Patient Information — Botulinum Toxin

Hardly another medicine has been so hotly discussed in recent times than botulinum toxin, often simply referred to as Botox. Unfortunately, a great deal of what is said is false!

First of all, there is no need to fear Botox.

If used properly, it is an excellent medicine with little or no side effects. In fact, it is the most suitable preparation available today for the treatment of many disturbing aesthetic changes to the face and neck areas.

Is there any danger of toxic reaction, i.e. poisoning inherent in the use of botulinum toxin for cosmetic treatment (botulism)?

Botulinum toxin is very strong and thus a potentially hazardous toxin. However, like all other substances, its toxic effect is completely dependent on how it is applied and, of course, the dosage!

For botulinum toxin poisoning, called botulism (cause of food poisoning), to occur the organism has to absorb larger quantities of the substance. Since only minute amounts of botulinum toxin are injected into specific muscle areas where they are locally absorbed and bound (meaning they do not enter the circulatory system or rest of the organism), there is no hazard of poisoning.

What is Botox or botulinum toxin exactly?

Botulinum toxin is more commonly known by the frequently used term “Botox”, which is actually a trade name. It is a natural protein produced by the bacterium clostridium botulinum. Today, botulinum toxin used for medicinal use is prepared via gene technology. In human bodies, it blocks the release of the messenger substance responsible for muscle contraction and, depending on the dosage, can cause muscles to relax to the point of paralysis.

As is the case with virtually any medicine, large doses can be toxic. However, due to the extremely diluted amounts used to correct wrinkles as well as the technique with which it is applied, no toxic effects occur when used for cosmetic application.

How are botulinum toxin treatments applied?

Precise doses of botulinum toxin are injected into the affected muscles with an extremely tiny needle. Together with the patient, the specific areas and the strength of the applications are discussed and decided on before the treatment begins. The patient feels little more than a slight pinprick. Sometimes, the area is cooled after the application.

How does botulinum toxin work to correct wrinkles and lines?

Through the constant activity of the facial muscles over time, lines or wrinkles may form in the skin covering them. Frequent areas affected include zones between the eyebrows above the nose, the forehead and the corners of the eyes from laughing (commonly referred to as crows feet).

Botulinum toxin blocks the nerve impulses that initiate muscle contraction, leading to the relaxation of the muscles and subsequently causing wrinkles to smooth out or even completely disappear, provided the patient didn’t wait too long to have the treatment performed.

Which wrinkles is botulinum toxin especially effective at treating?

Botulinum toxin’s active mechanism causes the muscles to relax, which is particularly effective in treating wrinkles that occur due to frequent, usually unconscious, muscle movement, such as forehead lines (often produced by efforts to concentrate) or wrinkles caused by facial expressions (laughing, smiling, etc.). The common areas of application for botulinum toxin are wrinkles in the upper third of the face, i.e. around the eyes and forehead.

Botulinum toxin, however is also very useful in smoothing unpleasant lines running parallel to the nose bridge, often called “bunny lines”, or the dimpled skin on a chin, sometimes referred to as “peau de orange”. New areas of application include prominent muscle bands in the neck and lines in the neckline caused by muscle contraction.

Are there visible signs of treatment that would make me feel uncomfortable or embarrassed being around other people?

No! Following the injection, minute punctures and occasionally minor “black and blue” spots may be visible. Such bruises may occur due to injury to delicate blood vessels in the skin. Easily covered with makeup, the bruises disappear after a few days.

How quickly does it take for botulinum toxin to take effect and how long do its effects last?

In most cases, the medicine begins to show its effects within 48 — 72 hours and the maximum effect is achieved after 1 — 2 weeks. Occasionally, the effects may take longer to appear. As a rule, the blocking of the transmission of impulses between the nerves and muscles lasts 4 — 6 months, as does the wrinkle smoothing effect. Afterwards, the changes produced by botulinum toxin begin to regress. If desired, the treatment may be repeated.

Following treatment with botulinum toxin, does the face remain stiff and frozen like a mask?

Frequently, patients express fears that their faces, besides looking smoother, will look stiff and unnatural after treatment with botulinum toxin. Such fears are unfounded, as careful dosage ensures that only a small area of the muscular structure is rendered inactive, which actually makes the face appear more relaxed and often friendlier. In spite of the treatment, you will still be able to look surprised, for example, when you see yourself without wrinkles.

Can side effects occur as a result of the cosmetic use of botulinum toxin?

With the consultation of an experienced doctor, the injection of botulinum toxin is a very safe procedure for the gentle removal of lines and wrinkles with little or no side effects.

The injection may cause minor bruises or slight swelling. Temporary nausea, fatigue or headaches have been reported, but are rare. Actually, many patients claim that they have fewer headaches after receiving botulinum toxin. Very seldom, patients may experience allergic reactions, itchiness or skin rashes. To avoid seldom occurring, unpleasant complications such as temporary drooping of the eyebrows, eyelids or brief visual impairment, the injections should be performed by a qualified, experienced physician.

In conclusion, all of the side effects produced by botulinum toxin, like the desired effects do not endure forever.

What about long term effects? What has experience shown?

Sometimes, prospective patients who are considering treatment of lines and wrinkles with botulinum toxin are warned that there is insufficient knowledge about the long-term therapeutic effects. This is simply not true!

Although, the treatment of lines and wrinkles with botulinum toxin is relatively new, it has still been in use since 1989 and there have been no indications of long-term side effects. In fact, it has been used much longer (nearly forty years) and with much higher doses to treat pathological muscle spasms.

Experience gained here clearly shows that there are no long-term side effects associated with botulinum toxin treatment. Microscopic examinations have found no evidence to indicate the permanent alteration of the nerves or muscles after the effects of botulinum toxin treatment have worn off. Everything appears as it did before the injection of botulinum toxin.

Is repeated treatment of wrinkles and lines with botulinum toxin possible and is it recommended?

To date, there have been no negative effects determined for the repeated application for cosmetic purposes. Microscopic examinations have shown that the changes affected by botulinum toxin returned to their previous states within a few months after the treatments were completed.

Therefore, there is no reason to expect side effects, habit-forming, adaptation difficulties or lasting changes with repeated use (refer to the paragraph: What about long term effects? What has experience shown?).

With repeated use, is it necessary to increase the dosage to achieve the desired effect?

No! As stated above, botulinum toxin’s effects are temporary. When the effects of the substance wear off, both it and its influence on the nerves disappear.

Since immobilized muscles usually become weak, (consider how weak an arm is after being immobilized in a cast), often, less medicine is necessary to achieve the same relaxing effect on the muscles if the applications are applied regularly.

Under which circumstances, should botulinum toxin treatments be avoided?

Women should avoid botulinum toxin treatments during pregnancy or nursing!

Patients who have been diagnosed with serious muscle weakness (e.g. myasthenia gravis) or blood-clotting disorder (coagulopathy) should also avoid treatment with botulinum toxin.

Is botulinum toxin suitable for the treatment of other disorders?

Botulinum toxin is used to treat neurological and muscular maladies with muscle cramps, but in much higher and more frequent doses. It has also proven to be extremely effective in recent years as a remedy for excessive sweating (hyperhidrosis) as well as tension-type and migraine headaches (For more, see the separate patient information section)

Further reading: Dr. med. Boris Sommer & Dr. med. D. Bergfeld,
“Sanfte Schönheit- Faltentherapie mit Botox &Co“(Gentle Aesthetic and Wrinkle Therapy with Botox & Co) published in 2005 by Trias Verlag.