You can’t buy happiness but you can buy botox…and that’s kind of the same thing.

Or so the new saying goes. I know that everyone reading this post right now has heard of botox and may have even tried it or considered trying it. Botox® is actually the trade name of botulinum toxin that is owned by the company, Allergan. There are other preparations available such as Xeomin® (Merz) and Dysport® (Galderma) but for the sake of brevity, I will use "botox" to refer to all preparation of cosmetic botulinum toxin.

Botox is one of the most common cosmetic procedures performed today. According to the website, Statistic Brain, botox revenue in 2015 was 2.4 billion dollars and the average age of a botox patient was 40-59 years of age. The average price per botox treatment was $340, and the average duration of a botox treatment was 4 months. But, wait. What is botox? We’ve all heard of it and a lot of us use it, but most people don’t actually know what it is.

Online dating is like botox. No one talks about it, but everyone does it.

Botulinum toxin A or botox is a purified neurotoxin produced by the bacteria, Clostridium botulinum. This bacteria, if ingested, is responsible for the very serious disease, Botulism, most often associated with poorly canned foods. First question that I get from patients, “ If Botox is a neurotoxin, doesn’t that mean that is toxic? Dangerous? Poison? Bad for me?” Of course the short answer is “no”.

Let’s break down the word neurotoxin. A neurotoxin is a substance that normally damages or hurts or even destroys neurons or the cells that make up your nervous system. But the key component to whether or not a neurotoxin is actually dangerous is the quantity. Alcohol can be toxic, dangerous, and poisonous if ingested in large quantities in one setting; even vitamins can be toxic if taken in large quantities. So, no, getting Botox injected into the wrinkles on your face are not going to poison you (if done with expertise).

Let’s digress for a minute to talk about wrinkles and what they are before continuing on to how Botox works. Wrinkles or rhytids are the formation of crease lines in the skin and is a normal part of the aging process. (Spoiler Alert) As women and men enter their 30s and 40s, the amount of skin elasticity and tightness starts to decrease; as a result of decreased elastin and collagen and SUN DAMAGE, we develop fine lines, creases, wrinkles, sagging skin, and furrow or frown lines.

Furrow and frown lines are called dynamic wrinkles because they form when we MOVE our face. That movement can be smiling or crying or laughing or scowling. The muscles that are responsible for our facial movement are responsible for the furrows or creases that show up on our face. Over time, these creases and furrows and frown lines can deepen and then they are present even when we are not moving our face. Enter botox.

I hate when my botox wears off. Then people can tell that I don’t like them.

Botox is a neurotoxin. That means that it can damage or hurt or temporarily prevent nerves from working. Nerves control our muscles. It’s the nerves that run from your brain that tell your lips to smile when you see someone that you like. So, if we temporarily weaken the nerves that control the muscles in our face, then the muscles won’t work as well and we won’t get those pesky lines, furrows, and creases in our face. If we never have the dynamic creases, then we’ll minimize the permanent or static creases that are present even when we don’t move our face (think of the wrinkles that form on a 40-year-old woman when she laughs vs. the wrinkles that are always present on a 80-year-old woman).

So, there you have it. We inject a small amount of purified neurotoxin into the overactive muscles of the face and it blocks the signal from the nerve to the muscle that tells the muscle to move. The muscle doesn’t move, and thus the skin overlying the muscle doesn’t move. This temporary suspension in communication between the muscles and the nerves lasts between 3 and 6 months (average of 4 months) and then the nerves wake up and start communicating to the muscles again. You see the creases coming back on your face when you smile or laugh or scowl.

In general, botox is injected into the upper 1/3 of the face where the creases and frown lines are the results of muscle movement unlike the lower 2/3 of the face where the deep creases and sagging skin is due to volume descent and decreased elastin and collagen (we’ll talk about volume changes and fillers in a later post). Botox is most commonly injected into the frontalis muscle to treat those forehead horizontal lines that come from lifting our eyebrows up, the corrugator and procerus muscles that are responsible for the “11” lines between your eyebrows and the orbicularis oculi muscles that are responsible for the crow's feet.

Just a reminder that my birthday is coming and Botox doesn’t pay for itself.

In general, the injection of botox is a quick and simple procedure. Topical numbing cream can be applied, but the pain associated with the injection is minimal. It feels like a rubber band snap or a mild bee sting. Other than not taking ibuprofen or other NSAIDs or aspirin for a week before the injection, there isn’t any prep time. Your provider will remove your make-up (you can re-apply after the procedure) and some providers use ice to numb the skin and decrease the chance of swelling and bruising. You can have mild bruising associated with the procedure but make-up can cover it. You shouldn’t exercise for four hours after the procedure. You can go back to work the same day as the injections. Of note, you won't notice a difference right away; you’ll see results within 4-7 days. Botox is one of the most highly rated procedures in terms of patient satisfaction and the results are reproducible.

Things to think about with Botox:

If injected too close to the eye, you can have a droopy upper eyelid that is temporary and can be treated with medication.
Some people are super metabolizers and might use up the Botox in 1 or 2 months compared to the average 4 months. A lot of ultra elite athletes (aka weekend warriors who run or bike miles upon miles) are super metabolizers. The results are temporary but you can get the same results by getting treatment again.
Costs can vary from $200 to $600 per facial area depending on where you live and who does your injection (MD vs RN vs esthetician).
When done properly, Botox is very safe with very few side effects. When looking for a provider look for someone who has training in the field and with whom you feel comfortable. There are several core medical and surgical specialities that have extensive training in botox and cosmetic injections and they include Facial Plastic Surgery (ENT), Dermatology, Plastic Surgery and Oculoplastic Surgery (Ophthalmology).

Cheap Botox is never good and good Botox is never cheap.

References:
1. Burgess, Cheryl. Cosmetic Dermatology. Chapter 5: Botulinum Toxin, p 83-92. Springer, 2005
2. Carruthers J, Carruthers A. Aesthetic uses of botulinum toxin A in the periocular region and mid and lower face. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2004;15(2):134-138.

By Melynda Barnes, M.D. - Co-Founder and Expert Facial Plastic Surgeon