News & Features

Facial Injectables

Botox -- Getting More Bang For the Buck

by Behrooz Torkian, M.D.
Torkian Facial Plastic Surgery

If you want to get good, consistent results from Botox treatments, try to avoid looking for the lowest possible price. Instead, look for the best surgeon-injector.

If you are a low price shopper, you may not think twice about hopping around to different doctors' offices, especially if you only want a little Botox between the eyes, or in your crow's feet.

But anyone who wants the most from Botox -- like lifting the brow or accentuating the arch of your eyebrows -- needs to look twice before leaping.


Understanding how Botox works to treat wrinkles and change the way your facial muscles move is the most important thing about getting the most from the money you spend on Botox.

Forehead Lines

Here's how Botox works:

Facial muscles affect aging by creating creases in areas where the muscles pull on the skin.

For example, the horizontal lines on the forehead are caused by the pull of the muscle underlying the forehead skin. Over time, that muscle activity leads to permanent wrinkles in the forehead, between the eyebrows and around the eyes.

Botox stops those muscles from pulling and has been shown in testing to improve wrinkles over the short term. The substance will also to help prevent more permanent wrinkles if used regularly.

Brow Lifts

What many people do not know about BOTOX injections in the face is how the selective weakening of the facial muscles affects the shape of your facial features - especially in the upper face. This is a concept I call "muscle balance". That refers to the relative strength of the facial muscles, so it plays a big role in where, and how much, to inject in each location.

"…I often suggest injecting Botox into the brow before a surgical brow lift."

Using Botox to weaken the muscles that pull up on the brow allows lowering of the brow. Weakening muscles that depress the brow results in a brow lift. Thus, the experienced injector who understands and pays attention to the balance of muscle activity in these areas can plan for the facial effects the patient wants.

Botox as a Preview

Patients are often surprised when I suggest injecting Botox into the brow before a surgical brow lift. But the concept is based on the principles I've mentioned above and may serve as a preview of how a brow lift may look after surgery. It can also be used in surgical planning for upper eyelid surgery, by allowing me to see how much excess skin exists in the upper eyelids after droopy forehead skin is elevated with the right amount of Botox.

The most memorable case of this I had was a 22-year-old patient with low set brows who came to see me about surgery of her upper eyelids. At first, she was upset when I told her I would not remove skin from her eyelids. But after injecting the appropriate amount of Botox to allow a quick lift of her brow -- that also lifted her upper eyelid skin -- she quickly realized that her real problem was that of early (most likely genetic) depression of the brow.

Droopy Brow

Another patient - a 42-year-old woman - with a droopy brow and an apparent excess of upper eyelid skin came to me seeking upper eyelid surgery and agreed to let me inject her brow with Botox so we could get a good preview how her brow would look after surgery. She was so pleased with the brow elevation result with Botox, she decided to continue on Botox treatments instead of surgery.

Because Botox results are injector dependent, it is important that your physician take the time needed to study your face and make a determination where to inject to give you the results you want.

A lot of variability comes into play. The Botox in the syringe has to be dispersed in a certain fashion. 20 units in the forehead doesn't mean just injecting anywhere above the eyebrows. In some cases, injections can be more toward the center of the eyebrows or more towards the outside. Others require some in the lower or upper part of the face.


The distribution of injections alters the balance of the muscles and affects the outcome.

Typical Botox injections start at about a total of 30 units. That is usually enough for the vertical frown lines ("the 11s") between your eyes, the horizontal lines on the forehead and the radial wrinkles around the eyes we know as crow's feet.

So a practitioner who injects the prescribed targets in the forehead (following the diagrams distributed by the makers of Botox) may not be able to get tailored results for different patients.

Moreover, an injector who doesn't ask, "How was your last injection, what did you like and not like…," or who doesn't analyze the patient's face, along with diagrams of previous injections cannot get consistent, or improved results.

My patients always say I am "diligent" or "pay attention to detail" when I'm injecting. Actually, I am just examining the anatomy of each patient's face, and never hurry.

Questions to Ask the Surgeon

To find the right surgeon for you, I suggest asking the following questions when you call a doctor's office or a medical spa.

  • How many years in practice do you have and how long has the doctor/nurse/physician's assistant been injecting Botox? Have you had any malpractice suits?
  • Will I receive a free follow-up visit with a touch-up if needed at no additional cost?
  • Do you have before and after photos of actual patients?
  • How do you handle imperfect results?

3 to 7 Years More Training

Beware of the surgeon who will not discuss his or her experience with imperfect results, including complications, near-misses, touch-ups and revisions. Every surgeon encounters them. So their honesty about these items proves the surgeon has the experience and maturity to treat and improve less-than-perfect results.

A skilled surgeon will examine you with his or her eyes, hands and ears. The doctor should not advise you on improving your looks until the formal examination is completed.

You may want to ask yourself: Who would you rather trust with your face?

A facial plastic or dermatological surgeon who has three to seven years additional training after the M.D. degree and a total understanding of the anatomy of the face?

Or a practitioner who may have taken a weekend course?

Plastic Surgeon Skill

While a family doctor may be great for colds, vaccinations and other general health issues, the specialist is always a better choice. If a plastic surgeon's skill with a scalpel is high, his or her skill with a needle will most likely also be just as good.

Nurses do most of the injections in any busy doctor's office, but make sure you have details on their training if they are also giving Botox injections.

Nurses may be the appropriate choice if you are only getting Botox in the glabella, the area between the eyes, but their training is usually limited in scope and understanding of artistry and the anatomy of the face.

"A skilled surgeon will examine you with his or her eyes, hands and ears."

Many nurses have been trained in the practice by the doctor, so you may take that into consideration. But if you want someone who is an artist with the needle, your best bet is always a board-certified facial plastic surgeon, plastic surgeon, or dermatologist who has a practice that features facial injectables.

Behrooz Torkian, M.D. is the facial plastic surgeon at Torkian Facial Plastic Surgery in Brentwood and Beverly Hills, California. Dr. Torkian is also a clinical instructor at the University of California, Irvine in the division of facial plastic and reconstructive surgery. Dr. Torkian is board certified in otolaryngology (head and neck surgery) and a member of the American Academy of Facial Plastic and Reconstructive Surgery.

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