Interview with Dr. Jerry Popham; Oculoplastic Surgeon regarding Botox for treatment of facial lines(

Dr. Popham Botox interview as seen on

Editor's Note: Jerry K. Popham, M.D., is respected among his peers as an authority and lecturer in the field of oculoplastic surgery. Dr. Popham completed fellowship training in oculoplastics at the prestigious Harvard Medical School and Massachusetts Eye and Ear Infirmary in Boston. He serves as Clinical Assistant Professor of ophthalmology at the University of Colorado Health Sciences Center and is in private practice at Advanced Oculoplastic Surgeons, P.C., in Denver. (Chris Knobbe, M.D.): Today, we are discussing the use of Botox with oculoplastics expert, Dr. Jerry Popham. Dr. Popham, can you tell me first, what is Botox, and second, what therapeutic use was Botox recently FDA approved for?

Dr. Jerry Popham: Botox is a chemical that is derived from bacteria called Clostridium botulinum. Botulinum toxin, for many people, is associated with a disease that we refer to as Botulism, and indeed the chemical is the same chemical that is related to the disease Botulism. However, like many other medications, the toxin is used in a purified and specialized way and in highly specific doses, which makes it very safe and very effective in its use. But, Botox generally blocks the connection between a nerve and a muscle. We know that contraction of a muscle is the cause of wrinkling of the skin in most circumstances and therefore using Botox reduces wrinkles in the skin. The FDA recently approved the use of Botox for cosmetic purposes, that is, to reduce skin wrinkles. More specifically, Botox was approved for use in the area that we refer to as the glabella, which is the area directly between the 2 eyebrows. Okay. So, Botox is FDA approved for use in cosmetic procedures. What types or locations of facial wrinkling does Botox seem to work best for?

Dr. Jerry Popham: I believe that Botox works best for facial wrinkling in the upper half of the face. I believe it is particularly effective for furrows between the brows, sometimes referred to as "frown-lines". Botox also works very effectively in horizontal wrinkles in the forehead and above the eyebrows and also is quite effective for what is commonly referred to as "crow's feet". Those occur in a region that is anatomically known as the lateral canthus, which is located at the outer corners of the eyelids. Does Botox work well for "laugh lines" around the mouth?

Dr. Jerry Popham: My opinion is that Botox is very tricky to use around the mouth and in the lower face, in general. Very often, patients treated even with very small amounts of Botox on the upper lip or at the corners of the mouth develop a droopy lip, which may adversely affect the speech pattern. Plus, it's much more common to have complications in that area than it would be to have complications from treatment with Botox in the glabella, the forehead, or in the lateral canthus ("crow's feet") region. In a typical treatment, how many injections would be required for the treatment of "crow's feet"?

Dr. Jerry Popham: Treatment of "crow's feet" would typically require 3 to 4 injections on each side of the forehead or above the eyebrows. Is the onset of action immediate? When do you see the peak effect?

Dr. Jerry Popham: The onset of action of Botox is 2 to 3 days after injection, so patients should not go home the first night and think that they should not be able to see wrinkles or move their forehead. The peak effect of Botox typically occurs 2 to 3 weeks after injections and the duration of effect is 3 to 4 months, once the right dosage for a particular patient is established. Another thing that I see frequently is that patients will sometimes come back and say the Botox didn't work - that they are still able move their forehead. The goal of using Botox is not necessarily to immobilize the treated area. The goal is to reduce the wrinkles… and I believe that you've got a better treatment if you can still move your forehead but don't have visible wrinkles when your face is relaxed. Approximately what is the duration of effect for Botox?

Dr. Jerry Popham: The usual duration of effect for Botox is 3 to 4 months. When a patient is initially treated with Botox, we very often don't know their individual responsiveness to the medication. So most commonly I err on the conservative side when I first treat a patient with Botox, and in that event it may last only 2 months, for example. But, we would rather err initially on the under-treatment side than we would on the over-treatment side and, eventually, we find a dosage that will last the patient 3 to 4 months. Are Botox injections safe? What would you consider the risks to be?

Dr. Jerry Popham: I believe Botox injections are safe and I would emphasize to patients that the effect of the injections is temporary. Meaning, that even if a complication were to occur, that complication would go away when the effect of the Botox wore off. Probably the complications that we are concerned about most would be drooping of either the upper or the lower eyelid. If for example, Botox is injected in the forehead and for whatever reason infiltrates under the skin into the levator muscle, which raises the upper eyelid, the upper eyelid could become droopy. Now if that were to occur, typically it only lasts for 2 to 3 weeks, whereas the beneficial effects would last 3 to 4 months. The beneficial effect being, of course, the reduction of wrinkles. Drooping of the lid is an uncommon occurrence, but I have seen it happen and you can have the same type of effect, the same drooping, in the lower eyelid. So you would say that Botox has a long track record for safety?

Dr. Jerry Popham: Yes, it does. Now, as we pointed out earlier, the FDA had recently approved Botox for use in cosmetic applications. Botox, however, has been approved by the FDA for use in treatment of benign essential blepherospasm and hemifacial spasm for many years and has a great track record for safety. In general, what types of physicians do you believe have the most experience with Botox?

Dr. Jerry Popham: Clearly, I think the physicians that have the most experience with Botox are ophthalmic plastic surgeons who have been treating patients with Botox for disease processes around the eyes for about 20 years. There are many neurologists, particularly neurologists specialty trained in movement disorders, who also have extensive experience using Botox for disease processes. For facial wrinkling, what are the alternatives to Botox injections?

Dr. Jerry Popham: There are a variety of skin treatments that are also effective for fine wrinkles. Those that come to mind would be pulsed- dye laser treatments, erbium laser treatments, carbon dioxide laser treatments, and other less invasive procedures such as microdermabrasion or chemical skin peels. Those types of treatments would not be effective in glabellar folds or the furrows that develop between the brows… those wrinkles are too deep to be significally affected by other treatments and I think that Botox is best suited for those wrinkles. Can you give me an approximate figure that physicians charge for Botox treatment? Is this covered by insurance?

Dr. Jerry Popham:Botox would be covered by insurance only when the Botox is used to treat a functional problem or a disease problem. The cosmetic use of Botox is typically not covered by insurance policies and fees vary according to the amount of Botox necessary to treat a particular problem. I would say, however, on the average, treatment of wrinkles between the eyebrows would cost between $200 and $300. Treatment of the entire forehead, on the average, would cost around $300 and the treatment at the lateral canthus in the crows feet area would probably be in the range of $150 to $200, on average. Okay. In your own experience have you been impressed with the results of Botox?

Dr. Jerry Popham: Yes, I have very much. I think that Botox has not only been a very safe, but also a very effective, medication and the vast majority of my patients are extremely happy with the results. Popham, thank you for sharing with the audience your expertise in this area. We look forward to discussing other oculoplastic conditions and procedures with you!

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