LAM FACIAL PLASTICS

hey dr lam! been watching those vids on ur site. really really love 'em. very educational. i've already picked up some gems i'm going to implement in my practice, hope u don't mind, i'll credit with 'a very well known facial plastic surgeon friend of mine'

Still got plenty to get through. just wanted to pick ur thoughts on a couple of things...

1. with botox under the eye, do you find 1 unit to be sufficent? i do a bleb of 1 unit very superficially and have gotten mediocre results. Have only done this 4-5 times. But last thing I want is to get an ectropion or diplopia. I'm usually very careful. I always do a lid lag test for <5 secs but don't know how effective that is. Heard that from a french surgeon I think.

2. 1cm above medial brows is what i've been told to avoid btx getting a droop. I've never injected below that, but on a 55 year old lady once she got a partial droop and I was like... wtf... what have I done! thankfully had some iopidine handy, and i was told electric toothbrush is good. I'm obviously not as experienced, but now have been injecting for over half a year, and think that was the only case I've had. Was wondering if this is just to be expected, and just to warn in advance and say if it happens will last 2-3 weeks?

3. Crows feet - I've heard best technique is to inject in a superficial plane away from the orbicularis? I've also seen a derm do it vertically. Not sure what your thoughts are. Also in one vid u mentioned about avoiding zygomaticus. I don't think I ever go as far down, but I do notice that often lower crow's feet creasing can be a pain to treat. what are your thoughts on this?

thanks again as usual
V

1. with botox under the eye, do you find 1 unit to be sufficent? i do a bleb of 1 unit very superficially and have gotten mediocre results. Have only done this 4-5 times. But last thing I want is to get an ectropion or diplopia. I'm usually very careful. I always do a lid lag test for <5 secs but don't know how effective that is. Heard that from a french surgeon I think.

NO, 1 UNIT WILL DO NOTHING. YOU NEED 10 TO 12 PER SIDE AT LEAST TO GET THE RIGHT BALANCE THEN YOU CAN ADD 1 TO 2 UNITS NEAR THE UNDER EYE AREA TO SUPPORT AND KNOCK OUT THE "JELLY ROLL". BY ITSELF WITHOUT TREATING THE CROW'S FEET, 1 UNIT WON'T BE THAT EFFECTIVE FOR THE JELLY ROLL. ECTROPION SHOULD BE TESTED WITH A GOOD HISTORY REGARDING PREVIOUS BLEPHS, DRY EYE, ETC. THEN DO A SNAP TEST (PULL THE LID BACK AND SEE WHERE THINGS GO. 5 SECONDS? TRY LESS THAN A SECOND. IF IT IS OVER A SECOND IT ALREADY IS TOO SLOW.). OBVIOUSLY, CHECK FOR PREEXISTING ECTROPION ETC.

2. 1cm above medial brows is what i've been told to avoid btx getting a droop. I've never injected below that, but on a 55 year old lady once she got a partial droop and I was like... wtf... what have I done! thankfully had some iopidine handy, and i was told electric toothbrush is good. I'm obviously not as experienced, but now have been injecting for over half a year, and think that was the only case I've had. Was wondering if this is just to be expected, and just to warn in advance and say if it happens will last 2-3 weeks?
WITH ABOUT A THOUSAND INJECTIONS A YEAR, I STILL GET 1 TO 2 EYELID DROPS. IT WILL HAPPEN WITH A VOLUME OF PATIENTS. IF YOU ARE HITTING THE CENTRAL CORRUGATOR, YOU HAVE TO GO DEEP NEAR BONE SO THAT YOU DON'T MISS THE CORRUGATOR. LATERALLY TOWARD THE SKIN DIMPLE, YOU SHOULD GO NEAR THE SKIN BECAUSE THE MUSCLE ARCHES UP TOWARD THE SKIN.

3. Crows feet - I've heard best technique is to inject in a superficial plane away from the orbicularis? I've also seen a derm do it vertically. Not sure what your thoughts are. Also in one vid u mentioned about avoiding zygomaticus. I don't think I ever go as far down, but I do notice that often lower crow's feet creasing can be a pain to treat. what are your thoughts on this?
YES, LATERAL CREASES ARE HARD IF THEY GO DOWN. YOU CAN MOST LIKELY BE SAFE GOING MORE LATERALLY UPWARD BUT NOT LATERALLY DOWNWARD. ABSOLUTELY STAY SUPERFICIAL. THE BOTOX WILL DIFFUSE INTO THE ORBICULARIS. YOU DON'T WANT TO GO DEEP WITH THIS (EXACTLY THE OPPOSITE OF THE CENTRAL CORRUGATOR) SO THAT YOU AVOID A BRUISE. I DON'T CARE IF IT IS VERTICAL (?) OR WHATEVER. JUST STAY SUPERFICIAL.

Ah thanks for that. Heh, i was assuming the 10-12 units for crow's feet already before treating the 'jelly' for that though, do u think fillers or laser may work better than botox?

Believe it or not I think the french surgeon guy said 5 seconds in the 'advanced' botox DVDs that came from Allergan! Certainly took me by surprise. With lid droops - what do u do when u get them? Is iodipine a good temporary solution in your opinion to activate mullers muscle?

iodopine is the best for those who have light blue eyes (since mydriasis will cause a darkening of the opened pupil contrasting against the iris making an asymmetry obvious) but a cheaper over the counter option is Naphcon D which I stock in my office in case that rare chance occurs.

Dr Vince, I swear by what Dr Lam said here:

"NO, 1 UNIT WILL DO NOTHING. YOU NEED 10 TO 12 PER SIDE AT LEAST TO GET THE RIGHT BALANCE THEN YOU CAN ADD 1 TO 2 UNITS NEAR THE UNDER EYE AREA TO SUPPORT AND KNOCK OUT THE "JELLY ROLL"".

A few months ago I asked him a second opinion on the matter because a friend was getting botox for the "jelly roll", Dr Lam said at least 2 units, and my friend got indeed, a stronger dose (do not know how much exactly) in the "outer" area of the eye, and many small injections in the under eye area of 2 units of botox (that, we know) and it worked wonderfully.
She had once, before that, had only an injection for the outer eye area, and it did leave her with no crow's feet but a jelly roll. Another doc had treated the undereye area only and it did not look ok neither (not sure if it was because she didn't have an injection in the "outer" part of the eye or if that doc used less than 2 units of botox).
When the last doc did on her both areas and I think in the way Dr Lam suggested, it worked wonderfully. She looks superb.

thanks for the corroboration!

Thanks but thank YOU.
My friend had had appointments with a few derms and they did not all say the same. It was thank to your advice in these boards that my friend chose that particular derm and not another and sure enough, the results were great
Your advice is what we call here "like a book to keep in the nightstand" (always available and ready to be consulted about everything )

thanks again!!!

hey mysteryagain thanks for that - appreciate it.

I always do crow's feet (the outer bit) before doing under the eyes. So I was really more curious about the 'jelly roll'. I've stuck to 1 unit, because that's what another American plastic surgeon seems to suggest in a tutorial I've seen. I don't know what the risks are of causing double vision or any other problems, or further sagging, by putting in any more than 2 units. I know studies have said that 12 units into crow's feet is optimal, but I've had pretty good results with 6, and didn't want to overkill.

I'll start trying 2 units under the eyes instead. Will report back for sure!

great!