A simple fix to those annoying deeply set facial lines, BOTOX Cosmetic is not new to the skin rejuvenation scene. So when the FDA finally approved the use of BOTOX Cosmetic for cosmetic use this past week, most dermatologists, plastic surgeons and even the aestheticians at the mall wondered what all the fuss was about.

Touted as a pharmaceutical launch comparable only to Viagra, the approval of BOTOX Cosmetic has sparked an amazing avalanche of opinion on how we as Americans feel about our appearance and the lengths to which we are willing to go to look younger. Are baby boomers so desperate to hold on to their youth that they'd allow poison to be injected into their skin? Compare this to the camp that wonders, "do we REALLY need to be able to frown, squint or look our age when surprised? Then there are the endless articles inquiring if doctors who throw BOTOX Cosmetic bashes have hit a low point in medical ethics? And what about the movie industry? Has it been dealt a blow from which it can't recover now that actresses no longer have the ability to show facial expression? (For the record, my responses are yes, no, yes and no).

It's been at least 10 years ago since a Vancouver ophthalmologist, Dr. Jean Carruthers, noticed that those patients who received BOTOX Cosmetic injections to treat conditions such as strabismus and blepharospasm were REALLY happy with the results and were requesting further treatments to help give them a more youthful, relaxed appearance.

Call it serendipity that Dr. Carruthers was married to another Dr. Carruthers (this one a dermatologist) who promptly began to look into forgoing the use of BOTOX Cosmetic for uncontrollable eyelid twitching and see instead if it indeed would help eradicate wrinkles.

A Poison For Pretty Skin?

BOTOX Cosmetic, or botulinum toxin type A, is the neurotoxin (poison) produced by bacteria most commonly known to cause botulism, a form of food poisoning. This toxin leads to muscular paralysis, which is why botulism is such a serious condition. So how on Earth did anyone even think of trying to use it for medical use?

BOTOX Cosmetic is a great example of turning a side effect into a positive outcome. Translate paralysis into relaxation of the muscle and you can see that there are going to be possible benefits to many medical conditions that arise due to prolonged or permanent contraction of the muscles. BOTOX Cosmetic is used to treat such conditions as spastic colon, blepharospasm (eyelid twitching), strabismus and neurological disorders such as cervical dystonia. Its use is continually being expanded by medical professionals and now is also helping reduce excessive sweating of the palms, underarms and forehead.

Location, Location, Location

When skin ages, there are more factors going on than literally meet the eye. Each problematic flaw is attributable to its location. Visualize them as placed within separate layers of an onion. Each layer has its own unique changes and characteristics. Address each layer and your results are maximized.

As you age, the epidermis thickens, becoming lack luster. Our oil glands start to dry up (especially with menopause) and our skin becomes dry and rough. Sun damage takes its toll with the addition of blotchy skin discoloration. These are all epidermal skin changes that typically respond nicely to your choice of skin bleaches, topical vitamin A creams like prescription Tazorac and Renova or OTC retinols such as Afirm as well as glycolic acid products like MD Formulations, chemical peels and microdermabrasion.

Down in the dermis, the collagen and elastin fibers are deteriorating. This results in loose, sagging skin, fine wrinkle lines and an increased likelihood of bruising. Here you need to dwell upon antioxidants with fibroblast stimulating properties like Neova or Cellex-C and perhaps a treatment like N-Lite.

The muscles on the other hand have been working overtime to show just how expressive you really are. Take a good look in the mirror. Remember when your mother told you to get that look off your face or your face would freeze?

Over the past 30+ years each and every time you smiled, frowned or raised your brows in surprise you were building those muscles of facial expression as much as if you were building a bicep from lifting weights. The more that bicep is exercised, the larger it becomes. Over many years, we overwork the muscles of facial expression in much the same way until they thicken, leaving deeply grooved wrinkle lines.

These are not the fine little wrinkle lines that respond to topical skin rejuvenation therapy. This is where BOTOX Cosmetic comes in. BOTOX Cosmetic helps temporarily paralyze these muscles that have literally frozen in place, inducing relaxation and a smoothing out of the wrinkles. Be sure to incorporate or maintain an active skin rejuvenation regimen in between treatments to keep the surface skin looking its best. MD Formulations Facial Cleanser, MD Formulations Vit-A-Plus Intensive Anti-Aging Serum and MD Formulations Vit-A-Plus Anti-Aging Eye Complex are the bare essentials needed to keep the skin looking its best between treatments.

Zoning

The areas of facial expression are broken into "zones" for ease of discussion as well as treatment. There are 3 zones most commonly treated with BOTOX Cosmetic. These include crow's feet (both eyes form a single zone), the deep frown lines between the eyes (globella) and finally the lines across the forehead. Many doctors charge by the zone. Costs are approximately $400.00 per region.

Incidentally, despite the widespread use of BOTOX Cosmetic and the recent governmental approval, BOTOX Cosmetic only received the indication for treating the frown lines between the eyebrows. Don't expect this detail to make a difference in the world of cosmetic therapy.

Where do I prefer to avoid injecting BOTOX Cosmetic? Remember that Botox paralyzes the muscles. That's good if you don't want to frown. It's not so great if you treat deep lines around the mouth and suddenly find you're drooling or can't smile. There are certainly some doctors who will inject the so called "smoker's lines" but I would caution that you verify only infinitesimal amounts are used so you don't resemble a stroke patient.

The muscular bands that run the length of the neck (platysma) can truly show your age. If you don't know where the platysma muscles are, exaggerate saying "plah teeez ma" slowly and you'll see the bands stand out. This is another area that is being experimented with by doctors. The problem here; you could conceivably receive either too much or have too deep an injection that could result in difficulty swallowing or breathing. Again, approach this area with caution.

Lunchtime Facelift

Called the "lunchtime facelift", BOTOX Cosmetic is a quick, simple series of injections with a tiny needle into the unwanted wrinkles. You'll be asked to make that undesirable expression. It may seem strange, but you may find yourself forcing a smile in order to say goodbye to your crows' feet!

Say "freeze" when you go for your BOTOX Cosmetic. I find that applying an ice pack to the area about to be injected for just a minute or two helps minimize the pain associated with the injection. Let's face it, nobody likes shots, even if we're asking for them. The use of an ice pack can also help reduce some of the potential bruising and swelling.

Post treatment, I apply a touch of T. LeClerc Loose Facial Powder- Tilleul to help minimize any redness that may result from the procedure. BOTOX Cosmetic may be a "lunchtime facelift" but you still may have a touch of redness at the site of each injection. For any immediate bruising, I will apply T. LeClerc Correcting Fluid Pen as camouflage.

Life tends to go on as normal after you've had your BOTOX Cosmetic injections. While you can pretty much go back to your normal routine immediately, it is crucial that you keep your head upright for 4 hours after injection. This prevents the BOTOX Cosmetic from spreading to adjacent muscles where you don't want it to go. This means no naps, laying down, exercising or even shoe shopping. Just think of all the time you spend looking down at your feet when trying on the latest pair of Prada heels!

Immediate Gratification

There is definitely something to be said about immediate gratification.

Within 2 weeks, you should see your improvement. If you have paper-thin fair skin, you may find your results are quite rapid. For those like myself who have thicker, oilier skin, 2 weeks is a pretty typical time to wait. The fastest result I ever saw was my babysitter whose wrinkles were gone by 5 pm that night. I've never seen anything like it since.

Nobody's face is perfectly symmetrical and a touch-up, particularly after your first treatment is not unheard of. Should you find that you have a hint of a frown or one brow goes up a little more than the other side leaving you looking somewhat quirky, I like to recommend that you wait for a touch-up until a full 2 weeks after the initial treatment have passed. This will allow everyone to judge how fully the treatment took as well as plan for adjustments to future treatments. Most dermatologists will make some arrangement so that the patient does not have to pay the entire amount all over again.

Not So Permanent Beauty

Nothing, not even a facelift is permanent. You can expect the effects of Botox last between 3-6 months. Be happy with 3 and then be thrilled if you find you're one of those lucky ones who can go 6! You will find that repeat treatments may extend the time between further injections. My analogy is that like the bicep you worked so hard to build, lack of use will result in a soft, flabby muscle. Paralysis of the facial muscles due to Botox helps soften these muscles of expression you're no longer using over time. Don't use it (the muscle) and lose it. In this case, you're losing the wrinkle. This is the rare instance when NOT working out works to your advantage.

Too Good To Be True?

Botox has really lived up to the claims. Fortunately problems are relatively minor and temporary. Side effects can include temporary paralysis of adjacent muscles such as eyebrow or eyelids resulting in ptosis, a drooping of the eyelid. This tends to last only 3-6 weeks. And it's unusual if the doctor stayed at least 1 cm away from your eyebrows when injecting. Prescription eye drops like Iopidine may help improve this while you wait for the side effect to wear off. Local bruising or temporary swelling of the treated area are also possible.

BOTOX Cosmetic is not for use by pregnant or nursing women or for those with neurological conditions.

Dermatologists are funny creatures. We thrive upon the search for new medical treatments for our patients, often looking to approved prescription medications to yield other fruitful therapies in what is known as "off label" use. Typically this results in solid medical advances for patients. BOTOX Cosmetic is rather unique in that a medical agent was found to possess cosmetic benefits. It seems that any doctor involved with cosmetic dermatology and plastic surgery has been on the "off label" BOTOX Cosmetic bandwagon for quite some time despite the recent media attention.

The rest as they say is history. BOTOX Cosmetic has probably been the most widely used "off label" cosmetic procedure to date in the U.S. And now we can happily tell our patients that the FDA has finally caught up to blessing this union of medicine and beauty.

Thank you for taking the time to read my article. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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