Botulinum toxin was originally used to treat to eye spasms and central nervous system disorders, and since the late 1980’s, it has been used for cosmetic purposes as well as medical therapies. BOTOX® (Botulinum toxin A), a natural purified protein made from Clostridium botulinum bacteria “sticks on” to nerve endings and prevents the release of the chemical transmitters that activate muscles. When injected in very low doses into specific areas of the face and neck, it inhibits the small muscles that cause frown lines, crow’s feet and other wrinkles that are creating by making facial expressions.
Botulinum Toxin treatment decreases muscle activity thereby preventing the appearance of “dynamic” wrinkles that are caused by repeated facial expressions. The toxin acts on the junctions between nerves and muscles, preventing the release of a chemical messenger called acetylcholine from the nerve endings. Tiny amounts of the fluid are injected into a specific facial muscle so only the targeted impulse of that muscle will be blocked, causing a local relaxation. This muscle blockade acts to immobilize the muscle contractions which are the underlying cause of the unwanted lines. The established lines gradually smooth out after prolonged relaxation and disuse and the muscle blockade prevents new wrinkles from forming. Only muscles that are treated are affected. Muscles needed for important functions like eating, kissing, smiling, and eye opening are not treated and their continued function helps to maintain a natural look. Although Botulinum Toxin therapy can have a dramatic effect on dynamic wrinkles, it has no overall effect on the texture of the skin. There should be no effect on skin sensation in the treated areas.
We use Botulinum Toxin most often for treating the creases between the eyebrows and across the forehead, but other areas of the face and neck can be treated. Improvements can be seen in a few days but you may not see the final result for up to two weeks. The effect generally lasts from four to six months with the lines gradually reverting to the pretreated appearance. Some studies indicate that after multiple treatments, results can last longer in between treatments. Every person responds differently, and different areas may have longer lasting results than other areas. Some people have a lasting partial effect or memory response, whereby the lines and creases never completely return to the preinjection appearance.
First, a thorough assessment of facial wrinkles and creases is performed by examining your face at rest, and then having you perform a number of muscle movements including eyebrow raising, eyebrow furrowing, squinting and wrinkling the nose. The location and depth of creases are noted and symmetry is assessed. Based on this evaluation, the decision is made which areas to treat and how much botulinum toxin to use in each area.
We perform the procedure in our office and it takes between 15 and 20 minutes. The skin may be treated 20 to 30 minutes ahead of time with a topical anesthetic. A thin, fine-gauge needle like that used in acupuncture is then used to inject the botulinum toxin through the skin and into the muscle of a specific part of the face. Crow’s feet are treated with three or more injections on the side of the face close to the outer eye area or orbital rim. Horizontal forehead creases are typically treated with 10 to 16 small injections, thereby weakening rather than paralyzing the forehead muscles. The muscles that create the vertical frown lines between your eyebrows are treated with four to six small injections.
Botulinum Toxin can be used to improve but not completely get rid of the folds between the outer part of the nostrils and the corners of the lips, and the fine lines above the lips. Vertical muscle bands in the neck can also be softened with botulinum toxin. When a small amount of BOTOX® is into specific places around the eyebrows, a “chemical browlift” can be achieved which can cause a change in the eyebrow shape (rounded or peaked) and can even create a mild lifting of the eyebrows. For deeper wrinkles, a combination of botulinum toxin and a filler such as your own fat or RestylaneÂ® is often recommended to achieve a maximum improvement.
Botulinum Toxin Type A is a purified neurotoxin complex that has been used since 1980 to treat ophthalmologic muscle disorders, such as lazy eye, eye ticks and uncontrolled blinking. This form has to be reconstituted with saline before use. BOTOX® COSMETIC received approval for cosmetic use from the FDA in the spring of 2002 for glabellar creases. Treating other areas of the face and neck with BOTOX® is considered off-label usage of the product. Botox has also been FDA approved for injection into the axilla for treatment of excessive sweating. Reloxin® is undergoing clinical trials in the US for FDA approval.
Botulinum Toxin Type B is FDA approved only for neurological disorders causing cervical dystonias, and is not intended for cosmetic purposes. This form comes as a pre-made liquid that does not require a diluting agent.
“The beauty of BOTOX® is that it is quick, safe, effective, predictable, versatile. It is the most popular non-surgical cosmetic treatment available today.”
Although there is some discomfort associated with the injections, the feeling is much like any other injection or an insect bite and there is virtually no pain afterwards. You can return to work and resume regular activities right after the treatment but strenuous exercise and activity should be avoided for one to two days. You should also keep your head upright for four to six hours and to avoid massaging the treated area after the injections so that the botulinum toxin will remain in the desired location and will not migrate into other facial muscles.
Treatment with botulinum toxin can sometimes cause a brief headache and occasionally slight redness or a small bruise may occur at the injection site. You can decrease your chance of bruising if you avoid non-steroidal anti-inflammatory drugs and aspirin containing products for 7 to 10 days before the procedure. A potential adverse effect of Botulinum toxin is a droopy eyelid but this occurs in less than one half of one percent of patients. Certain risk factors can predispose you to this effect, such as having a low eyebrow position. A drooping eyelid or ptosis is temporary but can take up to six weeks to disappear. In some cases, you may be given prescription eye drops to speed-up resolution of the problem. Typically, the droop appears about five days after injection. It may start with a slight droopiness at the beginning, progressing to being noticeably droopy for a few days, and then gradually gets better until it is gone.
Botulinum Toxin is used in higher doses in deeper muscles of the neck, and it is rare but possible to have difficulty swallowing temporarily after having a treatment in the neck. Anyone who has a neuromuscular disorder such as myasthenia gravis or who has been on amino glycoside antibiotics may be advised not to have Botulinum toxin injections. Women who are pregnant, nursing, or who are trying to become pregnant may be advised not to be treated.