WHAT IS BOTOX®?
Botox® is a toxin (toxic substance) which is naturally produced by the bacteria called Clostridium botulinum. Interestingly, it is currently believed to be the most toxic poison known to man, although the use of such tiny amounts has been used safely in man for over twenty-five years. This bacteria produces several types of toxin, of which only “type A” is used for medicinal purposes today.
HOW DOES BOTOX® WORK?
The Botox® toxin works where the nerve meets the muscle where the nerve sends its signal telling the muscle to contract. This results in paralysis of the treated muscle.
HOW LONG DOES A BOTOX® TREATMENT RESULT LAST?
Unfortunately, Botox® results are not permanent. Initial treatments for wrinkles typically last 3 to 4 months. Subsequent treatments may prove to have more lasting results. Treatment of hyperhidrosis (excessive sweating) may last up to one year (average 5.2 months)
WHAT WRINKLES CAN BE TREATED USING BOTOX®?
Although Botox® is only FDA approved for treatment of the frown lines (glabella), Botox® has been used with good to excellent results for the treatment of the forehead wrinkles and crow’s feet. Infraorbital wrinkles (wrinkles below the eyes) can be treated with moderate results. Newer therapeutic uses have been for the treatment of nasolabial folds (smile lines), perioral wrinkles (wrinkles around the mouth), corners of the mouth, and anterior neck which carry a higher risk of complications and have mixed results.
CAN BOTOX®TREAT EXCESSIVE SWEATING (HYPERHIDROSIS)?
Yes. Botox® has been recently FDA approved to treat hyperhidrosis of the hands and axilla (underarms) since at least 1995 with good results which may last up to 12 months (average 5.2 months). Treatment of the hands has resulted in mild weakness of the hands in a few patients as a result of toxin diffusion to the intrinsic muscles of the hand (muscles within the hand). Since this finding, more superficial injections have been used with good success and a lower incidence of weakness.
WHO SHOULD NOT GET TREATED WITH BOTOX®?
Botox® has not been studied in pregnancy, and it is therefore unknown if fetal harm will result if a pregnant woman is treated with Botox®. Therefore, the use of Botox® is not recommended during pregnancy. Additionally, it is unknown if Botox® (botulinum A exotoxin) is excreted in breast milk, where it could affect a nursing infant. Therefore, Botox® treatment is not recommended for use in lactating women. Additionally, patients with neuromuscular disease, such as myasthenia gravis and Eaton-Lambert syndrome, should not be treated with Botox® as it may worsen these conditions. Of course, anyone who has had an allergic reaction to Botox® should not be treated.
WHAT ARE THE SIDE EFFECTS AND COMPLICATIONS (PROBLEMS) ASSOCIATED WITH TREATMENTS WITH BOTOX®?
As Botox® is injected directly into the muscle body when used for wrinkles, bruising may occur. This can be minimized if patients avoid the use of aspirin, aspirin-containing products, and non-steroidal anti-inflammatory agents (i.e. ibuprofen, Motrin® , Advil® , naproxen, Aleve) for one week before treatment, although this is not necessary. Rarely, generalized reactions have been reported include nausea, fatigue, malaise, skin rash, and flu-like symptoms. It has been postulated that these generalized reactions occur from diffusion of minute amounts of the toxin into the circulatory system of which the significance of such reaction is unknown.
With treatment of the glabella (frown lines), ptosis (drooping of the eyelid) has occurred and may persist for up to 4 weeks. Some physicians believe that if patients remain in an upright position, avoid manipulation of the area treated, and actively contract the muscles treated for 4 hours after treatment, the likelihood of ptosis (drooping) is minimized due to increased uptake of the toxin. To avoid this problem, physicians are using more concentrated toxin that results in far less diffusion (spread) of the toxin to unwanted areas and therefore even less chance of eyelid droop (ptosis). In addition, most cosmetic surgeons believe that injections over the pupil should be at least 1 cm above the eyebrow. Although ptosis is now rarely seen, it is easily treated using alpha-adrenergic agonists (mild stimulants) topically applied to the eye (eyedrops).
Occasionally the glabella (frown lines) does not respond as well as one would like (i.e. frowning still occurs), especially in men. Therefore, this area may require a second treatment in 10-14 days.
Treatment of the forehead results in a more youthful appearance (due to decreased furrows), although there is decreased expressivity. Treatment must be carefully individualized to each patient. Patients who have a low brow and/or hooding of the upper eyelid (drooping upper eyelid skin) may have a total inability to raise any part of the eyebrow and may result in brow ptosis, worsening the appearance of the eyes. This can result in decreased visual acuity and the feeling of a ‘heavy brow’. Unfortunately, there is no treatment for this if it occurs, although the effects will wear off within 3-4 months. To avoid this, most cosmetic surgeons believe that treatment of the forehead should be above the first forehead wrinkle or at least 1-cm above the eyebrow. This may allow for some movement of the eyebrow. When the lateral fibers of the frontalis muscle (forehead muscles which wrinkle the forehead) have not been adequately paralyzed, a quizzical appearance may result in which one or both of the lateral eyebrows can be raised while the central portions remains depressed. This can be easily remedied by treating the lateral frontalis muscle (forehead muscles which wrinkle the forehead).
Bruising often follows treatment of the crow’s feet, occurs occasionally with treatment of the forehead, and rarely with treatment of the frown lines. Drooping of the lower lid margin and double vision have been reported, which can be avoided by injecting the toxin at least 1 cm from the lateral canthus (corner of the eye).
Treatment of the platysma (neck bands) has been reported to result in dysphagia (difficulty swallowing). Treatment with meloclopramide (Reglan) may improve swallowing if this occurs.
Treatment of the palms for hyperhidrosis (excessive sweating) has been reported to result in slight hand weakness in some patients. It is presumed that this has occurred due to diffusion of the toxin to the intrinsic muscles in the hand (muscles within the hand). Injecting the toxin very superficially has minimized this complication.
Therapeutic failures (patients do not respond to treatment) have now been reported. It is believed that these failures result when the body makes antibodies against the toxin, therefore neutralizing it. It is believed that with cumulative doses exceeding 200-300 Units, there is an increased likelihood of developing neutralizing antibodies. Therefore, when treating hyperhidrosis or larger muscle groups, it is recommended that injections be spaced at least 1-month apart. In the future, different types of this toxin may become available for clinical use that may be useful for those who have developed neutralizing antibodies.
Although Botox® is often used to treat migraine headaches, there have been a few reports of recurrent headaches occurring in patients undergoing treatment with Botox® for cosmetic purposes.
HISTORY OF BOTOX® USE
In the early 1970’s, Dr. Alan Scott began investigating the use of botulinum A exotoxin for the treatment of strabismus (crossed-eyes) in monkeys. In 1977 clinical studies were initiated in humans for the treatment of strabismus. In the mid-1980’s Dr. Scott indicated that he had treated a patient for “cosmetic reasons” using botulinum A exotoxin.
Shortly thereafter, a patient of Dr. Jean Carruthers, an ophthalmologist in Vancouver, Canada, had noticed improvement of the glabella (frown lines) after a patient was treated for blepharospasm (twitching of the eye). This finding prompted Dr. Jean Carruthers, with Dr. Alastair Carruthers, a dermatologist also practicing in Vancouver, Canada, to begin the use of botulinum A exotoxin (Botox®) for the treatment of the glabella (frown lines) and, shortly thereafter, the treatment of the crow’s feet. These results were soon published in the Journal of Dermatologic Surgery and Oncology in 1990 and presented at the annual meeting of the American Society for Dermatologic Surgery in March 1991.
These initial works inspired many dermatologic surgeons to use botulinum A exotoxin (Botox® , Dysport®) for the treatment of the glabella (frown lines), crow’s feet, and forehead which was soon followed by other specialties including plastic surgery and ophthalmology. The addition of the carbon dioxide laser to the cosmetic surgeon’s armamentarium has resulted in a resurgence in the cosmetic surgery field. Dr. David Duffy in one of the pioneers who began using botulinum toxin with laser resurfacing which was reported by the Carruthers in Dermatologic Surgery in 1998. Soon thereafter, trials were begun using botulinum A exotoxin in combination with other cosmetic procedures including endoscopic brow lift, upper and lower blepharoplasty (eyelid surgery), and in the lower face with facelifting. Platysmal bands, which are found in the front of the neck, were found to be responsive to treatment with botulinum A exotoxin by Blitzer et al. The treatment of axillary hyperhidrosis (excessive sweating under the arms) and palmar hyperhidrosis (excessive sweating of the hands) was introduced in 1995 by Bushara et al. with moderate success.
Now, more than twenty-five years after Dr. Alan Scott first described the clinical use of botulinum A exotoxin (Botox®) for the treatment of strabismus (crossed-eyes), the clinical possibilities for botulinum A exotoxin is most limited by our imagination.
HOW LONG DOES THE TREATMENT TAKE?
Most treatments can be accomplished within 10-15 minutes–one of the so-called “lunch-time” procedures. Most patients will have no evidence of having anything done, although some will have mild bruising (particularly when treating the Crow’s feet).
DO I NEED TO TAKE OFF FROM WORK OR OTHER ACTIVITIES?
For 3-4 hours after the procedure it is recommended that the patient remain in the upright position. Additionally, it is best to avoid strenuous or jarring activities such as exercising, running, or jogging for at least 3-4 hours. Nearly all patients may return to work immediately following the procedure and resume exercise the following day?
DO THE TREATMENTS HURT?
The treatments consist of a series of tiny injections using a fine needle. Although most patients tolerate the treatments with little discomfort, some patients request the use of a topical anesthetic which is applied to the areas to be treated 1-2 hours before the scheduled appointment.
HOW MUCH DOES BOTOX® TREATMENTS COST?
The toxin itself is expensive. The cost varies from doctor to doctor, and depends on which area(s) are to be treated. Some doctors charge according to the amount of toxin used while others charge per “zone” treated. The average cost per “zone” is approximately $260.00 – $500.00. A “zone” would be any one of the following: glabella (frown lines), forehead, or crow’s feet.
Robert S. Bader, M.D., Dermatologist
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