Botox & Other Neuromodulators by Dr. Marcie Ulmer

By Pacific Derm on May 3 2021

What is Botox and What are Neuromodulators?

Botox and other neuromodulator treatments are one of the most popular anti-aging treatments performed not only at Pacific Derm but around the globe.  Neuromodulators have proven safety records in millions of individuals and have been shown to be safe and effective in numerous clinical trials.  Neuromodulators available in Canada include Botox, Dysport, Nuceiva and Xeomin.  The active molecule is not only one of the most potent but one of the most well studied.  Applications for this powerhouse molecule continue to expand across various medical specialties making it a very exciting time to be in medicine and specializing in the dynamic field of cosmetic Dermatology.

Neuromodulators weaken signals from nerves to muscles to reduce the strength of muscle contraction.  They all work to improve wrinkles and lines by relaxing underlying facial muscles. Some facial lines only occur when the facial muscles are actively contracting. Other wrinkles are etched in by this repetitive muscle action over time.  Over the years the constant expressivity of the face results in lines and wrinkles often referred to as crow’s feet (radiating wrinkles from the corners of the eyes), frown lines (“11’s”) between the eyebrows as well as forehead wrinkles. Neuromodulators are very commonly used to help smooth the skin at these sites.  Neuromodulators are also often injected at other sites including the lower face (for example to reduce the effects of holding tension in muscles such as pursing the lips or clenching the jaw).  Treatment with neuromodulators has an incredibly high satisfaction rate as shown not only in clinical studies but also regularly observed in our daily practices.  Neuromodulator treatments have been positively linked to self esteem, mood and quality of life and our patients routinely report feeling more confident, refreshed and rejuvenated.

Neuromodulators are a minimally invasive non-surgical treatment that can be performed relatively quickly in a single appointment (easily a lunchtime type procedure). It is an A+ treatment in the hands of our board-certified Dermatologists and it is easy to see why this is one of the most commonly requested treatments in our practice.  Neuromodulators are most well known for their incredible ability to reduce lines and wrinkles on the face. When expertly injected neuromodulators can also balance the face by improving asymmetries and proportions, enhancing specific features, and subtly reshaping targeted areas (treated areas often include between the eyebrows, the forehead, lips, chin, jawline, chewing muscles, neck, nose, and around the eyes).

Many of our patients are curious about how we can use neuromodulators to assist them in looking more refreshed but some or our patients also want to look “less stern” or less like they are “frowning.”  Vertical wrinkles between the eyebrows can sometimes project a feeling that one is not actually intending to express (i.e. the appearance of a frown when you are not feeling the emotions associated with frowning). Neuromodulators applied between the eyebrows can soften or eliminate these lines (depending on their depth) minimizing the appearance of a scowl or frown.

Treating wrinkles on the forehead with neuromodulators is a delicate balance of softening lines and maintaining an attractive shape and height of the eyebrow.  Our knowledgeable injectors use a light touch in this area to maintain a natural appearance.

It is well-known that fillers are used for lip enhancement but the benefits of neuromodulators for this area are less commonly known (neuromodulators can be used for a lip-flip to subtly enhance the lips, to soften vertical lip lines or so-called smokers’ lines, to reduce a gummy smile so the lip doesn’t curl under or pull high above the teeth).

The lower face can be beautifully balanced by treating the chin (neuromodulators can reduce dimpling/pebbling and upward pull of the chin) and reducing the size and strength of the masseter chewing muscles. Individuals with very strong masseter muscles (linked to chewing and teeth clenching/grinding) often have the appearance of a strong square jawline, giving the lower face a bottom-heavy and wider appearance.  Treating the masseters with neuromodulators reduces the size and strength of these large muscles thereby slimming the appearance of the lower face and helping to achieve a face shape that is wider at the top and more tapered at the bottom if desired.  Some patients also have a strong downward pull at the corners of their mouth which can be reduced by neuromodulator injections into specific depressor muscles of the lower face thereby lessening this downward muscle contraction.  Over time the neck muscles also pull down on the lower face, contributing to sagging in this area. We all recognize that the neck is a challenging area to address as we age and treatment is often multi-factorial. Neuromodulator injections can improve the appearance of wrinkles and bands on the neck and enhance the jawline (often referred to as the Nefertiti lift) because treating these muscles minimizes the downward facial pull.

Contraction of the muscles on the upper nose when we squint or laugh can cause wrinkles on the upper nasal bridge (often referred to as bunny lines) which can be reduced with neuromodulator injection.  Smiling can cause the tip of the nose to pull downward in some people and a small injection at the base can help relax the nasal tip allowing it to tip up slightly.

In a time of donning a daily mask, the current visible focal point is without a doubt one’s eyes.  A skilled injector can beautify the eyes with small but perceptible changes such as softening surrounding wrinkles (including ‘crows feet’), reducing the appearance of heavy upper eyelids, slightly elevating the eyebrows, or assisting in providing a more open-eye appearance.  If a patient is bothered because one or both eyes squint when they smile, neuromodulators can be used to prevent the eye(s) from narrowing with a resultant more refreshed open-eye smile.  An skilled injector also recognizes that less can be more and that some expressivity is attractive, particularly around the eyes as smiling with our eyes in addition to our mouths (Duchenne smile) is perceived as a genuine sign of positive emotion. A softening of lines as an aesthetic goal, rather than complete elimination of wrinkles, often provides the most beautiful result.  At Pacific Derm we see every face as unique and therefore your neuromodulator treatment is customized to best enhance your individual features.

Am I a Candidate?

Neuromodulators not only help soften wrinkles and smooth the skin but can be helpful in preventing  wrinkles from deepening in the first place hence the commonly used terms ‘rejuvenation’ and ‘prejuvenation.’  Patients often ask when the right age is to begin Botox treatments and the truth is it is different for everyone.  In a more youthful individual who may be seeing early signs of wrinkles, neuromodulator injections can be used in low doses to prevent or minimize the depth of lines.  Some patients will begin to see fine lines as early as their mid to late 20s and others may not have fine lines until their 30s or 40s. Other patients enter our practice for the very first time at a more mature age to soften their existing facial lines. At whatever age you choose to come into clinic for consultation you can be assured that at Pacific Derm we will take the time to understand the goals you are hoping to achieve and provide our honest and expert advice.

Genetics, excessive sun exposure, stress and certain lifestyle choices such as squinting, consuming alcohol and smoking can all contribute to the development of premature wrinkles. Patients with fair skin are more prone to early wrinkles compared to patients with skin of colour. Patients with thicker oily skin are less prone to wrinkling than patients with thin dry skin. Some of these factors are within an individual’s control and others are not and we encourage our patients to mitigate reducing the above external stressors to the skin when they can.

Patients often have questions regarding the difference between neuromodulators and fillers. They are both injectables but are very different products. Neuromodulators act on muscles to decrease contraction and often to soften lines and wrinkles. Fillers are used for volume replacement, sculpting, lifting, and contouring. Optimal treatment is often best achieved by combination therapy with neuromodulators and fillers. Your Dermatologist will assess you and discuss what is right for you and your needs. Combination treatments are popular at our clinic and are often performed on the same day for patient convenience and to maximize results.

Before & After of Botox to Crows Feet Lines

What to Expect on the Day of Treatment

On the day of your treatment, consent forms are reviewed and signed and baseline photos are taken so your improvement can be followed.

Botox is a minimally invasive injectable procedure. The areas treated will depend on which muscles are contracting to form the overlying lines and wrinkles.  We all have different sized muscles therefore we all require customized dosing.  As a general rule, men have stronger facial muscles and usually require a higher number of units than women for the same facial location (for example a female may require 20 units for vertical lines between her eyebrows where a male may require 40 units for the same location). Everyone’s face is unique and it is our job to assess your muscle activity to determine best placement and precise dosing for optimal results during your consultation.

Downtime and Recovery

There is essentially a no downtime required and the treatments are quite quick. You can leave our office and carry on with your usual activities of the day.  Initial results are seen over the first few days with optimal results seen at 2 weeks. Results typically last 3-4 months.

Before & After of Botox to the Masseters


Is a neuromodulator treatment right for you? Call 604-682-7546 or email for a cosmetic consultation with one of our Dermatologists