The ProcedureAs for any surgical procedure, prior to Botox you should not use drugs that can increase bruising. Review the list of medications that you should avoid. You should not have Botox if you are pregnant or if you have any neuromuscular disease, such as amyotrophic lateral sclerosis (ALS—Lou Gehrig’s disease), Lambert-Eaton syndrome, or myasthenia gravis.The TechniquePrepare yourself for an assault with six to thirty needle sticks. To do this, you may want to use a cream that numbs the skin. Several are available. I like EMLA cream, which is a mixture of the anesthetics lidocaine and prilocaine. Apply the cream thickly, like cream cheese, onto the skin. Do not let it dry out. To achieve this, you can cover the cream with Saran wrap. (You will look quite attractive when doing this.) The cream must be applied one hour prior to your procedure in order for it to work. Many of my patients come into the office and have my nurse apply the cream; they then sit alone and read until their procedure.The surgeon removes the EMLA cream and cleans your skin with alcohol. I use gel ice packs to cool the skin, providing a little more pain relief and also shrinking the blood vessels to decrease bruising.The surgeon administers the Botox. A series of carefully placed injections deliver the toxin directly to the muscle. The zone of action is nearly half an inch on either side of the injection. If placed too low on the forehead, it can spread to the eye muscles and cause double vision and problems moving the eyelids and face. Do not let a technician or nurse inject the drug. Botox is a ‘‘chemoknife,’’ destroying anything it touches. If your surgeon is too greedy to spend ten minutes to inject the Botox himself, find another doctor.Proper injection of Botox is a true art form. Some patients require complete paralysis of a particular muscle while others just want a weakening of the muscle. Surgeons can ‘‘Botox’’ portions of a muscle, not necessarily the whole thing. They can look at stronger lines on one side of the face and weaken the muscles on that side of the face to create better symmetry.MORE: All the Facts Behind BotoxThe end result depends on many factors, including the injected dose. Botox can be used in concentrated or diluted solutions. It is not the amount of solution or the number of injections that is important—it is the number of units used. Botox is ridiculously expensive: I pay more than $500 for a vial of a hundred units. Unscrupulous doctors might use very dilute Botox to stretch out that quantity. Your result will be less profound if a lower dose is used. Beware. After Your SurgeryFollowing the injection, you should stay still for about ten minutes to allow the liquid to be absorbed by the muscle. Then go home and be tranquil for the next two hours. Botox will have adhered to the muscle by then and should not spread. You can apply light makeup and go about your business. But don’t exercise on the day of the injection.You won’t see immediate results. It takes between two and fourteen days for the Botox to work. I do have patients who have immediate results and are paralyzed before they leave the office. I hope they are not reading this, because they will learn that I believe instant paralysis to be physically impossible; it must be psychological.Once the Botox takes effect, it lasts two to six months. You should allow the first injection to wear off before having another. That way you will know how long it lasts in you. After that first injection, don’t let the effect fully wear off. The goal is to keep the muscle from working until it atrophies. We want to kill the muscle. We don’t want it to recover. After about two years of continuous Botox use, the muscle takes progressively longer to recover. You can begin to space out your injections. I have patients who have two years of paralysis between injections! Eventually, it may be possible to stop the Botox when you have permanently destroyed the muscle.The RisksWhile Botox is incredibly safe, there are potential side effects. Bruising is the most common nuisance. Paralysis of adjacent muscles can occur, but is largely dependent on the skills of the doctor. If it occurs, double vision or drooping eyelids or brows may result. Headache, an influenza-like syndrome, and nausea are reported to be relatively common side effects, although I have rarely seen them.Allergic reactions are exceedingly rare, but always possible. One patient died from an anaphylactic reaction to Botox mixed with lidocaine, underscoring the fact that Botox is a real drug with real potential complications. Its use should not be considered lightly, and it should be administered with the precautions necessary for all injected drugs.RELATED RESEARCH: Botox Weakens Emotion Botox can lose its effectiveness after multiple injections because some people develop antibodies to the drug. The Botox just seems to stop working, although no one is sure why.The most common problem is an uneven cosmetic result. A touch-up injection, done artistically, can resolve the issue. A tiny touch of Botox can make a huge difference.In about 7 percent of people, the Botox doesn’t work. Repeat injections in these individuals, performed a month later, usually do the job. In 2004, four people who received botulinum toxin developed symptoms of botulism. When this story broke, plastic surgeons knew something strange had happened. It didn’t make sense. Indeed, it turned out that the unlicensed osteopathic doctor who injected himself, his wife, and two friends had used industrial grade botulinum toxin—intended for research and not for clinical practice. The bottle that was injected contained ten million units of toxin, not the one hundred units contained in a bottle of Botox.One unit of Botox can kill a mouse. The lethal dose of Botox in humans is three thousand units, which is thirty times the recommended maximum dose. I guess that doctor missed the pharmacology lecture in medical school! He’ll have plenty of time to study this topic now, since he was sentenced to three years in a federal prison.In 2005 an Oregon physician and his nurse were indicted for using unapproved botulinum toxin in eight hundred patients. The only reason any doctor would use this unapproved drug is to save money. Veterinary-, research-, or foreign-grade materials are cheaper.About once a month, I used to receive a fax offering research-grade botulinum toxin. I always threw away the ad, wondering why the company would solicit a practicing surgeon rather than a researcher. I now know that the company banked on finding unethical, greedy doctors. I wonder how many used this toxin instead of Botox. The moral of this story is this: Choose your surgeon wisely—character matters in politics and in plastic surgery. For added safety, if you’re unsure of your surgeon or if the fee is suspiciously low, ask to see the bottle before the Botox is drawn into the syringe.WATCH VIDEO: How Botox WorksYears of Botox Actually Costs Less than Muscle Removal SurgeryThe major drawback of Botox is its short duration. Botox of the glabella costs about $500 and must be repeated three times a year, so over seven years a patient would spend $10,500. Some might think that surgery would be cheaper. However, a brow-lift with excision of the corrugator muscles costs about the same as the seven years of Botox. But if invested at 5 percent interest, the amount spent on the surgery would yield $500 per year, extending the use of Botox by another two or so years. By the nine years of Botox that you could afford with your surgical fee, your muscles might have regenerated and wrinkles might well have returned. For this reason I believe Botox is better than surgery.New UsesHollywood will never be the same, now that Botox has been found to decrease underarm sweating. About a dozen injections will keep the underarms dry for several months. Sweating decreases by over 80 percent. Similarly, sweating on the palms of the hand and the soles of the feet can be lessened with Botox. The treatment is painful and fairly expensive.People who grind their teeth may develop large muscles, called masseters. Injection of Botox into these muscles can decrease their size.Botox is currently in use for hundreds of other medical problems, including the treatment of migraine headaches and overactive bladders. It has truly become a chemical knife for many problems.And now Botox has been used to lift breasts! The fact that this procedure is totally illogical doesn’t stop some people from trying. It has even been injected into the wrinkles above the knees. While you may not be able to walk properly afterward, your knees will look beautiful . . .