Botulinum (botox)

Botulinum toxin

Botulinum toxin has become a ubiquitous drug for all seasons. A myriad of applications for the treatment of facial aging are now available that can be performed safely and effectively with minimal side effects. Botulinum toxin is produced by the bacterium Clostridium botulinum. In 1980, botulinum toxin started finding medicinal use for certain conditions, such as the treatment of strabismus in children, facial spastic disorders as well as asymmetries caused by facial nerve paralysis, deep glabellar furrows in patients with benign essential blepharospasm. It is use in the effacement of dynamic or hyperkinetic facial lines, it has also found use in treating conditions such as dystonias (cervical dystonias), facial and generalized muscle spasms, cranial nerve VII disorders, incontinence, autonomic disorders, blepharospasm, general spasticity and strabismus, migraine headaches, jaw pain and spasm, hyperhidrosis, and involuntary movement disorders.

There are at least seven different substances (serotypes), mostly proteins. However, only one of its type is used in medicine, namely neurotoxin of A type available in the form of solution called Dysport (from Ipsen Ltd.) and Botox Cosmetic (by Allergan). Botulinum toxin type A is the most powerful biological endotoxin, whose biochemical and physiologic effects. Primarily serve to block the release of acetylcholine at the neuromuscular junction in affected mammals, thus inhibiting focal muscle contraction.

Indications

The cosmetic form of botulinum toxin is a popular non-surgical injection, applied to various aspects of facial rejuvenation, that temporarily reduces or eliminates wrinkles in the region of 1/3 of the upper part of the face, i.e. the region of the forehead, frown lines between the eyebrows, and the so called crows feet around the eyes, rarely in the region of the mouth, chin and neck.

Studies have also suggested that botulinum toxin is effective in relieving migraine headaches, excessive sweating, under the arms to prevent perspiration, and muscle spasms in the neck and eyes.

Patient selection

Not all individuals are candidates for botulinum toxin injections. Among those who should not receive such injections are those who are sensitive to the ingredients, patients with neuromuscular diseases (such as myasthenia gravis, Eaton-Lambert syndrome, or amyotrophic lateral sclerosis) and pregnant also lactating women.

Injections should be applied with caution and discretion in those patients on anticoagulation (aspirin therapy), patients treated with aminoglycosides, penicillamine, or calcium channel blockers, as these drugs have been known to possibly potentiate clinical effects.

Patients who have unreasonable expectations or psychological issues that would prelude a satisfactory outcome should be excluded from treatment.

Patients should understand that the effect of botulinum treatment can last several months but will not achieve a permanent change nor will it produce the same effect as surgical rejuvenation, including facelift.

Treatment

Botulinum toxin works in the region of neuromuscular connection. It blocks the transmission of nerve impulses to muscular fibers paralyzing muscular contractions. As a result, muscles become lose and flaccid smoothening the skin face. Injections are performed without anesthesia or Emla can be used. The toxin, after having been injected, spreads in the radian of 1 to 3 cm from the injection place and removes only dynamic wrinkles such as mimic wrinkles of the face, depending on the muscles that are activated.

Botulinum toxin starts to work after 72 hours since the medication was injected, but the cosmetic effect is gain after 2 weeks. The toxin works for 5 to 6 months. It can be used only 2 to 3 times a year every 4 or 6 months. Even though the botulinum toxin does not pose any danger, some temporal side effects may appear such as slight pain during the injection, redness or small haematomata in the regions of injection or slight temporal swelling of those regions.

Complications

Potential transient adverse local effects include: rash, pain, edema, erythema, ecchymosis, headache or hyperesthesia at the injection site.

Systemic complication are very rare but they may include flu-like symptoms or distant skin rashes. The other rare but more frequently reported events are adverse or undersirable soft tissue effects that relate mostly to technique and result in temporary soft tissue malposition (such as blepharoptosis, brow ptosis, cheek ptosis, and lower eyelid ectropion or retraction, etc.).

The treatment with botulinum toxin may rarely result in the formation of antibodies that may reduce the effectiveness of subsequent treatments for cosmetic or other clinical uses. This may happen more frequently when toxin is given more often than recommended or at higher doses.

Botulinum injections can be a safe and effective temporary treatment of fine facial lines and wrinkles, can produce a temporary improvement of facial and periorbital shape, and can serve as a useful adjunct in a variety of plastic surgical procedures.

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