Exploring the Botox Fad

Dodie Kazanjin, like millions of Americans, was unhappy with her "frown lines . and bags under the eyes." Her solution? Botox. She described her experience, what felt like being "stung by a hundred killer bees," in an August Vogue

magazine article. She received five injections of the drug into her forehead, and endured the stinging pain for 10 minutes before it began to subside. Within half an hour, though, the Botox began to take effect, and she was ultimately pleased with the treatment. She says she feels as though she's "taken the first step, gotten [her] feet wet," and found that Botox isn't so bad after all.

Not unlike plastic surgery, the highly popular Botulinum Toxin Type A cosmetic treatment, "Botox Cosmetic," remains quite popular despite a significant amount of negative public reaction. Reactions to the newly sensationalized drug range from avid usage to downright disgust. The prospect of receiving a shot of neurotoxin in the face or neck isn't exactly appealing, but doctors have been using Botox and other similar injections for nearly 10 years to treat skin and gland problems.

Botox has been known to be an effective treatment for crossed eyes (strabismus), uncontrollable blinking (blepharospasm), and neurological disorders such as cervical dystonia (spasms of the neck and shoulder area), and has been Food and Drug Administration (FDA)-approved for such use since 1989.

The lunch hour procedure

The procedure is swift; it is no wonder enthusiastic customers, mostly well-to-do, middle-aged, urban men and women, are calling Botox the "lunch hour procedure." The cosmetic effect of Botox is to induce and to maintain a smooth, wrinkle-free forehead or temple and to effectively erase frown lines.

The American Society for Aesthetic Plastic Surgery (ASAPS) says nearly 1.6 million Botox treatments took place in the year 2001, a 46% increase since 2000 and a whopping 2,356% increase since 1997. The sudden and overwhelming interest in the procedure is most likely due to its FDA approval, which came in April 2002.

Before then, Botox was used only for very specific medical treatments, and not for widespread cosmetic purposes. A press release from the FDA says Botox should be used only for temporarily improving "the appearance of moderate to severe frown lines between the eyebrows." In the definitive study (a placebo-controlled, randomized study), researchers found that individuals injected with Botox had their frown lines vastly improve or disappear within a month.

A shot of neurotoxin to the face

It's not every day the FDA recognizes an alternative use for a poison. Botox injections come directly from a deadly bacterial toxin, but when used properly, there are surprisingly beneficial results. So how does Botox Cosmetic work? Botox is a purified form of Botulinum Toxin Type A, a protein complex produced by Clostridium botulinum, a bacterium well-known for causing severe food poisoning and even death. The toxin causes the muscles in the face, and thus, frown lines, to "relax" by blocking acetylcholine receptors and halting the pathway leading to contraction of those muscles.

Toxicity data shows the dose of botulinum toxin at which 50% of a test population will die (the LD50 value) to be 0.00001 mg per kilogram of body weight. In other words, one vial of Botox in a physician's cabinet has an extremely lethal potential - but only if ingested. Both Botulinum Toxin Type A and Botulinum Toxin Type B (Myobloc, a Botox-like injection), while extremely toxic, are nevertheless currently approved for use as intramuscular injections.

A typical administration of Botox Cosmetic is performed in a physician's office. The patient needs to sit or stand upright for the duration of the treatment as well as the next four or five hours. This helps the treated facial muscles to "settle in" and fall into the natural positions they would hold during a normal day.

A fraction of a teaspoon of Botox is injected into the face while the patient flexes his or her facial muscles. Dramatic disappearance of frown lines occurs any time from a few hours to a next couple of days after the treatment. Results last for about four months, so in order to keep up their appearances, patients must be re-treated every four to six months. Pre-injection anesthetics or numbing creams, and small post-treatment injections of collagen may be used, as every patient responds differently to the drug and adjustments are made accordingly to obtain the best possible results.

Analyzing the demand for Botox

A multi-million dollar market is expected from the sudden demand for Botox injections. One enthusiastic San Francisco-based dermatologist, Seth Matarasso, calls Botox "the aspirin of the decade." It is also creating so-called "celebrity dermatologists." "Botox King" Dr. Frederic Brandt, famed for his Florida and New York Botox practices, reportedly administers the drug more than any other physician.

Of course, one must consider both the pros and cons of Botox. Based upon its easy and quick use, almost immediate results, minimal invasiveness (compared to cosmetic surgery), and relatively cheap cost (several hundred dollars) Botox has in fact been hailed by the cosmetic industry as a nearly ideal procedure. But Botox also weakens the facial muscles. Adverse effects from the injections include flu-like symptoms, nausea, respiratory problems, and facial pain (stinging, burning, or allergic reactions).

The act of injecting the drug poses a danger; an unsuccessful application might cause the patient to have droopy eyelids for a week or longer. There is also the issue of possible complications with medications the patient is taking. And there are not yet any indications that Botox does not affect a pregnant woman's fetus. Yet another concern is that Botox may not be administered properly; the ASAPs asserts that Botox treatments have been injected by "unqualified people . dispensing Botox in salons, gyms," and other places that may not be safe. To safeguard against this, the FDA insists that Botox treatments be received in a sterile clinical setting from a certified physician, who is, if possible, an expert on facial cosmetics.

Competition for Botox

Competition for Botox also exists in the cosmetic industry. The second botulinum toxin to be approved, Myobloc, lasts for a shorter amount of time than Botox. Restylane and Perlane, hyaluronic acid derivatives that serve as a sort of collagen supplement, also belong to the category of cosmetic treatments used to smooth human skin.

Collagen, the most abundant protein in the body, is an elastic polymer that makes skin firm and durable; as we age, collagen is lost from the dermal, or deeper, layer, rendering our skin more wrinkly and stiff. The numerous "anti-aging" and "anti-wrinkle" creams on the cosmetic market do improve the skin temporarily (through hydration, vitamin-enrichment, and providing other nutrients), but they may only treat the outermost layer of skin, the epidermis - collagen glands lie in the dermis, and so are unaffected by these creams. Retinoic acid (vitamin A) is an excellent non-injection treatment for the skin, and is often used in medical treatments as well as in over-the-counter creams and lotions. The next cosmetic "miracle" could be just a few years away, bringing us more alternatives, perhaps longer lasting and better than Botox Cosmetic. Or we could just choose to age naturally.


Suggested Reading

Amdur, Mary O., Doull, John., Klaassen, Curtis D., editors. Casarett and Doull's Toxicology: The Basic Science of Poisons. Fourth edition. Pergamon Press, Inc. New York, U.S.A. 1991. Lewis, Carol. Botox cosmetic: a look at looking good. U.S. Food and Drug Administration. FDA Consumer magazine. July-August 2002. http://www.fda.gov/fdac/features/2002/402_botox.html

The American Society for Aesthetic Plastic Surgery (ASAPS). Botulinum toxin (BOTOX®, MYOBLOC®) injection is top cosmetic treatment: more than 1.6 million procedures: new 2001 statistics from the American Society for Aesthetic Plastic Surgery. 2002. http://surgery.org/news_releases/feb2502btx.html

FDA APPROVES BOTOX TO TREAT FROWN LINES. April 15, 2002. http://www.fda.gov/bbs/topics/ANSWERS/2002/ANS01147.html

Product Approval Information. December 21, 2000. http://www.fda.gov/cber/approvltr/botaller122100L.htm

Preboth, Monica. Frown lines reduced with botulinum toxin injection. American Family Physician. June 1, 2002 v65 i11 p2389.

Shea, Christine. Beyond botox. Vogue Magazine. V. 192. no. 2. August 2002. 258-260.

Vernarec, Emil. Botox approved for use on frown lines. RN, July 2002 v65 i7 p94(1).

Related web sites

Before and after images of Botox treatment

http://www.pschr.com/before_and_after_botox.html

http://www.peppercorn-md.com/ba-patients.html (Scroll down to "Example of Botox Wrinkle Treatment")

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