Three’s the Charm

Expert injectors discuss the promise and perils of Botox Cosmetic’s third nod.

By Joel Schlessinger, MD, Section Editor


Joseph Niamtu III, DMD, a facial cosmetic surgeon in Midlothian, VA, offers some counsel on how to speed the Botox learning curve for forehead lines and other indications.

Know your anatomy.

“Injection success or failure has everything to do with anatomy,” he says.

Find a mentor.

“Watching an experienced injector can fast forward your training,” Dr. Niamtu suggests.

Start with easy cases.

“Upper facial injections are more predictable than advanced lower facial techniques,” he says.

Distract patients from pain.

“Patients hate needles and anything you can do to mitigate pain and fear will make you successful,” Dr. Niamtu says. Ice, topical anesthesia, 32-gauge needles, and vibratory devices can distract from the needle and are all effective techniques.

Establish a broad informed consent.

“Although we look at injectable procedures as minor, they can still have problems that produce unhappy patients,” he says. “The consent must reflect the business aspect of injectables, like what happens if the patent says, ‘The treatment did not work,’ or, ‘I need more Botox, but I am not paying for it because you did it wrong.’”

The FDA’s recent approval of Botox Cosmetic (onabotulinumtoxinA) for the temporary improvement of moderate to severe forehead lines makes official what many an expert injector has been doing for years.

This new FDA nod marks the third one for Botox Cosmetic, joining approvals for moderate to severe lateral canthal lines and moderate to severe glabellar lines in adults.

And while this is a good thing for patients and physicians alike, there may be a learning curve for novice injectors when it comes to patient selection and dosing parameters, according to members of the Cosmetic Surgery Forum (CSF) faculty.

“Not all patients are good candidates for forehead line treatment, so the discerning dermatologist will probably only ‘pass’ about 80 percent of patients who come to them,” says Omaha, NE-based dermatologist Joel Schlessinger, MD, CSF Founder and Director. “The skill of determining who that 20 percent they won’t perform forehead line treatments on is what will separate a happy from a dissatisfied patient.”

The good news is that the new approval provides doctors with the ability to start a conversation with patients about what Botox and other neurotoxins can do, Dr. Schlessinger says. Additionally, “the options for full improvement are now from crow’s feet to forehead, which is fantastic,” he says. “Truly, the upper face is Botox territory and the lower face is covered as well with so many great filler choices.”

Don’t Overdo It

Houston dermatologist Suneel Chilukuri, MD has some concerns regarding the approved doses. He took a deep dive into the data that led to the FDA approval and worries that the specified amount may lead to cosmetic dissatisfaction and/or complications such as brow ptosis. The FDA approved 20 units of Botox to be used to help forehead rhytids, utilizing five injection points to stay on label, he says.

“In real clinical practice, I have found this amount of Botox for the forehead often causes a heaviness sensation for many patients. Most patients have excellent outcomes with four to 10 units to the frontalis,” he says.

“I caution inexperienced injectors to use fewer units as they start treating patients and to almost always treat the depressor muscles (the corrugators, procerus, and obicularis oculi) before or in conjunction with treating the frontalis muscle.”


Cosmetic Surgery Forum 2017 November 29-December 2, 2017

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About Practical Dermatology

Practical Dermatology is the monthly publication that provides coverage of medical care, cosmetic advancements, and practice management for clinicians in the field. With straight-forward, how-to advice from experts in various fields, we strive to enhance quality of care and improve the daily operation of dermatology practices.