More than any other procedure, botulinum toxin type A, more commonly known as Botox, has come to represent the public’s fascination with cosmetic surgery.Originally identified as a toxin from Clostridium botulinum bacteria, Botox was first used in 1977 to treat strabismus, a problem with the eye muscles. The Food and Drug Administration approved it in 1989 for this purpose. When it was later used to treat uncontrolled muscle spasms in the face, patients had fewer wrinkles in the skin overlying the treated muscle. Doctors started using Botox for cosmetic reasons in 1996, and the FDA approved this use in 2002.
Botox Is Big Business
Sixty-five thousand Botox injections were performed in 1997. By 2005, there were 3.3 million injections in the United States alone. The manufacturer, Allergan, sold $831 million worth in 2005. This meteoric rise is due to a number of factors. First and foremost, the drug works. It does what it is supposed to do, with a minimum of associated problems. Combine this fact with the public’s increasing desire to look young, the increase in lifespan, and a highly competitive business environment, and you have the formula for Botox’s success.Botox is the most common of the poisons produced by botulinum bacteria. It uses the type A toxin, while other companies market similar products with different toxins.
Since this bacterium produces a soup of different toxins, and animals such as snakes also produce paralyzing toxins, expect competing products in the future to promise better or longer-lasting results. Sounds a little like snake oil!Botulinum type B toxin, marketed as Myoblock, begins to work in three days, more quickly than Botox. However, it usually lasts less than ten weeks, whereas Botox lasts three to four months. Myoblock might be useful in people who are resistant to Botox or when blended with Botox to take advantage of both.
The Medicis Corporation will soon market Reloxin in the United States, Canada, Japan, and Europe. Called Dysport outside the United States, this drug will compete head-on with Botox. Perhaps then Allergan will lower the ever-increasing price of Botox.
Botox Is Most Commonly Used on the Wrinkles Between the Eyebrows
This area is called the glabella. The muscles between the eyebrows are called the corrugators and are useful for only one purpose: to create a fearful expression. Called vestigial muscles, they were at one time important because the scowling appearance scared away enemies, telegraphing an imminent attack. Let us hope that humans don’t need these muscles anymore. Botox is also used to eradicate the horizontal lines of the forehead. The injection must be placed in the middle portion of the forehead; otherwise, drooping of the brow will occur. Creative Botoxing can elevate eyebrows, evening out asymmetry. The crow’s-feet area, to the side of the eye, is also commonly treated. Newer locations include the lines on the sides of the nose (called bunny lines) and dimpled chins.
Brave surgeons may inject the muscles around the mouth, to decrease the wrinkles of the lips and even to lower the upper lip in the case of a ‘‘gummy smile.’’ But sixteen muscles around the mouth all contribute to the smile: the chance of injecting them exactly symmetrically is not high. Asymmetrical injections will make it look as if you have had a stroke. And overdoing the injections will cause speech problems, even drooling. It will affect kissing and playing the trumpet. I do not advise these injections.
Some surgeons have begun to inject the neck to reduce the vertical bands. I do so only in select patients, women with early bands and relatively good skin quality. If done too aggressively, the injection can cause problems with swallowing. But if it works, it can stall the need for a neck lift for many years. In addition, some surgeons inject the muscles of the chin to smooth out a rumpled appearance.
When Botox is used in the upper portion of the face, it works in two dimensions. The forehead and eye injections are on the bone. The farther down the face it is used, the deeper it penetrates. It soaks nearly half an inch in all directions and when it spreads deep, its effects become three-dimensional—an interesting twist! Injection around the mouth and in the neck is very dicey.A recent use of Botox is to balance the face in cases of facial paralysis. After face-lifting mishaps, Botox can be a lifesaver by balancing the facial muscles while waiting for function to return.
Botox Is Really a ‘‘Chemical Knife’’
It takes a few days to see the ‘‘cut.’’ Injection of Botox into the muscles causes paralysis. Wherever it is injected, the junctions between the nerves and the muscles are destroyed. When the muscles are not used, the wrinkles are not continually being re-created. Eventually the wrinkles actually ‘‘heal’’: the dermis gradually thickens and the wrinkles lessen. To understand how this happens, consider stroke victims. The day after a stroke, the patient has all of her wrinkles but can’t move one side of her face. A year later, the wrinkles on that side have softened and decreased. Botox does the same. Many people are disappointed when the wrinkles don’t disappear overnight. Remember that we are talking about a biological process, similar to plants growing. But the body battles Botox and begins to repair itself soon after injection. Between two and six months later, the muscles begin to work again. It’s time for another injection.
Long-Term Botox Use
The goal of long-term Botox is to keep muscles from repairing themselves between injections. After a nerve injury, a physical therapist’s job is to keep muscles moving and electrically stimulated. The goal is to prevent atrophy of the muscles while awaiting regrowth of nerves. The muscles will begin to work when the nerves connect. It is the opposite with Botox. We want to beat down the muscles to the point where they can no longer recover.After a few years of continuous use, the Botox effect persists longer in many people. By repeatedly hurting the muscles, and assuring that they don’t recover between injections, we can destroy them. Again, this concept is the opposite of what physical therapists do for patients with nerve injuries. They electrically stimulate the muscles to try and keep as much function as possible so that when nerve regrowth occurs, the muscles haven’t wasted away.
On the other hand, some patients who have used Botox for a long time become resistant to its effects, because of antibodies that effectively neutralize the Botox.