Botulinum Toxin A (Botox)

Comprehensive Overview

 

WHAT IS BOTOX AND HOW DOES IT CORRECT WRINKLES?

Not long ago, the so-called "dynamic" wrinkles; wrinkles caused by facial expressions, such as crow's feet, glabellar or frown lines, and forehead lines were the source of much consternation for patients and doctors alike because they were difficult to treat even with surgery. These wrinkles do not also respond well to laser resurfacing or dermal fillers, such as Juvederm and Radiesse (non-surgical methods).

Currently, botulinum toxin type A, commonly known as Botox, is the most commonly injectable used in the management of these wrinkles. A tiny amount of Botox when injected into tense facial muscles inhibits contraction of the targeted muscle, causing it to relax. With less muscle movement, wrinkles on the overlying skin begin to soften.

WHAT DRUGS DO YOU USE?

The BTX-A drugs that have European and FDA approval are called Botox® (Vistabel), Xeomin®(Bocouture), Dysport®(Azzalure) and Myobloc®(Neurobloc). Currently we use Botox, and Dysport at LK Aesthetics as they are the only two drugs licensed for Aesthetic use by the Irish Medicines Board.  

For a more detailed description of the drugs and there differences see our recent blog Is there More Than One Botox? Also, Check out our fact sheets on the three different drugs in the LK Library.

 

WHAT EXACTLY IS IT USED FOR?

Despite the fact that cosmetic injections of Botox, Dysport, or Xeomin in any site other than the glabella or crow's feet constitute an off-label indication in the United States, the scope of botulinum toxin applications in cosmetic surgery is increasing every year.  Botox, Dysport, or Xeomin are commonly used to correct the following:

FROWN LINES

These are the glabella lines for which Botox, Dysport, and Xeomin injections have received FDA approval for their use in cosmetic surgery. They develop over time between the two eyebrows as two vertical lines (known as the 11) as a consequence of repeated squinting and scowling. Botox when injected into the scowling (corrugator) muscles, causes them to relax and gives the individual a more relaxed and good-natured appearance. The number of units a person needs depends on the size and strength of the corrugator muscles. The average amount of Botox used for the "11" lines between the eyebrows is around 16-22 Botox units for a female, or equivalent units of Dysport or Xeomin. Males will usually require more units (about 20 to 30 units) as their facial muscles are often thicker and stronger. It should be noted that Botox injected between the eyebrows may often improve tension headaches and even migraines related to the repeated tightening of these muscles.

FOREHEAD LINES

These are the horizontal lines on the forehead that appear when we raise our eyebrows in surprise. Botox can be injected into certain points in the forehead to relax these lines. Typically, 10-15 units are injected, depending on the size of the muscles in the forehead, patient's gender, and the severity of the lines. Many patients report significant improvement of tension and migraine headaches following injections in this area. Forehead injections should be used with caution in patients older than 65, to avoid droopiness of the eyebrows.

CROW'S FEET

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These lines radiating from the outer edge of the eyes resemble crow's feet, particularly during smiling and forceful eye closure. They are caused by the contraction of the orbicularis oculi muscle, a thin and circular muscle that surrounds the eye. BtxA can be used to diminish these crow's feet-like lines by relaxing this muscle. Typically, 10-18 units of Botox are needed per side.

BUNNY LINES

These are fine lines that show up on either side of the nasal bridge. They are caused by repeated squinting, smiling and sniffing. Around 5 units of Botox or the equivalent units of Dysport or Xeomin on either side of the nasal bridge will allow these muscles to relax.

CORNERS OF THE MOUTH

This treatment intends to straighten the downward turning corners of the mouth that are sometimes more accentuated with aging, giving the person a depressed appearance. Around 5 units of Botox injected into the muscles that pull the angle of the mouth excessively downwards (the Depressor Anguli Oris or DOA muscle) will allow the corners of the mouth to turn upwards.

BROW LIFT OR BROW BALANCE

BtxA when injected at the lateral sides of the eyebrows has the ability to sculpt the brow and provide a beautiful lateral lift, a "chemical eyelift." Although not typically performed, strategically and carefully placed Botox injections will contour the position of the eyebrows, create a pleasing arch, and give a rested and more alert appearance to the eyes. The procedure can also be applied to even out asymmetric eyebrows; for example, if one eyebrow is higher than the other. 2-5 Botox units are usually used in this area.

SMOKERS LINES

These refer to the vertical lines that appear on the skin part of the lip. They and are commonly but not necessarily associated with smoking. Ideal patients for Botox injections have a few large but not highly etched-in wrinkles. It should be noted that Botox should be only administered in conservative doses (0.5-1 U per wrinkle) to minimize weakness in this area, as lips have an essential role in critical facial functions. Combination treatment with fillers like Juvederm or Restylane may be required for optimal results in these patients. Even when used in appropriate doses, botox injections in this area may sometimes prevent patients from being able to drink through a straw or whistle. For very deep lines or numerous very fine lines, deep laser resurfacing will be the treatment of choice for effective, long term results

Jawline Reduction and Facial Slimming

This is a Botox injection technique to reduce the flare and width of a wide jawline without resorting to surgery. Reducing the appearance of a wide jawline or slimming of the lower face can help establish improved facial harmony and soften a more masculine and angular appearance of a square face into a more oval and feminine one. Some people are genetically predisposed to have wide jawline; others develop it through habits like teeth grinding and frequent gum chewing. Weight lifters and body builders may also overdevelop their masseter muscle. The masseter muscle is the main muscle responsible for chewing, teeth grinding and clenching. The most important criterion to decide if you are a good candidate for jawline reduction is the thickness of your masseter muscle. Another important aspect to investigate relates to your habits that may predispose you to have a larger masseter muscle and flared jawline. You can easily determine if your chewing muscle is enlarged by biting down hard and feeling the outer jaw line near the ear. When Botox is injected into the masseter muscle it partially relaxes it. The underused muscle eventually loses its mass and shrinks. Botox injections of the masseter requires no anesthesia or downtime and takes about 6 weeks before you see the difference. Typically, about 25 units of Botox, or equivalent Dysport and Xeomin units, are required per side. Results will last between 6 months to a year and a half depending on several factors. Although rare, few patients may experience some tiring feeling after chewing for a while. This phenomenon is only temporary and will go away over time.

GUMMY SMILE

This treatment is ideal for people with high smile lines and short upper lips who wish to show a little less of their gums (but still show their teeth) when they smile. It is a simple and minimal treatment with botulinum toxin to relax the upper lip slightly, thus reducing the amount of gum show at smile. The lower lip can also be treated, though this is a less common problem area.

WRINKLED AND DIMPLED CHIN

Also known as peau D'orange chin, this is a chin that gets wrinkled up during talking, smiling and eating. It can be easily corrected by injecting 5-10 units of Botox into several points at the base of the chin. Wrinkles smooth out as the underlying muscles relax.

NECK BANDS

As some people age, the sheet like muscle underneath the neck skin, known as the plastysma, separates into bands creating vertical cords. These bands, and to a less extent the horizontal lines of the neck, can be temporarily improved with the muscle-relaxing effect of Botox injections. Typically 10 units of Botox, or the equivalent Dysport or Xeomin units is injected per band. This procedure is particularly suited to individuals who do not have a lot of excess neck skin. When excessive looseness of the neck skin is present, a surgical neck-lift is the most effective treatment.

TEETH GRINDING

Teeth grinding or bruxism is a problem that afflicts a large percentage of people. Those that only grind at night won't even be aware of it, unless told by someone or their dentist notices that they are wearing down their teeth. Teeth grinding can result in headaches, earaches, facial pain, chipped-teeth and may enlarge the masseter muscle, giving rise to a square face and wide jawline. 20 units of Botox injections per masseter muscle, or equivalent units of Dysport or Xeomin, may help individuals with severe bruxism who haven't responded to traditional treatments, such as bite blocks that keep teeth from coming together at night. Results from Botox treatment of bruxism start a day or two after injection and improve as the masseter muscles shrink over the following few treatments. The treatment does not interfere with chewing, smiling or anything else, because the injected dose of Botox is relatively small, but big enough to stop the cycle of bruxism. It should be noted that patients treated for teeth grinding have also reported a marked reduction in their general stress level.

NASAL FLARE

Refers to aesthetically unappealing flaring up of nostrils in situations such as anger, emotional upset, and also as a habit. A unit of Botox administered to each side of the nostrils in the region of the levator alae nasi will usually stop these unattractive nasal flares.

EXCESSIVE SWEATING

Excessive sweating, or hyperhidrosis, is caused by stimulation of the sweat glands by nerve endings which descend from higher centers in the brain. Excessive sweating on the forehead, armpits, underarms, palms, scalp and soles is a common problem that can be very annoying and socially handicapping. Topical treatments can work by reducing sweating in these regions, but not in everyone. These products can be irritating with continued use and are largely ineffective in people with excessive sweating. Oral medications currently used for excessive sweating often provide relief but can cause dry mouth, blurry vision, and other side effects. Tap water iontophoresis is only mildly effective for severe cases, and surgical alternatives are associated with pain, scarring and may result in permanent skin numbness. Individuals who have failed topical treatments may be eligible for BOTOX therapy for their excessive sweating. Botox treatments can help excessive sweating (hyperhidrosis) including underarm sweating and facial sweating, with results lasting between 4 to 8 months.

CHEST REJUVENATION

Some women may exhibit wrinkling of the central mid chest (décolleté) with aging. Botox injections can successfully reduce and eliminate these wrinkles.

HOW DOES IT WORK?

It works by reversibly targeting the small muscles of the face and damping down their contraction, thus softening lines and wrinkles. Botox also works in a similar way on sweat glands to stop the production of sweat.

WHEN WILL IT START WORKING AND HOW LONG DOES IT LAST?

Patients usually notice the clinical effect 1-3 days following BTX-A injections, and the effect is maximal by 1-2 weeks. The clinical results can vary depending on the skill of the practitioner, the nature, dose and concentration of the product, the frequency of the injections, the nature of the injected muscle, as well as the quality of the skin. For instance, a higher dose for a particular area might be needed if the interval between treatments is much longer than recommended.

The benefits of Botox, Dysport, and Xeomin treatments typically last 3-6 months, except when used for jaw reduction. Surprisingly, jaw line reduction results are slow to show, but usually last more than a year. Younger patients may also experience longer lasting benefits due to the better quality of their skin. Treatments can be repeated as the effects of BTX-A wear off. Deeper wrinkles may require 1 to 2 additional sequential sessions before the best results are seen. In select cases, it may be necessary for the patient to have additional procedures, such filler injections, for optimal results. It is not immediately reversible but always gradually wears off.

IS EVERYONE SUITABLE FOR BOTOX TREATMENT?

There are some groups of people who should not have Botox treatment. These include pregnant women, women who are currently breastfeeding and anyone with a neuromuscular disorder such as MS, myasthenia gravis or Eaton Lambert syndrome. In addition, people on certain medication may not be suitable for treatment. Liz will take a full medical and drug history from you as part of your assessment appointment to ensure that treatment is both safe and suitable for you. See our fact sheets in the LK Library for more detail.


WHAT TO EXPECT DURING INJECTION SESSIONS?

You will be asked to remove any makeup before Dr. Kelleher starts injecting Botox, Dysport, or Xeomin. This will help Dr. Kelleher identify and avoid the veins at injection sites that are prone to bruising, like the crow's feet area.

During the actual procedure, you will be placed in a sitting position. The areas to be treated will be cleansed and topical ice applied to help shrink the blood vessels and desensitize the skin. Just before the injections, Dr. Kelleher will ask you to repeatedly contract and relax your problematic muscles. Dr. Kelleher will then assess the thickness and quality of your skin, the thickness and size of the underlying muscles, and determine the most appropriate dose and point suitable for the injections. Finally, Dr. Kelleher injects the targeted muscles with the finest possible needle, thus minimizing discomfort and bruising. In the unlikely event that skin bleeding occurs, you will be asked to apply manual point pressure. This helps minimize the extent of bruising. Makeup may be applied as soon as the bleeding stops.

DOES BOTOX TREATMENT HURT?

The treatment consists of a small number of tiny injections, given with a minimum of discomfort, which cause relaxation of the targeted muscles. There may be a small amount of swelling and redness afterwards but this generally settles very quickly.

IS BOTOX TREATMENT SAFE?

Yes, as long as you are medically suitable it is extremely safe.

Although Botulinum, the neuromuscular blocking toxin in Botox is associated with botulism, there is no danger of botulism from Botox , because botulism is caused by very large amounts of the toxin in the system, usually from eating contaminated food. Very high doses, often 100 times more than would normally be used, would have to be injected to cause harm and botulism.

In fact, risks are very minor when Botox is used for cosmetic purposes. As of today, no serious issues have been reported among adults who have received botulinum products, such as Botox, Dysport or Xeomin, for cosmetic uses. Adverse effects are usually mild and transient. The most common substantive complication is excessive weakness of the treated muscles, and this resolves as the action of the toxin wears off. Complications such as brow ptosis, eyelid ptosis (Eyelid sagging), neck weakness are usually due to injector error or lack of injector experience. All of these effects are reversible, and fade with time. If you have eyelid drooping after a Botox procedure, it is a good idea to let Dr. Kelleher know because there are medicines available that may alleviate this condition. Ptosis can be treated with apraclonidine 0.5% eyedrops. Phenylephrine (Neo-Synephrine) 2.5% can be used when apraclonidine is not available. Note that Neo-Synephrine is contraindicated in patients with narrow-angle glaucoma and in patients with aneurysms. Any other difficulties, such as difficulty breathing or rashes, should be reported to Dr. Kelleher.

The most common side effects of Botox used in cosmetic surgery are temporary soreness or mild bruising around the injection sites. Bruising can occur, particularly if a small vein is lacerated or a patient has taken aspirin, vitamin E, or NSAIDs, or has consumed alcohol on the day of injections or the few days preceding the treatment. Ideally, patients should stop taking these products 1 week before the procedure. Applying ice to the injection sites before and after treatment may decrease the pain and the risk of swelling and bruising. Some people may experience a slight headache that lasts for several hours after treatment.

Contraindications include prior allergic reaction and injection into areas of infection or inflammation. Botox injections are contraindicated for patients with allergic history to egg albumin. Botox injections are not recommended in pregnant or breastfeeding women. However, many patients have been unknowingly injected during pregnancy and to date no fetal injury or birth defects have been reported in these cases. Nonetheless, to be on the safe side, delay of injections is recommended until pregnancy is complete and breastfeeding has ended.

Botox should be used with caution by patients taking certain medications that decrease neuromuscular transmission, such as aminoglycosides, penicillamine, quinine, and calcium channel blockers. Ask your doctor about possible interaction with these medications before a treatment. Patients with certain neurological disorders, such as myasthenia gravis, ALS, or LAMBERT-EATON syndrome could be at an increased risk of side effects. See the Patient Information Leaflets in the LK Library for detailed information.

WHAT IS THE AFTER CARE LIKE?

For most practical purposes Botox, Dysport, and Xeomin injections are considered lunchtime procedures, so people can return to normal activities immediately after the treatment. However, it is advisable for patients to avoid lying down for 2-4 hours after a treatment, as well as avoiding vigorous exercise, hot showers, sauna and bathtub. These activities may lead to excess blood congestion in injected areas and wash out the medication before it has a chance to interact with the targeted muscles. Furthermore, manual pressure should not be applied on certain injection sites, like the frown line (glabella), in order to avoid diffusion of the injected medication toward the upper eyelid area which may consequently lead to droopy eyelids. See the Botox after care sheet in the LK Library.

I DON'T WANT A FROZEN FACE!

Botox has had a bad reputation in the past for producing the 'frozen face' look. This is very much down to the "workman" not the "tools". Liz is very keen to avoid this unnatural look and does so by not over-treating and so maintaining some natural looking movement while softening lines. It should not be obvious to people that you have had treatment – only that you look rested and fresh.