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Botox – A Remarkable Story

EVOLV / October 12, 2021

I don’t really believe in marriage. Now Botox, on the other hand, that works every time.”  Samantha, Sex and the City, 2008

Botulinum toxins remarkably now have more than two decades of history in aesthetic medicine.

The injection of Botulinum, generally classified as neuromodulators, with the FDA-approved brand names Botox Cosmetic (Allergan), Dysport (Galderma), Xeomin (Merz Aesthetic), Jeuveau (Evolus), has become the most common cosmetic procedure performed today. Among the nearly 14 million non-surgical cosmetic procedures performed in 2020, the American Society of Plastic Surgery reports that close to 5 million Botox injections were administered last year and that number has increased significantly and consistently over time. From the FDA approval in 2002 to 2020, the use of injectable toxins for aesthetic applications has increased nearly 1000%. It has even become not only a medical triumph but also a cultural phenomenon as is reflected in the quote above from the Sex and the City character Samantha.

At EVOLV Plastic Surgery and Medical Aesthetics, Botox treatments in Toledo have been an extremely popular and growing part of our patients’ aesthetic programs so we thought it would be of interest to review this incredible story and the ever-expanding indications, applications, benefits, and exciting future of Botox treatments.

What is Botox?

Botulinum toxin or Botox is a protein produced by the bacterium Clostridium Botulinum. In nature, infection with Clostridfium Botulinum and exposure or ingestion of its powerful toxin may result in a rare and disabling paralytic illness called botulism that is sometimes lethal. Although the Clostridium Botulinum organism comes in several strains, only serotypes A and B are used to create clinical preparations. Medical companies manufacturing botulinum toxin for therapeutic injections must follow a rigorous and closely regulated multistep process creating the purified toxin and associated carrier molecules for patient treatments.

The Origins of Botox

Botox has a fascinating and interesting history. The bacterium Clostridium botulinum was first discovered in 1735 when the disease was first associated with the consumption of undercooked sausage and then in 1870, a German physician derived the name botulism from the Latin word for sausage. A Belgian scientist later discovered and named the organism following a botulism outbreak after a funeral dinner in a local village. It wasn’t until the mid-1900’s that the scientist Dr. Edward Shantz was finally able to isolate the botulinum toxin in a usable crystal form. In the 1970s physicians started using botulinum toxin to treat ‘crossed eye’ (strabismus) patients and then researchers later noticed that when using this treatment on monkeys, wrinkles between the eyebrows and in the forehead were diminished. The ophthalmologist Dr. Alan Scott had been using the toxin to treat crossed eye disorders and ocular spasms when he noticed that patients treated for these eye issues were then requesting additional injections because they loved the associated wrinkle reduction. In 2002 Botox received FDA approval for treating frown lines between the eyebrows marking the first time a pharmaceutical drug was given the green light for strictly cosmetic purposes.

In addition to receiving approval for forehead wrinkle reduction in 2002, FDA approvals for botulinum toxin have been given for multiple other applications and benefits including:

  • (1989) cross-eyed and eye muscle imbalance (strabismus and blepharospasm)
  • (2000) neck spasms (cervical dystonia)
  • (2004) excessive sweating (hyperhidrosis)
  • (2010) chronic migraines
  • (2011) bladder spasms/urinary incontinence
  • (2013) crow’s feet lines

How Botox Works

When injected in precise and tiny doses into targeted areas, the toxin binds to the motor nerve terminals preventing the release of the neurotransmitter acetylcholine thereby temporarily blocking muscle movement. This focal or site-specific blockade results in reducing or smoothing wrinkles and spasms by diminishing associated muscle movement. Facial wrinkles and lines caused by sun damage, skin laxity, and aging that are not related to muscle movement are not typically reduced by Botox and may require an injectable facial dermal filler or resurfacing treatment such as a chemical peel or laser therapy. Recent research has indicated that in addition to reducing muscle movement by blocking the release of acetylcholine, Botox also interferes with the release of inflammatory mediators including substance P and glutamine which may explain why botulinum toxin can be effective in reducing and treating migraine headaches.

Neuromodulators like Botox are injected precisely utilizing very small needles to minimize any discomfort.  Ice or topical anesthetics can be used as needed to minimize bruising or swelling. As with any injectable treatment at EVOLV, the use of aspirin or other anticoagulants should be discontinued at least one week prior to prevent or reduce bruising. Depending on the type of neuromodulator chosen, the muscle and wrinkle reduction may begin in several days but take up to 10 days for full effect. EVOLV Plastic Surgery and Medical Aesthetics places great emphasis on ongoing staff training, anatomy education, and credentialed certification which are especially important in Botox and injectable filler treatments, as well as in any aesthetic procedure, to provide safe, natural-appearing, and optimal results. For best results, EVOLV recommends consistent treatment to extend the result and enjoy the longest-lasting benefits.

Emerging Options in Botox Dosing

In recent years, reconstitution of the botulinum toxin in more concentrated (HDMF or high dose micro-focused) or more dilute (microtox) applications have been utilized to obtain more focused and natural appearing outcomes and to reduce unfavorable results or complications. Utilizing different concentrations and dosing options allow the more advanced injector to provide more precise and long-lasting results for the specific goals of female as well as male patients at any age while making the outcome more predictable.

Increasing Longevity

In addition to using higher concentrations of available toxins (HDMF), there is significant excitement in a new neuromodulator called DAXI (DaxibotulinumtoxinA) from Revance that is in the final stages of FDA approval and should be available later this year. The published research and clinical studies on DAXI support a significantly longer duration (up to 6 months) of effect that is not dose-related and should have a major impact in extending patient benefits not only in cosmetic applications but also in several medical treatments.

Off-Label Indications

Another exciting application of botulinum toxin for patient benefit besides aesthetic wrinkle reduction is in the ‘off-label’ arena. The term ‘off label’ for a medical indication refers to the use of an FDA-approved product by a licensed medical physician to treat a different concern in inpatient care. Tina Alster, MD, medical director of the Washington Institute of Dermatologic Laser Surgery co-authored “Alternative Clinical Indications of Botulinum Toxin” in the American Journal of Clinical Dermatology in December 2020. In this publication, Dr. Alster reviews more than 300 published studies on off-label uses of botulinum toxin and how this positively impacts the clinical use and benefits of neuromodulators. Some of these applications worth mentioning are:

  • Hyperhidrosis (excess sweating) – reducing excessive sweat gland output in the palms and armpits (axilla).
  • Masseter Muscle Hypertrophy – reducing the overactivity of the jaw muscle can soften the jawline, reducing the ‘boxy’ cheek appearance, and even reduce nighttime teeth grinding (bruxism) and related TMJ pain.
  • Scar Treatments – by reducing the mechanical force on some scars, the quality of the resulting scar may be improved.
  • Pores – the hyper dilution method or ‘Microtox’ has been shown to significantly reduce the appearance of facial pores and improve complexion.
  • Décolleté – the décolleté or décolletage refers to a woman’s neck and chest that often becomes wrinkled and aged with prolonged sun exposure.  Multiple studies have shown wrinkle improvement in the décolleté with Botox treatment.
  • Depression – one of the most recent and exciting considerations for botulinum toxin is in the treatment of depression. In a study published July 30, 2020, in Scientific Reports, patients with diagnosed depression who received Botox injections reported significantly more improvement in symptoms than patients undergoing medical treatment with antidepressant medication and in addition, the Botox group had far fewer side effects.  Researchers theorized that in addition to a possible central nervous system effect benefiting depressive symptoms, the wrinkle reduction and improvement in appearance may increase happiness and mood by elevating the ‘feel-good’ hormones serotonin and dopamine in the brain.  Not surprisingly, there is intense interest in pursuing this exciting option for the estimated 265 million people worldwide experiencing depressive symptoms.

With more than 25 years of real-world clinical experience, nearly 4,000 articles in scientific and medical journals, authorization in more than 90 markets, and many different indications, Botox and Botox Cosmetic are among the most widely studied and researched medicine in the world.

For all the above reasons, there is now more excitement than ever for the expanding applications and benefits of botulinum toxin when used by properly trained, credentialed, and experienced healthcare professionals. Unfortunately, as in other areas of aesthetic medicine, there is also misuse and improper treatment practices with neuromodulators by inadequately trained and inexperienced providers resulting in unnatural appearing and undesirable results and complications.

Numerous studies have confirmed that the training, credentials, and experience of the provider, rather than the type of product, technology, or service, is the most important factor in enjoying the best results and minimizing the risk of complications.

Experienced and well-trained injectors understand that aesthetic facial balancing with neuromodulators like Botox as well as with facial dermal fillers is not only a science but also an art form. Knowledge and training in anatomy as well as physiology along with an appreciation for and the development of artistic sensibilities are all integral in obtaining the most natural and balanced results while avoiding complications. The importance of a holistic and comprehensive approach in aesthetic care involving a personalized skincare plan, appropriate and personalized treatments, and long-term maintenance and healthy lifestyle programs are the foundation of the best outcomes in aesthetic care.

Botulinum toxins now have more than two decades of history, experience, and research in aesthetic medicine, and we look forward to a very promising future that is getting better with age!