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Chapter 2
What Is Botox and How Can It Rejuvenate Your Skin?
We have seen how the skin ages, forming lines, wrinkles, and creases on your face, making you look much older and less attractive than you want to look. Although you can improve your skin through better care, including protecting it from further damage, you cannot restore your youthful appearance or make any major improvements without some kind of medical treatment.
Until the appearance of Botox, most treatments for skin rejuvenation involved either major surgery or potential problems with unwanted side effects (see chapter 8).
Without a doubt, Botox is revolutionary: an inexpensive, rapid, minimally invasive procedure that can literally take years off your face. Let's find out exactly what it is, how it was developed, and how it works its miracles.
Q: What is Botox? What is in that little bottle and how is it made in the laboratory?
A: Botox is a purified protein, a diluted form of the botulinum toxin, which, in its concentrated form, causes the potentially deadly disease botulism. It is produced from fermentation of the Hall strain of Clostridium botulinum type-A toxin, sterilized and vacuum-dried in the laboratory, and grown in a medium containing casein hydrolysate, glucose, and yeast extract.
Botox is sold in bottles or vials containing 100 units. It is kept in a freezer in the doctor's office and is reconstituted with saline solution before being injected.
Q: But the toxin that causes botulism is so dangerous. How can Botox be safe?
A: It is not a practical concern because the amount of the botulinum toxin in Botox is known to be well within the safe limit.
Any toxic chemical is only toxic at a certain level. For example, the local anesthetic lidocaine that we get in the dentist's office could kill us if it were given in a much higher concentration. Even aspirin can kill at a toxic level. So almost any chemical in a concentrated form has the potential for being fatal.
In order for a product to be approved by the FDA, the parameters must be documented by the researchers and the safe levels versus the toxic doses for administration proven. The Botox dose that we use for reversing signs of aging skin is extremely small and well within the safe level. In addition, according to the manufacturer Allergan, the toxin is broken down and leaves the body within twenty-four to forty-eight hours, so there is no possibility of a buildup over time with continued treatments.
Botox has been used by neurologists for decades in much higher doses than we use for skin treatments. Neurologists may use 400 units in a session, and we use only 30 to 100 units on average. Yet there has not been one single case of botulism created by any of these injections.
And now millions of people have been injected with Botox, the number one cosmetic medical treatment. The studies show that there are very few side effects and that it is a remarkably safe drug.
Q: Can you tell us a little about the history of Botox? How was it discovered and what were its uses in the past?
A: The actual bacterium, Bacillus botulinus, was identified in 1895 by a Belgian researcher. It was purified in crystalline form in 1946 by Dr. Edward Schantz. In the 1970s, Dr. Schantz, working with Dr. Alan Scott of the Smith-Kettlewell Eye Research Foundation, discovered that the toxin, botulinum toxin A, corrected crossed eyes in laboratory monkeys. A few years later, Dr. Scott began to test the toxin's effectiveness in treating muscle spasms around the eyes of humans.
But the real breakthrough came in 1987, when Dr. Jean Carruthers, a Canadian ophthalmologist, noticed that after she used the drug to treat eye muscle spasms, the crow's-feet lines around the eyes of her patients improved dramatically. When she mentioned this side effect to her husband, dermatologist Alastair Carruthers, he decided to try it out on his receptionist. And that was how we discovered that the drug now known as Botox can reverse some of the signs of aging on the face.
Q: When was Botox actually approved by the FDA?
A: The FDA approved Botox for treating strabismus, or lazy eye (see below), in 1989.
Q: What does Botox actually do to achieve its results?
A: Botox works locally, not systemically. That means that if we inject it into the forehead, it only affects the forehead, not the muscles in the foot. It remains in the area where it's injected.
When the muscles contract to make creases in the skin, they require nerves to provide their stimulus from the brain to the muscle. The nerve does that by promoting an electric signal, which liberates a chemical called a neurotransmitter. The neurotransmitter sends the signal between the nerves and also between the nerves and other structures, such as muscles.
The specific neurotransmitter involved with Botox is acetylcholine, which is released from the end of the nerves to the receptor in the muscle. The brain makes a signal and the nerve releases the acetylcholine, which stimulates the muscle to contract. But if the receptor is blocked, the muscle doesn't receive the signal.
Botox blocks acetylcholine from making that connection, and as a result, the muscle is unable to contract. Since the muscle can't contract, the skin on the face is unable to form the unwanted lines, wrinkles, or creases. In effect, the muscle is paralyzed, and the lines, wrinkles, and creases diminish or disappear.
Q: Prior to its cosmetic use on the skin, what were some of the medical conditions that Botox had been used to treat?
A: Botox has been useful for a wide range of medical problems and is still used to treat them. Other possible uses are also being studied.
Botox has been FDA approved to treat cervical dystonia, which is a condition involving involuntary contractions or spasms of the neck muscles. An example is wryneck (torticollis), a condition of painful muscle contractions that distort the neck. If this condition is not relieved by other treatment, Botox can often be used successfully.
Also, patients with muscular dystrophy or a stroke, for example, often develop muscular spasms of the neck because they are unable to move for a long time. By injecting Botox, these neck spasms can be eased. Botox can also help to restore equality between one side of the head and the other when one side has been significantly weakened.
Ophthalmologists use Botox for a condition called blepharospasm, which is uncontrollable, exaggerated, and tight closure of their eyelids, causing the eyelids to squint or even close shut altogether. Sometimes patients will blink so hard that their eyebrows come all the way down, and of course, they can't control it. This condition can also cause headaches and loss of sleep. Botox injections can relax the muscles that cause this involuntary blinking and often get rid of the problem. Botox has FDA approval for use in treating blepharospasm.
Botox has also been useful in treating strabismus, a medical condition in which the eyes are misaligned and point in different directions. This condition is also called ``lazy eye," and it can cause serious problems with vision, including an inability to perceive depth, vision loss, and even functional blindness. With Botox, the eye muscles responsible for this condition may relax, and in some cases surgery can be avoided. Botox has FDA approval for this use.
Excessive sweating is another condition that responds well to Botox. Most people don't realize how disabling this condition can be for those who suffer from it. If someone is perspiring excessively, it's not unusual for them to be standing there, sweat literally dripping off their fingers onto the floor, creating a puddle. Their shoes are ruined and have to be replaced, their shirts are ruined, and they are often socially embarrassed. They can't get through job interviews, shake hands, or appear in public. And sometimes they perspire excessively even when they are completely calm.
Botox injections under the arms, in the palms, and in the soles of the feet can often greatly diminish this problem.
Another condition Botox seems to help is migraine headaches. In fact Allergan, the manufacturer of Botox, has applied to the FDA for approval of Botox to treat migraines. (Note: Physicians are legally permitted to use an FDA-approved drug for any medical purpose they find warranted, even though the FDA has not specifically approved it for that use. This is called ``off-label" use and it is very common and medically ethical.) Although the exact causes of migraines remain unknown, studies show that a significant percentage of migraine patients improve with Botox injections. That would seem to lead to the conclusion that muscle tension and spasms are connected with at least some cases of chronic migraines.
Botox is also used to treat back pain, which is frequently linked to muscle spasms around the spine. According to one study, 63 percent of patients who received Botox treatment said that their back pain was reduced by at least 50 percent.
Spasmodic dysphonia is another condition that responds well to Botox. It is characterized by muscle spasms and tightness affecting the vocal cords, causing the voice to become strained and hoarse. Before Botox, surgery was the only effective treatment.
Finally, giving Botox to children with cerebral palsy can help preserve their range of motion and, in some cases, help them avoid the need for braces or surgery.
Botox is also being studied for possible use in treating Parkinson's disease and Tourette's syndrome.
Q: Is Botox completely safe for all these uses, including cosmetic uses on the face?
A: There are patients who have used it medically for over twenty years and cosmetically for about fifteen years, and from all the evidence we have, it appears to be very safe. In addition, over these years of use there have not been any incidents of concern and no long-term dangerous side effects that have been directly connected to the use of Botox.
But it is impossible to guarantee that we won't learn something negative in the coming years. So w...
