COSMETIC DERMATOLOGY

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Introduction:

Since its discovery in 1895, to its introduction as a therapeutic agent in 1977, to today, botulinum toxin (BTX) has evolved into a versatile clinical tool with an ever-expanding list of its uses. The wide range of its uses results from its unique properties:

·  its transient duration and reversible effect

·  easy mode of application

·  its effects can be localized to the target areas

·  the degree of its effects controlled with varying doses. 

Allergan Pharmaceutical company, foresaw the great potential of botulinum toxin and named this therapeutic agent BOTOX which made it so popular around the world. 

Now Botox injections have become the quickest way and the most commonly done safe, non-surgical, cosmetic, anti-aging procedure in the world to ease away the signs of aging on your face. 

The clinical uses of BTX-A have expanded and encompass various disorders in the field of:

·  Ophthalmology

·  Otolaryngology(ENT)

·  Dermatology

·  Neurology

·  Urology. 

In 1992, Carruthers and Carruthers were the first to report the use of BTX-A for the treatment of forehead lines or wrinkles. Since then numerous studies have been conducted assessing the safety, durability, and outcome of BTX-A in the cosmetic setting and have made this subject a booming field of research and increasing interest.

Botulinum Toxin (BTX):

Botulinum toxins are produced by the bacterium Clostridium botulinum, and exist as eight serotypes. Each type is antigenically distinct and has a different site of action within the neuron. Types A & B are the only one available for clinical use. BTX-A was the first to be developed as a therapeutic agent and seems to be the most powerful. The cellular action of BTX-A results in temporary flaccid paralysis of the injected muscle and thus produces the cosmetic results in the face and neck caused by the over activity of the respective muscle groups.

Cosmetic use of Botulinum Toxin A:

BTX-A works by temporarily paralyzing the muscles, i.e., reversible paralysis. This effect can be used to treat the hyperactive muscles of facial expression which produces the dynamic wrinkles on the face, i.e., the excessive wrinkles which appears on the face during facial expression. These dynamic lines can contribute more aging looks. BTX-A can be used for cosmetic purposes for the following indications: 

A.  Face & Neck:

For upper face:

a.  Forehead lines (Fig.1, Fig.2)

b.  Frown lines (Fig.1, Fig.2)

c.  Lateral eyebrow lift

d.  Crow’s feet

e.  Lower eye lid lines

For Mid face:

a.  Crow’s feet

b.  Lower eye lid lines

c.  Bunny lines on the nose

d.  Exaggerated flaring of the nose

For lower face and neck:

a.  Gummy smile

b.  Lip lines

c.  Jowls

d.  Angle of jaw for masseter muscle hypertrophy

e.  Neck bands & lines

B.  Other cosmetic uses of BTX- A

a.  Excessive sweating of underarms and hands

b.  As an adjuvant in other cosmetic & cosmetic surgery procedures

c.  Used in facial wound repair

d.  Correcting facial asymmetry caused by various causes

e.  Revitalization of the skin by MesoBotox

BTX-A injections are used for cosmetic purposes in patients aged 18years and above. The safety of BTX-A injections below 18years are not well established. Even when BTX-A injections are indicated in primary hyperhidrosis of axillae from 12 years, the experience with BTX-A injections for this indication is limited in adolescents 12 and 17 years. There are only limited data in the use of BTX-A in patients 65 years old or more. Drooping of the eyelid may occur after treatment. The use of BTX-A is not recommended in pregnancy and breastfeeding women.

Extra precautions need to be taken or at the best BTX-A to be avoided if there is a previous history of chronic disorders of muscles like myasthenia gravis or Eaton-Lamberton syndrome or diseases of nervous system such as amyotropic lateral sclerosis and motor neuropathy.

The onset of cosmetic effect after BTX-A injection, starts 2 days after and the effect progresses over a period of one week to a maximum of two weeks. A retouch for the residual lines if patient desires, can be done after two weeks. The cosmetic effect of BTX-A lasts anywhere from two months to 9 months and in some cases, up to one year, depending on each patient’s nature of muscles, life style etc. A repeat treatment for the relapse of lines can be done after 3 months of the first injection. Too much BTX-A injections and too frequent sessions in less than 3 months should be avoided as this may produce antibodies which will reduce the effects of BTX-A in future.

A detailed consultation is essential with a specialist is mandatory before BTX-A injections

Discussing the various aspects of the dynamics of the facial muscles and BTX-A interaction of each areas is beyond the scope of this article but some of the pictures included below reveals the clinical indications and the cosmetic results.

Excessive Sweating of underarms, hands, soles:

The introduction of BTX-A has completely revolutionized the treatment of axillary and palmoplantar hyperhidrosis. Excessive sweating is called hyperhidrosis and is caused by the over activity of normal sweat glands in these areas due to various reasons. Adult patients who have a substantial impact on their quality of life due to hyperhidrosis can opt for treatment with BTX-A if no contraindications. BTX-A is easy to administer in a short office procedure, with highly effective results, no scars and irrelevant side effects. A pre-injection local anesthesia with an anesthetic cream will make the injections more comfortable in underarm treatment whereas hand and foot hyperhidrosis treatment requires anesthesia using nerve blocks.

As an adjuvant in other cosmetic and cosmetic surgery procedures:

BTX-A treatment has found to be very effective when used alongside other cosmetic procedures such as laser resurfacing and soft tissue augmentation using fillers for wrinkles which are discussed elsewhere in other chapters. These procedures showed prolonged results of wrinkle improvement when BTX-A injections are given before are after the above treatments. The rationale behind this is that, by temporarily paralyzing the underlying causative muscles responsible for the wrinkles, BTX-A will prevent the newly formed collagen bundles from reorganizing into wrinkles produced by facial animation. Also, it has been suggested that, collagen remodeling, the most important event in any resurfacing outcome, could take place in an “adynamic wound healing environment”. Furthermore, continued use of BTX-A treatments following laser resurfacing can add extended longevity to the effects of this procedure.

As far as soft tissue augmentation with fillers (discussed elsewhere) is concerned, BTX-A have a synergistic effect on the results. The paralytic effect of BTX-A will stop the filler material from being extruded from the injection site.

BTX-A helps to oppose residual muscular traction that could jeopardize the cosmetic outcome in lower eyelid blepharoplasty (discussed elsewhere). It helps to reduce the wrinkles over the lower eyelid and also prevent new wrinkle formation after blepharoplasty.

Correcting facial asymmetry:

BTX-A is useful in correcting the facial asymmetry which is caused by excessive and unbalanced muscular pull of an area in one side of the face versus the other due to causes both non pathologic and pathologic. Paralyzing the hyperactive region with BTX-A can correct and equal out subtle differences and make significant improvements in facial aesthetic appearance eg., unequal eyebrow height, positions of the corners of the mouth and uneven smile, hemifacial spasms etc.

Conclusion:

Botulinum toxin injection is a very safe, versatile antiaging tool, which could produce a remarkably satisfying result in a short office procedure, with minimal downtime. Considering its wide range of applications and its long track record of safety, it’s a must do antiaging procedure to those who seek youthfulness, alone or in combination with other resurfacing or augmentation procedures.