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Look Better Naked: When is it time for Botox?

Last month I discussed prevention: ways to avoid the ravages of sun damage and prevent wrinkles. Now let’s talk about treatment.

What should you do if the wrinkles and sun damage are already there?

Wrinkles on the face are managed with various modalities ranging from inexpensive and pain-free to more expensive, and more effective, with potential for pain and downtime for recovery.

There are cosmeceuticals (creams, lotions, gels, serums), injectable fillers (Restylane, Perlane, Juvederm, Radiesse, Sculptra, Artefill, etc.), light-based procedures (laser, IPL, LED lights, infrared), plastic surgery (face lift, mini-lift, string lift, implants, etc.) and Botulinum Toxin injections (Botox, Dysport).

Since Botulinum Toxin injections are the most widely used and popular wrinkle treatment and are often the first cosmetic procedure people try, I will spend the rest of this column discussing Botox treatment in greater detail.

Regarding Dysport (Ipsen BioPharm) vs. Botox Cosmetic (Allergan), in my experience there are really no major differences between the two brands in terms of cost or performance. Both are purified Botulinum Toxin A. Dysport claims to have a faster onset of action and last longer, but I have honestly not witnessed this in my practice. Dysport is much less expensive than Botox – about one-third the cost, however, it also requires 2.5 to 3 times as much to achieve the same results. So therefore it seems to be all a “wash” in the end.

You have probably heard of botulism, which is a disease associated with the consumption of food contaminated with clostridium botulinum, a bacteria that produces botulinum toxin A. This toxin blocks nerve transmission at the junction of motor neurons and muscle cells and renders the muscles weak or paralyzed.

The disease was first described in 1817 and so named because it was associated with sausage consumption (from the Latin word botulus = sausage). The disease was lethal because, once infected, a large amount of botulinum toxin A is produced by the bacteria. The toxin eventually paralyzes all muscles in the body including the muscles of breathing. Most people may have heard of the 1920s outbreak of botulism associated with contaminated canned food.

During World War II, after concerns were raised regarding the possible use of clostridium botulinum as a biological weapon, toxin type A was isolated in its pure, crystalline form in order to study its effects. Then in the 1970s, an ophthalmologist successfully used the isolated toxin to treat disorders of eye muscles by injecting small amounts of the purified toxin directly into the muscles to relax them. Soon thereafter, other doctors began using it to treat muscular disorders of the eyes.

In the 1980s, an ophthalmologist named Jean Carruthers discovered that some of her patients were experiencing a quite-pleasing reduction of their frown lines, as a side effect of their eye injections. After this accidental discovery, her husband, Alastair Carruthers, a dermatologist, began injecting the toxin to specifically treat facial wrinkles. And the rest is history!

Toxin type A is what Botox Cosmetic and Dysport are made of. There is NO bacteria in the injection – only the purified toxin. And in case you’re wondering, the amount of toxin used for cosmetic purposes is far too weak to cause any significant systemic effects. Some people may experience a headache or tiredness after injection, but the overwhelming majority of people who are injected with Botox experience no side effects at all.

The toxin is dissolved in sterile saline (a clear liquid water with 0.9% sodium chloride which matches your body fluids) and injected with a tiny needle – about the same size as an insulin needle. Due to the very small needle size, and ease of injection, Botox cosmetic treatment is the least painful of all the injection procedures we do. Pain is further reduced by pre-treatment of the skin with topical anesthesia or ice.

Botox can be used to soften or eliminate frown lines between the eyebrows, forehead wrinkles, and “crows feet” at the sides of your eyes. Other more subtle effects can be obtained with injection of very small amounts into precise areas such as to lift the eyebrows or soften vertical wrinkles of the lips. By relaxing the muscles underneath the wrinkles, the action that causes the skin to fold and wrinkle is eliminated. Slowly the collagen in the skin unfolds and the wrinkles disappear.

The toxin reaches its full effect 10 to 14 days after injection and persists in the nerve endings for about 2.5 to 3 months. Then the muscles slowly regain their ability to contract and after that you start to see the re-appearance of wrinkles.

So for most people, the effect of one Botox treatment “lasts” three to four months. It is true, however, that if you “keep it up” by not letting the wrinkles fully re-appear between treatments, the effect can last longer and longer, and sometimes you need less to maintain results. This happens due to weakening of the muscles, greater collagen unfolding (so it takes longer to re-fold and make a wrinkle once muscle action returns) and also re-training.

Re-training means your brain, after multiple attempts to perform an action that is not working finally abandons that action and “forgets” to do it. So, for example – if you frown when you are concentrating, after two or three Botox treatments your brain may start forgetting to make that frown when you are concentrating. It then takes longer and longer to re-learn to do that action again, so your results (wrinkle reduction) may last longer.

Botox is priced two ways – either by the area or by the unit. In my practice we price it by the unit to avoid any conflict of interest. In other words – everyone needs a different amount to achieve the same results. When you charge by the area, the incentive is to use the least amount possible to preserve profit. When you charge by the unit, each patient pays for only the amount needed and nothing more.

Most physician offices injecting Botox charge $10 to $13 per unit. An area such as the frown lines will need 15 to 20 units in a female and 20 to 30 units in a male, depending on how big and strong the muscles are. Foreheads take a similar amount and crows feet take 6 to 10 units per eye.

You may wonder when is the right time to start Botox treatments? The answer is anytime you see wrinkles in these areas. It’s never too early to start – in fact, the younger you are and the smaller the wrinkles, the more likely you are to achieve complete wrinkle elimination.

Older or more “etched-in” wrinkles will not always completely disappear. If your wrinkles are already deeply etched, the good news is they will still be greatly softened by Botox, even if they are not completely eliminated. This softening effect is preferred by many because it is more “natural” looking than a plastic surgery facelift, which might just simply stretch the skin and give a totally smooth look to someone who has had wrinkles for a long time.

Although I have talked mainly about the face, which can be seen even if you’re not naked, Botox is utilized in other areas of the body as well. It is often used to manage muscle spasms and tightness, plantar fasciitis (a common painful condition of the foot), chronic pain in certain areas, migraine headaches, or excessive sweating of the armpits, hands, or feet.

So you see – even Botox can make you look better naked! And besides, even if it’s only the face we end up treating, doesn’t a beautiful or handsome, youthful-looking face make all things naked just that much better?!

Darren A. Farnesi, M.D., APC, offers his sound advice and personal knowledge of the industry as a successful doctor with Medical Age Management Inc. He can be reached at (619) 299-0700 or online at www.manageyourage.com.