Author: Kesiree Naidoo

We’ve all heard that familiar hushed phrase ‘Too much Botox ‘ used to describe a cosmetic treatment gone wrong. But what does it really mean?

BOTOX is the name of the first registered brand of botulinum toxin used for cosmetic treatments. DYSPORT is another registered brand. Both these brands are used in South Africa.
Internationally there are other botulinum toxins registered for use, but the word ‘Botox‘ is often incorrectly used as a blanket term to describe all forms of aesthetic treatments.

Botox or other botulinum toxin treatments should not be confused with treatments with fillers, surgical threads and plastic surgery.
Botulinum toxin is a neurotoxin produced by a bacterium, clostridium botulinum, which causes food poisoning. Botulism is a rare and potentially fatal disease. It is fascinating that a poisonous toxin is now synthesised and used therapeutically in multiple medical disciplines across an ever increasing range of indications.

That ‘lightbulb’ moment
Botulinum toxin was first approved to treat blepharospasm and strabismus in the 1980’s. It’s ability to treat wrinkles was discovered by accident.

It began when a husband and wife team of ophthalmologists (Jean and Alastair Carruthers) noticed that patients treated with botulinum toxin had fewer wrinkles in the treated areas. They were initially met with much skepticism, but in 2002 the United States food and drug administration (FDA )approved Botox for use for frown lines, and subsequently for crows feet and forehead lines.

How does it work?
Botulinum toxin is injected into muscles causing paralysis (weakness) of these muscles resulting in a reduced ability of the muscles to contract and therefore, in terms of cosmetic indications, reduced wrinkling of the overlying skin.
It is also injected into skin to reduce excessive production of sweat by the sweat glands.
The toxin works by preventing the release of the enzyme acetylcholine at the neuromuscular junction and sympathetic and parasympathetic neurons.

The effect, in all cases is temporary.
Muscles recover after 3-4 months and are able to contract again. This means that if you have toxin injected, and you don’t like the results, you can take comfort that it will reverse in 3-4 months. The bad news is that botulinum toxin needs to be injected every 3-4 months to sustain the desired effect.
With regular injections the wrinkles or hyper-dynamic lines caused by repeated muscle movements will soften and the skin will become smoother.

Muscles that have hypertrophied (enlarged) will shrink in size with regular treatments.
Excessive sweating caused by hyper-secretion of sweat glands will reduce in the treated areas.
The effect on the sweat glands may last longer, ranging from three months to a year in varying reports.
Botulinum toxin does not treat wrinkles or creases that are not caused by the movement of muscles. This means it will not treat static lines that occur when one sleeps in the same position repeatedly, or wrinkling caused by redundant skin which forms when skin loses elasticity.

What are the uses?
In a recent Time magazine article Alexandra Sifferlin aptly referred to Botox as “The drug that’s treating everything ”
The uses of Botulinum toxins are extensive and extend beyond the uses approved by regulatory bodies like the US FDA.
We call these uses off-label uses. Remember that when the Carruthers first started using Botulinum toxin for frown lines it was also initially off label.
In South Africa Botox has been registered for use for frown lines, crows feet and underarm sweating, but in practice botulinum toxins are used for more indications, ranging from facial paralysis, muscular pain to scars, headaches and depression.
It has proven to be safe to use, especially since its effects are not permanent.
The approved indications are both cosmetic and medical and vary in different countries.

What is the process?
Botulinum toxin comes freeze dried in a small vial. It is reconstituted with saline before it is injected. The process is relatively pain free and well tolerated.

For aesthetic treatments small amounts of botulinum toxin are injected with a very fine needle at key points on the face, corresponding to the muscle anatomy.
The number of injection sites vary depending on the area treated. The amount of toxin injected depends on the size and activity of the muscles. You may need more toxin injected for stronger muscle activity.
I usually inject a conservative amount and review the patient in a week to see if more is needed.

Frown lines or glabellar lines.
These are the lines that form between both eyebrows, and often give one an angry or worried expression. They are caused by muscles called the glabellar complex.
5 to 6 points are usually injected.

Crows feet or lateral canthal lines
These lines form on the sides of the eyes and are caused by the orbicularis oculi muscles
Generally 3 injection sites per side are needed.

Forehead lines
These are horizontal lines on the forehead that form as result of contraction of the frontalis muscle.
There are a few techniques ranging from 5 injection points to multiple small injection points.

Excessive sweating of the underarms and palms
The treatment of hyperhidrosis (excessive sweating) needs large amounts of toxin compared to the cosmetic indications.
The toxin is injected at multiple, more or less equidistant sites on the affected areas.
The area to be treated can be anesthetised with a topical anesthetic or nerve block.

Bruxism is grinding or clenching of the jaws and usually occurs during sleep. It results in pain in the head and neck, teeth and temporomandibular joint (TMJ). The masseter muscles attached to the jaw increase in size. The condition can be successfully treated by injecting botulinum toxin into the masseter muscles causing them to reduce in size and decrease pain in the jaw. It also results in a slimmer narrower jawline.

Off label cosmetic uses are numerous and include injections for lateral brow lift, marionette lines, perioral lines and gummy smile. These have varying success amongst patients, and can be discussed with your doctor or dermatologist.

Make sure you have your toxin injected by a trained professional who has knowledge of the injection points and muscle anatomy to avoid poor results or a flat and expressionless face i.e. ‘overbotoxed’ results.

Some signs that indicate poor results are ‘spock eyebrows’, a lowered brow (brow ptosis) or a droopy eyelid (eyelid ptosis). These problems can sometimes occur even in the best hands, but can potentially be corrected so it is important to go for your follow up check with your treating doctor.

When performed well, aesthetic treatments can improve one’s appearance and self esteem. Remember it is the bad jobs that are noticed the most. The good jobs are difficult to see.

Please call 021 531 1107 if you have any queries or book an appointment if you would like to come in to discuss a treatment.