How to consult patients on the downsides of Botox without losing them
Aesthetic medical professionals are aware of their legal requirement and compulsion to consent their patients adequately and appropriately for cosmetic interventions, including the provision and prescription of botulinum toxins. They must explain the risks and potential complications, alongside the benefits; but it might be much more stressful having to explain any limitations, compromises, or subtle downsides that come with the cosmetic use of botulinum toxin brands, like Botox®, to your patients. The fear is that the patient will up and walk out of the door.
In this blog, Dr Tim Pearce will reveal how you can approach discussing the downsides of Botox treatments during your consultations, in such a way that leads patients to see you as an honest guide and expert in the aesthetic field. He also provides options on how to mitigate these downsides, so your patients still want treatment.
Dr Tim will be discussing more medical aesthetic training tips as part of his upcoming webinar series, so if you’re looking to increase your CPD-certified learning and want to learn more skills to make you a better clinician, then step one is to register for the free webinars by Dr Tim.
Patients understand not everything can be of benefit
Most patients will understand, when it is well explained, that all treatments come with some payoffs, compromises, or minor downsides, and it is in your interest to embrace this, become the expert, discuss their fears, and design treatments that work around any potential downsides.
Once you fully understand the likely downsides from botulinum toxin treatment in different areas of the face, you can work with your patient to justify, mitigate, and compensate for them, designing treatment programmes that achieve their goal and minimise inherent limitations or downsides. Many aesthetic practitioners do not accommodate such factors when they treat, and this often leads to patient dissatisfaction that could easily have been averted.
Downsides with Botox treatment in the upper face (frontalis muscle)
Relaxing the frontalis muscle reduces forehead lines and can help to lift the eyebrows, removing lines and wrinkles when muscle movement is stopped.
Humans use eyebrow movements to express interest, concern, openness, and honesty, and even to flirt. Thus, eyebrows can be a powerful method of non-verbal communication and show others some of what we are thinking. By treating the frontalis, we lose the undesired lines and wrinkles, but the perceived downside is a reduced ability to communicate.
As aesthetic clinicians, it is important to establish if you can justify, mitigate, or compensate for the loss of the non-verbal, eyebrow communication with each patient that you see in practice.
Justification means that the patient feels and behaves in a more empowering way when the lines are not present. However, we can mitigate the risk by adjusting the treatment pattern to allow for whatever movement you can whilst also improving the original lines of concern.
Dr Tim believes that the ability to show interest and concern is important to how people understand each other, thus the ability to raise eyebrows, even a little, is of benefit. He recommends leaving the lower part of the frontalis muscle untreated (regardless of the risk of a drop) to achieve this aim and mitigate the downside of treatment.
Your patients must be educated to understand that the best treatments are those that retain as much movement as possible whilst also removing lines, and that a goal to freeze all the movement in the forehead – the frozen look – has major downsides to them socially.
Downsides with Botox treatment in the glabellar complex (frown lines)
The glabellar complex is less nuanced that the frontalis and is much more centred around negative expressions – anger, disdain, dissatisfaction etc. By treating this area with botulinum toxin, we can reduce this negative expression, but can that ever be a downside?
The answer is yes it can, depending on the patient, especially those who are required to look negative in certain roles, command or control a room or others, especially where they may need to lay down boundaries. Non-verbal communication of the negative, by frowning, is of particular concern in certain professions including teachers, counsellors, psychiatrists, police, solicitors and barristers, and others in adversarial roles. Frowning can be regarded as a form of self-defence, to convey your conviction in a boundary.
It is important to know your patients and discuss the justification for treatment if the downside of losing their ability to frown completely will impact their job. There are multiple ways they can compensate for a loss of this negative expression, whether that be via other body movements or tone of voice, so they may still be happy to proceed with losing this ability.
As an aesthetic clinician, you also have options to mitigate the loss of movement in the glabellar area, allowing the patient to convey the bulk of the emotion even though they have far less movement than normal. Dr Tim refers to an injection technique known as the 3-point approach that uses fewer, more central doses of botulinum toxin, that leaves some lateral movement, and allows the patient to still convey some negative emotion.
Downsides with Botox treatment in the orbicularis oculi (crow’s feet)
The orbicularis oculi muscle is arguably the second most complex area after the forehead, according to Dr Tim. Treating this area reduces the contraction of the skin at the lateral canthal lines, so called crow’s feet.
A Duchenne smile, a smile that reaches the eyes, is a very important communication in human bonding, regarded as a genuine smile. Fake or non-Duchenne smiles are associated with psychological distance, conveying and communicating politeness and formality alone, thus inherently distanced. We have all made a joke and only received a polite smile in return, you certainly notice it. By treating the orbicularis oculi, the downside is the impact on the natural, Duchenne smile.
To mitigate this, remember that the orbicularis oculi is not the only communication of a genuine smile – movement of the head, opening of the mouth, and the degree of contraction of the zygomatic muscles all contribute to a sense of real and genuine emotion. As aesthetic clinicians, the best mitigation is to reduce the dosing of the botulinum toxin, particularly in the inferior section of the orbicularis oculi muscles.
Dr Tim regularly uses lower doses in the most inferior and medial injection points when treating the crow’s feet – usually, approximately 2 units of Botox, depending on the strength of the muscle.
Fuller cheeks can also transmit energy into the eye area and prevent the loss of the warmth from a genuine smile. It might therefore be appropriate to consider dermal filler treatment in the cheeks, if there is lost volume, as this will help transmit more energy to the eyes during expression.
Another consideration is the disruption of the normal harmony of facial movements which can occur when botulinum toxin is used in the upper face. Consider the sphincteric like shape of the orbicularis oculi, and how relaxing only a small section of it laterally may result in domination of other areas of the muscle during large expressions. Dr Tim referred to the classic ‘over Botoxed look’ characterised by a pinched appearance during smiling, where the facial features are pulled medially due to the lack of lateral resistance or ba
The orbicularis oculi are also accessory muscles for cheek elevation and in older patients, with small cheeks and skin laxity, it is possible that removing the lateral canthal lines causes an unacceptable drop in the cheek, creating an appearance of sadness at rest and a complete loss of warmth in the eye upon smiling or expressing positive emotions. This can be mitigated with lower doses of botulinum toxin, and, on occasion, replacing the lost volume in the cheeks with dermal filler.
For more hints and tips on botulinum toxin treatments, check out Dr Tim’s blog on the best tried and tested Botox® injection patterns and mistakes to avoid. And, why not download Dr Tim Pearce’s 26 essential patterns for Botox for more specific information on product placement when treating the forehead and other areas with botulinum toxin.
Learn more about how to manage and avoid Botox complications with Dr Tim’s eLearning courses on botulinum toxin complications mastery.
Aesthetics Mastery Show
How to Consult Patients on the Downsides of Botulinum Toxin
Without Losing Them
In his popular Aesthetics Mastery Show on YouTube, Dr Tim explains how to consult the downsides in such a way that leads patients to see you as the expert.
The show has had around 5k views already – visit our YouTube channel to leave a comment and join in the debate.
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Dr Tim Pearce eLearning
Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.
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