How to Maximize the Value of Botulinum Toxin?

Seven common ways to waste when using Botox:

-The residue in the bottle;

-There is residue in the syringe;

-Accidental spraying on the patient’s face;

-Inadvertent injection into the air (especially if there is no direct cost to the operator);

-Inject in ineffective areas;

-Inject in unwanted parts;

-Excessive injection in the effective area.

I think there are seven points of waste in our usage. The biggest challenge is how to transfer the botulinum toxin from the bottle to the syringe without leaving any residual liquid in the bottle? This is really tricky and most people leave some behind. But we need to find ways to minimize this waste.

If you prefer to draw directly with a new needle, you will almost always leave quite a bit of liquid in the bottle. Of course, if you remove the rubber stopper and stick the needle into the bottle, you can take out some residual liquid. But I would not recommend injecting with a needle that has been in such contact with the glass of the bottle, as contact with the glass can blunt the needle. But I noticed that many injectors have been doing this... The needle contacting the glass is very detrimental to the needle tip and will cause discomfort to the patient. If you feel a blocked sensation when injecting Botox, the needle is dull. Many injectors mistakenly believe that this is just due to the texture of the skin, but if a sharp needle is used, the feel is different.

To remove the last drop of solution from the bottle, first remove the rubber stopper. Then, look along the side of the label, tilt the bottle so that the remaining liquid collects to one side, and try to enlarge that small liquid arc (there may be small vacuoles in it). Next, slide the needle down with the bevel facing the glass. Don't worry about the needle being damaged because it won't be used for injections. You should be able to see the needle in the gap in the label, sucking up every last drop of solution. Sometimes I may also bend the needle to get deeper into the fluid. Aspirate the last drop of medicine, pull out the needle, and then transfer the medicine.

The liquid can now be transferred to a new bottle, simply puncture the rubber stopper and inject. Or as you did with filler, inject it into another syringe with the needle still sharp. If you go to another syringe you'll see a lot of bubbles and you'll need to tap the syringe gently to bring all the liquid to the bottom and then slowly push up the droplets and squeeze out the air... when I pull back , a bubble burst. Pulling back can often break up some of the air bubbles so there is no need to squeeze them out and waste product. In short, tap first to pop the bubbles, then squeeze out the air. When you get near the top, slow down and you'll see a bead form, which you can suck back in so there's no waste.

Second, and more commonly seen, is the problem of dead space at the top of the syringe. If you don't use a dead space needle (which most people are using these days), you could be wasting up to half a unit of toxin on the end of the needle. There is a way to avoid this waste. Similar to what is done with fillers, only a small portion of the product needs to be squeezed into the next syringe for the same patient. But the best approach is to prevent product from entering the syringe's dead space in the first place.

If you accidentally spray Botox on a patient's face, it's usually because there are small air bubbles left in the syringe. Think about how bubbles work, when you inject, especially the inertia on the rubber piston, when you press to inject, you're actually compressing the gas in the bubble. When the injection is completed, the needle is pulled out, and the bubbles expand again when withdrawing, and the botulinum toxin is sprayed on the patient's face. In fact, if the bubble is large, as much as 50% of the solution may be sprayed on the skin surface even if it appears to have been injected into the skin. This may be unknowingly wasting a large amount of Botox. Imagine being in a busy clinic, and if there are air bubbles in the syringe, you could be spraying thousands of pounds or dollars of product on the surface of your skin, where it won't work.

Another way to waste Botox is something I noticed when I first started training other doctors. Since they haven't purchased the product themselves, they don't know the cost. If you have a doctor with zero experience in your clinic, you may not realize how valuable these supplies are. With smiles on their faces, they inadvertently spill valuable potions on the floor, a sight that always shocks those aware of the cost.

To avoid this, you need to leave more dead space in the syringe before trying to expel any air bubbles. First pull the piston back, leaving enough space, and tap the exhaust gently so that only air is discharged, not the precious botulinum toxin. Another point to note is to move very, very slowly when approaching the top of the syringe, as a small bubble will often appear. I don't want that vacuole to flow down, so I pull it back a little bit to suck it back in, and then I can inject it.

Another common way to waste Botox is by injecting it into areas that won’t actually have a clinical effect. Typical examples include the aponeurosis on the forehead. We often mention in training that we should not inject in places where there is no muscle. Sometimes you may see a line that looks like there is muscle there, but there is actually very little that can be treated there. The second case is to treat wrinkles caused by muscles elsewhere. You might imagine that the muscles are near the wrinkles, and patients often direct their doctors to do this. Probably the most common example is treatment of the orbicularis oculi muscle, where at follow-up, because the zygomaticus muscle is still acting on the same area, the doctor will inject more botulinum toxin into the orbicularis oculi muscle, which actually causes the wrinkles. It's the zygomaticus major muscle. Another example commonly seen in many forums is the repeated treatment of the procerus muscle to treat wrinkles that are actually caused by the corrugator muscle. When you frown, if you have a long wrinkle that extends higher up your forehead, many people will take two injections to try to improve it. And actually, it's caused by the corrugator supercilii muscle, not the procerus muscle, and it's actually a waste of money.

For the procerus muscle, I usually only inject four units of botulinum toxin, which is sufficient for most patients. A lot of people may inject eight or even ten units into the procerus muscle, and I think for 99.9% of people, you don't actually need that many to get good results.

Another issue also related to over-treatment of already treated areas is the treatment of wrinkles caused by specific expressions. This is a very noticeable issue, as patients go home and, in order to ensure that the treatment is worth the money and to test the effectiveness of the treatment, they will make some special facial expressions in front of the mirror that they would never make in real life. guess what? If you contract every muscle in your face as hard as you can, you can sometimes form a line or wrinkle that has actually been treated well by Botox. A typical example is when testing the frown expression, the orbicularis oculi muscle is also mobilized. At this point, instead of doing a normal frown, they mobilize other muscles to create wrinkles. They then intensified the treatment during follow-up, injecting in the same areas that were already completely relaxed, because they were mobilizing extra muscles in the test to move the skin that was already well treated.

Finally, for those static wrinkles that never go away with one treatment. Many patients expect that every one of their wrinkles will disappear within two weeks of the first treatment and that they will come back for follow-up appointments, when in reality, that wrinkle may take several months to fade, or it may not fade at all. The muscle has been fully treated and the skin has not yet fully recovered and another injection, as I always say to my patients, is like mowing the same lawn twice in the same day. There is no benefit in doing it over and over again. In fact, the first round of injection has already had an effect on all receptors, and another injection is a waste of time and money.

To summarize, use a no-dead-space needle to drain the liquid within the liquid arc and transfer it to the next vial or syringe. One thing to note here is to buy a syringe that has no dead space.

The needle used for withdrawal may be damaged and will need to be replaced with a new needle for injection... Remove air bubbles from the syringe. Do not waste solution trying to align the dosage scale.

Master relevant anatomy and physiology knowledge. Not all wrinkle lines are caused by underlying muscles. The lines do not represent force muscle action, do not use the same injection method on everyone. There are some areas where a dose less than that recommended by the manufacturer may be sufficient. In the orbicularis oculi, at the tip of the brow, and of course ultimately depends on the patient's anatomy. In the glabella complex, I often don't treat the procerus muscle at all because not everyone has a strong procerus muscle and sometimes it's almost completely absent. For the corrugator supercilii muscle, sometimes only partial treatment is needed. For a significant number of patients, manufacturers recommend doses that are greater than those actually needed.

Finally, let’s talk about the differences in how Botulinum toxin treatments are priced in the United States and the United Kingdom. In the United States, treatment pricing tends to be based on the dose used per patient, or per unit. In the UK, the pricing system favors a more socialist system, where costs are averaged by treatment area, meaning that the costs for some patients subsidize others. This is a very noticeable difference, the British way is more average and the American way is more individual. This difference may explain why there are differences in the doses used - in the UK, doctors are incentivized to use smaller doses because they are charged the same regardless of how many doses are used. In the U.S., financial incentives favor higher doses…