Last Friday the FDA announced its approval of Botox as a treatment for chronic migraine. For years neurologists have used the drug as an off-label treatment for headache, migraines in particular, and many of our patients report more headache-free days after having only cosmetic Botox treatments. This exciting and potent toxin is currently being studied for disorders that effect every part of the body and is currently used by to treat a wide variety of diseases In addition to the new indication for migraine, Botox currently holds FDA indications for treatment of:
**cervical dystonia, to decrease the severity of abnormal head position and neck pain
** severe axillary hyperhidrosis (excessively sweaty armpits)
** strabismus and blepharospasm (crossed eyes and excessive blinking) .
Eight years ago, botulinum toxin stepped into the mainstream spotlight when Botox Cosmetic was approved by the FDA for treatment of frown lines. Botox and Dysport are now the two only forms of Botulinum Toxin type A on the market in the US for cosmetic purposes. When skillfully injected they provide a much more relaxed, youthful appearance, and all anyone else ever seems to notice is how "beautiful" and "well-rested" you look.
Frown lines and wrinkles in patients injected with Botox or Dysport are reduced (or eliminated) for about 4 months. Frown lines, forehead lines and crow's feet all respond extremely well to treatment. At Plush, we strive to eliminate the lines that occur with muscle movement while leaving enough strength in the muscle for some movement to still occur. Ideally you will still be able to express yourself as well as before Botox, just without the repetitive folding of the skin, a mechanical injury that will lead to deeper, more permanent wrinkles over time. Younger patients with less extensive wrinkling should be able to achieve a wrinkle-free look to the entire upper face using fewer units of Botox, while maintaining enough movement for a very natural appearance. The areas that suffered that repeated, folding injury (i.e. the wrinkles) will then have time to heal and fill-in, so that even the forehead lines and crows feet visible even without expressive muscle movement can be improved from treatment with Botox. With treatments 3 times a year, many patients have seen even those "permanent" vertical frown lines between their brows, that were once visible at rest, completely disappear even when viewed under 5x magnification.
Since muscles have a baseline amount of tone even at rest it is possible for static wrinkles (wrinkles present without muscle movement) to show improvement with treatment. This is the reason for almost always using Botox or Dysport before filler in these areas.
We discourage use of botulinum toxin around the mouth as it can be quite problematic. Drinking, eating, smiling and speaking could become difficult. For lip enhancement it's always best to use a dermal filler such as Restylane or Juvederm.
While the lines between the brows and the crows feet have virtually no downside to treatment, the horizontal lines of the forehead require more skill on the part of the physician. The skin of the forehead and the position and height of the eyebrows depend in part on the natural, baseline tone of the forehead muscles. When that slight tension is reduced, you may notice a small drop in the position of your eyebrows. Keeping injections higher in the frontalis muscles of the forehead and using fewer units are two keys for maintaining good eyebrow position after Botox or Dysport treatments. Strategic injection placement will also ensure that you get the eyebrow shape you desire and not the crazy "bat brow" that can occur when the physician does not adequately treat the lateral forehead muscles. Because of differences in diffusion of the drug between the two sides of the forehead, about 10% of patients at Plush that have their horizontal forehead lines treated will require a small (Free!) touch-up to even their brows at their 1 week follow-up appointment.
The differences between Botox and Dysport are small. Dysport has a quicker onset of action in our experience, with patients seeing a decrease in muscle movement at 1-2 days versus 2-3 with Botox. Both drugs seem to last the same amount of time with the majority showing clinical improvement for 4 months. The units of Botox and Dysport are not equal, in fact it's takes about 3 units of Dysport to equal the clinical effect of 1 unit of Botox., but that isn't necessarily a reflection of potency. . For example, 1 unit of botox (actually called a Mouse Unit) is defined as the LD50 (the leathal dose for 50% treated) when injected intraperitoneally into a 18-22g mouse. The lethal dose for humans is many times greater than the doses used for cosmetic purposes.
According to the FDA "There has not been a confirmed serious case of spread of toxin effect when Botox has been used at the recommended dose to treat chronic migraine, severe underarm sweating, blepharospasm, or strabismus, or when Botox Cosmetic has been used at the recommended dose to improve frown lines."
Some have suggested that Dysport may be more likely to induce antibody formation and therefore cause a patient to become "immune" to it and require more units and eventually perhaps not respond to treatment with Botox or Dysport. Studies have yet to show clear evidence of this. Interestingly though, patients that have shown a developing resistance to Botox have been sucessfully subsequently treated with Dysport.
Ultimately the choice between Botox and Dysport is yours! If you have questions, talk with your doctor or come see us at Plush. Consultations with Dr.Bell are always free, and she can tell you exactly how many units you will likely require in any area. 334-702-6869
