BOTOX Injections

BOTOX® Injections Overview

Botulinum toxin (BOTOX®) is a material that has been known for over a century and used for medical purposes for more than 50 years. Its initial uses were for strabismus (commonly known as a lazy eye), blepharospasm (inability to move the eye in certain ways), and cervical dystonia (wry neck). In 2002, it was approved for improving and relaxing frown lines in the area between the eyes on the forehead (the glabella) and has been used successfully in more than half a million patients since that time.

A common misconception is that BOTOX® actually paralyzes the muscles in the face. Although, with extreme amounts of BOTOX®, this can happen, most physicians strive to inject just the amount that allows the patient to have some limited activity but not so much that they have overactivity of the areas. Patients should know that BOTOX® is not used to keep them from expressing themselves but simply to keep them from making facial grimaces and frowns that have become habits and are unintended. When done correctly, most people who are not trained cosmetic surgeons will not notice that a BOTOX® procedure has been performed but simply that the patient looks more rested or happier.

BOTOX® Injections Preparation

The material BOTOX® comes as a crystalline substance from the manufacturer, which then has to be reconstituted with saline or another liquid. Practitioners add varying amounts of liquid when reconstituting it. Although there is no right or wrong amount of liquid to add, most physicians add about 2 or 3 mL (about a half a teaspoon) of liquid to each vial. Some add quite a bit more, which can lead patients to think they are getting more BOTOX® when, in reality, they are getting the same or less amount of BOTOX® than samples reconstituted in a stronger way. It is the total dose of medication, not the volume of liquid, that leads to the desired effect.

During the Procedure

The patient is placed in a somewhat raised position on the exam table, and the areas to be injected are cleansed with a nonalcohol cleanser, such as Hibiclens or Betadine. Some physicians will apply a topical anesthetic, such as EMLA cream, at this time. After this, the BOTOX® is injected into the desired areas. Typical injection patterns include about 4 or 5 areas on each side of the forehead and 2 or 3 areas on either eye area. More areas can be injected by skilled physicians, depending on the type of wrinkles and the desired effect for the patient. It is common for pressure to be applied if an area seems to be bleeding after the injection.

After the Procedure

After the injections, the patient will usually lay upright or semiupright on the exam table for about 2-5 minutes to make sure he or she feels good after the procedure, and, then, the patient should avoid lying down for 2-4 hours. If bruising is a concern, it will be important for the patient to avoid taking aspirin or related products, such as ibuprofen (eg, Advil) or naproxen (eg, Aleve) if possible after the procedure to keep bruising to a minimum.

There are many physicians who encourage their patients to either work the area several times during the next several days or, alternatively, to not use the affected muscles during the next several days. Studies of these patients have not yet been performed. (This author does not tell his patients to do anything in particular other than to avoid strenuous activity for several hours afterwards because of an increased risk of bruising. This author has had several patients who leaned over or strained after injections, causing bruising to develop.)

Next Steps

Results will be evident within 3-10 days. Photographs may be taken before the procedure so that patients can check their results themselves rather than relying on their memory. It is surprising to see how many people do not recall how they looked before the procedure and are amazed at the difference when shown a picture. Prior to having the procedure done, the patient should be prepared to realize that BOTOX® does not actually erase lines but relaxes them. What this means is that deeper lines will become somewhat less deep and superficial lines will nearly disappear. This can be likened to the act of steaming a garment’s wrinkles rather than ironing them.

It may be necessary for the patient to have additional procedures, such as the use of filler substances (eg, Restylane, Collagen) in order to plump up the wrinkles that are now relaxed. Additionally, it may be necessary to have 2 or 3 sessions of BOTOX® treatment for deeper wrinkles before results become optimal.

Risks

Risks are very minor with this procedure. The main risks consist of headache, pain, and flu-like illness. In rare cases, there may be a drooping lid or eyebrow area. It is important for the cosmetic surgeon to assess the patient's lids before injecting because the patient may not be a good candidate if he or she has an extremely droopy lid to begin with or one that is held up by constantly arching the lids. Ptosis (a severe drooping of the eyelid) can happen in up to 5% of patients but is very rare if the cosmetic surgeon does this procedure often (In this author’s practice, it occurs in less than 0.01%). These complications are typically very minor occurrences and resolve with time.

If the patient is allergic to eggs, it is very important not to use this material because it is prepared with an albumin (egg) base. Additionally, if the patient is pregnant, BOTOX® is not recommended (pregnancy category C).

Results

As stated before, the results usually start to be noticed within 3-10 days or even sooner. They tend to last in most people for up to 3 or 4 months. As time passes, the muscle activity will gradually return to normal. Additionally, other areas may return to activity sooner or later depending on the amount injected. The interesting thing about BOTOX® is that it tends to do fairly well even up to the third or fourth month, as opposed to many other cosmetic procedures that last a very short time at full strength and then go away quickly (collagen injections are an example of this type).

Results can vary depending on who is performing the injection on the patient. It is very important to go to a physician who is experienced at this procedure, does it himself or herself (rather than having a nurse, physician’s assistant [PA], or other nonphysician do it), and has a good reputation for performing this type of procedure. The manufacturers of BOTOX® recommend physicians inject the medication themselves. As with most procedures, the skill of the practitioner is related to how often he or she performs the procedure.

When to Seek Medical Care

If you have eyelid drooping after a BOTOX® procedure, it is a good idea to let the cosmetic surgeon know because there is a medicine available to help this condition. Any other difficulties, such as difficulty breathing or rashes, should be reported to the surgeon.

In the Future

There will be a competing type of BOTOX® available in the future (possibly 2005) called Dysport. It is currently available in Europe and seems to have relatively the same results as the current BOTOX® in the United States. It remains to be seen whether the addition of a competitor will drive down the price of BOTOX® in the United States.

Prices

This can be the most difficult question an office gets in a day. Prices charged can vary from $10 to $20 a unit. The cost of the procedure varies as it depends upon the total number of units injected and the number of sites treated.

For More Information

There are many sources in the lay literature that talk about BOTOX®, but many of these can hype the results or dwell inappropriately on the risks. BOTOX® is a great option for baby boomers and for young and not-so-young patients as well and honest information can be found at the following sites:

The American Academy of Dermatology, Botulinum Toxin is a brief overview of BOTOX®.

The American Society For Dermatologic Surgery site has an excellent search function for BOTOX® articles.

Multimedia

Media file 1: BOTOX® being injected for frown lines.

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Media file 2: BOTOX® being injected for frown lines.

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Media file 3: BOTOX® being injected for frown lines.

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Media file 4: BOTOX® being injected for frown lines.

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Media file 5: Patient after BOTOX® injections.

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Media file 6: Patient after BOTOX® injections.

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Media file 7: Area being prepared for BOTOX® injections.

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Synonyms and Keywords

botulinum toxin, Botox procedure, Botox treatment, Botox therapy, wrinkles, frown lines, Botox injections, plastic surgery, cosmetic surgery

References

1. Botox injection ranks No. 1 in nonsurgical procedures. (By the Numbers). Cosmetic Surgery Times. August, 2003.

2. Chet Scerra. The future of Botox, now a household word. (Anesthetic News). Cosmetic Surgery Times. Oct, 2003.

3. Karen Nash. Neither party animal nor party pooper: while most dermatologists agree alcohol and Botox Cosmetic don't mix, some physicians admit en masse participation has its merits. (On Call). Dermatology Times. Sept, 2002.

Authors and Editors
Author: Joel Schlessinger, MD, Consulting Staff, Dermatology, Skin Specialists, PC.

Editors: Dirk M Elston, MD, Consulting Staff, Department of Dermatology, Geisinger Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; William D James, MD, Program Director, Vice-Chair, Paul R Gross Professor, Department of Dermatology, University of Pennsylvania School of Medicine.

Taken From : http://www.emedicinehealth.com