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The following article has been repoduced with the kind permission from the editor of the Dental Summary Review Vol 3 Issue 2
The following articles have
been reproduced with the kind permission from the editor of
WHAT DOCTORS DON'T TELL YOU www.wddty.co.uk
So you think you need …
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.
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.
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).
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.
- 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.
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.
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