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DONALD J. CAPUANO, M.D.
Plastic Surgeon

BOTOX®

approved (circa 6/2002) for cosmetic uses

GENERAL INFORMATION

HOW DOES A WRINKLE FORM ?

HOW LONG BEFORE THE WRINKLES GO AWAY

BOTOX® UPDATE - AN ART FORM

A WORD OF CAUTION

CURRENT COST OF BOTOX®

MANUFACTURER'S BIOLOGY AND HISTORY OF BOTOX®

 

By fortune - BOTOX® - a poison - was found to make wrinkles go away or at least improve them tremendously.

An early word of caution. Millions of injections have been given, but please see below.

BOTOX® is obtained from the Botulinum toxin. Most everyone in the 1900s had heard of Botulism. My mother used to teach - never buy a canned product if the can was bulging. What she knew was that if you did buy the can and if you ate the food - or even tasted the food - you would not be around long. The can bulges because the Botulinum bacteria produces toxin and in the process produces gases. This made the can bulge - a warning that the toxins were present.  Good tip - thanks Mom.

Contrary to the uncontrolled Botulinum bacterium toxin, the amount of toxin used to treat wrinkles is very small. The chance of poisoning from the toxin is almost nil (IF the appropriate product is obtained from the makers of BOTOX®). You would have to be injected with many bottles of toxin (twenty is a ball park estimate). In reality, when you are treated, only a portion of one bottle is used, not twenty full bottles (vials). BOTOX® was recently approved by the FDA (Update 6-2002 FDA approves BOTOX®-Cosmetic® for the treatment of wrinkles in selected areas) for cosmetic treatments and it has been approved for other uses. It has been known to relieve headaches, decrease sweating of the palms and under arm area. In fact - as I hear tell - there was a run on BOTOX® during the 2002 Academy Awards in Tinsel Town. The Hollywood in-crowd had BOTOX® injections in the axillary areas (under arm area) to decrease sweating. The costly designer gowns would not be stained and of course 'looking good' all night long would be possible.

One of the first uses was the treatment of blepharospasm. This started the BOTOX® for wrinkles rage. Dr Caruthers of Ontario, Canada is an ophthalmologist who treated patients with eyelid spasm (blepharospasm). Usually these people develop deep wrinkles because of repeated squinting. She noticed that the wrinkles around the eyes of patients treated with BOTOX® subsided after several treatments. Dr Caruthers happened to be married to Dr Alistar Caruthers, a dermatologist. He began injecting his patients with BOTOX® and the wrinkles started melting as his wife had noted.

While tens of thousands of injections for wrinkles have been administered, studies are still in progress toward FDA approval for wrinkles. (The FDA approval for cosmetic purposes was accomplished around 7/2002. Note that not all areas were approved for treatment. There remains some 'off label' use). It is important that you understand that BOTOX® for some wrinkles is a so called "off label" use. Areas such as the neck, the smile area, around the mouth, may be considered 'off label' use. The risks of treatment are the same for most conditions.

When talking about treatment of wrinkles, one side effect that is bothersome is weakness and drooping of the upper eyelid muscle. The closer BOTOX® is placed near to the eyebrow in the center of the eyebrow, the greater the chance that the BOTOX® can seep down into the lid muscle. This happens reportedly in about one in a hundred patients treated just above the eyebrow in the middle part of the eyebrow. This is the most frequently reported side effect and the most bothersome side effect when used for wrinkles. We have seen it once so far since we began injection in 1999. The patient recovered and requested further treatments. The lid effect did not last the four to six months that BOTOX® usually lasts but for a few weeks. There are drops that can be placed in the eye. These medications have been known to speed the process of recovery.

Another effect of BOTOX® forehead treatment is a change in the configuration of the eyebrows. One of the reasons people raise their foreheads (unbeknownst to them) is to help raise the upper eyelids and help raise the skin so they can see better. As we age the skin of the lids hangs down and the forehead is raised - to try to keep our upper lids as free of excess skin as possible. When the forehead is treated with BOTOX®, the muscles cannot elevate the forehead and eyebrows and eyelid skin as well. Thus it appears that there may be more skin in the upper lids. Really there is no greater amount of skin in upper lids but rather the lid skin is not as pulled upward by the forehead muscle. We had such a patient - our first. If this occurs then you may know that you might soon need removal of some skin on the upper lids (blepharoplasty).

BOTOX® has been used for the past several years now, with the purpose of improving the human 'look' and dampening the effect of aging. The results are remarkable and patients 'love' BOTOX®.

There is never a perfect drug. This is true with BOTOX®. The drug is quite safe in the dosage that is normally used. The major drawback with BOTOX® is that it is not permanent. The action of the medication is to block the nerve impulses and the junction of the nerve at the muscle. This so called 'inhibition' lasts for approximately 4 to 6 months. Individuals differ in their sensitivity to this drug. Individuals differ in the number of nerve endings present. Individuals differ in the amount of stimulus their brain sends to the muscles. Individuals differ in their patterns of expression. These factors, and probably others, play into the longevity of the effect of BOTOX®. Thus the length of time that BOTOX® is effective varies from individual to individual.

In a way, this is good. As noted above, there is one significant problem (known at this time) with BOTOX® when used for wrinkles. When used in the area of muscles situated above the middle portion of the eyebrow, just above the edge of the bone, there can be weakness in the muscle raising the upper lid. This occurs apparently in about one in one hundred cases. Again - if this should occur, the drooping is self-limited but probably a definite problem for a number of months. There are steps taken during injection in this area if needed to try to minimize the chance of such a problem.

 

Other problems have been reported in individuals who have neuromuscular disorders such as myasthenia gravis. If you have a muscle weakness disorder or a so called neuromuscular disease then you should certainly check with your neurologist or personal physician before considering BOTOX® injections.

Injections about the neck in individuals with neuromuscular disorders have been associated with inability to swallow correctly for some time, and so forth. So check if there is any question of a neuromuscular disease process.

The injections are administered while the person is sitting upright. The area is not massaged for six hours after injection. This helps prevent the spread the toxin to unwanted areas. The muscles injected are used during the first few hours after injection so that the injected muscles will take up the toxin. A concentrated amount of toxin is used so that the toxin will not 'overflow' into unwanted areas.

When you are seen in the office you will be asked to read the above material. Subsequently if you decide to go ahead with treatment, you will be asked to sign a consent so that we have a record of your understanding of the treatment and possible problems and complications that are known at this time..

Makeup should be removed before the injections are administered. The areas of concern will be mutually agreed upon by yourself and Dr. Capuano. The injections are usually very well tolerated. A very fine needle is used. Multiple injections will be needed.

The cost of each treatment depends on the number of areas treated. Usually favorite areas that are treated are the areas between the eyebrows, the frown lines. The next most frequently treated areas are the areas around the lids. Other areas that can be treated are areas in and around the mouth. Neck muscles or very prominent muscles may be potential candidates for treatment. A minimal treatment cost is approximately two hundred and fifty dollars. More extensive treatment costs approximately four hundred and fifty dollars.

As mentioned above, treatments are needed if the effect of the medication is desired for long term effect. It HAS NOT BEEN PROVEN BUT IN THEORY AND from our knowledge of muscle function, muscle research and exercise physiology , we know that if a muscle is not exercised for a significant length of time (at least six months to a year), the muscle begins to atrophy. This means that the muscle loses its muscle cells and becomes smaller in size. Some of the muscle fibers can turn into scar tissue. The net effect of this is that the force of the muscle contraction is less and thus the effect on the skin is a decreased in the number and depth of wrinkles.

 

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HOW DOES A WRINKLE FORM ?

If there are two sheets of materials one on top of another, and the two sheets have different abilities to shorten (contract) then a wrinkle results in one or the other sheets. Thus a wrinkle is formed when a muscle contracts and shortens itself beneath the skin. The skin can also shorten but not as well as the muscle. The result is a wrinkle or better a buckling of the skin. After repeated buckling, the buckle becomes deeper and the furrow at the depth of the buckle becomes sharper and deeper. Over repeated buckling, the elastic fibers of the skin break and the skin no longer lengthens. Thus the wrinkle begins to form. Over time the depth of the wrinkle increases. This is especially true when the elastic fibers of the skin are damage by sun. Elastic fibers may be programmed to break because of your genetic predisposition. Wrinkles may 'go away' almost immediately, or at the other end of the spectrum they may not 'go away'. Note that a baby can have wrinkles when it smiles. But the wrinkles go away promptly when the baby stops smiling. Exposure to chemicals, x-rays, and so forth, can contribute to wrinkling.

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HOW LONG BEFORE THE WRINKLES GO AWAY?

Wrinkles may 'go away' almost immediately, or at the other end of the spectrum they may not 'go away'. Note that most babies have wrinkles around the eyes when they smile. These are dynamic wrinkles, and the wrinkles go away promptly when the baby stops smiling. The baby's skin has plenty of 'elastic' fibers. If your skin has elasticity left in it, wrinkles will go away much more quickly. If there is very little normal elasticity in the skin, and the wrinkle has formed a buckle, then it will take more time to 'go away'. If the wrinkle has scar holding it down to the underlying tissue, then it will never 'go away'. It will probably get much better, but filler materials may be helpful. Examples of filler materials are fat, Juvederm, Radiesse, Restylane, etc, (there are at least 20 fillers available - but only some in the USA) These would raise up the deep crevices from the underlying skin.

 

UPDATE - The Art of BOTOX®

Much has been learned during the past years. BOTOX® is quite amazing. Having tried the treatment, I can say that it works. Having given thousands of injections, I can tell you it is safe and it 'works'. What has been new and quite interesting is the use of BOTOX® in different doses - placed in the small muscles of the face. It can change a smile; it can change pursed lips; it can elevate a brow and it can change our 'look'. BOTOX® injections, as far as I can tell, have become somewhat of an art form. The medium is muscle, skin and soft tissue and that of human expression. The effect is a different look and even feel. The bands in the neck that bother us so much - we don't smile as broadly as we did; if you have BOTOX® on board - don't try to whistle after BOTOX® into the lip !

I am sure we will learn much more about changing our 'look' with BOTOX®.

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COST OF BOTOX®

Please note that these are estimates. Our office charges are usually not by the area but by the number of BOTOX® units used. Since some individuals need more toxin to paralyze a muscle, a graded fee schedule seems appropriate.

Glabella (Base of the nose) 250- 350

Crows feet 200-350

Forehead 400-650

Around the mouth 150-350

Neck Bands 150-400 per band

 

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OTHER USES OF BOTOX®

Relief of tension headaches

Relief of excessive sweating

Relief of muscle spasm

Many other applications - see

Manufacturer's BIOLOGY AND HISTORY OF BOTOX®

 

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A Word of Caution

Nothing is ideal. BOTOX® injections are probably not.

A couple of words of caution.

Can one become 'allergic' to botulinum toxin ? - perhaps. If allergy does occur it must be rare, as there have been no papers that I know of, that have been a cause for alarm. There are no reports forth coming, to my knowledge, that BOTOX® is potentially acutely or chronically harmful when used 'appropriately' for wrinkles. This statement can be made even after millions of injections over a number of years.

Can the body immunize itself against the toxin ?
I can only ask - why not? If one can become immunized after repeated venomous snake bites, why can't the body immunize itself from botulinum toxin (BOTOX®)? The implications and potential for harm of these speculations are unknown, but they are there.

There are reports about drug interactions and BOTOX® - It has been said that calcium channel blockers prevent or decrease the effect of BOTOX®. Such a report will certainly be followed up. If it is true then the implication is that BOTOX® might not work for that particular individual or that the effect will be less than expected. From the positive view, it means that you should not be harmed by the BOTOX®. If it doesn't work then there is no need to try it again. If it works but to a lesser degree than expected, then an increase in dose might be a consideration vs discontinuing BOTOX®. It is a personal choice.

So, for now those who want to take the seemingly small risk of injections will join the millions of others, including myself, who are using the botulinum type A toxin.

AS TIME GOES ON, I am sure that there will be more interactions and problems found. Hopefully they will be statistically improbable and not serious. The safeguards that we have are to be vigilant, read the information about BOTOX® whenever we can and check the manufacturer's web site at

The Allergan Corporation producers of BOTOX®

on a periodic basis.

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Manufacturer's BIOLOGY AND HISTORY OF BOTOX®

For a more exact medical description of BOTOX® , it origins and original uses please reference

The Allergan Corporation producers of BOTOX®

 

 

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