approved (circa 6/2002)
for cosmetic uses
fortune - BOTOX® COSMETIC - 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® COSMETIC 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
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® COSMETIC). 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® COSMETIC was recently approved
by the FDA (Update 6-2002 FDA approves
BOTOX® COSMETIC-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® COSMETIC during the 2002
Academy Awards in Tinsel Town. The Hollywood in-crowd had
BOTOX® COSMETIC 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
One of the
first uses was the treatment of blepharospasm. This started
the BOTOX® COSMETIC 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® COSMETIC subsided after several treatments. Dr Caruthers
happened to be married to Dr Alistar Caruthers, a dermatologist.
He began injecting his patients with BOTOX® COSMETIC 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® COSMETIC 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.
about treatment of wrinkles, one side effect that is bothersome
is weakness and drooping of the upper eyelid muscle. The
closer BOTOX® COSMETIC is placed near to the eyebrow in the center
of the eyebrow, the greater the chance that the BOTOX® COSMETIC 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® COSMETIC 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.
of BOTOX® COSMETIC 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® COSMETIC, 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
BOTOX® COSMETIC 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® COSMETIC.
There is never
a perfect drug. This is true with BOTOX® COSMETIC. The drug is quite
safe in the dosage that is normally used. The major drawback
with BOTOX® COSMETIC 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® COSMETIC. Thus the length of time that BOTOX® COSMETIC 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® COSMETIC 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.
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® COSMETIC 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.
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..
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
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.
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.
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.
LONG BEFORE THE WRINKLES GO AWAY?
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.
Much has been learned during the past years. BOTOX® COSMETIC 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® COSMETIC 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® COSMETIC 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® COSMETIC on board - don't try to whistle after
BOTOX® COSMETIC into the lip !
am sure we will learn much more about changing our 'look'
with BOTOX® COSMETIC.
note that these are estimates. Our office charges are usually
not by the area but by the number of BOTOX® COSMETIC units used. Since
some individuals need more toxin to paralyze a muscle, a
graded fee schedule seems appropriate.
of the nose) 250- 350
Crows feet 200-350
Around the mouth
Neck Bands 150-400
USES OF BOTOX® COSMETIC
Relief of tension
Relief of excessive
Relief of muscle
applications - see
BIOLOGY AND HISTORY OF BOTOX® COSMETIC
ideal. BOTOX® COSMETIC 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® COSMETIC
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® COSMETIC)? The implications and
potential for harm of these speculations are unknown, but
they are there.
There are reports about drug interactions and BOTOX® COSMETIC -
It has been said that calcium channel blockers prevent or
decrease the effect of BOTOX® COSMETIC. Such a report will certainly
be followed up. If it is true then the implication is that
BOTOX® COSMETIC 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® COSMETIC.
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® COSMETIC. 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® COSMETIC whenever
we can and check the manufacturer's web site at
Allergan Corporation producers of BOTOX® COSMETIC
on a periodic basis.
a more exact medical description of BOTOX® COSMETIC , it origins and
original uses please reference
Allergan Corporation producers of BOTOX® COSMETIC