Botox

Introduction

Wrinkles are one of the prime signs of aging for which patients consult the cosmetic plastic surgeon. Skin wrinkles fall into 2 types: Static and Dynamic.

Static: Static wrinkles are present all the time and are caused by sun damage, smoking and the effects of aging; namely skin thinning, gravity and laxity.

Dynamic: Dynamic wrinkles occur first in younger people. They are not present with the face relaxed, but appear as a result of contractions of the delicate underlying facial muscles every time we smile, laugh or frown. The more emotion we show the deeper these lines and wrinkles are likely to be. Over time, dynamic wrinkles develop into permanent, static wrinkles.

By treating the underlying cause of dynamic wrinkles, Botox can prevent or delay the onset of permanent static wrinkles. Once static wrinkles have formed, Botox can help prevent them getting worse, but it cannot eradicate these permanent wrinkles. Other treatments are needed for this.

Botox injection is currently the most popular cosmetic procedure with over 1.6 million Botox injections being performed last year. Due to great demand and its now established safety record, the Food and Drug Administration now license Botox for cosmetic use. For many people, Botox treatment represents their first experience with cosmetic surgery. As a quick and effective treatment, with excellent results and virtually no downtime, it is perfect for those patients who have minimal signs of facial aging such as forehead furrows and crow's feet. Whilst Botox can often delay the need for more extensive surgery, it is important to stress that it does not achieve the same results as surgical procedures.

What is Botox?

Botox is a nerve toxin produced by a bacterium called Clostridium Botulinum. In very high doses (>3000 units) it produces the disease called botulism. In much lower doses (20-40) units it can be safely used to temporarily weaken muscles.

How does it work?

When injected into a muscle, Botox poisons the nerve ending stopping the nerve from sending a signal to that muscle. By doing this, the muscle cannot contract and therefore relaxes. With the muscle relaxed, the overlying skin remains smooth and unwrinkled. Nearby untreated facial muscles continue to contract in a normal fashion, allowing normal facial expression to be unaffected.

Botox permanently blocks the nerve ending, but with time, the nerve grows a new nerve ending and the muscle starts working again. This takes about 3-6 months and the muscle recovers completely.

What areas can be treated?

Botox is most commonly performed in the upper face. The most common areas requested are the horizontal forehead lines, vertical frown lines between the eyebrows, and crow's feet (or laughter lines) radiating away from the eyes. While it would probably work around the mouth and chin, it would almost undoubtedly weaken the smile and we do not recommend its use around the mouth. Creases around the mouth are usually either treated by peels or by filling them out with a temporary filler or fat.

Can I have all of my areas treated on the first go?

Usually we recommend that only one or two areas be injected in the first instance, typically the frown lines and crow's feet. In the interests of safety we usually use the lowest dose of Botox at the first visit too because it is not possible to predict how sensitive any one individual may be to Botox. If the dose proves to be too little, a higher dose can be used several weeks later.

Who can perform Botox treatments?

Only a physician, skilled in the use of Botox, should perform the treatment.

What will happen at the initial consultation?

During the consultation, you will have the opportunity to talk to your surgeon about the changes that you'd like to make in your appearance. You will be given an explanation of the different options available to you, the procedure itself, and the risks and limitations involved. Pretreatment photographs will be taken and if you choose to proceed with the injection, you will be asked to sign a consent form before undergoing the procedure.

What are the alternatives to Botox?

Early permanent static wrinkles can be filled out by injecting a temporary filler material beneath them, or injecting fat beneath them which is more permanent. If the static wrinkles are a little more established, then the skin can be resurfaced by burning the upper layer of the skin off with an acid peel or with a laser. If there is excess, lax skin, the most effective method of treating the wrinkles is to perform a surgical lift of the forehead, midface and neck regions. Combinations of the above can all be used as appropriate.

Am I a suitable candidate?

Obviously only a consultation with a fully qualified physician will be able to establish this. After taking a detailed history and a performing an examination, your surgeon will advise on the most appropriate method of facial rejuvenation.

Who is the best candidate for Botox?

A wide range of patients benefit from Botox therapy. Botox is ideal for younger people (25-60) who are just starting to develop wrinkles. Botox treats existing creases, as well as potential creases before they start. Patients who have had laser resurfacing or a face lift also benefit by preventing repeated wrinkling of newly treated skin. In many cases, wrinkles in people over 65 are caused by sun damage and therefore are not disposed to this treatment; however, each person is different and must be evaluated by the physician.

Who should not receive Botox?

  • Pregnancy: although there have been no reports of birth defects with this medicine, no pregnant patients will be treated.
  • Breastfeeding: similarly, there is no evidence that Botox is expressed in breast milk but it is best avoided if breastfeeding.
  • Patients with a history of neuro-muscular disease (multiple sclerosis and myasthenia gravis) or other types of diseases involving neuro-transmission should avoid this medicine.
  • Patients taking the following medicines should not receive Botox: aminoglycoside antibiotics (Streptomycin, Tobmamycin, and Garamycin injections), penicillamine, and calcium channel blockers (Calan, Cardizem, Dilactor, Norvasc, Procardia, Verelan).
  • Known allergy to human albumin or Botox; currently there are no documented cases of allergy to Botox.

What happens if a female patient becomes pregnant shortly before or after treatment?

A number of neurological and ophthalmologic patients have delivered normal children after receiving their injections. For safety reasons no pregnant or nursing females will be treated.

Where are the treatments performed?

Botox treatments can be performed in the doctor's office or in a surgical suite. Anesthesia is rarely needed, though painkillers and numbing agents may be available on request.

How are Botox injections done?

The procedure itself is simple and safe. Botox is injected with a very tiny needle directly into the affected muscles. Depending on the area treated, between 4-10 injections are necessary. Because the needle is so fine and only a small amount of liquid is used the pain is usually minor, like a sting for a few seconds. Once the injection is complete there is usually no discomfort. No sedation or local anaesthesia is required and as no recovery period is required, you can resume normal activities immediately. You can even drive yourself home or back to your office. Very occasionally some patients experience a slight temporary bruising or redness at the injection site.

How painful are the injections?

The smallest needles are used and the medicine itself does not sting as much as local anesthetic. Most patients feel it less than collagen. Pain can be minimized by the use of ice cooling the skin just prior to injections. Some patients find that two paracetamol tablets taken 1 hour before the injections reduce the discomfort. After the procedure, there is virtually no pain

How long does it take?

The treatment session usually takes about 10-15 minutes.

What will I look like after my treatment?

Immediately after the treatment, there may be a mild amount of redness at the injection site, but this resolves in a few hours. Bruising is very uncommon.

Will I notice the effect straight away?

Initially you will notice nothing at all. The treated muscles will gradually weaken over the following week or so. Most people do not notice anything. They simply become aware that they are no longer able to contract the frown muscles. They can still lift their eyebrows normally and blink without problems. The injection is almost painless.

What is the outcome of Botox injections for most people?

Eighty percent of patients get a very good result. 15 percent of patients only get a partial response from the first injection and may require a further injection 10-14 days later. Five percent of people will not get a good response to Botox despite an adequate dose being injected directly into the muscle. This is probably because they have blocking antibodies and the toxin does not affect their nerves.

How long does it last?

The full effects of Botox treatment are not apparent for three to seven days. The muscle becomes very weak but is not usually totally paralysed so some movement usually remains. These effects are temporary and the muscle function returns to normal in approximately three to six months.

As most patients are quite happy with the effects of Botox, a top up injection will be required after this period of time to maintain the skin smoothing effects.

How often are top up treatments required?

This varies from individual to individual and we cannot predict or guarantee how long the effects of Botox will last. But on average, initially injections are required every 4 months, and with increasing use, the effects of Botox seem to last longer with some people reporting effects lasting 6-9 months.

Are repeat treatments with Botox always as effective?

The first time Botox is injected the results are usually the most dramatic, and patients love it. However, at the second time they are sometimes a little disappointed because they have started to recruit other muscles to accomplish the same facial movement. For this reason, the second time Botox is injected it is often put into more areas. We always warn patients about this so that they're not taken by surprise. We also explain that there are times when the batches of Botox are not 100 percent consistent, so it may not work as well as the previous time.

Does the body make antibodies to the Botox protein?

Yes, especially if enough toxin is injected often enough. Antibodies have been more of a problem for neurological disorders where a larger amount of Botox is required. When significant amounts of antibodies are formed, the therapeutic effects of Botox are greatly reduced.

For how long can I be treated with BOTOX?

Treatment with BOTOX can typically be repeated indefinitely. It has been in clinical use for nearly 30 years. However, there is a very small possibility that with repeated use your body may develop antibodies which block the effect of Botox. Different types of botulinum toxin are currently being developed so that people who do develop blocking antibodies can still benefit from Botox treatment.

Can Botox get rid of all my wrinkles?

This procedure can remove or deter wrinkles by preventing the repeated facial expressions that contribute to their formation. It cannot improve the overall texture of the skin, but procedures such as laser skin resurfacing and dermabrasion can be used to accomplish this. It cannot tighten the facial skin either. Look for facelift and forhead lift for ways to accomplish this.

Will I be unable to move my face after the Botox injection?

Some patients ask if they will have a mask-like appearance or lose facial expression after Botox injection. The answer is no, not when the procedure is done properly. Selected muscles are weakened not totally paralysed, whilst nearby muscles are unaffected, in this way, extreme movements of the forehead and eyebrows, which create the wrinkles, will be prevented, but other muscles in the face will not be affected by BOTOX injections and will move the face as normal.

Is there any danger of botulism from Botox?

Only tiny amounts of Botox are used for wrinkle reduction. It would require the full contents of 30 vials to be injected at one sitting to cause botulism. Once injected into the body, the toxin is rapidly broken down (within hours!), so levels of toxin do not build up over time with subsequent injections.

What other conditions can Botox be used to treat?

Botox has been used over the last 30 years for the treatment of many medical conditions including squints, muscle spasticity, migraine headaches, facial tics and spasms, multiple sclerosis and various pain conditions. It has proven to be a safe, effective short and long term treatment.

Are there any side effects?

There are no serious side effects associated with this procedure There have been no reports of permanent damage caused by the injection of Botox. Since the effects of Botox are temporary, so any side effects are also temporary.

The most common complications are:

  1. Bruising:  There will be penetration of the needle so smaller blood vessels may be injured. To minimise the risk of bruising, follow the pre-treatment instructions.
  1. Swelling: Swelling may happen and lasts a couple of hours to a few days.
  2. Pain: Pain only during the procedure, unless there is a big bruise, which may create pain. Ice packs help with both (2) and (3).
  3. Headache: ...or a few hours mostly. It is safe to take paracetamol to relieve this.
  4. Ptosis or Drooping: ...or drooping of an eyelid is the most common significant complication (less than 1%); this is caused by the botulinum toxin tracking into the upper eyelid muscle. It generally starts after 5-7 days and lasts just a few weeks. Let your doctor know if this bothers you; eye drops can be prescribed to lessen this effect.

What can I do to conceal a bruise?

When bruising occurs, the bruises are best covered by a green concealer make up followed by a foundation of normal skin color. Many companies make the green concelaer. Bruises usually resolve withing 7 - 10 days.

A recent study demonstrated that topical Vitamin K cream may hasten the resolution of bruises when applied twice daily, however, the study showed no beneficial effect from pretreatment with the Vitamin K cream.

What can be done for the drooping eyelid if this occurs?

There are two opthalmological preparations that are helpful: The first is 10% phenylephrine drops and the second is lopidine. Transient drooping of one eyelid or both is the most significant complication and occurs in less than 1% of all injections. This drooping is a result of the local dissemination of the toxin in the injection site and can be minimized by accurate dosing, proper placement, keeping the patient in an upright position and avoid massaging or manipulating the injected area for four hours after injection. If drooping eyelids occur, it is usually minimal and is usually resolved within two weeks.

What unexpected benefits have come from the use of Botox?

Tension headaches have disappeared in about 8% of patients. These headaches occurred in patients who were recruiting forehead and brow muscles during periods of stress and tension. When these muscles were relaxed, the headaches faded.

What follow up arrangements will be made?

If you develop any difficulty with vision or the eyelid becomes droopy this is not an emergency, but you should notify the office. If you feel abnormal and think you are developing an allergic reaction, go to the nearest emergency room. Notify the office immediately if you experience any increasing redness, tenderness, swelling, drainage or any other problem.

A return visit is available 1 to 2 weeks after the initial treatment, at which time post-treatment photographs will be taken and any touch-up injections performed as necessary.

How will I know when I need a repeat injection?

When the toxin begins to wear off, the wrinkles begin to reappear; however, they frequently are not as deep as the original ones. it usually takes two or three injections each year to maintain the smooth, youthful appearance that is desired. Clinical studies suggest that, after several rounds of treatment, the patient may require injections less often

What are the advantages of Botox?

  • Botox is a quick and effective way to remove wrinkles.
  • A typical treatment takes 10 minutes.
  • Results are seen within 4 to 7 days.
  • Long experience has proven Botox to be safe.
  • Little discomfort.
  • There is no "down-time", after the injection, you may resume normal activity or go back to work. There is no physical evidence that you had a cosmetic procedure done.
  • The is no decrease in sensation or numbness of treated areas.
  • The effect of Botox is reversible - lasting between 3 to 9 months depending on the number of previous treatments.
  • A memory response may develop with repeated Botox injections if they are done every 3 months for approximately one-year. So, although the effects are not permanent, there may be a gradual lengthening of the time interval between treatments. This will mean fewer treatments to obtain the same effect!
  • Botox is a nonsurgical approach to treat wrinkles.

Are Botox parties a good idea?

Botox injections are safe when performed by a qualified physician in an appropriate setting. However, before undergoing Botox injections at a party, or anywhere else, make sure you can answer "Yes" to the following questions:

  • Have you been asked to provide a complete medical history? No one should undergo Botox treatment without having provided details of his or her medical history that may be necessary in the event of an emergency or adverse reaction to the toxin. In addition, Botox treatment is not recommended for anyone who is or may be pregnant.
  • Have you been advised on alternative treatments? Part of the purpose of a pre-treatment consultation is the thorough evaluation of each patient for whatever treatment is being proposed. In the case of Botox, not everyone is an appropriate candidate. For some patients, other treatments or even a surgical procedure may be more effective than Botox. No one should undergo Botox treatment without personal evaluation by a qualified physician.
  • Have you been advised of the risks and given your informed consent? A discussion of both the benefits and risks of a procedure is required for informed consent. Such informed consent should be documented in the medical record. A person giving informed consent must not be under the influence of alcohol or other substances that may impair judgment.
  • Is a qualified physician administering the treatment? While Botox treatment is both safe and effective, every medical procedure has risks and possible complications. It is imperative that an experienced physician who understands facial anatomy and proper Botox injection techniques administer Botox.
  • Is the physical setting appropriate for administering medical treatment, including handling emergency situations? Any medical procedure requires sanitary conditions. In addition, drugs or equipment that might be necessary to handle an emergency situation must be readily accessible.
  • Are you willing and able to follow post-treatment instructions? Botox treatment requires that the patient restrict physical activity for a period following the injections. Failure to follow post-treatment instructions can lead to complications. In a party atmosphere, people may tend to forget such restrictions, particularly if alcohol is being served.
  • Will you receive adequate follow-up care? Botox is a temporary treatment, and results usually last only a few months. Nevertheless, follow-up care is an important part of the doctor-patient relationship, and should not be overlooked, even when treatment is administered outside of the usual medical setting.

Botox parties may offer some benefit to patients by reducing the cost of their individual treatment. However, unless proper measures are in place to ensure both safety and effectiveness of treatments, we would advise that you enjoy the party, but get your Botox injections in the doctor's office.

BOTOX Injections: Pre-Treatment Instruction:

Cosmetic patients are very unhappy when bruising results as a complication of botulinum toxin injections. The following can decrease the incidence of bruising:

  • Green Tea: avoid drinking green tea for 10 days before your injection.
  • Discontinue aspirin and non-steroidal anti-inflammatory agents (e.g. brufen, Ibuprofen, Voltarol) for ten days prior to treatment. Paracetamol is permitted.
  • Avoid Vitamin E supplements for two (2) days prior to treatment. Regular multivitamins are permitted.
  • Avoid alcoholic beverages for 24 hours prior to treatment.
  • Remove all facial makeup in any area that you may wish to have treated upon arrival to the office.
  • Some patients claim taking 2 paracetamol 1 hour before Botox treatment lessens the discomfort of the injection
  • Ice packs can be placed on the area to be injected just prior to injection. This may help decrease the pain of injection (which is minimal) and decrease the incidence of bruising

BOTOX Injections: Post-Treatment Instruction:

Because there is no sedative or anaesthetic used, you can return to normal activities immediately after the procedure. It is possible that you may experience a mild headache after the procedure. You may take paracetamol if this should occur.

1) For the first 4 hours after the injection you must:

  • Keep your head up
  • Not stoop over or strain
  • Not massage or manipulate the treated area; though you can apply light makeup after 30 minutes
  • Not take any naps or sleep in a reclining position
  • Exercise the remaining facial muscles by frowning or smiling frequently
  • Not take aminogycoside antibiotics (e.g. gentamicin, tobramycin, netilmicin and amikacin)

[Beware!! massaging or touching the injection sites and leaning forward or backwards can cause the injected Botox to spread and may result in a droopy eyelid or other unwanted facial weakness!!]

2) After 4 hours you can:

  • bathe/shower normally
  • apply make-up

3) The next morning you may:

resume your normal schedule of exercise and activity

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