Botulinum Toxin by Jan Stanek at Surgical Aesthetics

The use of ‘Botulinum Neurotoxin A’, more commonly known as ‘Botox’, is one of the most hotly discussed cosmetic procedures. Whether it’s celebrities acknowledging (or strenuously denying!) treatment or the media debating its pros and cons, there is no shortage of fascination with ‘Botox’ in the public domain. But, typically, alongside the more useful and insightful comment, there exists a wealth of misinformation that is at best confusing and at worst downright dangerous. 

Here we will look to iron out some of these commonly believed 'myths' about Botulinum Toxin and offer a concise overview as to its application.

What's in a Name?

Thanks to a host of candid case studies and a burgeoning fascination with cosmetic procedures amongst a better-informed public, Botox has experienced a meteoric rise from relative obscurity in the laboratory to the status of a household name. Now the best known of cosmetic procedures, Botox has half the global market share in facial aesthetics.

That said, its nomenclature has become a little more complicated in recent years since Allergan trademarked it for one of their products in 2006. This means that ‘Botox’ is no longer a simple contraction of the generic variation of Botulinum Toxin, but rather a specific product available alongside a number of others, including Dysport, Xeomin and a fresh wave of preparations originating in the Far East.

Whilst there are clearly obvious similarities amongst the properties of these toxins, proprietary manufacturing laws dictate that they are by no means identical and it is important to discuss with a medical professional which variation of the toxin will work best for you. And, where possible, to avoid mixing different products during the course of treatment.

Back Story to Botox

It was a German scientist, Justinus Kerner, who first discovered Botulinum Toxin in the early 19th century, naming it ‘sausage poison’ because of its tendency to be detected in poorly prepared meat products. Kerner also identified the violent strain of food poisoning known as ‘botulism’ – along with the potential therapeutic benefits of the toxin, which can block specific nerve impulses at their junction with muscles, restricting their function.

Later still, during the 20th century, the toxin was purified to make it safe for humans and, having been further researched, tested and refined, was administered therapeutically for the first time in 1980, to assist with the treatment of squints. By the late 1980s, its benefit in cosmetic procedures had been recognized and following extensive trials it was formally approved for use in 2002. The rest, as they say, is history.

A Few Lines About Wrinkles

How many of us have stood in front of a mirror conducting a forensic examination of our faces to detect the arrival of wrinkles, those tiny folds in the skin that are seen as a benchmark for impending old age.

But their presence is a little more complicated than the simple passage of time. There are actually two distinct types of wrinkles: static and dynamic.

Static wrinkles are more synonymous with the aging process and are caused by deterioration in skin quality. They are present in the skin’s surface and can be exacerbated by excessive exposure to sunlight and smoking – particularly the latter, which is very damaging to the elastic fibres within skin.

Dynamic wrinkles, on the other hand, are found in places of repeated and repetitive movement and are associated with the activity of facial muscles. The most common of these are so-called ‘crow’s feet’ around the eyes or frown lines that are formed between the eyebrows, known as glabellar lines.

The administration of Botulinum Neurotoxin A

The administration of Botox is a very straightforward, painless procedure and generally takes just a few minutes.

The injection is administered using a very fine needle so that the toxin can be precisely targeted at the muscle in question. It normally takes four to seven days to achieve full effect.

It is advisable to abstain from alcohol, fish oils and ibuprofen in the weeks prior to an injection of the toxin so as to reduce the potential for bruising.

How does it work?

As with all medical procedures, the efficacy of Botulinum Neurotoxin A is underpinned by a complex cellular mechanism. However, in essence, the neurotoxin works by paralyzing the underlying muscles and blocking the neurotransmitter receptors that convert electrical impulses from the nerve into an actual muscle action. Therefore the muscle is no longer able to contract and the appearance of fine lines or wrinkles is prevented.

These receptors are made from naturally occurring proteins within our cellular systems, and the reason that the injection of Botulinum Neurotoxin A only offers a temporary solution lasting a few months is down to the way in which the body responds to the blockage and looks to create new receptors to replace those that are no longer working.

Although the requirement for regular treatments is a source of frustration for some, it serves to reinforce one of the greatest benefits of Botulinum Toxin, which is that in the unlikely event of any complications, the effects are only short-lived.

The use of Botulinum Neurotoxin A in cosmetic procedures

The prudent use of small doses of Botulinum Neurotoxin A has been an aspect of cosmetic procedures since the turn of the century and is today one of the most popular treatments available.

The toxin is most frequently administered into the upper third of the face, though – with additional experience and care – it can be used elsewhere.

As a temporary and less invasive alternative to surgery, and with results that are considerably less ‘dramatic’, Botulinum Neurotoxin A is available to practitioners looking to perform non-surgical brow- and facelifts. The non-surgical brow-lift in particular is a complex procedure that requires a careful balance between elevators and depressors to achieve optimum results. As with the non-surgical facelift – also known as the ‘Nerfetiti’ in homage to the flawless good looks of the legendary Ancient Egyptian queen – it is imperative that the practitioner takes care to paralyze the correct muscles to ensure a smoother, but still mobile, visage.


Cosmetic problems solved

The following ‘wrinkles’ can often be successfully treated with a course of injections of Botulinum Neurotoxin A.

Glabellar ‘frown’ lines

Vertical lines situated between the eyebrows and produced by the action of frowning, which stimulates movement primarily in the corrugator supercilii muscles.

Forehead lines

The horizontal lines on the forehead, which can become more prominent when the eyebrows are raised, prompting further movement for the vertically oriented frontalis muscles.

Crow’s feet

Radial lines that extend around the outer eyes, caused by a contraction of the circular orbicularis oculi muscles. Often exacerbated by people squinting in bright sunlight and one of the most ‘obvious’ forms of wrinkle.

Bunny lines

An apt name for the collection of oblique lines that form at the side of the nose. These can occur naturally or as a by-product of the paralysis caused by the administration of neurotoxins elsewhere on the face, the body seeking to compensate by stimulating facial animation.

Neck bands

Subcutaneous, cord-like structures that appear on the front of the neck, becoming more apparent during the execution of particular facial expressions, such as grimacing. These cords are themselves muscle – part of the platysma – and as such can be injected directly. Though it is imperative that the procedure is undertaken with the utmost care so as to prevent any problems with swallowing should the dose be inaccurately targeted.


Other benefits of Botulinum Neurotoxin A

Anti-aging and the pursuit of eternal youth aside, Botulinum Neurotoxin A plays a pivotal (and fully approved) role in a number of other medical procedures, including:

  • Cervical Dystonia (also known as spasmodic torticollis) - a neuromuscular disorder that effects the head and neck.

  • Blepharospasm – excessive blinking.

  • Severe primary axillary hyperhidrosis – excessive sweating.

  • Strabismus – squints.

  • Achalasia – when the lower oesophageal sphincter is unable to relax.

  • Chronic focal neuropathies – problems that are focused on one or more specific groups of nerves in the body and which can come on very suddenly.

  • Certain types of migraine and other headache disorders.

  • Bruxism – excessive grinding of teeth or clenching of the jaw.

  • Idiopathic and neurogenic detrusor – overactivity of the bladder muscle.

  • Pediatric incontinence when caused by an overactive or neurogenic bladder.

The prescription of the toxin with each of these conditions varies – and it may not be the sole treatment. Nor is it recognized to be a failsafe solution to each and every one of these disorders. Further research is required, not least in the case of migraine where the evidence as to its benefits is somewhat conflicting.

Even wider developments have been made in the use of Botulinum Neurotoxin A as a treatment for other conditions. As yet, its application hasn’t been formally approved by the FDA (the US Department of Food and Drug Administration, which serves as the industry regulator) but pending the outcome of future clinical trials the toxin’s ameliorative potential extends to:

  • Painful bladder syndrome.

  • Excessive salivation.

  • Allergic rhinitis.

  • Anal fissure.

  • Vaginismus – spasms of the vaginal muscles.

  • Movement disorders associated with either injury to or disease of the central nervous system, such as traumas, strokes, multiple sclerosis, Parkinson’s disease or cerebral palsy.

  • Reduction of the masseter muscle – which assists with decreasing the apparent size of the lower jaw.

  • Focal dystonias – neurological conditions which effect specific muscle groups, particularly the limbs, jaw, face or vocal chords.

  • Vocal chord dysfunction.

  • Temporomandibular joint pain disorders – which effect the muscles around the jaw and those connecting it to the skull.

  • Diabetic neuropathy – a condition which can effect all peripheral nerves within the body.

  • Wound healing.

  • Detrusor sphincter dyssynergia and benign prostatic hyperplasia.

  • Treatment and prevention of chronic headaches and chronic musculoskeletal pain.

  • Potential aid in weight loss by increasing the gastric emptying time.


Safety and side effects

 Despite the fact (sometimes leading to irresponsible scaremongering) that Botulinum Toxin is one of the world’s most deadly substances, its use under proper clinical conditions is acknowledged as being perfectly safe.  The toxin undergoes a stringent process of purification before being administered to humans.

And, whilst dosages vary (for example, they are often higher when given to children), a single vial contains only a fraction of the potency of a fatal dose – i.e. between 50 and 100 units, when 2,800 units is considered lethal.

Reassuringly, in over twenty years of use in cosmetic procedures – amounting to several million individual treatments – there is yet to be a single reported death from an injection of Botulinum Toxin. And other side effects, providing that experienced and qualified professionals administer the injections, are few and far between. Those that can occur are for the most part only temporary, with the likelihood of any permanent damage miniscule.


These relatively rare and temporary (though well-documented) side effects include:

  • Eyelid and brow droop – primarily caused by an incorrect application of the toxin. In essence, either too high a dose is administered or the injection is too low, resulting in the surplus toxin extending beyond the target area. It is frustrating and nothing can be done to reverse the ‘damage’; but in the unlikely event that it does happen, the effect is only temporary and it will wear off within 7-14 days.

  • The ‘surprised’ eyebrow – a not uncommon sight that is regularly highlighted by those critiquing celebrities on-screen or on the red carpet. It is usually triggered by an inexperienced practitioner who has failed to grasp the complex anatomical interplay between opposing muscles, which requires both to be treated in order to achieve optimum results.

  • The frozen face. This principally occurs when too much Botox is administered, often at the request of the client. The moral of the story here is to take advice from your experienced practitioner rather than dictate your own terms.

  • Headaches and slight bruising – an occasional consequence, though the symptoms are temporary and seldom severe.


When Botox isn’t the answer

Whilst Botox is acknowledged to be a safe product, there are some circumstances in which it should categorically not be used:

  • If you are pregnant or breastfeeding.

  • If you are taking any form of immunosuppressant medication.

  • If you have any hypersensitivities, e.g. react strongly to eggs.

  • If you suffer from any bleeding disorder or local infection.

  • If you have a muscle or motor neuropathic disease, including myasthenia gravis and Lambert-Eaton syndrome.

  • If you are taking aminoglycoside antibiotics, e.g. gentamicin.

There are also specific scenarios cosmetically when the use of Botox is not appropriate, including for static wrinkles (those caused by the passage of time and further aggravated by sunlight and smoking). In this instance, and should you have problems with stati wrinkles, then it is best to discuss alternative treatments with your practitioner.


Future uses of Botulinum Neurotoxin A

There is no doubt that the use of a substance as potent as Botulinum Toxin will be extended and already there are a number of trials to explore its administration in a range of physical and mental health conditions.

Although research is still in the early stages and in need of independent corroboration, there is an indication that injections of Botulinum Toxin could stimulate hair growth, for example.

One of the most interesting developments is in its use to stimulate facial muscles; in turn an asset in the treatment of depression. The theory being that when people are ‘made’ to smile they become less miserable. A recent trial among thirty patients proved successful and if further research proves positive then this versatile toxin could revolutionize treatment pathways in mental health.

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