The Miracle Drug

By: Katharine Griffiths
Created on 20th September 2011

Is there any word in existence that conjures up such emotive images as 'Botox'? Mr Peter Paterson of Sandon House Clinic explores the aesthetic phenomenon that is botulinum toxin

The cosmetics industry owes a debt of gratitude to botulinum toxin, for it has transcended social barriers and become widely accepted as a ‘cosmetic treatment’.

A contentious statement, given that its cosmetic effect – the smoothing of lines and wrinkles – was noticed by chance, following treatment for strabismus, the condition where the eyes are not properly aligned with each other.

The toxin was first identified in 1895, but it wasn’t until 2002 that the Food and Drinks Administration in the USA licensed ‘Vistabel’, which is one type of botulinum toxin, for cosmetic use.

The anaerobic bacterium clostridium botulinum produces a neurotoxin more potent than any other natural substance known to man and is responsible for the disease botulism. In clinical use, the purified neurotoxin prevents the release of acetylcholine (a chemical messenger) from nerve endings to the motor end plate, producing a flaccid paralysis of the targeted muscles.

The effects are seen from three to five days after treatment with the duration of action lasting on average four months. The effect is only temporary because new neuromuscular junctions form and nerve terminals sprout.

The popularity of botulinum toxin has helped develop a multibillion dollar business built on non-surgical therapies, with an ever increasing array of treatment options available week on week.

As a drug, botulinum toxin takes some beating. Its therapeutic window is safe, its application is easy, its effect dramatic and, best of all, it's temporary! This is extremely important for prospective patients; if you get an undesired effect or do not like the ‘Botox feel’, then it will go.

Advanced practitioners may use botulinum toxin to alter brow position, masseteric muscle mass, chin dimpling and platysmal bands. I would like to add a cautionary note to patients seeking these procedures; the application of botulinum toxin below the crow’s feet may result in significant patient morbidity (illness or injury).

Producing an asymmetric smile, drooling, or a dropped lip is a recipe for disaster resulting in a distressed patient, a loss of goodwill and a negative impact on the practitioner’s reputation. As 95 per cent of patients are just seeking improvements in their forehead and peri-orbital region, I advise the practitioners that attend the botulinum toxin courses I run, to consider offering the more advanced treatments very carefully.

I have read with interest the arguments for and against a regulatory body to monitor the cosmetics industry, a ‘kite mark’ for injectable practitioners. It is ironic that the same government body claiming to protect cosmetic patients has deemed it sensible to de-regulate class four lasers. I do not believe that a kite mark will significantly alter patients' perceptions of good practice. Consumers are very good at networking and poor performing clinics will always fail.

The real danger comes from the trivialisation of botulinum toxin. We all know that botulinum toxin is a prescription only medicine and cannot be advertised, yet you only have to type ‘Botox’ in to any search engine to find it readily available on the internet for sale or promoted by clinics.

The Advertising Standards Agency and the Medicines Healthcare Regulatory Authority (MHRA) are supposed to enforce the law but it is obvious that they are failing. Social networking has also led to a glut of short videos showing you how to ‘do it yourself’, which I believe has encouraged the practice of ‘Botox parties’ with inevitable disasters.

The interests of patients and the industry are best served by ensuring that practitioners are adequately trained – not by attendance at a one-day course but by a process of ongoing mentorship and supervision.

I have seen a number of practitioners lose their confidence when there is a delay between training and hands on practice. Some stress the need for ongoing support as a means of enhancing their knowledge and confidence.

At the training courses I run at North West Cosmetic Surgery Ltd we take our responsibilities seriously, offering our trainees the opportunity to be mentored within their own clinic environment or by a short fellowship programme. I would advise patients, when going for their first consultation, to ask what sort of training the practitioner has received and how much hands on practice they have had since.

Wrinkles and beyond

The applications for Botox are being expanded all the time beyond the eradication of lines and wrinkles – although I would advise patients to thoroughly research the experience of their practitioner before embarking on any treatment.

Excessive sweating This condition, also known as hyperhidrosis, is the result of overactive sweat glands and botulinum toxin can be used to inhibit the nerves in the body that controls the sweat glands. As well as under the arms, it is also possible to treat the palms, feet and face. The effect is temporary.

Migraine headaches Migraine sufferers can get relief as Botox can block the brain receptors from registering migraine pain.

Relaxing the bands in neck As we age, we sometimes develop vertical bands in the neck, which can be softened with Botox. The effect can also simulate a neck lift, if a lot of excess skin is not present.

Face sculpting Skilled injectors in the US are increasingly using Botox to sculpt the face, turning up the nose, lifting the eyebrows to enlarge the eyes, and adding the illusion of volume in strategic areas.

Pout the lips, and turn up corners of mouth Botox has also been used in the US for enhancing the lips, either injected under the bottom lip to puff it out, creating the appearance of a pout, or injected into the corners of the mouth to turn them up slightly.

Dimpled chin Botox can relax the muscles in the chin, reducing the appearance of dimples.

CS&AG