Botox

 

GENERAL INFORMATION ABOUT BOTOX

 BOTOX is a type of cosmetic medical treatment that is performed for the purposes of smoothing out wrinkles in the skin. Throughout the years many factors take a heavy toll on our skin, including daily stress, environment and the aging process. While Botox does not prevent wrinkles from forming in the skin, it does make it possible for patients to receive a rejuvenated facial appearance. Botox is most commonly used for treating wrinkles, such as frown lines, crow’s feet and lines that appear in the forehead over time.

Botox works by temporarily paralyzing the area of the skin that has been injected. As a result, the muscles that are used in the process of frowning or squinting no longer have the ability to contract. During a Botox procedure, it is injected directly into the muscles that surround lines around the lips, nose, in the forehead and the sides of the chin. The procedure is very short and typically only takes about ten minutes. A very fine needle is used during the procedure, which helps in reducing any discomfort that might be experienced during the injection.

You might experience a slight sting during the injection, but there is typically not any discomfort that lingers. One of the benefits of a Botox injection is that you do not have to worry about any downtown. Following the ten minute procedure you are typically able to return to your regular activities. There may be some short term side effects associated with the use of Botox, such as headache, flu syndrome, respiratory infection and nausea. Other risks may include redness, pain, bruising, swelling, muscle weakness and numbness. In most cases, such symptoms typically go away within a week. This is due to the fact that Botox only remains temporarily in the body. Individuals who are pregnant or think they may be pregnant, who are allergic to any of the ingredients in Botox or who have an infection where the Botox would be injected, should not use it. Botox is primarily intended for patients between the ages of 18 and 65 years of age.

Most people notice a significant improvement in frown lines that appear between the eyes within a few days of their Botox injection. This can last up to SIX months following the treatment. It is important to keep in mind that results can vary from one person to the next.

Botox is a protein that has been purified and is produced by a bacterium known as the Clostridium botulinum. It is the only treatment approved by the FDA for its type.

THE VARIOUS USES OF BOTOX

After evaluating the medical literature, the eight indications with the highest quality trials for the use of botulinum neurotoxin in plastic surgery were as follows:

  1. Wrinkles
  2. Facial dystonias and tics
  3. Facial nerve palsy and aberrant regeneration
  4. Migraines
  5. Hand tremor
  6. Palmar / Plantar / Axillary hyperhidrosis
  7. Neuropathic pain
  8. Upper limb spasticity.
  9. Masseter hypertrophy and parotid fistulas following face-lift procedures
  10. Sialorrhea
  11. May improve some scars

 

FACIAL DYSTONIAS

Facial dyskinesias presenting to the plastic surgeon include benign essential blepharospasm, hemifacial spasms, orbicularis myokymia, Meige syndrome, and apraxia of lid opening. Particular focus on benign essential blepharospasm and hemifacial spasms has been studied in the literature.

Subcutaneous injection of botulinum toxin into the orbicularis oculi every 3 to 4 months is the standard treatment for benign essential blepharospasm, with some minor variance in injection sites for each patient. Dosage and injection sites are similar for hemifacial spasms, with additional injections into the involved lower facial muscles if required. Hemifacial spasm has a longer spasm-free interval of 4 to 6 months.

 FACIAL NERVE PALSY AND ABERRANT REGENERATION

A rare consequence of chronic facial nerve palsy is aberrant facial nerve regeneration, which can lead to gustatory epiphora, gustatory sweating, or abnormal synkinetic facial movements. Gustatory epiphora, or “crocodile tears,” is an excessive lacrimation while eating or smelling food. Several small studies have suggested that this can be treated with intraglandular injections of botulinum toxin. Temporary ptosis was noted as a temporary complication.

MIGRAINES

Botulinum toxin A was incidentally found to benefit headaches while being used for cosmetic use. With respect to chronic migraines (>15 migraines/month), two large multicenter controlled trials (Phase III Research Evaluating Migraine Prophylaxis Therapy 1 and 2) were conducted to clarify earlier years’ inconclusive results of prophylactic botulinum neurotoxin injections. The pooled results of these studies showed that Botox was significantly superior to placebo in reducing headache days and multiple quality-of-life measures. These large studies also showed that Botox was safe and well tolerated for the prophylactic treatment of chronic migraines, leading to the subsequent approval by the U.S. Food and Drug Administration in 2010 for this use.

The approved Botox dose is a total of 155 U divided among 31 injection sites in the head and neck, repeated every 12 weeks. The target of these injections is superficial to the peripheral sensory nerves. A combination of a fixed-dose/fixed-site injection plan and a follow-the-pain method is appropriate.

HAND TREMOR

Essential tremor is an autosomal dominant neurologic movement disorder that causes uncontrollable shaking in different parts of the body, most often affecting the hands, head, and voice. Two double-blind studies have compared the injection of Botox to placebo into wrist flexor and extensors in 158 total patients with moderate to severe essential hand tremor. Significant improvements in both postural and kinetic tremors were observed. The data suggest that botulinum toxin has minimal effect on functional ability.

PALMAR HYPERHIDROSIS

Focal hyperhidrosis is chronic, idiopathic excessive sweating that commonly affects the underarms, palms, and face.

Studies have demonstrated good outcomes with doses of 100 to 120 U of Botox per palm divided into 50 sites. The onset of anhidrosis is usually noticed within 3 weeks, accompanied by some decrease in muscle strength of the hand, which typically lasts for 4 months on average.

The evidence for the use of botulinum toxin in palmar hyperhidrosis is limited to only Level II and III trials. Larger trials are needed to determine the duration of anhidrotic effect, injection technique, optimal dosing, and the long-term effects on muscle tone.

NEUROPATHIC PAIN

Botulinum toxin has been used successfully in the treatment of various painful conditions. Initially, the analgesic property of botulinum neurotoxin was thought to be associated with reduction of muscle activity. Higher evidence trials have suggested that botulinum neurotoxin is effective in the treatment of diabetic neuropathy, postoperative neuropathy, and other idiopathic chronic neuropathic states.

UPPER LIMB SPASTICITY

Spasticity can be seen as a result of various causes, including trauma, multiple sclerosis, central nervous system tumors, stroke, and cerebral palsy. Patients with spasticity experience reduced function secondary to muscle weakness, soft-tissue contracture, and muscle overactivity. Most clinical trials of botulinum neurotoxin in the treatment of adult spasticity have emphasized improvements in spastic posturing, whereas functional improvement, defined as activities the subject can perform with the spastic limb, have been reported in only one case series.

CONCLUSIONS

The use of botulinum toxins has revolutionized the treatment of various disorders presenting to the plastic surgeon’s office, ranging from rhytides to neuropathic pain. We are seeing significantly more scientific work on the subject of botulinum toxin and its various forms. In the future, we will likely see further data with respect to the potency and efficacy of the various toxins.

BOTOX PRE & POST-TREATMENT INSTRUCTIONS

Pre-Treatment Instructions

  • 3 DAYS BEFORE treatment:
    • AVOID topical products such as Tretinoin (Retin-A), Retinols, Retinoids, Glycolic Acid, Alpha Hydroxy Acid, or other “anti-aging” products.
    • Also AVOID waxing, bleaching, tweezing, or the use of hair removal cream on the area to be treated.
  • 7 DAYS BEFORE treatment (to prevent bruising):
    • AVOID blood thinning over-the-counter medications such as Aspirin, Motrin, Ibuprofen, and Aleve.
    • Also avoid herbal supplements, such as Garlic, Vitamin E, Ginkgo Biloba, St. John’s Wort, and Omega-3 capsules.
  • Do not drink alcoholic beverages 24 hours before (or after) your treatment to avoid extra bruising.
  • Inform your provider if you have a history of Perioral Herpes to receive advice on antiviral therapy prior to treatment.
  • Do not use BOTOX if you are pregnant or breastfeeding, are allergic to any of its ingredients, or suffer from any neurological disorders.
  • Please inform your provider if you have any questions about this prior to the treatment.

Day of Treatment

  • Arrive to the office with a “clean face”.
  • You can apply EMLA cream for local anesthesia 45 minutes before the treatment
  • Please do not wear makeup. You may bring your own makeup to apply after your treatment.
  • You may experience a mild amount of tenderness or a stinging sensation following injection. Redness and swelling are normal. Some bruising may also be visible.

Immediately After Treatment

  • It is best to try to exercise your treated muscles for 1-2 hours after treatment (e.g. practice frowning, raising your eyebrows, and squinting). This helps to work BOTOX into your muscles.
  • Stay in a vertical position for four hours following injection.
  • DO NOT “rest your head” or lie down; sit upright.
  • You may apply an ice or cold gel pack to the area(s) treated (avoiding pressure) as this helps reduce swelling and the potential for bruising.
  • Once you have adequately cooled/iced the area(s) as instructed and any pinpoint bleeding from the injection site(s) has subsided, you may begin wearing makeup.
  • AVOID placing excessive pressure on the treated area(s) for the first few days; when cleansing your face or applying makeup, be very gentle.
  • AVOID exercise or strenuous activities for the remainder of the treatment day; you may resume other normal activities/routines immediately.
  • You may take DEPON / LONARID / Acetaminophen / Tylenol if you experience any mild tenderness or discomfort. DO NOT TAKE ASPIRIN.
  • AVOID using a hair dryer for 24 hours.
  • AVOID extended UV exposure until any redness/swelling has subsided. Be sure to apply an SPF 30 or higher sunscreen.
  • Wait a minimum of 24 hours (or as directed by your provider) before receiving any skin care or laser.