Better BOTOX™ – “Virtually Painless” BOTOX™

BOTOX™ Video – USA Plastic Surgery – Dallas – Fort Worth, Texas TX – Dr. Steven J White MD


  • 00:00 – Botox Overview
  • 05:15 – Better Botox
  • 16:01 – Key Points – Better Botox – Virtually Painless Botox

So, let’s talk about Botox. Botox is MAGIC for plastic surgeons. I like to think of it almost like Photoshop for the face. It can do remarkable things.

The FDA approved Botox in 2002 for treatment of wrinkles for cosmetic surgery, for the area between the eyebrows, that’s called the glabella, and they talk about “the elevens.” In other words, if you tighten and scrunch here, you can see the little lines. Now, I love Botox. Mine has unfortunately worn off.  But I wanted to be able to show you what the lines could be, and then the Botox will help relax those later.

What is Botox?

So, what exactly is Botox? Botox is a toxin … it’s a neurotoxin. And it’s designed to decrease nerve impulses.

How’s it made? It’s made by bacteria, and there’s different options.  There’s now Dysport, and some others that are coming along with time … so it’s kind of Coke versus Pepsi.  But the idea is that it’s a neurotoxin made by bacteria that comes as a powder, you turn it into a liquid so that you can inject it.

How does Botox Work?

And since it blocks the nerve impulses, it can block the impulses to the muscle. And by doing that, relaxes the muscle. And by doing that, relaxes the wrinkles.

It can also decrease the nerve input to the sweat glands, and that can lead to less sweating. And so, a lot of patients are unaware of the fact that Botox can work wonders for patients who have a lot of sweating, most commonly in the area under the arms. And that’s an area that’s wonderfully treated with Botox.  And it tends to last quite a bit longer because you’re not trying to relax a muscle, it doesn’t take as much Botox to have a prolonged effect. So, areas under the arm that are treated, the duration of effect can be a year or a year and a half in some cases.

Versus Botox in the face, how long does it last? Well, the answer, of course, is … it depends upon the muscles. For most people, it’s about three months. Sometimes it’s longer, maybe four or even five. The concept is, if you inject the Botox into the muscle, it relaxes the muscle, and therefore the wrinkle relaxes because the wrinkles occur because of the motion of the muscle.

In other words, if you look at my forehead … as I raise the frontalis muscle, that is the muscle that goes up and down, you see the creases here. As I try and scrunch … you begin to see the lines here because the corrugator supercilii move in this direction. Around the eye, it’s a circular muscle, and as you tighten the eyes, you can see the little lines there … and we call those the “crow’s feet.”

Botox: What Are the Best Areas to Treat Wrinkles?

Botox Video – USA Plastic Surgery – Dallas – Fort Worth, Texas TX – Dr. Steven J White MD

So where do we use it for wrinkles? Most commonly, we treat three areas. We treat the glabella (the area between the brows), we treat the forehead, and the corner of the eyes, or the “crow’s feet.”

Sometimes patients will have little lip lines, and those also respond quite nicely to a little touch of Botox. So that’s a nice thing that many people aren’t aware of, but particularly patients, maybe smokers that have a lot of lines or some people with sun exposure, a little touch of Botox in the upper lip, and sometimes the lower lip, can make a nice change as well.  Some patients also want to treat their “Bunny Lines” which can occur when they scrunch their nose like a bunny due to the nasalis muscle.  Relaxing these muscles with Botox can help them fade away.

Botox: Who Are the Best Candidates?

Now that we’ve talked about what Botox is, where it comes from, how it’s made, how it’s used, let’s talk about who are the best candidates. And the answer is pretty much anybody with wrinkles … provided they’re healthy, they’re not pregnant, and they don’t have an underlying neuromuscular type condition. If you have myasthenia gravis, or Eaton-Lambert syndrome, or Lou Gehrig’s disease, or one of those neuromuscular things (very rare), obviously that would not be the best candidate for Botox.

Botox: When is the Best Time to Start Botox?

But what age is the best age? Well, when you begin to see wrinkles … it’s a good idea to consider Botox. One fact that a lot of people are unaware of is that once you begin to develop a crease in the skin … then by doing Botox, you can relax the muscles and hopefully prevent that crease from getting deeper, but that crease is already there. So, some patients begin to go perhaps a little earlier. Because if they can relax the muscle … then they can prevent the crease in the skin. So that’s one of the benefits of starting on Botox at an earlier age.

Better Botox = Botox Re-Imagined

Botox Video – USA Plastic Surgery – Dallas – Fort Worth, Texas TX – Dr. Steven J White MD

One of the other considerations with Botox is sometimes, by repeated use, the muscles will begin to relax a bit on their own. And so perhaps less Botox is needed over time, or perhaps less frequently. Most patients, when they come, find that it lasts about three months, and maybe four months, and so they come in three or four times a year. And, as I said, it’s one of my favorite things to do because it really creates a wonderful change very quickly, and the patients tend to be thrilled with it. So that’s the magic of Botox.

And what do I mean by Better Botox? Well, since I’ve had Botox done myself (again, mine has worn off at this point, unfortunately) but there’s the normal way that it’s done … and the way I do it differently. And I want to share that with you.

Botox comes in a box, and this is Botox Cosmetic. Now, Botox Therapeutic is the same stuff, they just put into a different box. It comes as a powder, and you can’t inject a powder, so you have to turn it into a liquid. And the doctor term for that is reconstitute it.

So, you’ve got to put some sort of liquid in to mix it up, and you can mix it up to different concentrations. Now, I think just about everybody pays the same amount for Botox. They’ve (Allergan) really cornered the market. And yet … if you dilute it a lot … then it goes a lot further. Of course, it doesn’t last as long …  but if you can use less of it per person, then chances are you could probably charge less for it as well.

So, the concept is that you want to think about what it is that you’re doing … and what it is that’s going to give you the best possible result. And my approach is different. Better Botox means let’s stop and look at each aspect of the procedure … and figure out a better way of doing it.

Better Botox: Powder to Liquid

Traditionally, the liquid that is used to mix the Botox stings, and when it’s injected, it hurts. And so that’s concerning to me because I’ve had it done and I’m like, “Hey, this stuff hurts. There’s got to be a better way.” And so, the fluid that I use to inject it (to mix it with) doesn’t sting when it’s injected. And that’s a big difference. It’s essentially … “virtually painless” Botox.

Better Botox: Concentrated

Now, the other concern is I use a highly concentrated amount of Botox and therefore I can get the same effect with less volume of fluid injected, because it’s more concentrated. The secret is you’ve got to know where to put it. And so, you want to customize it exactly to the muscles that you want to treat. And I develop a customized plan for each individual person.

Better Botox: Customized Plan

Botox Video – USA Plastic Surgery – Dallas – Fort Worth, Texas TX – Dr. Steven J White MD

Now you have heard perhaps or seen patients with a real Botox-type frozen look. Well, you don’t want that. To me, the goal is not a frozen look …  It’s not designed to abolish your emotions … but rather to get rid of the wrinkles, to soften the facial appearance …  but yet preserve the function and preserve the emotions. And that’s why you have to really understand where are the muscles? How much needs to be treated? And which muscles need to be treated with what amount?

And so, I develop a very customized plan for each individual patient. And when I do Botox for the first time, I do all my markings.  We do the injections, and then I see the patients back in a couple of weeks, and then I want to look and see, do we need to tweak that plan?

So, it’s almost a customized cookbook, if you will, a recipe for each individual person. And then we can modify that if we need to.  We can add a little more here or there … and then follow them over time once we’ve determined what works best for them.  Typically, we’re right on with the first plan, but we may want to adjust it a bit. Then we know in the future and patients typically are very good about coming back every three, four months in order to have their repeat Botox.

“Emergency” Botox

Now, occasionally I’ll get the “Emergency Botox.” And that’s often a male physician who will call me on a Monday and go, “Oh my God, Steve, you’ve got to help me out here because my Botox is just gone,” and they, I think, woke up on Sunday and looked in the mirror and said, “Oh my gosh, what happened?” So that’s the Monday night Emergency Botox, if you will.

Botox: How Soon does Botox Work?

But the idea is that it tends to onset rather quickly. Most commonly you’ll begin to see results in a couple of days … particularly with the thinner muscles, the ones in the corner of the eyes when you smile, that tends to soften pretty quickly. In most cases, they’ll see a change in about two days.

And then it’ll max out in about two weeks and typically last three or four months, maybe a little longer, it depends on each individual.

So Better Botox is not just what I mix it with … and it’s not just using a higher concentration.  It’s not just specifically targeting the exact muscles. It’s also not just what you injectIt’s how you go about injecting it.

Better Botox: “Virtually Painless” BOTOX™

Botox Video – USA Plastic Surgery – Dallas – Fort Worth, Texas TX – Dr. Steven J White MD

If we think about the pain, the pain relates to how big the needle is … how quickly the needle goes in … how much fluid is injected … and how quickly it’s injected … as well as what fluid gets injected. So, let’s find a fluid that doesn’t sting. Yay!

Next let’s find a super tiny needle … okay, special order needles … and let’s change them frequently so that they stay really sharp. Yay!

Next, let’s go through the skin very quickly because that’s the pain … but inject very slowly.  Because the slower you inject … the less you distend the tissues …and the less volume you put in … the less you distend the tissues … and the less your pain.

Finally, very frequently, we’ll ice the tissues just before and just after (lips and nose). And what that does is it tightens the skin a bit, squeezes the blood vessels, and also you get a little numbing effect. So typically, we don’t have any bleeding.  Typically, we don’t have any bruising. And it can be a really nice change.

One doctor’s wife came to me and she said, “Dr. White, I just want to try one more time with the Botox”. Now she’d had Botox twice before, done in a plastic surgeon’s office, with a nurse doing the injections. And the first time she said it just didn’t work, so she came back and they did it again, and she said it still doesn’t work, and they just told her she’s just not a good candidate for it. And I said, “Well, that’s kind of silly because you can paralyze a horse with Botox.” Of course, it’d cost about $65,000 worth of Botox to paralyze a horse, but the point is … it’s not that it doesn’t tend to work … it’s just that you have to use the appropriate concentration and the appropriate amount targeted to each individual muscle.

So, she decided she wanted me to do it. And when she showed up for the appointment, she said, “I’m all ready, I brought my baseball cap and everything.” And I said, “Baseball cap?” She said, “Yeah. You know, for the swelling.” And I said, “What swelling?” She said, “Well, it gets all swollen afterwards, so that’s why I got my cap.” I said, “What are you talking about?” She said, “Well, it just swells up.” I said, “No, it doesn’t.” And she said, “Really?” And so, she was so surprised.

Patients very frequently will have dinner appointments that evening and evening events and typically we have very little swelling and very little bruising, Again, because we specifically target the muscles and use a smaller volume but a higher concentration to target each individual muscle.

Better Botox: Why is Better Botox the Best?

So Better Botox is … a different liquid, a higher concentration, a specific targeted muscle, a smaller needle, and icing before and after, frequently change the needles, go through the skin very quickly, inject very slowly, and it’s essentially … “virtually painless” Botox.

I had a patient once who was an attorney, and she was on blood thinners for a blood clot that she’d had. And she was interested in Botox and fillers. And surprisingly, with this approach, after not only the Botox, but also her fillers … she had no bleeding … and not even any bruising afterwards.

So, again, if you apply precision surgery … to something as straightforward as Botox, then I think Better Botox is the way to go.

And it allows me to essentially erase the lines, if you will, in a Photoshop-type effect for the face. And this is one of the reasons why the Botox patients tend to be so happy and are so eager to come back. And some of them, in fact, are eager to schedule their follow up appointments well in advance. They said, “Look, I don’t want it to wear off. I want to come back in two months. I don’t want to wait three months.” And I said, “Well now, most people, let’s just figure out what works best for you and put you on a regular schedule.”

And it does create a wonderful change. And we’ll look at some of the results.

I want to clarify something. When I talk about changing the needles frequently, what I mean is obviously we don’t use the same needle for multiple patients. The concept is … I draw it up in very, very small syringes (1 cc tuberculin syringes) … and I only inject a little bit with every needle.  And then we get rid of the needle and get a new needle. So very often I’ll go through a whole handful of needles just for one patient for Botox.  Because we change it frequently so that those really tiny little needles stay sharp so that it’s … “virtually painless” Botox.

Botox: What Are the Risks of Botox?

Botox Video – USA Plastic Surgery – Dallas – Fort Worth, Texas TX – Dr. Steven J White MD

One of the things that makes Botox such a great procedure is it’s very uncommon for there to be an untoward event with Botox. You relax the muscles … but it’s a temporary effect, so it tends to wear off. And, yes, it’s possible to have some bruising or possibly a little bleeding … again, that’s uncommon but possible. I think that’s probably the most common thing that you may see, but again, you could wear some makeup in a day or two, and that tends to camouflage it.

The other thing that would be more significant would be if some of the Botox were to go to an area that you didn’t want it to in the upper eyelid or down around the muscles to the mouth, and you could have some asymmetry of the smile or a droopiness of the upper eyelid.

And, in fact, a number of times, that’s when patients will seek me out … when they’ve gone to their family practice doctor or their dermatologist or their OBGYN doctor and had Botox. And then they discovered that, “Wow, wait a minute, how come my eyelid is drooping afterwards?”

And that’s when they do a little due diligence … do some research … and say, “I’d really like to go see the plastic surgeon  … in particular one who’s board certified, both in ENT and plastic surgery … that really understands the muscles … and let’s try and take the precautions to avoid that from happening again.”

So, we want to precisely target the muscles … to minimize the chance of droopiness of the eyelid. Should that occur … there’s some eyedrops that can be beneficial, and that would tend to wear off with time. So, I think those are the big concerns that we have for Botox … very rare, but possible. And that’s why I put so much attention to using a concentrated amount and being very careful about where it’s being placed.

Better BOTOX™ – “Virtually Painless” BOTOX

BOTOX™ Video – USA Plastic Surgery – Dallas – Fort Worth, Texas TX – Dr. Steven J White MD

Key Points – Better BOTOX™ – “Virtually Painless” BOTOX™


  • “Bunny Lines” frequently treated
  •  On the nose – the nasalis muscles

Key Points – Better BOTOX™ – “Virtually Painless” BOTOX™


  • Mix Botox powder with liquid
  • Liquid doesn’t sting
  • Concentrated solution
  • Same effect with less volume


  • Target specific muscles
  • Use loupes to avoid vessels
  • Mark sites before injecting
  • Custom markings every patient

Key Points – Better BOTOX™ – “Virtually Painless” BOTOX™


  • Special order, super tiny
  • Change frequently, stay sharp


  • Quickly through skin, less pain
  • Slowly inject fluid, less pain


  • Less trauma, less swelling
  • Less bleeding, less bruising
  • Faster, easier recovery