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Welcome to Skin Side Out where Science Meets Beauty! In this episode, Dr. Zain Husain, MD, Heather Murray, PA-C, and Courtney Carroll, LE inject themselves into the world of Botox, or more accurately, neuromodulators. They discuss what neuromodulators are, how they work, the areas they treat, potential side effects, and the importance of selecting the right provider. Their conversation also touches on preventative Botox, medical uses of neuromodulators, and upcoming advancements in the field. Whether you're curious about cosmetic treatments or interested in the medical applications of toxins, this episode has it all. Tune in for an enlightening discussion and find out if Botox might be right for you!
00:00 Introduction to Skin Side Out
00:36 Understanding Botox and Neuromodulators
01:47 Different Types of Neuromodulators
02:54 Medical vs. Cosmetic Uses of Toxins
03:40 New Developments in Toxins
04:02 Safety and Trust in Botox Injections
04:53 Mechanism and Allergies Related to Toxins
07:34 Personal Experiences with Botox
09:30 Factors Affecting Botox Duration
12:50 Off-Label Uses of Botox
16:39 Baby Tox and Preventative Tox
18:06 Importance of Proper Injection Techniques
20:32 Patient Consultation and Conservative Dosing
21:20 Preventative Botox: Controversies and Benefits
23:34 Anatomical Differences and Injection Techniques
24:36 Side Effects and Complications
29:57 Cautions and Contraindications
31:07 The Botox Procedure: What to Expect
34:08 Innovative Uses and Future of Botox
37:47 Conclusion and Final Thoughts
Creators and Guests
Host
Host
What is Skinside Out?
Welcome to Skinside Out, where science meets beauty, the ultimate dermatology podcast! Dive deep into the fascinating world of skin health with expert insights, evidence-based discussions, and myth-busting truths. Each episode explores the medical, cosmetic, and surgical aspects of dermatology, while keeping you informed about trending skincare topics. Whether you’re a skincare enthusiast, medical professional, or just curious about how to achieve your best skin, Skinside Out is your go-to resource for staying informed and inspired.
[00:00:00]
Dr. Zain Husain, MD: Welcome to Skin Side Out where Science Meets Beauty. I'm Dr. Zane, your host, and I'm joined with Pa Heather and aesthetician Courtney.
So today we're talking all about Botox today. Technically, we should call it neuromodulators. That's the technical term we should be using. But everyone knows Botox. It's kind of like Kleenex. Everyone knows the term. It was the first neurotoxin out there. So whether you hear us call it neuromodulator, neurotoxin, toxin tox.
Botox, you know what we're referring to?
Heather Murray, PA-C (2): Yeah. So we're gonna dive into what tox [00:01:00] is, how it works, the duration, um, areas to treat adverse reactions and potential complications. And we'll
Courtney Carroll, LE: also touch on, um, preventative Botox or to, and as well as different areas you can treat, um, prevention, which is a very hot topic right now.
Mm-hmm . And, um, yeah. Let's get into it.
Dr. Zain Husain, MD: I mean, everyone's heard of Botox. It is one of the, if actually it's probably the most popular aesthetic treatment out in the world. Um, in 2024, there were over 4 million injections in the US alone, which accounts for nearly 43% of all global Botox injections.
Courtney Carroll, LE: I feel like tox is kind of like the gateway drug of the aesthetic world.
You know, it, it's, it's kind of that starting point and, um, I think it opens the door to, you know, other cosmetic procedures.
Heather Murray, PA-C: Absolutely.
Heather Murray, PA-C (2): Yeah. So what is tox, or what are neuromodulators? are injectable treatments that temporarily block the signals that go from nerves to muscles and it blocks acetylcholine. So acetylcholine is responsible for causing that [00:02:00] muscle to contract.
So if you don't have that acetylcholine, the muscle can't contract and it kind of results in inactivity and therefore, um, you know, there are multiple . Ways to use this. You can use it to freeze muscles from smoothing fine lines and wrinkles,
they can treat migraines, um, treat your traps for neck pain, so lots of uses. And there's
Courtney Carroll, LE: a lot of different kinds of toxins out there. Um, Botox, like you mentioned before, is gonna be kind of the most known brand because it's kind of like like you mentioned, like the Kleenex of the, the tox world. But, um, we do have dis, you know, Dysport, we have Xeomin, Dify vo, so there are different neuromodulators out there and they do all work a little bit differently.
So just depending on the patient's goals and what they're looking for, that's when a provider might use one versus the other.
Dr. Zain Husain, MD: Yeah. And just to clarify, those are cosmetic toxin uses? Correct. [00:03:00] So they're, those are like, you know, toxins that are available for cosmetic uses. There are medical toxins used for like, you know,
Dystonias and spasticity and things like that. Mm-hmm . So I just wanted to clarify that.
Courtney Carroll, LE: Yeah. And I think a lot a big misconception sometimes we get, I know in clinic is, um, people who want to use Botox medically speaking, let's say for migraines, and they will contact their, you know, injector for that.
But, um, if you are needing that, you do have to go through your doctor, um, your neurologist for that. And you do have to try and fail many different things. So it's best to go to your neurologist. I. To get that treated. So, yeah,
Dr. Zain Husain, MD: and interestingly, there is a new toxin out in the pipeline. So Galderma is in a phase three trial for a new ready to use pre constituted, um, toxin.
Um, and that's exciting. I think that it will probably first get approved in Europe. So [00:04:00] we're waiting to see what that's like. That's gonna be pretty exciting.
Courtney Carroll, LE: I think that's gonna be very interesting just because I think what a lot of people don't know about talks is that, um, it doesn't come diluted, so we end up diluting it on the back end.
And so with that being said, that's, you know. A little scary sometimes, which is why you don't want to go to somewhere that you don't really trust. I mean, some of these like Groupon, um, ads and stuff like that because you don't know what their dilution is and how water
Dr. Zain Husain, MD: down exactly
Courtney Carroll, LE: how watered down it truly is.
So it'll be interesting to have that concept come out. Yeah.
Heather Murray, PA-C (2): Yeah. So kind of going off of the, um, Galderma new, Toxin. There are other toxins that Courtney touched on. There's, um, Botox, Dysport, juve, Xeomin, Dify. They're all slightly different, but they're all similar in their kind of base model. So, um, Clostridium botulinum is a bacteria that is found in soil dust, [00:05:00] um, sediment.
It's also found in honey. And, um, that is what creates that botulinum toxin. Like I said, they're kind of slightly different. There are some. Botulinum toxins that have complexing proteins on them, others do not. Some have, um, other molecules kind of added to it. And so that's kind of the difference in those brands.
But, um, kind of going back to the honey, the um, reason that you don't give honey to infants is because there's this botulinum toxin in honey, which could . Increase their risk for botulism. So the, um, flacid muscles paralysis, it could be very serious.
Dr. Zain Husain, MD: It's so funny. Um, culturally, um, so my family's Pakistani and you know, back in Asia a lot of you know, new parents, um, give their newborns honey.
Mm. It was just part of, you know, like customs and traditions and, . I'm like, the doctor in me just kind of cringes when I hear that. And my wife's a pediatrician and she like freaks out about that. [00:06:00] So, but it's just funny. Um, you know, just the whole relevance with botulinum toxin. Mm-hmm . And, you know, not giving it to kids
Courtney Carroll, LE: Yeah. . I don't abide it. That's a, yeah, real smooth baby skin. That's, that's really preventative . Um, yeah. And um, I know some of the different toxins. Um, I believe it's Dysport that has the, um, milk protein in there. So, um, just looking at things like allergies, um, being cognitive. Yeah, that's
Dr. Zain Husain, MD: interesting. I actually had a patient, um, who has this mm-hmm
Um, and. I'll never forget, um, we were injecting her and then she was just getting these really itchy wheels, like these hives that were developing and it was just like so bizarre. 'cause I've never seen anything like that before. And then, you know, I asked her like, do you have any, you know, milk, protein allergies or anything like that?
I said, oh yeah, I happened to have that. I'm like, okay.
Heather Murray, PA-C (2): Yeah. Makes sense. Yep.
Dr. Zain Husain, MD: That's why we learn in residency. Yeah. So now I'm really careful [00:07:00] about asking all my patients prior to toxin injections, Hey, do you by chance have a milk protein allergy? It's rare, but it happens. And I actually saw it happen in front of me.
Courtney Carroll, LE: Yeah, and I think that speaks to also how to kind of determine what tox you will want your injector to use. I mean, . Like we've mentioned Botox has been around, um, for a while, but we do see people becoming, um, you know, resistant to that extra molecule on there. So that's where Xeomin kind of comes in and we've been using a lot of Xeomin just to help prevent that.
Um mm-hmm . You know, loss of efficacy responders. Exactly. Yeah.
Dr. Zain Husain, MD: And I am a non-responder, so mm-hmm . Just kind of giving you my story. I've been doing talks since I was in residency. I started when I was 26. Um, and, you know, we're in residency. The, you know, the cosmetic companies give us, you know, samples to try practicing and training on, and so I naturally use Botox and, you know, the residents, we would all just inject each other, getting familiar with how to use it, how to inject it.[00:08:00]
Yeah, it worked great for a couple years and then I just noticed like, okay, I wasn't getting the same effect anymore. And then eventually, like, okay, I did not respond at all. So we repeated it with another, like 50 units in my forehead, still full movement. So that's when I sadly learned that I was a non-responder.
And that's due to auto antibodies, um, usually to the binding proteins on the toxin molecule. So, you know, that is increasingly becoming a phenomenon. We are seeing a lot of patients, oh, you know, like I used to do Botox, but it's not working on me anymore. So sometimes we have to mix and match, try different toxins.
They're slightly different molecules, so different properties. So it's a good thing that we have, um, more than one toxin on the market and more of them coming down the pipeline. But just know that it doesn't work on everyone, and it could just, could be your own body and your immune system.
Courtney Carroll, LE: And duration, you know, can vary too, um, with the different toxins.
So, I, you know, for example, I do feel like the Dysport on myself tends to work a little bit longer as [00:09:00] opposed to, you know, I'm kind of in the same boat with the Botox. I feel like I've kind of hit that non-responding . Dify has come out with theirs. Mm-hmm . And . Allegedly is lasting longer.
I think they say six months. Um, . Yeah,
Dr. Zain Husain, MD: I dunno about that. I mean, it's, it's a great neurotoxin, but essentially we're having to inject double the amount. Yeah. Yeah. Um, so it's really not adding that much of a benefit if we were to inject equivalent amounts of a different toxins such as Botox or Dysport, things
Courtney Carroll, LE: like that.
Yeah. Heather, you wanna touch on what might affect how long the tox lasts for someone? Yeah.
Heather Murray, PA-C (2): I think there's a . A number of reasons why you might need to come in three months versus needing to come in in four or five months. Um, age definitely does play a role. Mm-hmm . Um, your metabolism plays a huge role too.
Mm-hmm . It depends on how quickly you metabolize that neurotoxin or that tox. Heat can play a role, so if you're in hot environments, especially right after the injections could play a role. . [00:10:00] The way that your provider stores the neurotoxin or tos, um, I think that really plays a role, especially if they're, um, mixing the bottle and then just leaving it out all day.
That can play a huge role. Technique, dosing the area that you're treating, there are a ton of. Different, um,
Dr. Zain Husain, MD: mod even the depth of the needle, um, where you're injecting if you're doing it more superficially in the skin or more into the muscle. Yeah. We can see differences in, you know, duration.
Courtney Carroll, LE: Again, just going back to the dilution aspect it's really important that you go to these reputable senders because that can really give you the outcome that you don't want, especially if you're spending all that money on it.
Dr. Zain Husain, MD: Yeah. I mean, mean, did you see that article about that? I think he was an aesthetician. Mm-hmm. He was. I guess getting a legal tox, which was counterfeit. Mm-hmm .
Courtney Carroll, LE: Um,
Dr. Zain Husain, MD: injecting in multiple people. So, I mean, this stuff goes on and you don't know where they're sourcing it from, whether it's even tox. Yeah. So it's scary.[00:11:00]
Courtney Carroll, LE: Yeah. The whole, um, DIY aesthetics. Red page is like such a jump scare, um, . Um, so let's talk about places where we use talks. Um, we'll start with kind of our on-label areas, which are gonna include your glabella. People also call these your 11 lines. So, um, I would scowl, but I don't think it'll make a difference to show you
Um, we treat forehead, um, and then crow's feet, which are around the eye area.
Heather Murray, PA-C (2): There are other places on the face though that you can treat. Mm-hmm . So lots of areas. I mean, you can do a brow lift. Um, if you scrunch your nose and you get little lines at the tops of your nose or the top of your nose, that's your bunny lines.
You can treat that. There's jelly rolls. So jelly rolls are where if you smile and you get this kind of bunching underneath your eye, that's your jelly roll, you can relax that muscle and kind of help smooth out the under eye.
Dr. Zain Husain, MD: Actually the same muscle that's creating your crow's feet.
Heather Murray, PA-C (2): And the
Dr. Zain Husain, MD: one that we also inject [00:12:00] for brow lift is like a circumferential muscle.
Mm-hmm . The
Courtney Carroll, LE: Oculus.
Dr. Zain Husain, MD: Orbicularis or oculi, but very good. I'm impressed. But it can help someone studied their anatomy . Yeah.
Heather Murray, PA-C (2): It can help eyelid twitching too. Yeah. Um, there are other areas on the face, the masseter, so that's your, um, large kind of jaw muscle. People who grind their teeth at night. Mm-hmm
Definitely notice a difference with that. You can treat your lips, you can do a little lip flip. You can treat like a gummy smile. So if you smile and your lip kind of pulls upwards, um, nasal
Dr. Zain Husain, MD: tip lift.
Heather Murray, PA-C (2): Mm-hmm . Your DAO. So if you feel like you're kind of downward turned on your, um, when you're just at it resting, if you feel like you're frowning all the time.
um, your chin. Mm-hmm . Dimpling, chin there. Peach
Dr. Zain Husain, MD: chin, . Yeah. It's a thing. .
Heather Murray, PA-C (2): Yeah. There are lots of great uses for it. Yeah.
Dr. Zain Husain, MD: And like moving down, like there's also uses that we do in the office off label. Um, I love doing the Nefertiti lift where we're injecting, [00:13:00] you know, the platysma muscle, which wraps around our neck and also integrates into
The jawline area, so it kind of gets a nice contraction. Um, it also helps with those little rings that we get from tech neck just to smoothen them out. Um, those Patal bands, those tricky neck . So that, um, that can relax those and improve that. Um, along the lines of like migraine injections, like I do them, I do 'em on my wife and it really helps her migraines.
But um, you know, there's obviously a lot of injections in the temporalis muscle behind the, you know, the scalp and into the neck, into the trap. So you can actually just do just traps Botox just to kinda get that swan like, um, you know, appearance. So that's something that's very popular in Korea and like women, um, like that slender, elongated neck look.
So I think that's really an interesting place to inject. Um. . You can also inject other areas, so like your scalp. Um, a lot of women [00:14:00] like getting Botox where we inject the toxin to reduce sweating so that, you know, they don't have to wash their hair as often. Mm-hmm . . Um, so I mean, it's a practical thing, I guess.
Mm-hmm . There's some other off-label. What other areas?
Courtney Carroll, LE: Hyperhydrosis, which we talked about earlier. Mm-hmm . Yeah. So, um, that's excessive sweating. So, um, that's a nice option for mm-hmm . Those people who have tried you know, oral medication and topical medication.
It typically is a lot of injections. So it's not for the faint of heart, I would say. , and it can sometimes be a little costly. Yeah. But it does do a fantastic job and patients are usually happy that they've,
Dr. Zain Husain, MD: yeah. And there's like other areas, um, in medicine that we're using toxin. Yeah. So interestingly, um, I have treated patients with vaginismus, which is a painful, like tension of the muscle around the vagina in women and that can cause significant pain, [00:15:00] Nia.
So we've actually injected Botox in there to relax the muscle, giving them pain relief, and that was really incredible. I did that with, um, my one of my attendings in residency and it just made such a big . Difference for them. Mm-hmm . Like it reduced pain. It allowed her to have, um, intimate relations with her partner which she wasn't able to for the past two years and it really did change her life.
You can use it for overactive bladder, so that is something that urologists use to really help with that tension. Um, and then strange uses of tox. So men, um, have . At times requested Scrotox . So as you may think from the name, it's when men want to get injected in their scrotum so that the rouge or the wrinkles of sack
Courtney Carroll, LE: smoothen
Dr. Zain Husain, MD: out.
So I guess some people like that look, um, and tends to make your your testicles hang a little lower. So . [00:16:00] I mean, whatever floats your boat, right? Yeah. Yeah.
Courtney Carroll, LE: It's, I feel like yeah, there's something for every, everyone . Yeah, there is.
Dr. Zain Husain, MD: There is, and that's the cool thing about tox, like we're using the toxins property
To really make differences and whatever differences you're looking for, you know, as long as it's safe and effective mm-hmm . And done by someone who's professional who knows what they're doing, I think it's fine.
Courtney Carroll, LE: Yeah. That is definitely not something you would wanna go to, like someone who is not knowledgeable on anatomy about, I feel like that is something really bad waiting to happen,
Heather Murray, PA-C (2): Yeah. So there are definitely, you know, the classic ways to inject tox. Um, let's kind of dive into, . Baby tox and preventive tox. So baby tox or microdosing is another thing that they call it. Um, this is where we're actually using little micro droplets of the tox into a kind of a spread out area. So instead of just injecting, you know.
Four or five spots [00:17:00] on your forehead, we might sprinkle tiny little dosing all across your forehead, spread it out more. I think that does give a much more natural look.
Courtney Carroll, LE: Mm-hmm .
Heather Murray, PA-C (2): Um, and works very well. Not to just completely, I mean, some people do like the completely frozen look, but I think there's definitely, a trend towards the microdosing.
Courtney Carroll, LE: Yeah.
Heather Murray, PA-C (2): Yeah. And I think also
Courtney Carroll, LE: what a lot of people don't tend to realize with talks is that you can still have expression, it's . More personalized than people would assume. Mm-hmm . I think people just think either you're frozen or you don't have talks, and there's a lot of ways to, um, decide how natural you want your you know, talks to be, um, depending on how it's injected.
Um, like Heather had mentioned just about spreading it more throughout rather than just focusing on one area. Um, I've, you know, worked alongside injectors who tend to just do one or two right here without [00:18:00] spreading it out through this, like a big bolus of the big bolus and yeah, then it's just frozen, but then the rest looks a little unnatural.
So,
Dr. Zain Husain, MD: I mean, when you're looking at the face, you're seeing a culmination of multiple muscles interacting with each other, right? So we're using this toxin to . Really reduce the movement activity of a muscle. So I definitely can tell when someone has had only one area injected and has left other areas alone, it just looks odd because you don't see the, the muscles moving and then the other muscles tend to overcompensate.
Mm-hmm . And you see even more unnatural lines forming. It almost looks better if they didn't do anything. Yeah. Than had they just, you know, done a little bit more of a natural approach, kind of spreading it out. . I think that's a way better look. And, you know, some patients just aren't educated by their injector, um, about that.
And they're, and that's in part because of their training.
Courtney Carroll, LE: Mm-hmm .
Dr. Zain Husain, MD: So yes, you can go to a weekend course and start injecting TOXs if you're, you know, a doctor, [00:19:00] a nurse, or pa. That doesn't mean you're gonna be a good injector. And understanding how these muscles intricately work together.
And if we're able to kind of look at the whole face as a unit mm-hmm . And just making sure that we address the muscles, their movement and the look that we're trying to achieve and the look that the patient wants, I think we can get a really beautiful result.
Courtney Carroll, LE: Yeah, definitely. It's like how, you know, we will have patients sometimes come in that just have mm-hmm.
Forehead lines. Yep. And they just wanna treat those four headlines. Mm-hmm. And we tell them, yeah, you can't treat this, it's gonna drop without treating that glabella region. And, um, people sometimes are a little surprised. And once you kind of explain it to them, I think they understand how it, how it works.
But it again, like you said, it will end up looking very weird to just treat sometimes that one area so heavily.
Dr. Zain Husain, MD: Many times patients come in with horror stories from prior experiences, like they were treated at a med spa and [00:20:00] they got a droop. Um, or it just looked really odd and migration or had other symptoms and.
I think that with the proper education, you can restore their confidence. As long as you know what you're talking about, you go in with a plan, do an extensive consult and educate the patient. I think that you know, you can achieve good results even after having poor results. I. In the past with other injectors who may not have been as knowledgeable or skillful with injections?
Heather Murray, PA-C (2): Yeah, I think the consultation makes a big difference. Huge
Dr. Zain Husain, MD: difference. And that's why we spend time with our patients when we're consulting them, especially the newbies. Like if they never had talks before, like we are holding their hands, starting off with more conservative dosing. And I always have my patients come back two weeks later.
Yeah. Because I'd rather be conservative because once you inject the tox. You can't undo it. Yeah. So I mean, if you get a bad result, you're gonna have to wait about four months for it to wear off, for, you know, those results to go away. And I'd rather bring a patient back [00:21:00] and add a little bit more as a little touchup.
And I think patients also like that because I. They are feeling comfortable in your hands, you're going slowly. Um, especially if they've never done it before, they feel reassured and you know, I think that really helps with, um, restoring confidence.
Courtney Carroll, LE: Yeah. Agreed. Yeah. So let's touch on preventative talks. I think this is such a controversial subject and I hate that it's so controversial.
I don't get it because. I, I believe in , repetitive talks, support. I believe in it too. , . As someone who, I don't know, Heather, when you started getting talks, I don't know that you told us. I think I was 27, so around 30. Okay.
Dr. Zain Husain, MD: By the way, everyone, we're all like 60 years old. talks, .
Courtney Carroll, LE: I also started getting talks maybe around 23.
Granted, I did work in a dermatology office, so I think that, you know, I . Had more access to it for sure. Mm-hmm . [00:22:00] As well as you did being in the dermatology field. I know you said you've started around that same age, so I think there's nothing wrong with preventative talks, getting a few units here and there just to help keep those lines from forming.
Mm-hmm . Will really benefit you in the long run because I tell patients this all the time, it is so much easier to prevent than it is to correct, especially wrinkles. Mm-hmm .
Dr. Zain Husain, MD: Mm-hmm .
Courtney Carroll, LE: So.
Dr. Zain Husain, MD: Remember these etched lines that we see at rest, these static riptides are due to repetitive movements over time. So as we're, you know, in our daily lives expressing ourselves, making those facial expressions, those lines become etched and they are really hard to treat.
Especially if it's gone on for decades. So I really think that if you can prevent those lines from forming in the first place, or at least keeping them soft, it's a much better, better result.
Heather Murray, PA-C (2): Yeah. And the most ideal candidate for this would be, you know, somebody in their twenties or thirties who's kind of like us when we started out, who's [00:23:00] really getting into trying to keep those muscles relaxed, keep those mm-hmm
Lines from forming and stay smooth.
Courtney Carroll, LE: And I think it also varies on the person. I mean, for example, . I didn't start getting my crow's feet done until later when I started with talks. It really was just glabella. I don't even think I got forehead until recently, maybe, I don't know, two or three years ago. So it was more of a gradual mm-hmm
Um, trajectory for me, but it still was a little bit at a time that I feel like helped a lot. Yeah.
Dr. Zain Husain, MD: Also, let's be mindful of the anatomical difference between men and women. Mm-hmm . Yeah. Um, we have different biological, um, you know, muscle, you know, patterns, movements. Um, men tend to have more powerful muscles, um, so they tend to have deeper lines.
Um, it's just part of our anatomy, so we may need a little bit more toxin to achieve the same results compared to women, however. Also from a cultural [00:24:00] standpoint, there are certain ways we inject to really capture . Feminine as well as masculine, as well as fluid ideals. Mm-hmm . So it's really what the patient wants and you can't just assume that they wanna look like this way or that way based on their identity.
And you really have to ask the patients what they're looking for. Like I've had, um, men who really want arched eyebrows and we can achieve that with tox. And I've had women who really want flat lower eye eyebrows and that's fine. So. Using the dosages, looking at muscle patterns, and also looking what they want to look like is really important.
Heather Murray, PA-C (2): Yeah. So let's get into, um, side effects and potential complications. So I think the most common side effects we see with tox are injection site reactions. Maybe some pain, redness, swelling, potential bruising. They do, um, go away after a couple days. Yeah.
Courtney Carroll, LE: Occasionally people might get some headaches or on rare occasion flu-like symptoms. If you're getting your tox in the winter, just know it's probably because it's [00:25:00] flu and cold season. . Yeah.
Dr. Zain Husain, MD: Yeah. And then one of the biggest complications that we hear about is ptosis, um, lid ptosis especially. Um, that means when your eyelid droop, and that's due to
Diffusion of the neurotoxin getting into the levator palp superioris, that's a mouthful, . Um, so what this muscle is responsible for doing is kind of raising the eyelid. So with the toxin coming in. Inactivating that muscle, it weakens it. So you get that ptosis. So I'm sure you've seen it on social media.
Mm-hmm . Um, with some patients who, um, have gotten eyelet. Ptosis and it's not a good look. Mm-hmm . Um, and unfortunately, um, you really can't do too much about it. There are some eye drops that you can use that help to reverse some of that. You know, activity. Um, but it's still not a home run. But there is something that you can do for that.
That's for lid ptosis. And then for brow ptosis, um, you know, your eyebrows are basically drooped because [00:26:00] you have injected either too low in the frontalis muscle, which are the forehead muscles, and that leads to in activation of that muscle, which normally elevates, and then you cut that droop. That's a pretty common one that we see.
Yeah, I would say that's pretty common in other places, and unfortunately when a patient comes in with those complications coming to see me to reverse it, it's really hard. Um, usually have to wait it out. Yeah.
Courtney Carroll, LE: Yeah. Sometimes we'll see the watery eyes or even dry eyes depending, same thing on kind of where that drooping is coming from.
So, and again, just having to wait that out, unfortunately. Mm-hmm . Um, for the three, four months. And we
Dr. Zain Husain, MD: have some patients who, um, you know, complain about twitching of their eyelids as well, um, you know, as a result of it too. And also some issues with vision. So these are all things that are avoidable with proper injection technique.
Heather Murray, PA-C (2): Yeah. And even like around the mouth, if, if the toxin is getting into a muscle that you don't want, you could have a crooked smile. Um, that even goes all the way up [00:27:00] to when we're treating the crow's feet. There's a risk that you could. Inject the wrong muscle. Mm-hmm . And then when you smile, yeah. Your smile is very uneven.
Um, back to kind of around the mouth, you could potentially have drooling if the wrong muscle is injected. So definitely make sure you're getting the right care. Yeah.
Dr. Zain Husain, MD: It's not a good look. I mean, talks around the lips. Everyone's talking about it. They love the lip flip, but they don't realize that. When we're injecting toxin around the lips, you are weakening the muscles around the lips.
So normal functions such as talking,
Heather Murray, PA-C (2): eating,
Courtney Carroll, LE: drinking outta a straw, a straw. Yeah. . I have been there, especially, I went through such a, a year of my life where I would not stop touching my lips and I literally could not drink out of a straw. I, there was like times I was like drooling, like it was just misery for like a year.
Oh my God.
Dr. Zain Husain, MD: Yeah. It's not a good look. And then also like. You can hear the lisp.
Courtney Carroll, LE: Yeah. , like the filler lis here. The to lips, the tox lips.
Dr. Zain Husain, MD: It just doesn't sound right. You don't look right [00:28:00] and it doesn't last that long. I tend to not be a huge fan of lip lips in general. Yeah. Like the only ones I really consider are like, you know, younger females who just want a little bit of improvement of their pout but don't wanna do filler.
And I just tell them like, I'm gonna do a little bit of sprinkle. Very conservative just to kinda achieve that look. But you're gonna be back here in four, eight weeks. Mm-hmm . It's not gonna last very long. Yeah.
Heather Murray, PA-C (2): It does
Courtney Carroll, LE: not last long at all.
Dr. Zain Husain, MD: Yeah.
Courtney Carroll, LE: Yeah. I wanted to mention, not that this was bad injecting at all, but I'm just, it's making me think about the last time Heather and I did our talks and.
We did our DAOs and I literally could not frown to save my life. Couldn't. Not that I'm like a frown, but I was in the mirror cracking up because I literally just like couldn't move down .
Heather Murray, PA-C (2): It was too good. It was too good. Yeah, it
Courtney Carroll, LE: was upward for like, yeah, three months. Just smiling nonstop. .
Dr. Zain Husain, MD: Um, so that's why you're in a good mood.
That's, yeah. .
Courtney Carroll, LE: So maybe more Back
Dr. Zain Husain, MD: to grumpy. Courtney . [00:29:00]
Courtney Carroll, LE: Listen, I've been on prednisone . , lastly, um, we do wanna touch on allergic reactions because that can happen. Um, we tend not to see it very often, I would say, but it definitely is a possibility that you do wanna be aware of. So things like difficulty swallowing or difficulty breathing.
Itching a hive like reaction. Mm-hmm . Um, those are all things that you want to inform your provider about as soon as they happen.
Dr. Zain Husain, MD: But that's different than botulinism. Mm-hmm . So, you know, this toxin can, at the wrong doses and high doses cause issues of muscle paralysis and that is a serious issue and some patients freak out because they may be having an allergic reaction.
Mm-hmm . , but it's, they're thinking that it's botulinism. Mm-hmm . And that they're being poisoned and like they are like having those symptoms. So just be careful. Like some of those symptoms may actually truly be an allergy.
Heather Murray, PA-C (2): True. Yeah. So let's talk about some cautions and [00:30:00] contraindications for tox.
Courtney, do you wanna get started?
Courtney Carroll, LE: It's like those commercials, like, don't use Botox if you're allergic to Botox. Yeah. . Obviously women who are pregnant or breastfeeding, we typically do not want to inject them. Kind of like you were talking about with the infants earlier. Obviously we don't wanna pass that along to any babies,
Yeah.
Heather Murray, PA-C (2): I think you have to also have to be mindful of people who have neuromuscular disorders. A LS and ms. So multiple sclerosis and a inotropic lateral sclerosis. Um, not very common, but I think those people do know that they shouldn't be coming into the office for
Dr. Zain Husain, MD: attacks.
And of course, like being a cosmetic dermatologist, you see patients who have body dysmorphic disorder. I tend not to touch these patients in general because no matter what you do. If they will not be happy and will ask for more or for you to do something else, so I just caution [00:31:00] with that because you're never ever gonna make these patients happy and they really need the, the care of a psychiatrist.
Courtney Carroll, LE: Yeah. So what can you expect when you come in for a treatment? At least with us, you'll start with a consult where you'll get a good gauge on how many units per area that you will need. Um, typically we don't numb for this procedure. Most people don't need numbing. I think it's pretty tolerable.
We use insulin needles, so teeny tiny needles to inject the face. Um, and we do use ice to help just, um, with bruising and help numb that area a little bit. Um, once you've kind of determined what you will need, typically, then it will, you know, be drawn up, um, usually by one of us. , not Dr. Hussein. No.
Heather Murray, PA-C: I'm a diva .
Courtney Carroll, LE: During the procedure we'll basically have you sit back to relax. Um, like I said, we'll use a little bit of ice, make sure it's pretty comfortable, and then yeah, just start, you know, injecting, like I said, it's, it's tiny little insulin needle, [00:32:00] so most patients tolerate it really well.
Um, some areas can be a little bit more tender. Sometimes doing those lip flips can kind of bring a little tear to your eye. But overall, very tolerable. Um, I don't think I've ever had anyone that's tapped out, so,
Dr. Zain Husain, MD: and it's really quick. Yeah. Mm-hmm . Um, it's considered a lunchtime procedure for a reason.
Um, so you can literally come in. And within 10 minutes be treated, um, safely and effectively. And immediately after, you may see some small, little, um, you know, almost like little pinpricks where we injected that goes away. Um, you might have some mild swelling goes away in an hour. Um, so, you know, relatively easy.
Um, in terms of recovery.
Heather Murray, PA-C (2): the day of your talk appointment, ideally you don't want to have any excessive or aggressive exercise or heat. Um, I. You also don't wanna lay down for four hours afterwards. It's also best to kind of use those muscles and be a little bit more intentional and active with those muscle [00:33:00] movements that actually helps the tox kick in a little bit quicker sometimes.
Um, so just things that you can do that day of the procedure, but otherwise you're kind of back to normal the next day.
Dr. Zain Husain, MD: Yeah. And I know that there's been a lot of talk about using zinc supplementation to help extend the, duration, um, of your tox that has been disproven.
Courtney Carroll, LE: Yeah, and there are products out there, um, I know revision makes one called reox.
We have a new PTX from SkinCeuticals that Heather and I have started using. So there are some of these adjunct treatments that you can use that are, um, supposed to kind of elongate your results. I haven't used the reox frequently enough, but I will say I have been really liking the PTX from SkinCeuticals.
I do like, it's okay. Yeah. I feel like it has been helping, again, an adjunct to extend those results. It's,
Dr. Zain Husain, MD: it's hard to tell. It's, yeah. Yeah. But I do feel like my face and my skin looks better.
Courtney Carroll, LE: We're always like. Yeah, I think it's working, but we're doing, we're doing Lees md we're doing . Well, you're,
Dr. Zain Husain, MD: you're yellow half the time [00:34:00] for the maestro
Courtney Carroll, LE: Don't get me started on that. We're not the best like gauge sometimes, but I like it. Yeah.
Dr. Zain Husain, MD: Yeah. One other thing I wanted to touch on, um, just from another cool use of neurotoxin, um, as a surgeon, I'm, I'm a MO surgeon, so for some patients, um, especially for like facially cosmetic. Sensitive areas you can actually use toxin to help wounds heal better.
Part of the wound healing process requires some of these neuromuscular, um, you know, interactions, um, as the scars contracting. So if you are able to relieve tension around the site, like say on the forehead. Of the muscles around it, you're having less tension on the scar, which will help it with healing.
So I have done that for a few patients where I've done like cosmetic excisions, um, you know, some facial cosmetic surgery, um, even for some of my most patients. And it has helped dramatically with, you know, improving [00:35:00] the scar.
Courtney Carroll, LE: Hmm. Yeah, that makes a huge
Heather Murray, PA-C (2): difference.
Courtney Carroll, LE: Um, I think that's a pretty good chat. All about talks
Yeah, I mean, I think that. .
Dr. Zain Husain, MD: A lot of people are afraid of toxin. They know. They think that, you know, it's something scary. Especially probably from the word toxin itself. Yeah. Yeah. And I think that's why I prefer the term neuromodulator. Mm-hmm . And I think that with the proper education by the right professionals, it is a phenomenal, phenomenal treatment.
There is nothing that can do what Botox does. Oh yeah. There is nothing,
Courtney Carroll, LE: my TMJ alone, I. It has made worlds of difference for me. The quality of life has just been, yeah, so much improved with, with talk. It has so many different areas I can treat. And again, I, I think that for so long we just saw this whole, um, fear of that being frozen.
Look, but again, that's not necessarily. What you should be expecting at your [00:36:00] appointments. Um, there should be some fluidity with your movements. And again, the, the customization is yeah. Up to your provider. Yeah.
Dr. Zain Husain, MD: Well, I disagree with that. I actually think that, you know, patients may like the frozen look, and that's what they're looking for.
And if that's what your injectors, . Philosophy and aesthetic, um, is then that's fine. But I think that for me, um, I tend to naturally gravitate. That's more conservative treatment. That's fair. There are some people who like that.
Courtney Carroll, LE: I'm, I, I'm that person, . I don't wanna move. I don't want
Dr. Zain Husain, MD: move. I, I force you to have some movement because I don't wanna want you to scare my patients.
I
Heather Murray, PA-C (2): know that is. Why a consultation is super important so that you know that you, your youth and your goals are the same as aligned. They have to align provider. Yeah. Like
Dr. Zain Husain, MD: it's a partnership. It's a journey. Yeah. We have to work together to achieve that goal. If you are asking for something that's fundamentally different than how I view aesthetics.[00:37:00]
It's just a, it's not a match. Yeah, yeah. You know, so like, I think then there's probably another provider out there for you who can inject you to your liking, but I really want my patients to look refreshed. Yeah. I don't want them to look done. Yeah.
Courtney Carroll, LE: Yeah. And that's okay if they're, you know, as long as you're seeing someone who, again, is skilled, knows what they're doing mm-hmm
Knows the anatomy and has been properly trained, I think, you know, those are the most important things. Yeah.
Heather Murray, PA-C (2): And be confident during your consultation if you have questions mm-hmm . Or worried about something, just ask . Um, your provider should always be happy to answer the questions that you have and make you feel more comfortable during your process.
Dr. Zain Husain, MD: And take it slow. You don't have to do it all at once. You can take baby steps and that's totally fine. And it's a journey. So you can do this over multiple sessions. That's not a problem.
Heather Murray, PA-C (2): Awesome. All right, .
Dr. Zain Husain, MD: Well, I think this was a great discussion. We talked a lot about the different uses for neurotoxin or neuromodulator for aesthetics as well as medical purposes.
So it's not just for, you know, wrinkles. You know, there's a lot of clinical [00:38:00] applications for tox. You know, we also talked about how important it is for a good consultation, looking at your provider for education and for guidance, and then also how we see innovation in the future. How there is new topical and injectable formulations that are coming out to market.
I'm excited to see what the future holds.
Courtney Carroll, LE: Yeah, me too. Yeah.
Dr. Zain Husain, MD: Yeah. So. This episode of Skin Side Out was a lot of fun, and I think that a lot of people have questions about Botox and they're scared to ask. So hopefully this was a good enlightening discussion about it. And if you guys have any questions, you know, feel free to reach out to us.
Um, if you like this episode, please subscribe and follow us. Otherwise till next time, skin. Skin side, skin.
Heather Murray, PA-C: Ouch. [00:39:00]