeding or plan to (it is not known if BOTOX® or BOTOX® Cosmetic passes into breast milk).
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