Health Journal: Botox Lore

Paul Van Camp MD for CBN

Since the FDA approval of Botox for cosmetic use on wrinkles last year, it seems a whole folklore has grown around it. The stories include the Hollywood "Botox Parties". There were endless Botox jokes by late-night TV hosts like Leno. Then there are the inevitable gossip items: Which stars have had Botox for their Oscar night appearances? (Answer — probably over half of them.) Which politician(s) had Botox for key campaign appearances? (You may have noticed how George W.’s deep brow furrows disappeared for his second presidential debate with Al Gore.)

None of this puts the use of a cosmetic medical procedure in an appropriate light. It is a drug and Botox administration is a medical procedure with risks, alternatives and limitations. Yet the uses of Botox have certainly increased over the past year. So I want to review some of the facts and medical news about Botox.

Botox is botulinum toxin. Yes, "toxin" means "poison". It is the same molecule that causes botulism. That said, it is also one of the safest medications we have. How can this be? Botox does one thing, and only one thing in our bodies: It attaches to the junction of nerves to muscle cells so they don not receive the signal to contract. The muscle stays in a continued state of relaxation. The Botox does not circulate through the blood. It does not affect any other organs. It stays bound to the muscle cells until new receptors are grown over a period of months. Then the effect goes away. The muscle cells and nerve cells are undamaged and recover to function normally. Cosmetic Botox places very small doses directly into specific small muscles to relax problem areas such as frown lines and crow’s feet. This tiny amount (less than 100 units) could not cause botulism even if it was injected directly into the blood.

Recently the former chairman of Tri-Star Pictures filed a high-profile lawsuit against Allergan Inc., the maker of Botox. The suit alleges Botox caused chronic disabling headaches, respiratory problems, fever, fatigue and severe muscle pains. Can this be caused by Botox? No, these are not known complications of cosmetic doses of Botox. Botox has been in wide use for many years now. For perspective: it is no doubt less risky than taking an aspirin. Which is not to say that it is risk free.

A few patients do get a mild headache from the injections. However, far more patients have noted improvement in their chronic migraine or tension headaches that may be triggered by facial muscle tension. 50% or more of migraine headache sufferers may experience significant improvement with Botox treatments. Unfortunately, not everyone’s headaches respond.

One rare side-effect (affecting less than one in 100 persons) is a mild drooping of an eyelid. This can occur if some Botox molecules from above the eyebrow drift down into the eyelid muscles. This droopiness can last for several weeks. A medicated eye-drop can be used to correct the droopiness while waiting for the condition to resolve. This will not occur when Botox is not used above just above the eyebrow.

Botox used to sting when it was injected. This is no longer the case when newer preparation methods are used — preparing it in a "non-stinging" solution. Finally, about one in ten persons may get a tiny bruise at an injection site, even with the greatest of care.

Botox has been used primarily to treat wrinkles and furrow of the upper face that are caused by excessive muscle action. These are called dynamic wrinkles and include frown lines, crow’s feet or smile lines, and brow furrows. It is important to use Botox only for muscle actions that do not contribute to normal and positive facial expressions. Some 52 muscle groups contribute to our intricate and wonderful capacity for facial expression. Only a few regions are appropriate for Botox treatment. For example, many people habitually frown whenever they concentrate on something. Socially this is misinterpreted by others as being stern, upset or even angry. Botox for frown lines is excellent to correct this. It gives them the appearance of someone who is calm, relaxed and friendly while preserving "normal" facial expressiveness.

Another popular and newer use is for the small "cushion" muscle (orbicularis) beneath the lower eyelashes that is prominent in some persons when they smile. Just one or two units of Botox can soften and relax this muscle without causing full paralysis. It looks natural and gives a softer smile around the eyes.

Botox can also give a "lift" effect to the middle and outer eyebrows. This is accomplished by using Botox in just the middle portion of the forehead between and above the eyebrows. This causes an adjustment on the rest of the forehead with more resting muscle tone. This can "lift" the eyebrow resulting in a higher eyebrow arch and more open eyes.

Some patients have a tenancy to habitually "purse" their lips giving a narrow, wrinkled appearance to the lips (like "smoker’s lines"). This may occasionally be improved with judicious use of very small amounts of Botox to relax the lip edges.

The real problem with Botox is that it wears off and must be repeated. The effects typically last for four months. Longer results, up to 6 months, may be achieved with subsequent treatments in some patients. Botox is expensive. (Allergan raised the price of Botox markedly after their expensive national ad campaign for Botox Cosmetic.) So some physicians have tried to use as little Botox as they can. However, with less Botox the results may not be as good and the improvement will not be as lasting.

Patients need to ask about how many Botox units they are receiving. A typical dose may be 25 to 30 units for one facial region such as frown lines, forehead or crow’s feet. Most patients will get excellent results from doses like this. However, a few women and most men may require substantially more. About one in 20 women, and 9 out of 10 men will require doses that may be twice this (40 to 60 units) to fully treat their frown lines or eyebrow furrows. Of course, it will cost more when more Botox units are required. Note that it only matters how many units of Botox are used, not the amount of fluid injected, which can be misleading.

Here is one final note: Another type of "Botox" called Myobloc was released last year. It was hoped that this might be longer lasting. Unfortunately, this has not proven to be the case. Most physicians are finding that traditional Botox is still the most advantageous for cosmetic applications.

The above information is presented for educational purposes and not to recommend treatment for any individual or condition. Dr. Paul Van Camp is a physician and surgeon and is medical director of Aesthetics MD. Further information is available at www.aesthetics-md.com/ or by calling 330-6160. References to original publication of these studies is available upon request.