In some way, at almost every single injection appointment for any kind of injectable at Southwest Plastic Surgery, our first interaction with patients is a complete shock, and it is this: no syringe.
The first 90 seconds are spent observing the facial expression: raised eyebrows, furrowed brow, narrowed eyes, broad smile, tightened jaw. Each patient undergoes this, according to Dr. Frank Agullo, the practice’s founder, before a neuromodulator (e.g., Botox, Xeomin) treatment. It stems from his philosophy: he is not injecting lines on the skin, he is injecting the muscle underneath that pulls in a particular direction at a particular tension, within an individual face which, again, is asymmetrical just like every other face is.
It boils down to an injection versus a strategy. Here is the strategy construction.
One Mechanism, Several Targets
Botox works by blocking acetylcholine, which is a chemical message that nerve cells use to trigger target tissue response.
Muscle on the other side. No contraction. Sweat gland on the other side, not activated. Same product you use for erasing frowns, and it also unclenches an angry jaw and keeps your palms dry. One mechanism does all three.
And most nerve endings recover within months. Movement comes back the way it was. Nothing burned, nothing severed, nothing permanent. Which is the first thing the team tells anybody who walks in nervous.
Four Brands, and Why Units Are Not Interchangeable
Botox Cosmetic, Dysport, Xeomin, Jeuveau, and Daxxify all use a botulinum toxin type A and therefore are all administered similarly with nearly indistinguishable physiological effects.
Botox and Dysport come with accessory proteins linked to the active toxin, which affects how they distribute. Xeomin has the proteins removed; hence, it is sometimes called the “naked” toxin. Jeuveau is marketed only for cosmetic uses and behaves more like Botox. Daxxify, on the other hand, ditches the human albumin and uses a peptide to stabilize the molecule; it is designed for longer duration.
Dysport shows results sooner but travels further, great for a broad forehead and a liability anywhere near a brow you do not want to drop. Xeomin is an appropriate swap for a patient whose results seem to be fading sooner than they used to.
The worry is not the number that has been presented. Any unit price does nothing on its own. You cannot compare any dollar amounts unless the two units being quoted are identical; and they are not. It takes about 2.5-3 units of Dysport to achieve effects equal to one unit of Botox. So the lowest number per unit could also be the highest bill. Or it could end up being not enough of a dose that would have never had the effect desired. So ask what product they are injecting. Then ask how many units of it the job takes.
| Product | What is different | Typical use here |
|---|---|---|
| Botox Cosmetic | Longest track record | Default around brow and eyes |
| Dysport | Faster onset, wider spread | Broad forehead, larger fields |
| Xeomin | No complexing proteins | Response feels shorter over time |
| Jeuveau | Cosmetic-only formulation | Comparable to Botox |
| Daxxify | Peptide stabilized | Longer intervals between visits |
The Classic Three, Without the Frozen Look
The only three cosmetic areas the FDA approves Botox for are glabellar lines (between the brows), forehead lines, and crow’s feet (around the eyes), which is typically where the overdone look stems from.
The only thing that lifts your brow is the frontalis muscle. Every unit of Botox injected into this muscle slightly reduces the height the brow can be lifted. This will result in the patient looking even heavier when it is blank, especially if their brows already droop or they have been using their forehead muscle all day to prop up a heavy lid.
The muscles of the upper face, those raising the brow, are treated gently and the injectables placed relatively high. Muscles that pull the brow down, the corrugator supercilii and procerus; are treated more vigorously. Relax these muscles and the brows will naturally lift. Then, for the crow’s feet around the eyes, the injections are lateral and more superficial, well clear of the lower lash line, to keep your blink and eye crinkles intact while smiling.
Dr. Agullo’s standard on this is short: you should still crease when you mean it.
Treatments Most Patients Have Never Been Offered
The difference between this setup and a menu with three fixed prices on it is considerable.
Nefertiti neck lift. The platysma originates from your chest, travels over the angle of your jaw and depresses the corners of your mouth. By treating bands and loose tissue of the mandibular border of your neck, you can get a sharp jawline and look taller by elongating your neck. It works wonders in necks with good, tight skin quality. If you have true loose or descended skin tissue and other structural problems in the neck, as Dr. Agullo will tell you plainly, your options move towards surgery, not Botox.
Masseter treatment. The muscle just under the jaw corner is the masseter, responsible for chewing. When people grind or clench their teeth, the masseter muscle becomes overgrown, much like any overused body part would, which results in a square lower face. Treatment reduces the bulk of the muscle over a course of 2 to 3 months and alleviates teeth grinding and jaw pain, as well as the headaches that often accompany the jaw soreness. Many patients initially come in for their jawline and end up sleeping better in the process.
Lip flip. No change in volume at all; a few units in the muscle surrounding the mouth allow the upper lip to roll outward instead of tucking under, so more of the lip shows without anything being added. That effect lasts only 6 to 8 weeks. Good candidates for this have the lip already but start to lose the show of it.
Gummy smile. Excessively active muscles elevate the upper lip, creating excessive gingival display. Precise injections of small amounts of Botox can fix the problem, but accuracy is paramount because those same muscles produce the smile.
Chin dimpling. The pebbled, orange-peel chin is the mentalis muscle, and it relaxes very well.
Excessive sweating. It is FDA approved for axillary hyperhidrosis (sweating under the arms) and is also prescribed off-label for hyperhidrosis of the palms, soles and scalp. For hyperhidrosis that has a noticeable impact on a patient’s daily work or ability to choose clothing, Botox is one of the most life-changing services offered at the Med Spa.
Chronic migraine. FDA-approved use of this Botox type began in 2010 and on a determined schedule once every twelve weeks, following a set injection protocol targeting the forehead, temples, scalp, neck and shoulders. It functions by reducing the frequency of migraines, as opposed to alleviating ongoing headache pain.
Why Skill Beats Price
Every one of these drugs is the exact same chemical compound. How well it works hinges on its injection depth, location, and concentration.
The one brow is higher, the other side of the smile tugged more to one side of the mouth, the left masseter is larger, the same injection dose that will open one eye could have the other heavy. For each patient we will do the same sequence of smiling and frowns and raising of the brow as the team observing each muscle contraction maps out each portion of the plan.
That droopy brow you fear or that slightly crooked smile you hate? It is just placement. And it is temporary.
Shopping around El Paso, three questions answer most of it. Product, quantity of units, and who will be administering the injectables and what their training is.
The Realistic Calendar
Nothing happens for the first three to five days. The full effects are seen in about ten to fourteen days. The doctor prefers to see patients back after two weeks anyway, to fine-tune, because it is better to start conservative and add than to overshoot and wait it out.
Most areas last three to four months; the masseter tends to last slightly longer once the muscle starts to shrink. The short lip flip lasts between six and eight weeks. If you are treating migraines, it runs on a strict 12-week schedule.
Here is the thing. The maintenance routine that I and everyone around here most consistently stress is “do not wait until it is totally gone”. If you take it on schedule, you never live the cycle of a few great weeks followed by a couple of obvious ones. And muscle that does not have to work as hard will shrink. As it gets smaller, it requires fewer units.
Neuromodulators make a good pairing with the rest of the other Med Spa procedures. Microneedling and resurfacing address skin texture and skin tone, and you know this issue is not related to muscle motion at all. Treating both is usually what produces the result most patients thought Botox alone would give them.
Three Myths the Team Hears Every Week
“It is unsafe.” Cosmetic doses are a small fraction of anything harmful, and botulinum toxin has decades of medical use behind it, starting with eye muscle disorders. Real contraindications exist, including certain neuromuscular conditions and pregnancy, which is why it belongs in a medical practice.
“It is permanent.” It is the least permanent treatment in aesthetics.
“It is all the same.” The molecule is similar across brands. The map is not, and the map is the treatment.
About Dr. Frank Agullo
Frank Agullo, MD, FACS, double board-certified by the American Board of Plastic Surgery and the American Board of Surgery and a Fellow of the American College of Surgeons, established Southwest Plastic Surgery in El Paso, Texas. He completed his fellowship in plastic surgery at the Mayo Clinic. Dr. Agullo also works as a Clinical Associate Professor of Plastic Surgery at the Texas Tech University Health Sciences Center Paul L. Foster School of Medicine and Affiliate Professor at the University of Texas at El Paso. Dr. Agullo received Castle Connolly Top Doctor awards consecutively for 13 years.
There is always an M.D. nearby if the needle simply is not appropriate for what is going on with you, since the med spa is a suite within the surgical practice itself.
Ready to Talk?
Book a consultation and plan on spending the first few minutes making faces in front of a mirror. That part decides everything else.
Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com/appointments. #StayBeautiful.
@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.
Cross-links
- Editorial version on drworldwide.com: “Botox Is Not a Menu Item: Why the Map Matters More Than the Units” (link once live)
- Patient-facing version on agulloplasticsurgery.com: “Beyond the Forehead: What Botox Actually Treats, and How I Decide” (link once live)
