Gives an overview of the best practices when it comes to botox.

1. Botox:Botox:
Strategies For SuccessStrategies For Success
Maximize patient care andMaximize patient care and
office efficiencyoffice efficiency
Richard A. Weiss, M.D.Richard A. Weiss, M.D.
Newport Beach, CANewport Beach, CA

4. Other 2001 Botox statisticsOther 2001 Botox statistics
• Average price: $358-503Average price: $358-503
• 86% women86% women
• 80% of patients were over 35 y.o.80% of patients were over 35 y.o.

5. The first published report ofThe first published report of
Botox A in treatingBotox A in treating
hyperkinetic facial lines washyperkinetic facial lines was
published by Carruthers inpublished by Carruthers in
19921992

6. Ten years later…Ten years later…

7. No more frown lines!No more frown lines!
My kids are more relaxed!My kids are more relaxed!

8. When I look in the mirror,When I look in the mirror,
I like what I see now!I like what I see now!

9. What exactly is Botox?What exactly is Botox?
• Botox is a natural, purified proteinBotox is a natural, purified protein
produced by the Clostridium botulinumproduced by the Clostridium botulinum
bacteriumbacterium
• Very low doses of Botox are administeredVery low doses of Botox are administered
via a few tiny injections directly into thevia a few tiny injections directly into the
overactive muscles that cause lines tooveractive muscles that cause lines to
form.form.

10. How does Botox work?How does Botox work?
• Botox blocks the transmission of nerveBotox blocks the transmission of nerve
impulses at the neuromuscular junction byimpulses at the neuromuscular junction by
binding to acceptor sites on motor nervebinding to acceptor sites on motor nerve
terminals, entering the nerve terminal, andterminals, entering the nerve terminal, and
inhibiting the release of acetylcholine.inhibiting the release of acetylcholine.
• This produces a local weakness or flaccidThis produces a local weakness or flaccid
paralysis of the injected muscleparalysis of the injected muscle

14. What is Botox used for?What is Botox used for?
• FDA approval as a safe and effectiveFDA approval as a safe and effective
therapy for blepharospasm, strabismus,therapy for blepharospasm, strabismus,
and hemi facial spasm in December 1989and hemi facial spasm in December 1989
• Botox Cosmetic was approved for use inBotox Cosmetic was approved for use in
the glabella on April 15, 2002the glabella on April 15, 2002

15. Off label usesOff label uses
• CosmeticCosmetic – forehead, crow’s feet– forehead, crow’s feet
• FunctionalFunctional
– MigraineMigraine affects 18% of women and 6%affects 18% of women and 6%
of men in USof men in US
– Axillary hyperhidrosisAxillary hyperhidrosis - ~1% of- ~1% of
populationpopulation

16. Off label usesOff label uses
Many other medical uses includingMany other medical uses including
adductor spasmodic dysphonia,adductor spasmodic dysphonia,
oromandibular dystonia, torticollis,oromandibular dystonia, torticollis,
cerebral palsy, back spasms, newcerebral palsy, back spasms, new
uses every dayuses every day

17. Clinical Use of Botox CosmeticClinical Use of Botox Cosmetic

18. Facial wrinkles and contributoryFacial wrinkles and contributory
underlying musclesunderlying muscles

20. Forehead wrinklesForehead wrinkles

21. Glabellar wrinklesGlabellar wrinkles

23. Orbicularis muscleOrbicularis muscle

24. Nasalis muscleNasalis muscle

25. People are different,People are different,
so results can varyso results can vary

26. Botox dilution: 100U=100UBotox dilution: 100U=100U

27. Complete Botox trayComplete Botox tray

28. Individual Botox disposableIndividual Botox disposable
packpack

29. How to injectHow to inject
• Glabella and forehead – more perpendicularGlabella and forehead – more perpendicular
• Crow’s feet – more parallel to skin surfaceCrow’s feet – more parallel to skin surface
• Axilla – intradermal, hair bearing skinAxilla – intradermal, hair bearing skin

30. Botox injection techniqueBotox injection technique

31. MarkingMarking

32. Typical glabella distributionTypical glabella distribution

33. RelaxRelax

34. Now smileNow smile

35. Ice pack aids anesthesiaIce pack aids anesthesia

36. More parallel to skin surfaceMore parallel to skin surface

37. More perpendicularMore perpendicular

38. Rotate syringe toward youRotate syringe toward you

39. Grid pattern in hair bearing skinGrid pattern in hair bearing skin

40. Intradermal injectionIntradermal injection

41. How much to injectHow much to inject
• Forehead ~ 20-40UForehead ~ 20-40U
• Glabella ~ 15-30U, 40U lasts longer thanGlabella ~ 15-30U, 40U lasts longer than
20U!20U!
• Crow’s feet ~30-50UCrow’s feet ~30-50U
• Axilla 35-100U per sideAxilla 35-100U per side

42. Risks and complicationsRisks and complications
• Precautions:Precautions: Pregnant or lactatingPregnant or lactating
womenwomen
• Preexisting disorders affecting thePreexisting disorders affecting the
neuromuscular junction function, such as Eaton-neuromuscular junction function, such as Eaton-
Lambert syndrome, myasthenia gravis,Lambert syndrome, myasthenia gravis,
amyotrophic lateral sclerosis and motor neuronamyotrophic lateral sclerosis and motor neuron
disease.disease.
• Aminoglycosides interfere with neuromuscularAminoglycosides interfere with neuromuscular
transmission and may potentiate the effect of atransmission and may potentiate the effect of a
given dose of Botox.given dose of Botox.

43. General risksGeneral risks
• Swelling or bruising,Swelling or bruising,
• Headache (15.7% Botox group, 15%Headache (15.7% Botox group, 15%
placebo),placebo),
• Flu syndrome (Botox group 4.9%, 8.3%Flu syndrome (Botox group 4.9%, 8.3%
placebo),placebo),

44. Specific risksSpecific risks
• ForeheadForehead –– droopy eyebrows and eyelidsdroopy eyebrows and eyelids
especially in patients with preexistingespecially in patients with preexisting
secondary frontalis contraction and significantsecondary frontalis contraction and significant
dermatochalasis, noticeable asymmetry,dermatochalasis, noticeable asymmetry,
spotty coverage, inability to raise the eyebrowspotty coverage, inability to raise the eyebrow
• GlabellaGlabella –– few complications, veryfew complications, very
infrequent bruisinginfrequent bruising

45. Specific risksSpecific risks
• Crow’s feetCrow’s feet –– more chance of bruising,more chance of bruising,
weakened orbicularis occasionally can causeweakened orbicularis occasionally can cause
a sagging appearance over the inferior orbitala sagging appearance over the inferior orbital
rim, can also get transient swelling due torim, can also get transient swelling due to
lymphatic blockage, focal facial paralysislymphatic blockage, focal facial paralysis

46. Swelling one day post injectionSwelling one day post injection

47. Photography can fool you!Photography can fool you!

48. Swelling after BotoxSwelling after Botox

51. Office efficiencyOffice efficiency
• Discussing Botox with patientsDiscussing Botox with patients
• DocumentationDocumentation
• PricingPricing
• MarketingMarketing

52. DocumentationDocumentation
• Consent forms on every patientConsent forms on every patient
• Detailed Botox treatment maps, refer to atDetailed Botox treatment maps, refer to at
subsequent visitssubsequent visits

53. Be a scientist!Be a scientist!
Document each injection siteDocument each injection site

54. Informed consent and post injectionInformed consent and post injection
instructionsinstructions

55. DocumentationDocumentation
• Photography – stills and video clips reallyPhotography – stills and video clips really
help shorten subsequent discussions -help shorten subsequent discussions -
Sony FD-97 MavicaSony FD-97 Mavica

56. Dr. Weiss before botoxDr. Weiss before botox

57. Dr. Weiss after BotoxDr. Weiss after Botox

58. PricingPricing
• Charge by the unit!Charge by the unit!

59. MarketingMarketing
• Internal – office brochures, displays,Internal – office brochures, displays,
Botox information sheet in waitingBotox information sheet in waiting
roomroom
• Botox log for patient analysis and fuBotox log for patient analysis and fu
• Have them fill in the address on reminderHave them fill in the address on reminder
postcards when they leavepostcards when they leave
• Direct Mail or insert with billing or patientDirect Mail or insert with billing or patient
remindersreminders

60. MarketingMarketing
• External – don’t start until you have yourExternal – don’t start until you have your
office systems in placeoffice systems in place
-cost effectiveness for a print or radio ad-cost effectiveness for a print or radio ad
varies by marketvaries by market

61. MarketingMarketing
Botox patient seminarsBotox patient seminars

62. Food and drinkFood and drink

64. Botox lectureBotox lecture

65. Promote your other proceduresPromote your other procedures

66. What’s the difference betweenWhat’s the difference between
Botox and Collagen?Botox and Collagen?
• Botox stops muscle motion that causesBotox stops muscle motion that causes
wrinkles to occurwrinkles to occur
• Collagen fills in fine or deep wrinkles thatCollagen fills in fine or deep wrinkles that
are already thereare already there

67. Collagen science (1 of 1)Collagen science (1 of 1)

68. Collagen before and aftersCollagen before and afters

69. Brow lift, eyelids, and laserBrow lift, eyelids, and laser

70. Patients help in the planningPatients help in the planning

71. Numbing cream appliedNumbing cream applied

72. Injections are not frighteningInjections are not frightening

73. Smiling facesSmiling faces

74. Having fun with BotoxHaving fun with Botox

75. Make up artistMake up artist

77. Botox:Botox:
Strategies For SuccessStrategies For Success
Maximize patient care andMaximize patient care and
office efficiencyoffice efficiency
Richard A. Weiss, M.D.Richard A. Weiss, M.D.
Newport Beach, CANewport Beach, CA