Botox: Misunderstood Gem of Cosmetology.

Botulinum toxin type A (a.k.a.Botulinum A exotoxin) is arguably one of the more ingenious anti-wrinkle treatments on today's market. Is is best known under the brand name Botox (also sold as Dysport, etc.). Success with Botox depends on whether it is appropriately used and correctly administered. When misused, Botox is at best a waste of money. When used properly, it can produce results as dramatic as laser resurfacing but with lower risk of side effects.

Botulinum toxin type A is a neurotoxin produced by the bacterium Clostridium botulinum. This substance acts by causing a reversible paralysis of muscles. Large doses of botulinum toxin circulating in the bloodstream (like those occasionally seen in cases of botulism) are extremely dangerous and may cause death. On the other hand, small doses administered locally via a targeted injection to properly selected patients are generally safe (with certain rare exceptions) and have been used by ophthalmologists for decades to treat a condition known as "lazy eye." In the 90s, botulinum toxin type A (marketed as Botox) has become a part of a cosmetic practitioner's arsenal. It is now also being used off-label for a variety of other conditions where its risks and benefits are not as well researched. (See our article on the risks of botulinum toxin injections.)

In cosmetology, Botox is good for one thing only, the treatment of hyperkinetic wrinkles a.k.a. motion wrinkles. Motion wrinkles are the ones resulting from facial movements (e.g. frown lines, smile lines and crow's feet). Botox does not reduce fine lines, sun damage or skin roughness, nor does it help with acne scars, uneven pigmentation or age spots. On the other hand, it often dramatically improves motion wrinkles. Sometimes Botox-treated motion wrinkles become virtually unnoticeable. In cases when wrinkle reduction by Botox alone is insufficient, additional injections of fat, collagen or other fillers under the wrinkle may be performed.

The rationale behind Botox treatments is the following. Motion wrinkles result from the contraction of facial muscles. If the cause is eliminated, i.e. the facial muscles responsible for the wrinkles stop contracting, the skin gradually reshapes itself making the wrinkles less noticeable. If motion wrinkles were shallow to begin with, they might virtually disappear. Botox helps eliminate wrinkle-causing contractions of facial muscles by producing reversible local paralysis.

Botox injections are a simple outpatient procedure. Basically, the physician injects small amounts of Botox under the skin in the affected area. As the muscles relax, the wrinkles improve over the next few weeks. The effectiveness depends on the skill of the physician, accurate dosage, individual variation and other factors. Typically, the effect lasts for 3 to 6 month, after which the treated muscles regain mobility and the wrinkles begin to "grow back." Hence, most patients undergo additional treatments. One treatment generally costs from $400 to $800. One study has reported that injecting Botox deep inside a facial muscle rather than under the skin increases the duration of the effect up to 10 months.

Generally, a patient receives multiple injections during one procedure. Depending on the technique, wrinkle severity and the muscle involved, doses per injection vary from 5 to 50 IU of Botox. Correct dose choice depends mainly on the physician's experience. Some unscrupulous practitioners use lower than optimal doses so that the effects aren't as lasting as they can be. As a result, patients need to repeat the procedure more frequently (at $400-$800 a pop).

Compared to invasive cosmetic procedures like face lift, dermabrasion, laser or deep peels, Botox has a favorable safety profile. Side effects are uncommon and, with rare exceptions, benign. Temporary bruising infrequently occurs at the injection site. Droopy eyebrows or eyelids occur in about 1% of patients. The problem usually resolves by itself within a few weeks. However, there have been a few reports of serious complication or even deaths possibly associated with botulinum toxin injections. These cases primarily (but not exclusively) involved patients with certain predisposing conditions, such as nervous system disorders. (See our article on the risks of botulinum toxin injections.)

There is a theoretical possibility that facial inactivity caused by Botox may contribute to facial sag. It is claimed, although not proven, that facial exercises reduce facial sag by plumping up facial muscles. The opposite might also be true -- facial inactivity might thin out facial muscles and increase the sag. So far, however, there is no scientific evidence showing that Botox contributes to facial sag. Perhaps the muscles responsible for motion wrinkles are different from the ones associated with facial sag.

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