What is Botulinum Toxin?

Botulinum toxin is a nerve poison produced by the bacteria Clostridium botulinum. It is the cause of a serious type of food poisoning known as botulism. Whilst Botulinum toxin is an extremely potent poison, in very small doses it is very safe and useful for treating facial lines.

Botulinum toxin type A is used for the treatment of facial wrinkles and is available in two commercial forms - Dysport and Botox. These two varieties of botulinum toxin have the same clinical effects but are administered in different doses. Throughout the rest of this article the term Botox will be used to mean Botulinum toxin type A, without preference to either of these commercially available toxins.

What Causes Facial Lines?

These are the result of internal factors, such as your genes, the ageing process and muscle activity/overactivity. External factors such as sun damage, the effects of gravity and smoking are also important. Excess sun exposure can be reduced by the use of sun blocks and avoiding strong sun. Smoking can also be avoided. The patient cannot influence most of the other factors in the appearance of facial lines and wrinkles.

Which Facial Lines Are Suitable For Treatment With Botox?

Botox treatment can help the appearance of facial lines due to activity/over activity in the small muscles of the face. Botox can also improve the appearance of deep facial lines associated with facial expressions. Botox is not effective for the treatment of, so called static lines. Static lines are lines that do not disappear when the skin around the line is stretched out under tension.

Which Sites Of Facial Lines Are Most Amenable To Botox Treatment?

• Glabella - the glabella is the area between your eyebrows and bridge of the nose. Vertical and horizontal lines in this area are common. The presence of these lines is ageing and also may be taken to imply a person is tense or frowning. Glabella lines are readily treated with Botox.



• Forehead - horizontal forehead lines are also amenable to Botox treatment. These lines are also ageing and may convey the appearance of stress or surprise.



• Crows feet - crows feet or laughter lines around the outside of the eye respond well to Botox treatment.

All of these lines are due to contraction of the underlying small muscles of the face. The aim of Botox treatment is not to paralyse these muscles but to weaken them so their effect on the skin is less marked.

What is Botox?

The Botox preparations available come as a sterile freeze dried powder. This powder has to be stored in a deep freeze until it is used. The doctor adds a small amount of sterile saline prior to injection.

Treatment of wrinkles with Botox is considered "off label". This means that the American Federal Drug Agency and the British Committee for Safety of Medicines has not yet licensed Botox for the treatment of facial wrinkles. Botox is licensed for the treatment of squints and eyelid spasm. However, Botox is widely used to treat facial lines and has been demonstrated, in the medical literature, to be safe.

How Does Botox Work?

Tiny amounts of Botox are injected into the small muscles of the face that are responsible for wrinkles in the overlying skin. The toxin produces temporary weakness in the muscles by interfering with the normal nerve-muscle connection.

How Is Botox Treatment Performed?

The doctor will mark the injection sites to be treated. A local anaesthetic cream (EMLA) may be used if desired prior to treatment. Tiny amounts of Botox solution are injected into the appropriate muscles. Botox administration is an out-patient procedure and takes about thirty minutes

Effect of Botox

Botox takes between twenty-four and forty eight hours to show an effect. The peak effect will not be seen for seven to ten days. At this stage patients will notice smoothing in the facial lines treated.

Limitations Of Botox Treatment

Whilst Botox is very effective in the treatment of facial lines there are some limitations.

Botox treatment is temporary. For most patients it will be effective for three to six months after the first procedure. Repeat treatments seems to have a longer gap before Botox is needed again. Botox will not remove static wrinkle lines. Botox is best for the upper face and should only be used with extreme care in the lower face. Use in the lower face risks weakness around the mouth.

There are a small number of patients who do not respond to Botox treatment. It is not clear why these, so called non-responders exist; they may have had a very minor form of botulism and, therefore, have antibodies to the toxin.

Side Effects Of Botox

There are no known permanent side effects of botulinum toxin.

The following is a list of problems that rarely complicate botulinum treatment: -

• Eyebrow and eyelid drooping - These complications occur in 1-2 %of patients and usually last two to four weeks. If the drooping eyelid is a problem eye drops can be administered to correct it.



• Double vision 1-2 % - Lasts two to four weeks; may need to patch the effected eye.

These two complications are probably due to injection of the toxin too close to the eye socket.

The following minor side effects may also occur: - bruising, headache, asymmetry and change in sensation.

Who Should Not Have Botox?

The following patients should not have Botox: -

• Pregnant women, nursing mothers. Whilst no adverse effects from the administration of Botox to these groups have been reported this has not been extensively researched and it would be inappropriate to use Botox in these patient groups.



• Patients taking certain antibiotics (Aminoglycosides) calcium channel blockers (eg Verapamil and Nifedipine) and Penicillamine.



• Patients with certain neuromuscular disorders (eg. Multiple sclerosis) should not have Botox.