With noticeable results and no recovery time injections of botulinum toxin, known as ‘botox’, is one of the most common and popular aesthetic procedures in the history of plastic surgery. In the last two decades, it has evolved from a single procedure for a single region with the same doses for everyone into a complex, highly individualized treatment of multiple areas with differentiated microinjection techniques and dosages. Based on recent scientific evidence of kinetic, hyperkinetic and hypertonic muscular patterns and meticulous pre-treatment analysis, we can now offer a customized approach that produces well harmonized and natural result. Understanding the facial musculature allows us to manipulate the balance of counteracting muscles with the aim of global facial rejuvenation. The artful application of botulinum toxin not only reduces facial rhytides but repositions eyebrows, flattens pretarsal (eyelids) muscle folds and diminishes platysmal (neck) bands. More and more commonly botulinum toxin is used as adjacent procedure to enhance and prolong the results of laser therapies or injectable filler treatments.
In facial aesthetic enhancement with botulinum toxins, no two patients are necessarily treated exactly the same. Best outcomes can only be achieved with background knowledge of the facial musculature and detailed pre-treatment analysis and consultation. Plastic surgeon injecting this product should have a thorough understanding of the physiology of botulinum toxin its strength and potential complications. Most importantly he should be able to provide complementary or alternative treatments to achieve the results patient desires. To learn more about the options to address undesirable effects of aging, please refer to facial rejuvenation.
Wrinkles are part of the ageing process. Dynamic (active) wrinkles are caused by muscle contractions resulting from facial expressions. The example are the vertical lines between the eyebrows know as frown lines, which become more pronounced, when the eyebrows are furrowed together. After years of frequent contraction, those wrinkles can linger even after the muscles are at rest and are often the first lines to form in an otherwise youthful face. An example are horizontal forehead lines which appear when the eyebrows are raised in a surprised appearance, or the lines extending from the outer aspect of the eye, known as crow’s feet. Static wrinkles are those lines that are constant, even when the face is relaxed. Beside repeated muscle contraction, they are caused by sun damage (tiny wrinkles on the skin surface) and facial volume repositioning (deep folds caused by natural sagging of tissue).
Botulinum toxin type A is commercially known mostly as Botox® Vistabel® or Dysport®. However, these injections are commonly referred to as ‘Botox’ whichever product is actually used. Botulinum toxin is a neurotoxin which temporarily blocks nerve impulses to the tiny facial muscles. This reduces muscle contractions and smoothen the skin so that lines and wrinkles disappear. Untreated muscles are not affected, nor are normal facial expressions. Botulinum toxin is widely used in medicine for many purposes where weakening of overactive muscles is desired.
By temporarily weakening the muscles that are causing the wrinkles the injections of botulinum toxin is very effective in reducing dynamic (active) wrinkles. Also, the static rhytides caused by repeated muscle contractions can be reduced to some degree. It has, however, no effect on the fine lines caused by sun damage, and wrinkles due to sagging of facial skin and soft tissues. Most commonly we use it to reduce worry wrinkles between the eyebrows or pronounced vertical lines on the forehead. It can also be used on overactive muscles around the eyes, mouth and neck muscles. Botulinum toxin injections are most appropriate treatment for age associated wrinkles that are just starting to appear and to postpone or improve the results of more invasive procedures such as resurfacing, brow lifts and facelifts. Botox is also used to help those with overactive sweat glands in the hand or arms.
Botulinum toxin is injected with a tiny needle into the muscles that cause wrinkles. Several injections are needed at specific sites, depending on the area treated. With understanding underlying anatomy, the exact site of application and dosages are individually chosen according to pre-treatment analysis with relaxed and contracted muscles. Precise tailoring of dosing regimens can leave some residual movement in a given area to preserve more youthful look without frozen appearance. When used to treat excessive sweating in the armpits, botulinum toxin is injected directed into the axillary skin. Localized discomfort and bruising can occur, but sedation or local anesthesia is not required. Normal activities can be resumed immediately after application. Injection takes approximately 15 minutes, and any discomfort is usually minimal and brief. In patients with very heavy lines, repeated treatments may be needed for maximum effect. Too frequent or excessive dosing of botulinum toxin may lead to resistance to treatment due to antibody formation.
When injected into the muscles that are responsible for expression wrinkles, it gives the face a more relaxed and smoother appearance. After the botulinum toxin is administered, a marked improvement in moderate to severe lines can be seen within a two to three days, with maximum effect at about 1 to 2 weeks. Results generally last for approximately 4-5 months. Sometimes longer lasting effects (9-12 months) are seen after treatment of excessive sweating. The goal of the procedure is natural and relaxed look, and although the results are obvious the treatment should not change the overall facial appearance.
Botulinum toxin should not be used in people with neuromuscular disorders such as Myasthenia gravis, those who are taking certain muscle relaxants or aminoglycosides, pregnant or breast feeding women, those with infection or inflammation at the proposed site of injections and bleeding disorders.
No severe complications after cosmetic use of botulinum toxin have been reported in the literature, and no serious side effects have been discovered. Very rarely temporarily excessive weakening of the target muscles and paresis of adjacent muscles can occur. When injecting above the eyebrows, upper eye lid ptosis or slight drooping may occur. This can be corrected with eye drops but will also improve as the effects wears off. Possible temporary side effects include bruising at the injection site and infection.