Botox is the trade name of the first commercially available preparation of botulinum toxin A (henceforth BTN-A). It is the miracle drug par excellence in aesthetic medicine, plastic surgery and neurology. Botox is so popular in aesthetic medicine because it predictably works each and every time. It is a medication in the real pharmacological sense of the word. Like a blood pressure pill lowers the blood pressure if taken as directed by the doctor, Botox decreases facial wrinkling if injected correctly by a knowledgeable plastic surgeon. Like any other medication, Botox has to be reapplied at certain intervals to maintain its effects in facial rejuvenation and anti-aging.
Botulinum toxin A (BTN-A), the pharmacologically active substance in Botox, is a very potent neurotoxin. It is naturally produced by spores of the bacterium Clostridium botulinum and results in severe poisoning if ingested in high doses. Clostridium botulinum produces a range of neurotoxins, which were named very creatively Botulinum Toxin A to F. They bind to the junction of the nerve endings with muscle fibers and prevent those nerve endings from secreting the neurotransmitter acetylcholine in response to electrical impulses. Without acetylcholine the muscle fiber at the downstream end of the junction does not contract. Such paralysis explains the symptoms occurring in systemic poisoning with BTN-A.
Paracelsus already stated several hundred years ago that the main difference between poison and medication is the dose. If BTN-A is used in small doses as a Botox preparation and injected directly into the relatively small target muscles in the face then activity of those muscles and formation of wrinkles at right angles to the course of the muscle fibers are reduced without any systemic toxicity.
The therapeutic application of BTN-A is not new. It has been used since 1989 to treat painful spasticity in the context of various neurological diseases. One of the best known applications in the face is still the treatment of spasticity of the eyelids, so-called blepharospasm. We have used BTN-A frequently to treat hyperactive muscles in the context of facial paralysis and in spasticity of the hand in children with cerebral palsy or adults with brain trauma. Use of BTN-A for cosmetic purposes was not approved by the FDA for the longest time, although large quantities of the preparation Botox were used for wrinkle treatment off label. Only in 2002 was Botox officially approved for treatment of forehead wrinkles and glabellar frown lines. This application remains the best documented and researched cosmetic use of Botox to date. In principle it is feasible to use Botox in any muscle or muscle groups, where decreased activity is desired., although injections into some of these muscles may again be off label. The most frequent cosmetic applications of Botox today are the aforementioned forehead wrinkles and frown lines and the small radial wrinkles around the eyes, the so called crow’s feet.
Why does the effect of Botox not last infinitely? The reduced but still present activity of muscle fibers represents a stimulus for the sprouting of new nerve endings secreting acetylcholine without impediment of previously applied Botox. Thus the activity of muscle fibers is again increased. This process takes three to four months on a molecular level. One can picture it like a potato forming sprouts if left in darkened storage. Additionally, nerve endings replace the entire blocked mechanism of acetylcholine secretion.
Being a true miracle drug, the areas of application off Botox are continuously evolving and are often added to the list of approved indications due to the safety and efficacy of Botox. One of the milestones in the Botox success story was undoubtedly the successful treatment of certain forms of migraine headaches, where severe headaches are caused by certain hyperactive muscle of the face, which in turn compress nerves running through them. after Botox injections this type of migraine headaches often improves to the degree that the affected patients do not any longer need to take chronic suppressive medications and yet remain free of migraine attacks. Many patients suffer from excessive sweating in the armpits, palms of the hand or soles of the feet. This problem can be reliably ameliorated for up to a year with Botox injections. Botox is equally effective to reduce so-called gustatory sweating (facial sweating while eating), which is frequent problem after removal of the superficial part of the large salivary gland situated behind the lower jaw.
BTN-A was originally manufactured by the US company Allergan under the trademark Botox and marketed worldwide. Until fairly recently, Allergan owned a patent which conferred a monopoly on the market. The latter was lost when alternative preparations of BTN-A were approved in the form of Dysport and Xeomin. From a client perspective and clinical effectiveness there is hardly any difference between these products. They differ mainly in their pharmaceutical preparation, dose equivalents, necessity of an intact cooling chain, activity after reconstitution and similar, all problems the distributors and injectors but not clients should have to worry about.
The potential of BTN-A irrespective of its preparation is by far not exhausted. New applications will continue to be added in the future as long as inquisitive minds practice medicine and surgery.
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