What is " Botox "

Reviewed By:
Mary Ellen Luchetti, M.D., AAD
Sandeep Singla, DDS, MD

Botox (Botulinum Toxin Type A) is the brand name for a cosmetic treatment that temporary improves facial lines (wrinkles) between the eyebrows and in other areas. It is a sterile, purified form of the Clostridium botulinum, a bacterium that contains the toxin responsible for food poisoning. Saline is added to Botox to dilute its potency before use, in varying amounts according to the physician.

Normally, the brain sends electrochemical messages to the muscles, causing them to contract and move. These messages are sent from a nerve to the muscle by a substance called acetylcholine. The cosmetic use of Botox works by producing a protein that blocks nerve signals to muscle, causing paralysis of the injected muscle. It stops the release of acetylcholine from the nerve which relaxes the muscle. This greatly reduces, and in some cases prevents, movement of the muscles.

It takes 24 to 48 hours for the muscle weakness or paralysis to develop. The results, however, are not permanent. After about two to six months, the nerve will recover and start releasing acetylcholine again, causing the muscles to become active. At this point, the patient will require a new injection of Botox.

Botox was originally used to treat muscle disorders, including facial dystonias, uncontrolled blinking and lazy eye. In addition, fewer units per injection of Botox may be used to treat hyperhidrosis (a disorder characterized by excessive sweating) by paralyzing sweat glands in the underarms, hands and feet. Botox was approved for cosmetic use in the United States by the U.S. Food and Drug Administration (FDA) in 2002.

Studies have suggested that Botox can be effectively used as a treatment for a number of other conditions, including migraine headaches, overactive bladder, tennis elbow (lateral epicondylitis) and enlarged prostate. However, additional research is needed to determine the safety and effectiveness of using Botox to treat these conditions.

Wrinkles that appear across the forehead, between the eyebrows (glabellar lines), around the eyes (crow’s feet) and on the bridge of a person’s nose are the result of muscle movement (e.g., frowning, squinting) over time. Muscle bands on the neck may also become visible with age. When Botox is injected into these wrinkles, it temporarily reduces the contractions of the underlying muscles. This diminishes the appearance of wrinkles for up to 120 days, according to the FDA.

Improvement in the appearance of wrinkles will vary according to the practitioner performing the injections and the depth of the facial lines. Botox is not typically used for lines around the mouth because the underlying muscles in this region are needed for essential functions, such as talking and eating. It is important to note that Botox injections will not radically alter a patient’s facial appearance or affect their ability to make facial expressions.

There are some effects from aging that cannot be temporarily remedied with Botox. Excess fat around the face, loss of skin elasticity and decreased muscle tone will not respond to treatment with Botox.

According to the American Society for Aesthetic Plastic Surgery (ASAPS) 3,181,592 Botox injections were given in 2006. It was the leading cosmetic procedure (both surgical and nonsurgical) among both men and women. The treatment is indicated for use by adults between the ages of 18 and 65.

There is growing controversy in the medical community over the mass treatment of patients who attend “Botox parties.” During these gatherings, individuals socialize with one another, consult with a Botox practitioner and receive injections of the toxin. Some practitioners contend that Botox parties are a good way for patients to receive more affordable injections in a more relaxed atmosphere. However, critics claim that the bulk distribution of Botox is potentially dangerous because each vial of Botox is intended for a single patient during a single treatment session, and there is no preservative in Botox to prevent contamination if a single vial is used repeatedly. In addition, Botox parties often involve the consumption of alcoholic beverages, which may intensify bruising in some patients.

In addition, the FDA is growing concerned that there is a great potential for Botox abuse. Recent ASAPS reports indicate that Botox is being dispensed by unqualified people in home-based offices, hotel rooms, gyms, salons and other retail settings.

Currently, Botox is the only drug of its kind available for use in the United States. However, other similar drugs are presently awaiting FDA approval for use in the United States. One such drug, Myobloc (Botulinum toxin type B), has been approved for the treatment of cervical dystonia (muscle spasms in the neck) and patients may consent to “off-label use” of the drug for cosmetic purposes. The term “off-label” refers to the use of approved drugs for a purpose other than which it was originally intended, and that was not approved by the FDA.

Before, during and after the Botox procedure

Botox injections are increasingly being administered by non-medical practitioners. However, the U.S. Food and Drug Administration (FDA) recommends that patients interested in receiving Botox consult a qualified physician (often a dermatologist) because results may vary depending on who administers the injections. The physician will compile a complete medical history, including a list of current medications and allergies, to determine if the patient is a good candidate for Botox injections (e.g., does not have droopy eyelids, neurological, muscular disease). If the patient is deemed an appropriate candidate, the physician will describe the procedure in detail. It is important that the physician inform patients about the capabilities of Botox so they do not have unrealistic expectations going into the procedure. Although Botox can temporarily relax certain facial lines (wrinkles), it cannot actually erase them. This means that superficial facial lines will practically disappear, and deeper facial lines will appear shallower after treatment. Botox may also help prevent new facial lines from forming. A photograph may be taken at this time for comparison after the procedure. Before Botox injections are administered, the patient is placed in an upright position on an examination table. The patient may be asked to contract the muscles in the area being treated. This enables the physician to determine the correct location for the injection. The future injection sites are cleansed with a nonalcoholic solution, and a topical anesthetic may be applied to the skin. In some cases, the area to be injected can be iced to decrease the discomfort associated with skin penetration by the needle. The physician then injects the Botox directly into the muscles that cause the facial lines. Typical patterns of Botox injection include two or three areas around each eye and four to five areas on both sides of the patient’s forehead. Depending on the skill of the physician, the type of wrinkles present and the desired effect, additional areas may be injected. If a site appears to bleed after injection, pressure may be applied to the affected area. Discomfort during Botox injection is typically brief and minimal, and the entire procedure normally takes approximately 10 minutes. After the procedure, the patient will usually be instructed to lay semiupright or upright on the examination table for approximately two to five minutes to ensure that the injections did not produce any ill effects. It is recommended that patients avoid lying down for up to four hours after Botox injections have been administered. There is no downtime required after the procedure and patients can immediately return to work and resume normal daily activities. To avoid or reduce bruising, patients should refrain from using aspirin and related products (e.g., ibuprofen), clopidogrel and warfarin after the procedure. They should also avoid manipulation in the treated area for several hours. This reduces the movement of Botox, which can cause ptosis (eyelid droop). Patients can apply make-up to the area after treatment. Some physicians recommend that patients work the injected area several times in the days that follow the procedure, whereas others instruct patients to avoid using the affected muscles for several days after the injections. To date, no studies have been conducted to determine which course of action produces the most desirable results. Potential benefits and risks of Botox Benefits of Botox injections include a reduction in facial lines (wrinkles) and a more youthful appearance. Botox may also effectively treat certain medical conditions. For example, individuals who receive Botox injections to treat hyperhidrosis (a disorder characterized by excessive sweating) may experience a decrease in sweating. Very few risks are associated with Botox injections administered by a qualified physician. Though uncommon, tenderness, burning, numbness and mild bruising may occur around the site of injection. The procedure may also result in pain, headache, flu-like illness, nausea and rash. Rarely, drooping of the eyebrow area or eyelid or dry eye may occur. Risk of severe eyelid drooping (ptosis) or ectropion (condition in which the eyelid turns outward) is minimal. Individuals may experience double vision (diplopia) in very rare instances. When Botox is injected into the neck, patients may experience drooling, bruising, weakness of neck muscles, drooping of the corner of the mouth and difficulty swallowing (dysphagia). Injections into the lower portion of a patient’s face may result in lip drooping or asymmetry of the mouth. Pain, temporary muscle weakness and coughing may occur when Botox is used to treat hyperhidrosis. Patients are urged to report these and any other unusual symptoms to their physician. There are a number of medications that may interact with Botox. These include antibiotics, heart medicines and those used to treat Alzheimer’s disease. Patients are advised to fully inform the physician of all medications or supplements (e.g., vitamins) that are used before exposure to Botox. Because Botox is prepared with an egg (albumin) base, it is not indicated for individuals who are allergic to eggs. Patients with immune system disorders should also avoid the treatment. In addition, Botox is not recommended for women who are or may be pregnant or those who are breastfeeding. It is unknown whether Botox can negatively affect the fetus or whether it is found in breast milk. The effects of Botox on children and the elderly are also not known. Patients should notify their physician if they have any of the following: Neurological or muscular disease Heart problems Infection, swelling or muscle weakness in the injection site Previous allergic reaction to Botox History of botulism infection Swallowing problems