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news - botox and other instant facelifts

January 2005 vol 15 no 10/surgery

So you think you need...Botox and other instant facelifts

The new year is when many of us take a long look in the mirror and don't like what we see. If you are over 40, it's tempting to succumb to one or more of the 'instant facelifts' now available.

There are several types, each promising to smooth out the fine lines of middle age. Botox, the grand dame of the instant facelift in a bottle, is so popular that it has replaced Tupperware as the object of mass-sales parties, with doctors treating up to 10 people an hour.

Botox, made by Allergan Pharmaceuticals, is the proprietary form of botulinum toxin type A, a neurotoxin produced by Clostridium botulinum, the anacrobic bacteria responsible for food poisoning (botulism). Of all neurotoxins, this is the most deadly of any variety yet known. Just 1g of pure crystalline type A toxin can wipe out a million people, which is why the US military has considered it for biological warfare (JAMA, 2001;285: 1059-70).

Its use as a facelift in a bottle stems from the fact that, when ingested, it causes severe paralysis. A purified, vacuum-dried version of the toxin A has been approved since 1989 for treating eye twitches (blepharospasm), crossed-eyes (strabismus) and, since 2000, cervical dystonia, involving severe contractions of the muscles in the neck and shoulders.

While using it for these eye conditions, Canadian ophthalmologist Dr. Jean Carruthers noticed that it also smoothed out forehead wrinkles. She and her dermatologist husband then began using it to treat forehead wrinkles - and a bloodless form of cosmetic surgery was born.

In 2002, the US Food and Drug Administration (FDA) widened its approval to include cosmetic problems, approving its use on moderate-to-severe frown lines between the eyebrows (glabellar lines). The procedure soon landed the dubious distinction of being the number-one procedure (surgical and non-surgical) in 2002 and 2003. The American Society for Aesthetic Plastic Surgery's 2002 report noted that some 1.6 million procedures were carried out that year, an increase of 2000 per cent in five years.

Botox is now so de rigueur in Hollywood that many performers can no longer produce a full range of facial expressions. It is not yet licensed in the UK so, although British doctors may administer it, they are liable for any resultant adverse effects.

how does it work?

Botox interrupts the release of the neurotransmitter acetylcholine Without this neurotransmitter to signal contraction, a muscle is effectively paralysed. Being unable to crease those muscles for a period of time effectively smoothes out lines and wrinkles. In most cases, the effects are temporary, lasting between three and eight months.

A single vial of Botox contains 100 units of botulinum type A, with 50 units being the most common treatment dose. The cost of a single injection ranges from $300 to $700 per treatment in the US and is around £200 per treatment in the UK - hence, the arrival, and popularity, of Botox parties, which offer discount group rates.

what doctors tell you

There's no doubt that paralysing your facial muscles will diminish your wrinkles. In a review of studies of its use on glabellar frown lines, of 537 subjects (mostly women) with moderate-to-severe lines, around 80 per cent had their lines gone or reduced to a minimum after 30 days, and 89 per cent had at least a moderate improvement. Most have even better results after the second or third go (Am J Clin Dermatol, 2003: 4: 709-25).

Botox was also given an unexpected boost when patients claimed they had fewer headaches than normal after their injections, largely because it makes muscles less sensitive.

Emboldened by this success, doctors now use it to treat the middle and lower parts of the face to, as the Carruthers put it, "smooth, shape and sculpt, blurring the line between science and art". It has now even been used to enhance the results of cosmetic surgery (Dermatol C in, 2004; 22: 151-8).

what doctors don't tell you

Doctors have assumed that Botox doesn't travel in the body and that any adverse effects are temporary (Dermatol Clin. 2004; 22: 145-9). Despite FDA cautions, even the most minimal precautions are often abandoned where Botox is involved. A January 2004 Which? Survey revealed that four of the 16 clinics visited undercover failed to even take a patient's history before administering Botox or other non-surgical cosmetic enhancements. Too often, Botox is given inappropriately by doctors untrained in the nuances of plastic surgery.

So, far from being totally safe, Botox comes with a number of risks, according to Allergan's prescribing information and other sources.

You can die from it. Rarely, people have choked to death because of difficulty swallowing, developed pneumonia or died from anaphylactic shock (a severe allergic reaction).

It can cause potentially fatal heart attack or irregular heartbeats, particularly in those who have cardiovascular problems.

It can cause the very problems it's meant to treat, including headache (5-18 per cent of cases) and eye twitching (3-5 per cent of cases) (Am j Clin Dermatol, 2003: 4: 709-25)

You have a 5 per cent chance of developing tolerance to the treatments due to the build up of antibodies, which means that you will require more Botox to produce the same effect (Dis Mon, 2002; 48: 336-56).

The continually injected muscles stop working and atrophy, resulting in the so-called 'hourglass deformity', or eyelid droop. Also, more than a quarter of the patients given Botox for migraine (it's injected into the temporal muscle) develop a temporary depression of the temples (Headache, 2004: 44: 262-4).

You may develop blurred vision plus respiratory infection, flu, nausea, facial pain, redness at the injection site and muscle weakness, says the FDA - effects that can last for several months.

You can develop wrinkles from continual Botox use, according to Dr David Becker, assistant professor of dermatology at Weill Cornell College in New York. Following treatment to frown lines, other muscles in the upper nose, middle eyebrows and eyelids attempt to make a grimace or scowl. "Repetitions of this action cause new wrinkles," he says.

The more wrinkled you are, the more you need, which increases the risk of complications. Those who have had plastic surgery or neuromuscular diseases are also more likely to face complications (Facial Plas: Surg Clin North Am. 2003; 1194: 483-92. Patients with ALS (amyotrophic lateral sclerosis or Lou Gehrig's disease), myasthenia gravis or Lambert-Eaton syndrome (characterised by muscle weakness) should also avoid Botox.

Cosmetic surgeons and dermatologists are increasingly giving Botox for unapproved uses (Dermato. Clin, 2004: 22: 145-9). As in other areas in medicine, where doctors shoot first and look later, consistent guidelines for the use of Botox other than for glabellar lines - such as crow's feet, bunny lines (lines on either side of the nose), lines around the mouth, dimpled chins and what is unkindly referred to as 'turkey-gobbler neck' - have not been established, nor have there been any controlled studies of Botox for the lower face and neck (Clin Dermatol, 2004; 22: 18-22).

Many physicians now offering Botox are not trained in the subtle art of plastic surgery. The Carruthers themselves admit that Botox for other uses may require a detailed knowledge of face and neck anatomy and muscles. As the number and sites of injections are widely variable, it requires someone well trained in such nuances (Clin Dermatol, 2004: 22: 66-75).

A panel of experts has developed guidelines, which have been published (Plast Reconstruc. Surg. 2004; 114 [6 Suppl]: 1S 22S). But the runaway use of Botox with little control is one reason why, in 2002, the FDA insisted that Allergan advertise Botox only as a medical procedure - not, in effect, as a facelift in a bottle.

what to do instead

Clean up and customise your diet (see our Special Report) and eat an unprocessed, organic diet, rich in antioxidants.

Eat RNA-rich foods such as sardines, salmon, tuna, shellfish, lentils, and beans - all of which help in skin renewal.

Take a good multivitamin plus mixed carotenes, vitamins A, B, C, D3 and E, selenium, zinc, copper and manganese. Suggested dosages: at least 1g of vitamin C, 5000 IU of vitamin A and 400 IU of vitamin E per day.

Get your oil balance right. Good amounts of fish or flaxseed omega-3 fats improve skin appearance and tone. Omega -6 polyunsaturated fats can make skin more susceptible to sun damage (Nutr Cancer, 1987: 9: 219-26)

Consider supplementing with alpha-lipoic acid (ALA), which eliminates damaged collagen and prevents skin-ageing clycation, ultimately smoothing out fine lines.

Apply vitamin C-rich lotion to your face (but, if it's a cream, make sure there are no damaging chemicals such as parabens), proven to reduce fine wrinkles and roughness, and to improve skin tone and complexion (Arch Otolaryngol Head Neck Surg, 1999; 125; 1091-8)

Check your thyroid function. An underactive thyroid results in dry, flaky skin. For a sluggish thyroid, consider iodised sea salt and fish, and eliminate vegetables that interfere with thyroid function (see box, page 3).

Creams with evidence of success include those that contain alpha- and beta-hydroxy acids (glycolic acid and salicyclic acid), DMAE (dimethylaminoethanol) and natural vitamin A (retinyl palmitate), but watch out for ingredients that could damage your skin as well as the rest of you.

Revere your own ageing process and recognise it as the gaining of wisdom and experience.

the cutting edge in the world of derma-fillers

Besides Botox, clinics offer a number of other ways to enhance, sculpt and prettify. Medicine and the pharmaceutical giants have been experimenting with various injectable materials to fill in the gaps left when the basic foundation of our skin unravels.

Temporary biological fillers: collagen and 'lipofilling' Besides Botox, doctors use collagen (called 'collagen instant therapy' in the UK, or by product names such as Zyderm and Zyplast). Purified bovine (cow) or porcine (pig) collagen, the protein that forms the scaffolding of skin, bones and cartilage, is injected into the lips or wrinkles and, several weeks later, after the animal collagen has broken down, your body supposedly replaces it with your own new human collagen.

Collagen implants were the fifth most common aesthetic procedure in 2002, according to the American Society for Aesthetic Plastic Surgery (ASAPS), but their use has fallen by 20 per cent as hyaluronic acid-based fillers become more popular. Hyaluronic acid, found in the body's movable joints, is often derived from the cocks' combs and used to treat cataracts and arthritis. It is the UK's most popular temporary derma-filler as it is thought to have fewer allergic reactions. Based on this assumption, doctors don't require allergy testing beforehand, as they do with collagen. Other possibilities include Cymetra - collagen derived from human skin - and Isolagen, where collagen-producing cells are harvested and grown from your own skin cells, then injected back into you. However, most biological materials are readily reabsorbed by the body within just a few months, and body fat is not ideal for sculpting such features as lips.

Downsides: Like Botox, collagen is temporary. As with most biological materials, including microlipoinjection - injecting tiny amounts of your own abdominal or thigh fat - it is absorbed and must be repeated every 3-18 months . But even biological materials can solidify inappropriately. British actress Leslie Ash's collagen implants made headlines after they resulted in a permanently disfiguring 'trout pout' . Also, some 3 per cent of patients are allergic to collagen. Although allergy tests are performed, many won't react until the stuff is literally in the mouth. Other reactions include joint and muscle pain, headaches, soreness, blistering and, most seriously, shock and difficulty breathing

Non-biological dermal 'fillers' As a consequence, doctors and drug companies have been casting about for the perfect filler material that won't be absorbed and will also be 'biologically inert' - in other words, it won't travel to some other place in the body. The latest favourites include Artecoll, or Artefill, and - believe it or not - Gore-Tex, the plastic used for all -weather coats and boots. Artecoll, used in Canada and Switzerland, and awaiting US Food and Drug Administration (FDA) approval, is three-quarters bovine collagen and one-quarter Plexiglas microbeads. The natural collagen is supposed to fool the body into producing its own collagen. The advantage is that, although it appears 'natural' to the body, it doesn't degrade as quickly as other varieties, so the effects are more permanent. Gore-Tex is made of e-PTFE (expanded polytetrafluoroethylene), the same material used in Teflon. The FDA has specified that e-PTFE be used only for serious facial surgery - facial augmentation or lip reconstruction - and not for lip augmentation or wrinkles, but that hasn't stopped doctors from using it as a more permanent 'Botox', often for the lines running from the nose to the corners of the mouth.

Downsides: Gore-Tex requires surgery and may cause scarring. Although it doesn't degrade, repeat treatments may still be necessary and, as these plastics become more and more commonplace, more cases of adverse reactions are being reported (J Am Acad Dermatol. 1999; 40: 100-2). These include irritation, allergic reactions, blurred vision, discomfort, slow healing and its visible appearance - even leaking of the substance - under the skin as the face moves. More worryingly, Artecoll and other bead-containing products can cause red lumps to appear beneath the skin, sometimes several years later (Arch Dermatol, 2003; 139: 17-20), which are nearly impossible to surgically remove.

Lynne McTaggart

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