Botox and expression lines
The wrinkles of the upper third of the face are almost exclusively caused by the contractions of the facial expression muscles. These so-called expression lines are caused by the involuntary contraction of small facial muscles that act every time we smile, laugh, think deeply or express an emotion with our faces. In time these lines can become actual wrinkles that are present even at rest.
Today it is possible to reduce these wrinkles considerably using a pharmaceutical product. Botulinum toxin (Botox® is the name by which it is universally known, but the pharmaceutical products that are authorized for aesthetic use are called Azzalure®, Bocouture® and Vistabex®) and in fact are drugs that derive from a protein of a bacterial origin that, when injected into the facial expression muscles, is able to cause them to weaken temporarily by reducing their contractile activity, thus softening the wrinkles and expression lines.
What is the botulinum toxin?
Botulinum toxin is a drug that has been used for about 20 years in ophthalmology to cure squinting and in the field of neurology to correct muscular spasticity. Since the beginning of this century the Ministry of Health has authorized its use in aesthetic medicine and surgery for the treatment of facial expression wrinkles, in particular for those between the eyebrows. Another non-aesthetic dermatological use, but one that has important use in personal relationships is linked to excessive perspiration (hyperhidrosis) of the armpits, hands and feet.
Botulinum toxin acts in blocking the nervous transmission between the nerve and the fine expression muscle that causes the wrinkle. In this way we act on the cause of the formation of the wrinkles and the skin, as a result, is more relaxed and the face more rested. The best results are obtained on the horizontal wrinkles on the forehead, on the vertical ones between the eyebrows, and on the periocular ones (“crow’s feet”). Our philosophy induces us to prefer a very light correction, which is only able to weaken the muscolature but not to paralyze it, so that the face maintains its mobility and expressivity, appearing just more relaxed and luminous. Actually the most appreciable result of the treatment is the relaxed aspect of the area treated, which is in natural harmony with the context of the face’s features, giving luminosity and fullness mainly to the expression of the eyes and to the eyebrows, without changing their normal expressivity. The drug has little or no effect on wrinkles caused by photo-ageing or by posture and does not act on sagging of the skin, so that it is not suitable for those patients in which there is considerable sagging of the skin or excessive skin and it does not substitute treatments like skin resurfacing with lasers, or surgical lifting of the face.
Treatment with botulinum toxin
After an accurate study of the static and dynamic muscular anatomy of the patient, the treatment consists of injecting small quantities of the drug, thanks to a syringe fitted with a very small needle. No anaesthetic is necessary and in a few cases only, the injections leave a modest redness for several minutes. The pharmacological effect of the substance begins to produce appreciable results after 2-3 days and reaches it maximum effect after 20-30 days. Since the result is not immediate, it is indispensable to have a check-up, with a touch-up, if needed, 2-3weeks after the treatment. The effect of the drug is temporary and lasts from 3-7 months depending on the person. Subsequently the effect slowly disappears and the treatment can be repeated. After several treatments there is a certain stabilizing effect of the results due to the reduction of many involuntary movements that the brain “forgets” after the treatments.
It is important not to repeat the treatment before time so as not to compromise the capacity to respond and therefore to go on obtaining better and better results (it is a good rule not to undergo treatment more than 2-3 times a year). In certain cases just the treatment with botulinum toxin is sufficient (folds and fine lines) but in the case of particularly deep folds, the result can be further improved with the subsequent implant of a filler. In some cases it is possible, with the use of the drug, to achieve a slight modification in some features, and in particular it is possible to obtain a certain lifting of the eyebrows. Botulinum toxin has few but significant contraindications (these are pre-existing situations that advise against the treatment) such as myasthenia gravis and all the neurological syndromes with a reduction of contractile strength and some other neurological diseases. Its use is also not recommended in pregnancy or when breast-feeding.
Side effects of botulinum toxin
The most common side-effect is the possibility of the injection marks remaining visible for a few hours (it is rare to have bruising). Sometimes a headache may occur following the treatment, but it is readily curable. In rare cases there can be a modest lack of symmetry in the expression of the face, (correctable with the same drug) or the involvement of adjacent muscles, the most important of which is the muscle of the eyelid, with a reduction in opening the eyelid itself, a phenomenon that is reversible in the space of a few weeks (2-4) All the effects of the drug, including the side-effects, are always, in any case, reversible.
Urban legends on botulinum toxin
Botulinum toxin represents a very effective and safe treatment, and it is considered, all over the world, to be the first choice drug to treat the ageing of the face. In Italy, for unfathomable reasons, a long series of metropolitan legends has arisen on botulinum toxin which are based on gossip steeped in pseudoscience, which have led people to look at this drug with suspicion…
“It is a poison”…: the botulinum toxin based products are drugs, and as such are classified by all the ministries of health and world organizations which control all pharmacologically active substances. This means the careful and scrupulous monitoring of all of the possible side-effects or adverse occurrences. Up to today there have never been any reports of intoxication with this drug in humans. The fact that the active ingredient derives from a potentially toxic substance is common to many drugs used on a daily basis (for example aspirin). The dosages used in aesthetics are about about100 times less than the dosages that could start to cause symptoms of an intoxication, which means that we would have to administer a dose which is 100 times more than the therapeutic one to cause intoxication. This represents a very high safety margin and a total guarantee for the patient (as a comparison, if we take an anti-inflammatory tablet for a headache or joint pain, our symptoms will be cured. But if we take 100 we are almost sure that this would cause a stomach hemorrhage).
“Through repeating it you poison yourself”…: the effects of the drug are temporary and transitory and there are no accumulation phenomena, so that the treatment can be repeated indefinitely without any risks. The drug is not composed of natural botulinum toxin but of a medicinal speciality that contains minimum quantities of the active ingredient (about four thousand millionths of a gram) and does not contain the spores of the bacterium. There are patients who have been treated with it for 20 years without any problems.
“It can paralyze”…: “it should paralyze”!! one might say! Muscular paralysis is exactly the pharmacological effect required. In reality, in aesthetics a moderate use is made of it and we never want to obtain the effect of paralysis, but rather the remodeling of the altered muscular equilibriums.
“It is a new treatment, the long term effects are unknown”…: the use of botulinum toxin in aesthetics has been authorized since 2002, but the drug has been used in neurology and ophthalmology since the 1980s, after more than 10 years of pre-clinical tests. There are patients in the world today who have been treated for more than 20 years (above-all for muscular spasticity) and who have had no long term adverse effects.
“It can cause cancer”: this is gossip referred to many substances used in medicine and not probably due to an ancestral fear of tumoral diseases. But there is no scientific proof at all in this direction.
“There have been cases of intoxication”: in 2005, in Florida, four people each received about 8 million units of laboratory toxin (a dosage that is about 3000 times above the lethal injectable dose estimated for man). These people showed the symptoms of classic botulism and it was necessary to hospitalize them and place them on artificial respiration, but they all survived. It is important to stress that the neurotoxin that was injected in this case was not the drug for human use but a raw laboratory product and that its inoculation was carried out as a test that was outside any form of control.
“It goes to the brain”: a recent experimental study on mice, with a laboratory drug and dosages that were well over the therapeutic levels, was carried out by injecting the drug directly into the central nervous endings, showed that a product deriving from the metabolism of the drug was identifiable in the nervous system. But this is quite normal!!! Probably, if it had been injected into the paws it would have been found in the paws, and if it had been injected into the tail it would have been found in the tail… Treatments with medical purposes (not only aesthetic) are designed to be injected into the peripheral muscles and it has never been proved that there is any migration of the effect of the drug at a distance.
“It has a pulling effect”: in reality the effect of the drug is not to contract but rather to relax the muscles treated. The effect of pulling depends on the muscles that are not treated. It is up to the physician’s skill to produce tension with a resulting lifting effect. To obtain this effect the injections must be carried out in completely different points from where most people think.