Here is another study with beer. In Predictably Irrational, Ariely asked a group of individuals sitting down at a table in a bar to order from a limited list of beers: Summer Wheat Ale, Franklin Street Lager, India Pale Ale, and an Irish Stout. The first individual would call out his or her beer and then the ordering would progress around the table. At the conclusion of imbibing, the individuals would be asked to write down their rating of their beer. Interestingly, the person who asked for the beer first consistently rated his/her beer satisfaction to be the highest. The ratings would then go down proportionately to when the beer was ordered. The same experiment was tried by having individuals hand in their beer order silently without declaring their wishes aloud. Interestingly, almost every individual rated the satisfaction of their choice very highly. Also interestingly, when beers were ordered out loud, almost every person ordered a different type of beer; whereas when beers were ordered silently there was much more similarity in what was ordered. The same experiment was carried out in Hong Kong. However, in this case, when people ordered out loud, the second, third, etc. person would order most likely the same thing that the first person had ordered. As would be expected, their enjoyment was greatly less than what the first person ordered. What we learn from this experiment is that in the United States we value our maverick individualism even in spite of our best interest, and in Asia conformity is prized to a similar detriment. In summary, if you are going to order, order it first before everyone else so that you can enjoy your meal!

Sometimes in our society, we want to be different just for the sake of being different. Sometimes different is bad. Sometimes there is a reason why no one else is doing what you are doing. Sometimes different is good because the majority out there are doing things that are not good. We should fight against any of our cultural legacy (whether from the Occident or the Orient) that is our natural tendency to be “predictably irrational” so that we can make choices that are the right ones. In my field, I truly believe that too much lifting is being done for all the wrong reasons with absolutely dreadful results. As you know, I believe that the majority of docs out there who believe that lifting brows and cheeks is right are in a word wrong. However, I believe that Botox, almost despite its popularity, is so very right thing to do for long-term gains and to avoid what would otherwise be ineluctable aging. (If you don’t know what I am talking about, watch my 3 video logs: 1, 2, 3). I believe that Restylane and Perlane, which are the most popular fillers on the market in Europe and the U.S., are the most popular for a reason (which is corroborated by my clinical experience). Believe in the right thing whether it is popular or not, but don’t believe in something either because it is popular or because it is not.

I wrote a blog a few months ago on perspective that was actually stimulated by a patient’s comment regarding the book, Predictably Irrational, as source material. I would like to use this blog that borrows heavily from PI, for more inspiration. The opening psychological study presented in PI was quite brilliant. Using a real-world subscription plan by the famed British magazine, The Economist, Ariely the author subjected students at MIT, where he is a professor, to a small test in human psychology. The Economist offers 3 subscription plans: Internet only for $59, Print only for $125, and Internet plus Print for the same $125. With these 3 plans, the students overwhelmingly chose the combined Internet plus Print option. Removing the “print only” decoy, he offered the Internet only for $59 and the Internet plus Print for $125. The students overwhelmingly chose the Internet only at the bargain price of $59.

We as humans tend to require a comparison for us to make good decisions (or not so good decisions). As mentioned in a previous blog, the patients who are truly loyal to me are the ones who have had Botox, fillers, surgery somewhere first before coming to me. Without a comparison, people enjoy the experience and results that I offer but their mind may think for a moment I could get it cheaper down the street. That thought almost never crosses the mind of a patient of mine who has been down the street. By offering a uniquely better product, service, and experience, I think I have garnered more loyalty from my patients who have chosen me after they have been elsewhere.

Well, we have covered that ground before in a previous post so I wanted to explore this idea in greater detail. I am about full disclosure and not trying to trick a prospective patient into choosing me. Instead, I would like to think of how could I help a prospective patient truly understand the service difference that I offer. What I have done in the past and would like to continue is to try to frame the differences of a procedure that I do to contrast that with another practice down the street or, to be honest, anywhere else. I have done that in many ways without ever mentioning a competitor by name, just the philosophical, technical, and artistic differences that LFP is all about. For example, I explain how my Botox is intended for long-term goals not short term which I reinforce with baseline photographic documentation and photographic progress reports with how their skin is doing over time through sequential photographs. That alone is almost a comparison within itself, that is a comparison of one’s current state and one’s former state.

I really enjoyed this book, Predictably Irrational, and would like to help my patients not to think irrationally but to think things as rationally as possible. Knowing our own irrational behavior can help us free ourselves from it. Comparisons are important, in my opinion. Without them, we fail to judge the quality of something because we only see that attribute in isolation. The language I use is oftentimes trying to articulate what I offer so that if the comparison is not immediately obvious, it will become so by your speaking with your friends about their experience elsewhere or simply put you would already know this fact if you had tried services elsewhere in the past.

In fact, besides trying to have a service down the street, I ask my patients a small favor if they have never tried any services besides my own is to ask their friend some explicit questions: 1) How painful was your Botox? 2) Did you get a wow effect from just filling your smile lines with Restylane? (no) 3) Were you educated about your options or just brought back and injected? 4) Did you get baseline photographs and shown the before and afters of the work? 5) Were you offered free touch ups and asked to come back to make certain the result was good enough? 6) Were you given long-term goals so that you could determine what would be in your budget and goals for now versus where the physician desired you to be in a year? 7) Were you educated about options that would clearly be harmful or a waste of time and money for you and actually talked out of a service that was not right for you? REALLY? “My doctor, Dr. Lam, did all those things for me.” I hope that you can say those things about your experience at LFP.

Okay, I hope you liked Part 1 yesterday, “The Botox Scale”.  In review, if you don’t do Botox, every year you don’t your wrinkles will get worse. (Remember Botox does not fill in lines it prevents motion in the muscle, albeit temporarily.)  Every year you do CONSISTENT Botox, they will get better.  

Now, let’s think of a shirt analogy for you to better understand the situation.  I have used the shirt analogy extensively throughout the learning modules and virtual consultations.  But who has bothered to read those?  If you already understand what I mean by thinking of Botox like a shirt, you can skip this blog.  If not, read on.

Here’s the deal, your skin is undergoing constant creasing and wrinkling every day every movement you make.  Think of your skin like a shirt you would wear.  If you wear the exact same shirt every day consecutively for 5 years what will your shirt look like.  Obviously, pretty bad.  Now, let’s say you take a somewhat crumpled shirt and let it hang on the wall for 5 years, the wrinkles will look much better over time being hanged on the wall.  Let’s say your best friend at the same time wears his/her shirt for that same period of time, what will that shirt look like?  Obviously, bad.  There are really only 2 options:  wear the shirt (no Botox) or don’t wear the shirt (using Botox).  Like the principle of the Botox scale, wrinkles will either get better with Botox or worsen without Botox.  Now, one caveat.  Some wrinkles will persist in a shirt even hanging it for a long time.  However, with Botox the skin can completely heal since it has regenerative capacity so the analogy is not perfect.  

Many people then ask, “How about ironing the shirt?”  I always say, “Ironing the shirt is like laser or plasma skin resurfacing”.  The ironing can make the shirt look better but what if you start wearing it again.  It will start the process over.  So in almost any case Botox is a critical part of a regimen toward healthy skin, more important than anything else you can do for the skin other than sun avoidance and sun protection.  If the wrinkles are early, “ironing the shirt” with lasers, etc. may not be necessary and “hanging the shirt on the wall” (Botox) may be sufficient.  Whatever technique you do to make your skin look great:  facials, skin care products, drinking water, etc., the most important thing to do is Botox to prevent the source problem which is motion and the cause of wrinkles.

I would like to take a step back and go back to basics.  I think that Botox is one of the most fundamentally important treatments to limit aging especially in the fairer skinned individual.  However, it is also one of the most misunderstood treatments. Every day, I spend countless time explaining to each patient why to do Botox.  I use 3 analogies to explain how the LONG-TERM effects of Botox are nothing short of miraculous.  These analogies are “The Botox Scale”, “Botox Like a Shirt”, and “Botox Like Exercise”.  We will take 3 separate days to explain my philosophy to you so that there is no question you understand why Botox is so very important for you over the coming years of your life.Although most individuals focus on the “quick fix” mentality that you look better with Botox immediately, they oftentimes do not focus on what benefits they are actually accruing over the coming years.  My goal in this blog is to explain the long-term effects of Botox.

First off, Botox is not a filler. It does not fill in lines or plump up lips. It blocks a muscle from moving for 3 to 4 months. This allows the wrinkles not to form and the treated area to look more relaxed and refreshed. I think most of you know that but I should at least state that again from the outset.

Okay, let’s begin today with what I like to call “The Botox Scale”.  Let’s first discuss where your wrinkles are today.  Perhaps, they don’t exist.  Perhaps, they are just starting.  Perhaps, they are already advanced.  Whatever the situation, every day, every month, and every year that you do NOT do Botox, they will inevitably get worse.  There is no doubt that over time they will get worse without Botox.  Besides the short-term gains with Botox, consistent long-term usage of Botox will gradually let the skin heal, the collagen grow, and the wrinkles to fade even with the Botox completely faded, i.e., even when the Botox has completely gone after a few sessions you will eventually see the wrinkles STAY gone. (See my Botox gallery to see both the short-term and long-term effects of Botox. The short-term photos were taken when the Botox was in full effect (2 weeks after treatment). Believe it or not, the long-term after photos were taken when the Botox had completely faded and the patient returned for additional services.)  

So in summary, every year you do Botox your wrinkles continue to fade.  Every year you do NOT do Botox, your wrinkles will get worse.  In 5 years without Botox, you will be worse off.  You will never be at time point A, i.e., today, even if you don’t mind your wrinkles today, they will get worse over time without Botox (Just look at an old photograph of yourself).  I always like to say that if I can reverse your wrinkles in 2 to 3 years with consistent Botox usage and you move to a remote Eskimo village and can’t get Botox, you will have to fight to get back to time point A, i.e., today’s wrinkles, and regain all those bad wrinkles that you accumulated over the years.  So always remember the Botox scale.  You are either getting worse without Botox over time or better with Botox over time. There are no other options.

1. BOTOX IS A POISON
Botox is one of the most beneficial long-term products for anti-aging on the market and has been around for about 25 to 30 years. It is not only safe but it is beneficial for you over the long haul, as will be discussed more in-depth in the following point #2. Botox, as produced by Allergan, is currently the only FDA-approved version of botulinum toxin, that is a purified protein and has a very safe track record. The problems that occurred in Florida arose from a physician using a home brew made in Arizona not by Allergan. They have all been served jail sentences.

2. BOTOX IS A WASTE OF MONEY SINCE IT LASTS SO SHORT. I WANT SOMETHING PERMANENT.
Botox is the most important LONG-TERM treatment for aging, more important than skin care products, facials, lasers, etc. Why? Okay, Botox helps minimize excessive motion of the upper facial muscles and even muscles around the mouth. This is the most potent treatment for wrinkles. I look at Botox as one of the most effective treatments for wrinkles that exists. If you read the Learning Module section on Botox (under Resources), you will see that I liken Botox treatments to hanging your shirt (your skin) on a hanger. Over time, the wrinkles begin to fade and your skin starts to look stunning. (Also read my micro-Botox section for more ideas.) You must think of Botox like brushing your teeth, exercise, etc. Regular usage of the product will help you maintain your skin and minimize and erase over time your wrinkles. Can you just brush your teeth one time? Of course not! Even if you can’t afford Botox more than 1 to 2 times per year, it is still better than nothing. Think of this: if you exercise 1 time a week. Is this better than nothing? Of course, 3 times a week is ideal but one time is still worth something.

3. BOTOX WILL MAKE ME EXPRESSIONLESS
No, good Botox will keep some motion but remember the goal is to shut down wrinkles. Sometimes a stronger dose of Botox is necessary to knock out bad habits like excessive frowning or browlifting when you begin. A consistent regimen of Botox over a year will begin to erase those habits making consistent Botox use the most important during your first year if you are a habitual frowner or whatever. Not being able to engage in excessive motion can lead to actually your brain forgetting to do that behavior. However, Botox can be titrated to adjust to your desired level of expression. I like to say that Botox softens the negative expressions like surprise and anger but maintains the positive expressions like laughter and smiling

.4. BOTOX IS PAINFUL
Actually, it is in most clinics. Without even topical anesthetic, I can make your experience virtually painless. I have needle-phobic individuals now trust me to do their Botox because they can’t feel the needle. How is this possible? Well, that’s my secret. I have a very careful and methodical way of doing Botox and careful marking out of all the areas so that I maintain consistently smooth Botox every time that remains painless.

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That being said, I actually have been doing some thinking recently that incorporates some of the ideas from micro Botox treatments. Here are my thoughts. As you know, I am a Botox zealot. I truly believe that consistent use of Botox over time can start to reverse the aging process, namely the big wrinkles on your face. If you read the other sections of my website, you will see my many references to the long-term benefits of Botox, quite antithetical to the reason that many people have Botox which for them is a quick fix, make me look better for a few months strategy. Yes, of course, that is a great reason to do Botox, but I am more concerned about the long-term benefits of Botox if used consistently. I think besides sun avoidance it is one of the most important things you can do to fight aging in the face.

Now, let’s marry two ideas. When looking at my patients 2, 3, 4 year followup photographs with consistent Botox use which you can study for yourself in my Botox before and after gallery, I see that most of the wrinkles have disappeared over time. That is quite exciting to me, as I know they would have instead gotten quite a bit deeper over time without Botox. However, I really study my results carefully and I see beyond the big wrinkles, the texture of the skin starts to look really amazing even without peels, facials, plasma, laser, intense light treatments of any kind. What gives? My theory is that the Botox is actually doing exactly what micro Botox is doing in that the local skin texture and tone are becoming softened and more youthful over time. Now, a bit of marketing. I have seen a lot of patients who have had Botox elsewhere without the same benefits that I provide with my Botox. My thinking is the way that I administer Botox is very different. Most physicians inject Botox without marking the area carefully or only inject 3 to 6 injections, whereas I am injecting approximately 2 to 3 times the number of sites per area of the upper face meaning that most likely I am getting a lot more local changes in the skin texture than someone who injects only a handful of sites. Okay, for those of you who have not experienced my Botox, don’t panic. I know you have felt oftentimes excruciating discomfort with Botox. Anyone who has tried my Botox knows they feel really nothing at all. So despite a few more injections, you feel NOTHING! So that is my theory of how micro Botox really may be making a long-term impact on my patients’ skin besides the macro effects of just knocking out wrinkles.

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