Overview

Botox is used medically to treat certain muscular conditions, and cosmetically to remove wrinkles by temporarily paralyzing muscles. It is made from a neurotoxin called botulinum toxin that is produced by the bacterium Clostridium botulinum. Although Botox is a powerful poison, when used correctly, it has a number of applications.

Fast Facts On Botox:

Botox is the most popular non-surgical cosmetic treatment, with more than 6 million Botox treatments administered each year.

Botox is a neurotoxin derived from Clostridium botulinum, an organism found in the natural environment where it is largely inactive and non-toxic.

Botulinum toxin is used to reduce fine lines and wrinkles by paralyzing the underlying muscles.

People also use Botox to treat excessive sweating, migraines, muscular disorders, and some bladder and bowel disorders.

Botulism, an illness caused by botulinum toxin, can cause respiratory failure and prove deadly.

Just 1 gram of botulinum toxin could kill over 1 million people. Two kilograms could kill the entire human population of Earth.

What Is Botox?

Clostridium botulinum, the bacterium from which Botox is derived, is found in many natural settings, including soil, lakes, and forests. The bacterium can also be found in the intestinal tracts of mammals and fish and in the gills and organs of crabs and other shellfish. Such naturally occurring instances of Clostridium botulinum bacteria and spores are generally harmless. Problems only arise when the spores transform into vegetative cells and the cell population increases. At a certain point, the bacteria begin producing botulinum toxin, the deadly neurotoxin responsible for botulism. Neurotoxins target the nervous system, disrupting the signaling processes that allow neurons to communicate effectively.

How Does Botox Work?

Botulinum toxin is one of the most poisonous substances known to man. Scientists have estimated that a single gram could kill as many as 1 million people and a couple of kilograms could kill every human on earth. In high concentrations, botulinum toxin can result in botulism, a severe, life-threatening illness. Botulism, left untreated, may result in respiratory failure and death. Despite botulinum toxin being so toxic, Botox is in huge demand. Despite this, botulinum toxin has proven to be a successful and valuable therapeutic protein. Botulinum toxin can be injected into humans in extremely small concentrations and works by preventing signals from the nerve cells reaching muscles, therefore paralyzing them. In order for muscles to contract, nerves release a chemical messenger, acetylcholine (a neurotransmitter), at the junction where the nerve endings meet muscle cells. Acetylcholine attaches to receptors on the muscle cells and causes the muscle cells to contract or shorten. Injected botulinum toxin prevents the release of acetylcholine, preventing contraction of the muscle cells. Botulinum toxin causes a reduction in abnormal muscle contraction, allowing the muscles to become less stiff.

Usefulness Of Botox

Botulinum toxin is predominantly used as a treatment to reduce the appearance of facial wrinkles and fine lines. Beyond aesthetic applications, Botox is used to treat a variety of medical conditions, including eye squints, migraines, excess sweating, and leaky bladders. Botulinum toxin is currently used to treat over 20 different medical conditions, with more applications under investigation.

Botulinum toxin is currently approved for the following therapeutic applications:

• Blepharospasm (spasm of the eyelids).
• Idiopathic rotational cervical dystonia (severe neck and shoulder muscle spasms).
• Chronic migraine.
• Severe primary axillary hyperhidrosis (excessive sweating).
• Strabismus (crossed eyes).
• Post-stroke upper limb spasticity.
• Detrusor (bladder wall muscle) overactivity – causing urinary incontinence.
• Overactive bladder.
• Hemifacial spasm.
• Glabellar lines (frown lines between the eyebrows).
• Canthal lines (crow’s feet).

Botulinum toxin is also used off-label (not approved) for:

• Achalasia (an issue with the throat that makes swallowing difficult).
• Anal fissure and anismus (dysfunction of the anal sphincter).
• Sialorrhea (producing too much saliva).
• Allergic rhinitis (hay fever).
• Sphincter of oddi (hepatopancreatic) dysfunction (causes abdominal pain).
• Cerebral Palsy.
• Oromandibular dystonia (forceful contraction of the jaw, face, and/or tongue).
• Laryngeal dystonia (forceful contraction of the vocal cords).

Botulinum toxin is sold commercially under the names:

• Botox, Vistabel, Botox cosmetic (OnabotulinumtoxinA or botulinum toxin type A).
• Dysport (AbobotulinumtoxinA or botulinum toxin type A).
• Bocouture, Xeomin (IncobotulinumtoxinA or botulinum toxin type A).
• Myobloc (RimabotulinumtoxinB or botulinum toxin type B).

Botox for Chronic Back and Neck Pain

Botox isn’t just for celebrities anymore — patients with chronic back and neck pain may want to consider using it. The same injection that works to smooth out wrinkles just may work to relieve persistent, life-inhibiting pain caused by muscle tension. In fact, Botox was originally approved by the FDA in 1989 to treat severe muscle contractions caused by cervical dystonia. So before Botox was the new “it” anti-aging treatment, doctors knew it could relax muscles. Botox does that by blocking the neurotransmitters that tell muscles to contract. No signal from the neurotransmitters, no contraction, no tension — no pain.

Procedure

Botox Injection Preparation

Botox comes as a crystalline substance from the manufacturer, which then has to be reconstituted with saline or another liquid. Practitioners add varying amounts of liquid when reconstituting it. Although there is no right or wrong amount of liquid to add, most physicians add about 2 mL-3 mL (about a half a teaspoon) of liquid to each vial. Some add quite a bit more, which can lead patients to think they are getting more Botox when, in reality, they are getting the same or less amount of Botox than samples reconstituted in a stronger way. It is the total dose of medication, not the volume of liquid, that leads to the desired effect. Therefore, it is important to remember that if a clinic or medical spa states that they are providing Botox at a certain dollar amount per unit, it is quite possible that they are diluting the Botox and actually not providing the agreed-upon amount. This is much like the concept of a watered-down drink at a bar, but the costs are much larger when it comes to Botox or its alternatives, Dysport and Xeomin.

During the Botox Procedure

The patient is placed in a somewhat raised position on the exam table, and the areas to be injected are cleansed with a nonalcohol cleanser, such as Hibiclens or Betadine. Some physicians will apply a topical anesthetic, such as EMLA cream or some alternative, at this time. The Botox is then injected into the desired areas. Typical injection patterns include about four or five areas on each side of the forehead and two or three areas on either eye area. More areas can be injected by skilled physicians, depending on the type of wrinkles and the desired effect for the patient. It is common for pressure to be applied if an area seems to be bleeding after the injection. While ice is sometimes applied beforehand for comfort reasons, direct pressure is much more effective than ice for control of bleeding and bruising.

After the Botox Procedure

After the injections, the patient will usually lay upright or semiupright on the exam table for about two to five minutes to make sure he or she feels good after the procedure, and then the patient should avoid lying down for two to four hours. If bruising is a concern, it will be important for the patient to avoid taking aspirin or related products, such as ibuprofen (Advil, Motrin) or naproxen (Aleve), if possible after the procedure to keep bruising to a minimum. There are many physicians who encourage their patients to either work the area several times during the next several days or, alternatively, to not use the affected muscles during the next several days. Many practitioners do not tell the patients to do anything in particular other than to avoid strenuous activity for several hours afterward because of an increased risk of bruising.

Results

Results will be evident within three to 10 days. Photographs may be taken before the procedure so that patients can check their results themselves rather than relying on their memory. It is surprising to see how many people do not recall how they looked before the procedure and are amazed at the difference when shown a picture. Prior to having the procedure done, the patient should realize that Botox does not actually erase lines but relaxes them. What this means is that deeper lines will become somewhat less deep and superficial lines will nearly disappear. This can be likened to the act of steaming a garment’s wrinklesrather than ironing them. It may be necessary for the patient to have additional procedures, such as the use of filler substances (for example, Restylane, Perlane, Juvederm, Sculptra, or Radiesse) in order to plump up the wrinkles that are now relaxed. Additionally, it may be necessary to have two or three sessions of Botox treatment for deeper wrinkles before results become optimal. The area of the crease between the eyes is a particularly ideal area for Botox use in conjunction with filler as these fixed wrinkles don’t always respond optimally to Botox alone. There is some controversy about using filler in that area as it may block veins or arteries and result in loss of blood and a scar to the area. Generally, the smaller particle fillers, such as Restylane or Juvederm Ultra, are best in the area between the eyes for this reason.

Risks and Side Effects of Botox

Injections with botulinum toxin are generally well tolerated and there are few side effects. In rare cases, an individual may have a genetic predisposition that results in a mild, transient unusual response to the drug. Around 1 percent of people receiving injections of botulinum toxin type A develop antibodies to the toxin that make subsequent treatments ineffective. Along with its intended effects, botulinum toxin may cause some unwanted effects. These can include:

• Mild pain, local edema (fluid buildup) and/or erythema (reddening of the skin) at the injection site.
• Numbness.
• Headache.
• Malaise – feeling generally unwell.
• Mild nausea.
• Temporary unwanted weakness/paralysis of nearby muscles.
• Temporary upper lid or brow ptosis (drooping).
• Weakness of the lower eyelid or lateral rectus (a muscle controlling eye movement).
• Dysphagia – trouble swallowing.
• Neck weakness.
• Flu-like illness.
• Brachial plexopathy – a condition affecting the nerves either side of the neck and chest.
• Gallbladder dysfunction.
• Diplopia (double vision).
• Bleeding.
• Blurred vision.
• Decreased eyesight.
• Dry mouth.
• Fatigue.
• Hives.
• Rashes.
• Wheezing.
• Swelling.