Dr Michele Koo, MD, St Louis, Missouri, is a Board Certified Plastic Surgeon who treats facial wrinkles including crows feet, glabellar frowns (11’s between eyebrows), forehead creases, peri-oral (lip wrinkles), and platysmal bands (neck bands) with BOTOX. She also treats nasolabial grooves, chin creases, thin lips, and downturned lips with various fillers including JUVEDERM, RESTYLANE, AND EVOLENCE.

If you’ve been feeling tired and people keep asking you if you are sad or disinterested, then perhaps it’s time to refresh your face with some filling out of the creases and hollows to make you look softer, fuller and more alive.  

BOTOX along with filler and a simple skin care regimen can make a significant difference in the appearance of your face in very little time in the office of Dr Koo. You will have very little if any recovery time and you can do it on a Friday and be ready to go out the next night.

Dr Michele Koo feels that the following information will be helpful in educating you about BOTOX and its safety. She feels if you understand its actions and chemistry that you will feel much more comfortable and understand that BOTOX is very safe used by trained personnel such as Dr Michele Koo, MD, of St Louis, Missouri, 314-984-8331.

Inactivation of the orbicularis oculi muscle by chemodenervation with botulinum toxin type A (Botox, Allergan, Inc., Irvine, Calif.) as a sole procedure or in conjunction with blepharoplasty has proved to be a reliable method to improve the appearance of the periocular area. Botox has the unique and ideal characteristic in that, with repeated use, there is potential for a prolonged clinical effect with smaller dosages. In addition, if a complication does arise—while not aesthetically acceptable and potentially untoward—it is time-limited, and the anatomical area will eventually return to its pretreatment baseline status.

The eradication of facial wrinkles has traditionally been approached with facelifts, blepharoplasties, and various surgical interventions of soft-tissue augmentation, and resurfacing methods. Facial wrinkles are a result of a combination of basic chronologic aging compounded by sun damage and smoking.

Facial wrinkles can be categorized as dynamic (accentuated with animation) or static (present regardless of facial expression) in nature. An example of dynamic facial wrinkles are the crow’s feet wrinkles. These facial creases  are primarily a consequence of hyperkinetic activity of the orbicularis oculi muscle that encircles the eye. With animation, there is hypertrophy of the lateral muscle fibers. Treatment, therefore, should ideally be aimed at the underlying muscular component. One of the most recent advances in the aesthetic arena has been the expanded use of the botulinum type A neurotoxin (Botox, Allergan, Inc., Irvine, Calif.) to improve the appearance of dynamic facial wrinkles.

BOTOX, temporarily prevents these dynamic muscles from working by inducing chemodenervation by preventing release of acetylcholine at the neuromuscular junction of striated muscles. The result is muscle-fiber atrophy and subsequent clinical flaccid paralysis, thereby smoothing out an area that once had facial wrinkles.

This form of therapy is particularly well suited to the muscles of the upper one-third of the face: the vertical midline glabellar groove (corrugator supercilii, procerus, and medial fibers of the orbicularis oculi muscles), the horizontal forehead lines (frontalis muscle), and the crow’s feet (lateral fibers of the orbicularis oculi muscle).

Botox is received in crystallized form (25°C) in a vial containing 100 units of toxin, 0.9 mg sodium chloride, and 0.5 mg human albumin. The toxin is reconstituted with preserved or unpreserved normal saline yielding various concentrations for the obliteration of facial and neck wrinkles. Dr Koo dilutes the BOTOX depending on the location of the muscle and how deep the wrinkles are and how hypertrophied the muscles are and whether this is a first or repeat injection, and when the last injection of BOTOX was.

The toxin is reportedly quite labile and readily denatured; therefore, Dr Koo  prepares the solution immediately before use and prefers to use it within 24 hours. Contingent upon the degree of orbicularis oculi muscle hypertrophy, Dr Michele Koo, St Louis, Missouri, typically uses an average of 7.5 to 15.0 U per side. The patient is asked to perform an exaggerated smile (squint), and equal divided aliquots of 2.5 U (0.05 ml) of Botox are injected into the raised folds of the skin corresponding to the presumed muscle pattern.

Three or four injections are spaced at 1.0- to 1.5-cm intervals, beginning immediately beneath the lateral edge of the eyebrow down to the lateral infraorbital rim. Because there is an inherent spread of Botox both in between and within muscle fibers, it is injected 1.0 to 1.5 cm (a fingerbreadth) from the lateral orbital rim to prevent its migration into adjacent periocular muscles.

Dr Koo performs the injections in the office in 15 minutes and the patient is ready to return to the office or out for the day immediately afterwards. The onset of action, with the loss of muscle activity and rhytids, can be rapid in this area, and although some improvement may be noted 48 to 72 hours after injection, the full effect may take 3-5 days.

Wrinkles in the crowsfeet area can be one of the earliest signs of aging. In large part, they are the result of muscle hypertrophy of the fibers of the orbicularis oculi that encircle the eye. Consequently, blepharoplasty, soft-tissue augmentation, and resurfacing of any depth are only partially effective in reducing their appearance, and muscular inactivation would therefore be the optimal treatment modality. However, given the muscle’s size and the critical function of tightly closing the eyelid, weakening of the muscle with BOTOX is an ideal and preferable method to diminish and eradicate the creases around the eyes.

Perhaps the most common untoward event that occurs when the crow’s feet are treated is bruising which Dr Koo minimizes by holding pressure for a minutes after the injection. This can also be minimized with superficial injections, because the relatively thin orbicularis oculi muscle seems to be satisfactorily affected when the toxin is injected into the subcutaneous space overlying the muscle. This not only reduces the chance of bruising but may prevent intravascular injection and hemodilution, which can affect potency. Furthermore, injection into the subcutaneous compartment may allow for more local and even diffusion over the targeted muscle and provide an additional safety barrier to structures deep to the muscle.

Botulinum type A neurotoxin physiologically denervates mimetic muscles, thereby eliminating the pull on the skin and the appearance of superimposed wrinkles. The improvement in the appearance of crow’s feet can be profound. Botox does not, however, address other stigmata of aging of the eye, such as fat-pad herniation and excess skin, both of which require surgical intervention. Botox injections and blepharoplasty should not be viewed as mutually exclusive but rather as potentially complementary procedures. Dr Michele Koo, MD, FACS, Board Certified Plastic Surgeon, St Louis, Missouri, will advise you as to the best approach for your complaints regarding your wrinkles and the excess skin around your eyes depending on your desires and your anatomy.

Currently available injection suggestions for the periocular area are general and primarily include a safety zone of approximately 1.0 cm (one  fingerbreadth) from the orbital rim in an arclike pattern. To reduce the temporary yet disfiguring risks of periocular Botox injections alone or in concert with blepharoplasty or facial surgery, Dr Michele Koo performs  precise identification of the muscular anatomy and needle placement.