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Smile: You're On Botox

by Jeanine Barone  

We can’t turn back the clock on aging. But millions of people get injections of botulinum toxin (sold under the brand name Botox and others), which can temporarily reduce some kinds of facial wrinkles. And it’s used for a variety of medical purposes as well—some approved by the FDA, and some off-label. Here’s what you should know if you’re considering the procedure.

What is botulinum toxin, and how does it work?

Botulinum toxin is a potent paralyzing agent produced by Clostridium botulinum bacteria. Botulinum toxin can cause the life-threatening illness botulism, which you can get from eating contaminated food. But injected in tiny amounts and in a purified form, botulinum toxin has been widely used over the last few decades to treat muscle spasms and other medical problems. It was discovered that the toxin could also reduce wrinkling by relaxing the small muscles involved in repetitive facial expressions, leading to its approval as a drug for smoothing eyebrow furrows. The effects last about four months. The drug does not work against fine wrinkles caused by sun damage. In addition to Botox, the FDA has also approved Dysport and Xeomin, rival brands, for cosmetic use.

What are the side effects of cosmetic botulinum toxin?

Botulinum toxin is considered less risky than plastic surgery. But you can get temporary muscle weakness or paralysis adjacent to the injection site, which can result in a droopy eyelid or brow, double vision, or asymmetry in features. Temporary loss in facial expression is common. Side effects are more likely with larger doses and with less experienced practitioners. As with any injection, botulinum toxin can cause redness, bruising, mild swelling, and pain. Allergic reactions—characterized by itching, rashes, wheezing, and asthma-like symptoms—are possible.

If it’s safe, why does botulinum toxin carry a “black box” warning?

After reviewing the safety data, the FDA announced that packages of botulinum toxin must display prominent warning labels (similar ones are required in Canada), and doctors must give patients a guide explaining that there’s a risk the toxin will spread beyond the intended site. A laboratory study published in 2016 in Cell Reports provided concrete evidence of how botulinum toxin can spread from one neuron to another. Anyone who experiences muscle weakness, dry mouth, loss of bladder control, double vision, or difficulty talking, breathing, or swallowing after botulinum toxin injections should get immediate medical attention, since these symptoms may indicate spread of the toxin through the body. Numerous lawsuits have been filed related to both cosmetic and other uses of botulinum toxin, claiming a variety of adverse reactions and even deaths.

For what medical conditions is botulinum toxin used?

It’s FDA-approved for treating excessive sweating under the arms, crossed eyes, eyelid spasms, crow’s feet, cervical dystonia (a condition characterized by severe neck muscle contractions), overactive bladder, and spasticity in the muscle that connects the elbow, wrist, and fingers (which may result from a stroke or traumatic brain injury). It is also approved as a preventive treatment for chronic migraines, defined as 15 or more headaches a month, each lasting at least four hours. In April 2016, the American Academy of Neurology gave this migraine treatment its top rating. It is usually injected by a doctor once every 12 weeks or so into several areas of the head and neck.

Botulinum toxin is also used off-label for a diverse array of conditions, including excess sweating on the palms or in the armpits, phantom limb pain, and temporomandibular disorder (TMD), which causes jaw pain.

Several studies have found that it may also help alleviate depression when injected into the forehead. The mechanism isn’t clear, but one theory is that it works by virtue of how facial movements affect emotion: the toxin makes it harder to frown, which in turn sends the brain the message that the person is happier. Another possibility is that botulinum toxin indirectly impacts a part of the brain, the amygdala, that plays a role in emotions. Recent studies suggest that botulinum toxin may also help relieve patellofemoral syndrome, a common cause of knee pain, and reduce the incidence of arrhythmia or irregular heartbeat after cardiac bypass surgery.

More recently, researchers are investigating botolinum toxin as a treatment for obesity; injecting it into the muscles of the stomach wall may help reduce food intake by increasing the feeling of satiety. Probably the most surprising use is what’s being colloquially called “scrotox”—getting botolinum toxin injected in the scrotom for aesthetic purposes, i.e., a less sweaty, wrinkled scrotum.

Should some people avoid botulinum toxin?

Women who are pregnant or breastfeeding should not get botulinum toxin. If you have a neurological disorder, such as multiple sclerosis or myasthenia gravis, talk to your doctor first, since you may be at increased risk of serious side effects. People with psychiatric disorders related to body image may not be good candidates for cosmetic procedures, including Botox. The same goes for people who are allergic to albumin (a protein found in milk and egg whites), which is used in the manufacture of Botox, as should anyone who has an infection at the injection site. It should also be used with caution in people with certain types of glaucoma or respiratory diseases, or who take medications that affect nerve transmission to muscles.

If you're thinking of using botulinum toxin, tell your physician if you are taking medication, since certain medications, including calcium channel blockers, may in theory increase botulinum toxin’s effects. Anti-clotting medication such as aspirin and warfarin (Coumadin) can increase bleeding at the injection site. Also tell your physician if you have a history of bleeding disorders, a recent heart attack, or cardiac arrhythmias, or if you are planning to have surgery soon. (All of these may negatively interact with botulinum toxin and increase the risk of adverse effects.)

Who is qualified to give botulinum toxin injections?

Anyone with a medical license—or a nurse or physician’s assistant under a doctor’s supervision—can give them. But you should seek a board-certified dermatologist, plastic surgeon, or other professional with a lot of experience, since getting good (and safe) results requires more finesse than simply giving an injection. Be wary of “Botox specials,” such as $100 for your whole forehead; the drug might be diluted and thus may have less effect or not last as long. The FDA warned in 2013 that counterfeit or fraudulent botulinum toxin has been found in the U.S. and it may have been sold to physicians and clinics. If it’s the real thing, the package should say "Onabotulinumtoxin A," not “Botulinum toxin type A.”)

Bottom line: Whatever you’re considering botulinum toxin for, take into account your medical history and medications, the potential adverse effects, and the cost. Even for approved uses, such as chronic migraines, depending on your insurance coverage you may still have to pay quite a bit of out of pocket. Botox for cosmetic use can cost $350 to $500 per area and is not covered by insurance. And it must be repeated every four months or so if you want to maintain the appearance, which can add up to thousands of dollars over a few years.

Also see Can Facial Exercise Reduce Wrinkles?