Botox Is Safe When Properly Used By an Experienced, Qualified Physician
Recently there has been much publicity about the dangers of Botox® injection however a closer inspection of reported adverse events reveals that improper injection techniques, use by unlicensed persons, and use of off label preparations have been the cause of most complications.
Botox® is the most revolutionary and effective facial anti-aging treatment since the advent of laser resurfacing. Unlike laser resurfacing, there is no down time with the procedure, which, along with the effectiveness of Botox® accounts for its incredible popularity. Yes, the name Botox® is short for botulinum toxin, a toxin produced by the bacteria Clostridium botulinum. It was discovered in 1895 and purified as botulinum toxin A (the type we use today) in 1946. It was first used in the late 1970’s to treat torticollis and other severe forms of muscle spasm and was found to be very safe and effective.
In the 1980’s, doctors Jean and Alastair Carruthers noticed that when they used Botox® to treat patients with ocular spasm (spasm of the eyelid) the wrinkles or crow’s feet around the treated eye disappeared (4). These results encouraged doctors to use Botox® to treat the lines of facial expression, frown lines, worry lines, and crow’s feet. The cosmetic use of Botox® was approved by the FDA in April 2002.
Before (left) and 3 weeks (right) after Botox injection for “crows feet” (patient is actively smiling in both photographs.)
Botox® works by weakening the muscles of facial expression. When you contract or tighten one of the muscles of facial expression, the nerve which connects with the muscle releases a chemical called acetylcholine. The acetylcholine then stimulates the muscle to contract or tighten. Botox® works by blocking the effect of acetylcholine on the muscle, and causes the muscle to relax and quit pulling on the skin. When the muscle stops pulling on the skin, the wrinkle caused by the muscle pull goes away. Importantly, the muscles of facial expression function to produce an expression on your face.
The muscles of facial expression are not involved in chewing or other important functional tasks. If they were, we would not use Botox® on them. Botox® also works well on the bunny lines, those little lines at the base of your nose when you squint or wrinkle your nose. The part of your eyelid muscle that is important for eye closure is not treated with Botox®, we treat only the outer part of that muscle which causes the crow’s feet. [Figure 7].
Botox injections are quick and relatively painless, especially when the area to be injected is iced first and a small 32 gauge needle is used.
Doctors who are expert at the use of Botox® can also use Botox® to lessen lipstick lines and some of the deep furrows below the lip on the chin. Only small amounts, two or three IU’s (International Units ) are used in these areas.
Correction of the lines of facial expression is not permanent, so Botox® injections must be repeated. The initial injection last three to six months, but the second injection often lasts six to nine months. The effect of Botox on the muscle seems to be cumulative in my experience, raising the possibility that after two to three years of use, the muscles will have atrophied and will be weak enough that repeat injections may not be necessary. At the present time, however, you should assume that you will continue to need Botox® injections every 6 to 9 months for as long as you want the lines to be gone.
It is essential that the physician who injects Botox® be experienced in the injection techniques for this drug. Botox® must be accurately placed within the muscle for it to work. The muscular anatomy of the face is very complex and injections can easily be placed too deep (below the muscle), or too superficially (in the dermis.) In either case, the injection will not work as well and you will be unhappy with the result. This is not something that a nurse or anyone other than a physician should be doing. It looks so simple, but technique is very important.
If Botox® is placed into the wrong muscle, your eyelid can droop or your smile can become crooked. Ask the right questions when you seek this treatment. Adverse reactions that have been reported are headaches (13%), nausea (3%), and flu-like syndrome (2%), but whether they are related to the Botox® is unknown. Three percent of patients in initial studies had temporary eyelid droop lasting three to six weeks, but in my opinion, eyelid droop can be avoided by proper injection technique.
Botox® injections sting, but the discomfort can be significantly reduced by icing the area prior to injection and diluting the Botox® with a preservative containing saline. Botox® is expensive. Botox® comes from the manufacturer as a powder which must be refrigerated. It must be mixed and diluted with saline (salt water) prior to injection and after it is diluted, it must be kept refrigerated. The company that makes Botox® recommends that the diluted, refrigerated Botox® be used within two weeks, or it loses much of its effectiveness.
Treatments are charged by the unit of Botox®, usually around $20 per unit. A typical initial treatment uses 25 units, which costs $500. Fifty units is usually the maximum treatment recommended for one session. In my practice, 50 units could easily treat frown lines, worry lines, crow’s feet and bunny lines. Very small amounts (1-3 units) are used around the mouth for lipstick lines, carefully placed to avoid the corner of the mouth where smile muscles and the muscles used for chewing are present.
We still don’t know the long term effects of Botox® treatment on the muscles, but it has been in clinical use since 1978 and no adverse long-term effects have been reported in the past 26 years. Recent widely-publicized stories of complications in
For more information on Botox and other facial rejuvenation techniques read Save Your Face or contact me. Be sure to sign up for our free email newsletter.
978-369-4499
Concord, Massachusetts
Boston, Massachusetts
