Best Practices – Effective Pain Management For Botox Patients

Since first introduced to the medical community in 1989, as a treatment for eye muscle disorders, administering of Botulinum Toxin Type A: Botox and similar neurotoxin injectables, has now become the most popular non-invasive aesthetic medical procedure performed worldwide. However, as physicians strive to make aesthetic medicine procedures more comfortable for their patients, a “cold war” of sorts has emerged regarding the use of topical anesthetic and ice during injectable procedures.

Through a survey of expert practitioners the following “best practices” for the use of topical anesthetic and ice emerges.

The critical factor to minimizing discomfort and bruising is technique. However, based on a patient’s tolerance, topical anesthetic can be used to minimize, but not extinguish, the pain associated with subcutaneous injections. Ice is generally considered the best tool to minimize bruising. Other tools in the physician arsenal to minimize pain are size of needle (32 gauge is recommended) and ensure minimal volume is injected (e.g. dilute the Botox at 2.5 cc per bottle =4u/.1 cc). Finally, for a select group of physicians and patients, ice and topical anesthetic completely take a back seat to a “gentle” hand.

Proponents of Ice and Anesthetic

Dr. Mauro C. Romita, Specialist in Aesthetic and Reconstructive Plastic Surgery in New York, shares that “for Botox I typically use iced gel packs which hold the low temperature well and don’t melt. Further, “they may be able to be chilled slightly colder than regular ice, but ice is already cold enough.”

“If one leaves the cold pack on long enough the tissue chills very well, so much so, that the patient finds the cold intolerable. That’s the ideal time to quickly inject the Botox which should only take a few seconds to inject in small volumes. The ice chills the dermis and subcutaneous tissues, which topical anesthetics do not. I use topical BLT anesthetic (benocaine, lidocaine, tetracaine), with cold packs only in a very few patients who are extremely intolerant of any discomfort, as it minimizes the discomfort of the 32 gauge needle at the skin level only. The cold usually does this well enough for 90% of my patients. A minority of patients don’t like the feeling of ice packs and just take the Botox ‘straight’.”

Moreover, “ice compresses put the tiny vessels in spasm and make them harder to injure especially in the glabellar area. Unfortunately, this doesn’t apply so much to the veins at the lateral orbicularis.”

Finally, Dr. Romita offers this final best practice. “I dilute the Botox at 2.5 cc per bottle =4u/.1 cc so the volume injected is minimal. This helps make it more comfortable.”

Dr. Richard Foxx, founder of The Medical and Skin Spa in Indian Wells, also sees the value in the use of topical anesthetic. Dr. Foxx has “adopted the technique of using a topical anesthetic (and giving it enough time to work)” and afterward, begins the pre-injection consultation. “Whether a repeat patient or a new patient, I apply a topical anesthetic and leave it on for about 15 minutes….then begin injecting. I ask the patient to move their muscles and then makes appropriate marks with a white pencil.” Furthermore, prior to injecting Dr. Foxx applies a small packet of ice for 15 seconds or so to each area.

Gentle Technique Can take the Place of Anesthetic

Dr. Louis DeLuca, a treatment leader in aesthetic medicine and plastic surgery options in Boca Raton, has found that he has been disappointed with topical anesthetic creams and ice application. “I provide my patients with ample warning before each injection. I touch the area where the injection will be placed and count 1-2-3. Just like the Pediatrician. Nobody likes surprises in the doctor’s office. Over the past five years I have had maybe 1 or 2 patients who have requested ice application,” attests Dr. DeLuca. “Be gentle with your technique and the patients will have a remarkably comfortable experience.”

Furthermore, rather than using ice to minimize bruising, Dr. DeLuca suggests that these tactics work equally well. “Avoid superficial veins (particularly around the eyes…the sentinel vein is a nuisance) as this will lead to excessive bruising. Also, apply direct pressure to the injection sites to minimize post-injection bruising. This absolutely works!”

Dr. Jennifer Linder, Dermatologist, Chief Scientific Officer for PCA Skin and faculty member of the IAPAM, echoes Dr. DeLuca’s insights. Dr. Linder finds that “talkesthesia” works well, and she recommends, “keep the patient comfortable and relaxed, tell them before you are going to do any thing, and apply pressure near the needle as a distraction.” “I occasionally use ice to vasoconstrict and for anesthesia. If you apply the ice to another area with the assistance of a nurse that can also work well as a distraction. I find most patients do well with cues for relaxed breathing, squeezy balls, tiny gauged needles and 2 cc dilution of Botox. I rarely use topicals for Botox but I always use it for fillers.”

In Both Camps

Of course many seasoned physicians find the use of anesthetic and ice is entirely “patient dependent.”

For example, Dr. Nathan Mayl, a respected leader in the Fort Lauderdale Plastic Surgery and Cosmetic Medicine field, offers this insight on the companion uses of ice and topical anesthetic.

“I am actually in both camps regarding how to do Botox as well as other spot treatments. I will use both topical and ice for my admittedly “wimpy” patients. They love it. However for the average patient I use ice, but in a special way. We place a single half moon shaped piece of ice into the finger of a glove and hold it in place until the patient says ‘cold’. This gives targeted anesthesia and vessel spasm with minimal discomfort (and perhaps less bruising as well).”

Dr. Douglas S. Steinbrech, renowned plastic surgeon in the Manhattan area, concurs. “I like to give my patients a variety of options. Most people prefer ice, while second most common is people requesting anesthetic cream, followed lastly by the “toughies” who don’t want anything. Some of my patients have a higher tolerance to the needle and a cold sensitivity to the ice which they don’t like. Also, many busy people don’t want to wait 20-40 minutes for the anesthetic cream to work.”

“I like to use the ice because it is immediate and I find that the topical cream EMLA (Eutectic Mixture of Lidocaine and Prilocaine) takes longer.” Moreover, “the ice causes vasoconstriction of small arteries and veins which diminishes the chance of capillary disruption and subsequent bruising.”

Dr. Steinbrech also offers this “best practice” to ensure a comfortable experience. Like Dr. Romitra, Dr. Steinbrech finds the “key is small needles. I use 32 gauge, which are tiny,” and minimize discomfort significantly.

Dr. Thomas Sterry, a board-certified plastic surgeon in New York City generously shares his expertise. “If I’m using Juvederm or Restylane, I prefer to give the patient a block or to mix the product with local anesthesia. For Botox, you can’t do that, and I do want my patients to be as comfortable as possible, so I do have patients who decide to use the BLT topical anesthetic. I give them an ice pack but I really don’t know how much it helps. What I’ve done that I think has helped my patients to minimize the pain they feel during Botox injections is to dilute it with 1 cc, which means that the volume of the injection is much smaller and much more comfortable and that’s really my answer to the issue of pain. Years ago when I diluted with 4 cc’s, they had four times more product and that much more discomfort.”

Know the Limitations of Both the Anesthetic and Your Patients

The last word goes to Dr. Sterry. “My experience with topicals for Botox is that they don’t really work and it’s simply because when you’re giving the injection, the needle goes deeper than the cream can penetrate. Having said that, I go patient by patient, and always offer the cream, but I let them know that it doesn’t really make much difference for an injectable. If you’re getting a laser, which is much more superficial, it’s great. But for an injectable, not so much.”

Botox is a trademark of Allergan, Inc. Dysport is a trademark of Medicis, Inc.

A Furniture Removalist’s Observations on Buying a New Home

As a professional furniture removalist, we observe some great and some not-so-great arrangements that people make when buying a new home.

Similarly, if you’re getting ready to move, you’ve probably been contemplating on whether to do the local or interstate furniture removal yourself, or to hire a professional moving team instead. (If you are moving interstate, whether you need a professional or not, always remember that there is the option of interstate backload.) Nonetheless, the goal of this article is to help you resolve a particular issue may be facing – buying a new home, and it is our hope that you will find this informative and useful.

When purchasing a home, understand the gravity of that task. You will usually have to undergo a lot of trouble before you get a satisfactory deal. The common man doesn’t know where to begin the house hunt and from there, how to secure the house hunted. These tips are designed to make your house-buying journey a smooth one:

Know the Facts 

Prior to taking the plunge, learn the facts. They’re not kind, but in the real estate game, ignorance is often not bliss. Allot a good amount of time into finding your dream home. Be patient and keep your energy up because it is very often a stressful process.

Learn from Property Brokers

Property Brokers will be able to educate you on the ins and outs of properties. Make sure you don’t allow any particular broker to suck you in at the beginning of your search. Talk to 6 or more so that you can just shop around for the time being. Don’t finalize a sale until you are armed with knowledge to decipher the difference between a good or bad deal.

Read the Newspapers 

Newspapers always have real estate sale ads so look over the options. Then, telephone dealers from different areas so that you can get first-hand information about rates and available properties in a particular area.

Ask the Banks 

Shop around for banks for your loan needs. Negotiate on the following items:

o           Interest rate

o           Filing costs

o           Hidden charges

o           Down payment

o           Installments made on a monthly basis

o           Obligations

o           Penalties

Don’t forget to discuss and figure out what all those numbers will be because not knowing is very dangerous to both you and your wallet.

Bank Needs 

Don’t devote all of your savings to purchasing your property. Get a loan. Banks will validate the home prior authorizing the loan; it would be useful to get a safe property. After securing a loan with a bank, you’ll figure out how much you should spend to purchase your ideal home.

The Real Cost 

Get an actual assessment of the property by asking several property brokers as well as neighbors in the area. You’ll most likely obtain some useful information from these people.


Go into the bargaining table carrying a big packet of notes. You can use them to prove to the owner that the negatives are as bad as you say they are. Use your evidence to persuade the seller that the price is above and beyond appropriate. For instance, if you know the property value is $1 million, begin at $800,000 as the offer price and try your hardest to settle the price somewhere in between.

How to Do Or Start a Short Sale in Massachusetts Or New Hampshire

One thing I’m constantly asked by homeowners is how can they short sale their property? I wish this was an easy question to answer, but there are many variables that affect a homeowner who is underwater with their mortgage.

First, what Massachusetts and New Hampshire homeowners should know is that those states are recourse states. What this means is the lender CAN pursue a homeowner for any deficient amount. The deficient amount is the amount that the homeowner owes minus what the lender sells the house for at auction or short sale purchase amount. The lender will also add on their fees and any other payments owed.

The second thing they should be aware of is a short sale is NOT like a traditional sale. It can take anywhere from 2 – 12+ months to fully complete the process. Every short sale in Massachusetts and New Hampshire is unique and there are no cookie cutter outcomes.

If a homeowner has exhausted all other options, including cutting back spending, budgeting, loan modifications, refinancing, and realized they still cannot afford their home, the likely option if the home wants to avoid foreclosure is a short sale. They should contact their lender to explore if their lender will accept a short payoff of the mortgage and what the requirements are for the mortgage.

If you lender is open to accepting a short payoff, the next step is to find a buyer. There are several ways you can do this. The fastest way is to search out an investor that has experience in purchasing short sales. They will likely be your quickest route to getting your property under contract. Another option is to do a For Sale By Owner advertisement. Start marketing your property for sale and see if you can get it under contract. An agent or Realtor experienced in short sales is another great avenue to try to get the property under contract. You will want to interview the agent and ask them how many short sales they have assisted in, how fast they can get your property under contract and what their role is in the sale.

I’m going to shock some homeowners right now, but I can tell you from experience the listing price and the purchase price DO NOT MATTER in a short sale. What matters most is that upon approval the lender releases the lien and agrees NOT TO PURSUE the deficient amount.

The next step is to start the paper trail

Most lenders want a short sale packet that includes:

1) A purchase contract
2) The homeowner’s hardship – So many homeowners over think this one, but the lender wants to know why the homeowner could once afford when they took out the mortgage and now find the mortgage difficult to pay. That is the essence of a hardship letter explanation
3) 2 copies of recent pay stubs, disability checks, or unemployment checks. If you are self employed the lender will likely request a profit and loss statement
4) A copy of your last two month’s worth of bank statements
5) Your financial statement. This form can be provided by your lender, an investor, or real estate agent. It will outline your income vs. your expenses.
6) Copies of your two last completed tax returns or a 4506-T form
7) A listing agreement if the property is listed. You can try to do a For Sale By Owner, and the lender will likely want a copy of whatever advertisements you placed.
8) Authorization for release – This form shows the lender who is allowed to speak to the lender regarding your short sale.
9) A HUD-1 form – Which should be provided by the closing company, agent, or investor

The above represents what most lenders look for in a short sale packet, however some lenders may require more information or they may require information filled out specifically on their forms.

I caution homeowners to be prepared to present ALL THIS information. Do not skimp on what you’re asked for. It will only delay your approval if you aren’t prepared with this information. Loss mitigators have hundreds of files on their desk all waiting approval and if you are missing information you risk your packet going to the bottom of that pile OR in some cases if you have a particularly nasty mitigator, they may close your file out all together.

Once you accept an offer, and again, I don’t care WHAT you’re offered because the important thing is the approval, not the offer or the listing price, your packet needs to be submitted to the lender. Your negotiator whether it’s you, your agent, an investor, a lawyer, should then be taking the complete packet and submitting it to your lender.

The most important aspect of the entire short sale is the negotiation. What will you do if the lender denies your short sale? That’s where an experienced short sale negotiator can open a shut door.

After the package is submitted, the lender will likely order what’s referred to as a BPO or Broker Price Opinion. That is where a contract representative on behalf of your lender visits your property and evaluates your home based on comparable sold property in the area. This agent’s opinion carries a lot of weight with the lender. You will have a tough time getting your short sale accepted if this person over-values your property. When a BPO agent isn’t from the area, they may not know certain things about the town, such as a bad street or road, good street, crime rate, etc., and those things can affect the sale of a property. A reason I don’t participate in HAFA short sales is the homeowner’s LENDER sets the sale price of the property based on their BPO evaluation. If you don’t get a BPO agent that has experience with property in your direct area, the value of your property could be WAY off.

After the BPO agent determines their opinion of the property, they submit it to the lender (usually within 48 hours) and the lender will then make a determination regarding the sale. Now there are MANY factors that can affect the speed of your approval or denial. If for any reason the lender requests more information for you, you should be prepared to send it in as quickly as possible. Most negotiators will give you a time frame to respond to their requests and I’ve seen it be as little as 24 hours. Again, keep in mind if they don’t get a response in the time they want they COULD close your file out. Any time the lender requests paperwork such as updated pay stubs, bank statements or anything else, the homeowner should return that information to them as promptly as possible.

A short sale is lengthy and it can take 30 days or more for the lender to respond after the BPO has submitted their information. It’s important to be patient.

There are three possible outcomes for a short sale:

1) The lender agrees to forgive the deficient amount. The deficient amount is the amount the homeowner owes minus the accepted sale amount. So for instance, a home that had a mortgage of $200,000 and was bought for $140,000 would have a $60,000 deficient amount. Most distressed homeowners can’t come to the closing with that $60,000 so the lender has the say on what happens to that $60,000. If the lender agrees to forgive the deficient amount, a 1099-C will be generated and the homeowner MAY have tax ramifications on that $60,0000. MOST homeowners will be deemed insolvent under the mortgage debt forgiveness act of 2007 and a homeowner could walk away at that point and never think about the house again. Only your accountant can tell you if you are insolvent.

2) The lender does NOT forgive the deficiency. They “reserve the right to pursue” the deficient amount. In this case, they are reserving that right to collect their $60,000. Now it doesn’t mean they WILL pursue the homeowner, only that they are reserving the right to pursue the homeowner. What homeowners in Massachusetts and New Hampshire need to be aware of is the statute of limitations is 6 years. They have 6 years to collect that deficient amount. If this is the outcome of your short sale, you will NOT be issued a 1099-C – This is from the Massachusetts Attorney Generals site on debt “Is There a Statute of Limitations on Billing for Bad Debts?, Mass. Attorney General. the former Attorney General says, “There is no statute of limitations on billing for bad debts, but there are statutes of limitations for filing lawsuits and for reporting the debts to the credit reporting agencies. Although these do vary depending upon the type of debt, in general there is a six year statute of limitations for filing a lawsuit to collect upon a debt, and a seven year statute for reporting bad credit. It is rarely a good idea to decide not to pay a good debt if you are relying wholly on the statute of limitations, because there are more complicated issues involved, including when these may be tolled, or extended, or even when the statutory period has begun to run. But for your question, even if the statute of limitations has run, as long as a collector follows the debt collection rules and is not harassing you, they may continue to make reasonable collection efforts, short of going to court.”

3) The lender could ask for some form of payment at closing or a promissory note. So for instance they may ask for $12,000 in the form of a promissory note. This amount is usually spread over a few years. There is no way to tell what amount they will ask for or how long they will spread out the repayment of that amount.

It is important for homeowners to understand their options. I’ve heard countless homeowners ask if the bank “reserves the right to pursue” the deficiency, do they have to proceed with the short sale? The short answer is “NO” – If the homeowner cannot live with the terms of the approval, they do not have to move forward, however, if they don’t proceed with the short sale and they default on their mortgage, the bank will foreclose and they will AUTOMATICALLY have a deficiency which could be larger than the short sale amount, PLUS they now have a foreclosure on their record. There could be other ramifications if the homeowner backs out of the sale and they should always seek legal council if necessary.

The approval comes in a lengthy format with the terms of the short sale and typically a closing date. Again, there is other paperwork that the homeowner may be required to sign for the lender, such as arms length transaction forms. What many homeowners don’t realize is most of the time, they receive NO money at closing. Because the lender is taking a loss, they don’t take kindly to the homeowner walking from the sale with money in their pocket. I’m not saying that it can never happen, but if it does, it needs to be documented on the HUD form so the lender is well aware. A buyer, Realtor, investor or anyone can ask to give the homeowner money, but the lender would have to approve that, and doing anything that is NOT listed on the HUD form may have legal ramifications.

Most homeowners in New Hampshire and Massachusetts have no idea how to get started with a short sale. They are a large part of today’s real estate market and a great option for homeowner’s to avoid foreclosure. Short sales are not going away any time soon. The most important thing for homeowners is to educate themselves on the process and what is expected. That will save them a lot of frustration later.

Finding the Right Candida Doctor is Very Important to Get Your Candidiasis Cured!

Finding the right candida doctor is essential for those who suffer from candidiasis. I remember about a lady who has been on the candidiasis diet for awhile. She finally decided to find a specialist. So she went there today.

The doctor was extremely expensive, but she was able to see the candida in her blood. He had the microscope hooked up to a TV and there it was. She saw the yeast, the budding and also saw some that had changed into a worm like thing. It was really amazing. She also received a packet of information. Tomorrow she will go for more tests. She hopes that she can finally get some medication that can knock it out of her system.

My other friend, Tracy, has different experience. Her new doctor only sees 2 new patients a day, because he spends hours with each new patient. He requires an extensive blood work up and exam. Most of the time was for tests and a complete physical test. Then, the doctor gathers the information from all of the tests and devises a health plan specifically designed for that person.

Tracy found that she had a thyroid problem and a sugar problem as well as other health problems that were never picked up by standard tests run by her other doctors. The doctor has his microscope hooked up to a TV so that you can actually see your blood samples under the microscope and explains in detail what is going on, on the slides.

She saw the candida, watched it form buds and then also saw how it changed into these little worm like things.

The program the doctor gave her is: 1) a very strict diet, 2) prescriptions for nystatin powder, nizord tablets, 3) a multitude of supplements to repair and rebuild the body and to fight the candida.

Medication and supplements for other related health problems that she had including supplements that would assist the thyroid into working properly again, so that the amount of medication needed could be lowered in time. However, this program is very expensive.

If this doesn’t work, there is another procedure that is very costly but effective. The blood is drawn out of the body in an IV, and then exposed to a specific kind of light and then it is reintroduced to the body. The light kills the yeast. She talked to several people who had it done and it was successful for them.

Making A Fresh Start For The New Year

Everyone loves the new year. It offers a chance to start afresh and an opportunity to forget their past years’ mistakes and work on improving themselves. The most common resolutions include quitting smoking, losing weight, saving more money, eating healthily and being a “better person”.

However, most people fail to follow their new year resolutions. After a few weeks, or worse, a few days, of trying, a lot of people give up and feel frustrated at their failure and lack of determination. The common factors that determine the failure are quite simple:

  1. They are not ready for the change.
  2. As much as they want to make the change in their lifestyle, regardless if it is important decisions like quitting smoking or simple adjustments to their daily routine, like exercising regularly, the mind must be prepared for the change. For instance, if a smoker wants to go “cold turkey” and quit smoking, he must be prepared when he buys his last packet of cigarette and know that after that last stick, he is never going to smoke again.

  3. They have too many resolutions to keep up with.
  4. Making resolutions is good but they must be manageable. It is difficult if a person decides that he is going to quit smoking, start exercising and eating healthily all at once. These are all great resolutions for his well-being, but when he quits smoking, he might need to have a few days of junk eating to help him cope with the urge to smoke.

  5. They are not patient to wait for the results.
  6. Although making a reasonable resolution is important, they have to bear in mind that nothing in life comes easy. If a person decides to lose weight, she cannot expect herself to lose ten pounds in a week. She has to make gradual changes to her lifestyle and perhaps with the right diet and exercising regularly, she will lose ten pounds in a month. The same goes for quitting smoking. He has to understand that he will have a few difficult days coping with the urge and that if he keeps to not smoking, the urge will slowly fade away.

Achieving and fulfilling new year resolutions is easy as long as the person recognize that it is not going to be easy, it takes time to achieve goals and making reasonable and attainable resolutions.