Botox is well known as an injectable facial treatment for wrinkle reduction. Its effectiveness at reducing or blocking unwanted facial expressions, mainly those in the foreheads and around the eyes, has virtually created an industry around non-surgical facial rejuvenation. As a result, it has been primarily responsible for the popularity of early intervention for preventing or softening certain facial wrinkles.

The concept of early intervention for facial wrinkle reduction has taken on an extreme approach for one 8-year-old California girl. One mother and her daughter has been using Botox to compete in beauty pageants and has raised the question of exactly how young is too young when it comes to using medical treatments for the sake of beauty. According to the mother, it was actually her daughter who wanted to try Botox. As she was getting into beauty pageants, the daughter was apparently complaining about her face having wrinkles. Her mother, who is an aesthetician and uses Botox herself, suggested doing the treatment on her.

This story would certainly be viewed by most as odd enough, but it takes another interesting twist. Since the daughter has seen her mother inject herself with Botox, she agreed to have her mother inject her. The mother states that typically administers the Botox to her daughter through a total of five shots in three different locations on her face. While a child would have no static wrinkles, they felt it did satisfactorily reduce some dynamic facial wrinkles. But it’s enough of a difference for this mother-daughter team to continue on with the treatments.

While many will no doubt be agasp of the extremes that a mother would go to help her daughter compete in beauty pageants, there are actually more serious undertones to this story. Where does the mother get her Botox? Since she is not a physician, how does she legally get it? Either she knows a doctor from whom she is getting it or is being sold to her under some doctor’s name. Allergan, the manufacturer of Botox, requires a physician’s license number to fill an order. The other possibility is that the local Botox sales representative is providing it to her. Either way, shame on the doctor or Allergan for allowing it to happen.

Patients administering Botox to themselves or to other patients is a reflection of just how much Botox is really viewed as a commodity by many and not a medical treatment. While there is a very low risk of any serious complications of Botox in the face and at the doses that are used, it is still a muscle paralyzing agent. It is not the same as inserting a suppository, administering ear drops or performing any other off-the-shelf medicament from your local pharmacy. Self-administration or injecting Botox into a child demonstrates that the potential dangers of a medical treatment are simply not appreciated. Lack of medical training also makes it easy to not be able to balance the risks vs benefits of any type of ‘beauty’ treatment. There is a legal concern also. Botox is not approved for use in patients under the age of 21 unless there is a medical condition being treated. 

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The popularity of Botox for cosmetic facial uses is that it does something that not even surgery can do…stop unwanted expressions. Its downside is that its results are not permanent. Most patients would wish that its effects were either more long-lasting or were permanent.

One question that some patients ask about the long-term use of Botox is whether it becomes more effective or, conversely, does one become resistant to its effects. In the very long-term (10 plus years of regular use), no one really knows for sure as so few patients have been treated for that long. It is tempting to think that regular use of Botox injection over many years results in muscle atrophy and either an increased response to injections or the need for less treatments or lower doses over time.

New research might give some insight into whether such effects from Botox may actually happen. A study shows injections turn muscle to fat. The findings were part of a new study by researchers at the Faculty of Kinesiology at the University of Calgary.

The study found that animals injected with botulinum type A neurotoxin complex experienced muscle weakness in muscles throughout the body, even though they were far removed from the injection site. The study also found that repeated injections induced muscle atrophy in the limb that was not injected with the toxin.The study used dosages that approximated therapeutic doses used to treat conditions like cerebral palsy where muscle contraction can’t be controlled resulting in spasticity. This study shows, for the first time, that over time botulinum toxin type A use also results in muscle weakness and atrophy in noninjected muscles far removed from the injection site.

Previous research has also shown that botulinum toxin A easily crosses the muscle membrane barrier, resulting in muscles weakness in the surrounding (noninjected) muscles as well. We call this diffusion or zone of spreading. (it can account for the potential problem of eyelid ptosis or droopiness that may potentially occur with cosmetic injections between the eyebrows)

What do these study results have to do with cosmetic facial injections with Botox? These were limb injections in animals and relate to what happens to limbs that were not injected. Perhaps nothing as the type of muscle and the doses used were in excess of what is injected into much smaller muscles of facial expression. But it may also suggest that long-term Botox use in any muscle may eventually weaken it through ‘disuse atrophy’. We know that easily happens in extremity muscles but does it or will it happen in the muscles of facial expression? Many patients hope so…the next decade of Botox use will undoubtably answer that questions.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Teeth clenching, otherwise known as bruxism, is a common phenomenon amongst  many people.  To some degree, almost everybody clenches his or her teeth. The issue lies in the intensity of the  teeth clenching is. A person with severe bruxism will often clench their teeth with not only excessive force but with great repetition, often occurring during sleep. Patients awake with tooth and jaw muscle soreness. At pressures on the teeth that can be up to greater than 500 pounds per square inch, it is not wonder that tooth damage can occur.

Why clenching occurs in anyone is largely unknown. Theories usually point to stress or habits  but the problem is no doubt from many causes that collectively creates masseter muscles that are overactive. Besides excessive tooth wear, the hallmark of clenching is sore jaw muscles either near and around the angle of the jaw in front of the ear and in the temple area.                                                                                           

Currently, the most common treatment for clenching is a custom-made mouth-guard that is worn during sleep to prevent tooth damage and, in theory, to stop the muscles from overactivity.The effectiveness of dental appliances covering the tooth surfaces is unchallenged. But the muscle problem is a different story. This is evidenced by the array of other available muscle treatments including drugs, transcutaneous nerve stimulation, thermal therapies and biofeedback, to name a few of the most prominent. For some these work, but for many others the results are less than needed or simply don’t work at all.

One direct muscle treatment for the masseter muscles of clenching is Botox injections. As a well known cosmetic wrinkle treatment for much smaller muscles that cause facial expressions, it can similarly be injected into any other muscle. The intent into the masseter muscles is not paralysis but to control its hyperactivity and break the cycle of spasm and pain. Good candidates are those that have significant masseter muscle flaring or bunching while clenching with palpable pain of those areas.

Injection into the masseter muscles is a very simple and near painless treatment, The key is to stay in the lower half of the muscle near the jaw angle. Using an imaginary line drawn from the corner of the mouth to the lower end of the tragus of the ear, the injection points should stay south of this near horizontal line. Injecting above this line may create weakness of the buccal branch of the facial nerve which would be evident by paralysis of the upper lip during smiling. By having the patient clench, the bulging areas of the muscle are injected. I use 25 units of Botox per side as a baseline dose. Some patients may require more but this is a good economical place to start.

If there is any temporalis muscle tenderness, it can be injected as well. This is best done just above the level of the zygomatic arch at the junction of the scalp and the non-hair bearing temporal skin. This is also the area beneath the temporalis fascia where the zygomaticofrontal nerve branch comes upward from the deeper muscle belly. This sensory nerve branch of the maxillary nerve has been implicated in migraines of the temple region. About 8 to 10 additional units can be injected into each side of the temporal area.

One effective technique is to add Marcaine (with epinephrine), a longer acting local anesthetic, into the Botox solution. This provides immediate relief of pain within minutes of being injected as Botox will take days to exert its beneficial effects. The ratio I find effective is 0.3cc per 1cc syringe of Botox. (0.7cc volume = 28 units of Botox or 4 units of Botox per .1cc) Each masseter or side then receives almost 1cc of Botox/Marcaine solution.

As a direct muscle treatment, Botox works very well for clenching problems. For some patients, it is eliminated completely. For others the relief is significant but not complete. It should be expected to last around 3 to 4 months.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Every cosmetic Botox (also Dysport, Xeomin) patient would love to have it last longer. Whether it would be a new molecular form of Botox  or some additive method of drug prolongation, there is considerable interest in that effect. The offshoot of lasting longer is most manifest for patients in that they would be exposed to lower costs in the long-term and  not having their forehead pierced quite so often.

Recent research from an oculoplastic surgeon in Dallas has resulted in a patent-pending dietary supplement combining zinc and phytase (trademarked as ZYTAZE™) in which an initial clinical study showed improved results with Botox. Over 90% of the patients in their study (41 out of 44 patients) who took the oral supplements showed increased responsiveness to Botox in the treatment of blepharospasm, an uncommon form of eyelid twitching. The study concluded that the Botox seemed to last longer and with greater effect. No mechanism has yet been suggested as to how this combination supplement may prolong Botox’s neuromuscular blockade.

Does this mean we can start prescribing this supplement, or even zinc, to our patients in the hope of making Botox better? While such study results are interesting, they are far from conclusive. Most, if not all, of the patients in this study had blepharospasm, an abnormal neuromuscular interaction. This should not be confused with a normal neuromuscular synapse in the cosmetic patient. Whether such findings will occur as in this study requires a much larger blinded study which I am sure the researchers are currently doing. Recruiting subjects for this kind of cosmetic research would certainly not be a problem.

As appealing as the concept of an oral supplement is to improve the effect of a pharmaceutical drug, it is more science or just hope? Much of the supplement world is often more of the latter. Scientific proof is hard to come by and much of the evidence of their benefits is testimonial and theoretical. This work is novel and will attract a lot of attention by many Botox patients. Until some real science is put forth, I will remain optimistic but skeptical.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana   

It looks like Botox just smoothed the largest wrinkle it has ever seen. Calling it a wrinkle might be an understatement, a better description would be a very deep furrow. News from today reports that Allergan, the manufacturer of Botox the world’s number one wrinkle reducer, has agreed to pay $600 million to settle a years-long federal investigation into how it marketed its top-selling drug.

The company says it will plead guilty to a misdemeanor charge known as misbranding. This charge is based on claims that the company deliberately marketed to doctors on the use of Botox for non-FDA approved uses starting in 2000. Such unapproved uses included the treatment of headache, muscle pain, spasticity and cerebral palsy. It will cost the company $375 million in connection with that plea and an additional $225 million in civil fines related to the investigation, although the company denies any liability in that regard.

While this is a whopping fine for sure, it is well in line with such plea agreements that have been metered out against other major drug manufacturers in recent years. There is some supposition, probably for good reason, that the company agreed to settle as it is awaiting FDA approval for the treatment of migraines which is reported to be worth $1 billion in sales annually.

As a plastic surgeon and provider of Botox treatments, do I think the company did anything wrong? At the patient care level, I would have had no indication that these alleged practices were ongoing as there were never apparent to me. I suspect that the company got overenthusiastic and even greedy as a monopolistic provider of this type of drug. It has never had any competition until just last year. The FDA has rules for marketing and the company obviously transgressed them.

But the reality is Botox is one of the most used drugs when it comes to off-label or unapproved uses. While it is not magic pixie dust, it has been shown to be useful for a wide variety of neuromuscular uses. I regularly use it in the treatment of migraines, masseteric hypertrophy and myofascial facial pain, all with significant relief and results. The ‘problem’ is that Botox appears to be good for a lot of difficult medical conditions. Because it works it becomes highly used for non-FDA approved indications. As a physician that is within my province to make that judgment. The company, however, does not have that leeway as it is not in the business of practicing medicine.

Some patients will undoubtably wonder if this massive fine means the product is tainted or unsafe. There is nothing wrong with Botox as a drug. It remains safe and effective and freely available for clinical use. This fine is in response to the legalities of marketing, not as a response to how it works or is manufactured.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Any drug that can change facial expressions can certainly influence how other people see and interpret you. But can they also change how you feel as well?

In the June issue of Emotions, researchers out of New York published a paper which reported that people who were treated Botox treatments not only change their appearance but may also had a weakened ability to experience emotions.

The facial feedback hypothesis (FFH) in psychology has long purported that if an emotion can not be expressed physically then it really doesn’t exist. It has remained largely an unproven theory as it is difficult to isolate an emotion as a physical loci. But the widespread use of Botox, a muscle weakening agent used for cosmetic wrinkle reduction, can suppress emotion by its effect on facial muscle units. This now makes it possible to work with people who have a chemically-induced expressive muscle weakness.

As a result, the theory of FFH can be tested for the first time. A person who has received treatment with Botox can still respond to an emotional event (something that makes them angry) but their facial muscles will be less active. Less muscle stimulation to the brain results with less feedback to the brain about what the face is expressing. This allows for a test of whether facial expressions and the feedback to the brain that it creates can influence our emotions.

The reported study used two groups of patients, one who got Botox injections and a control group which received a cosmetic filler (Restylane) which does not affect the facial muscles. Such a study design allows one to isolate the effects of facial expression and the subsequent sensory feedback to the brain that would follow from other factors, such as intentions relating to one’s expressions and motor commands to make an expression. In the study, the subjects filled out questionnaires about how they felt after watching positive and negative video clips before and after treatment.

The findings of the study shows that those who received Botox had no changes between the pre- and post-treatment emotional responses to the most positive and negative video clips. But, compared to the control filler group, Botox patients had much lower strengths of emotional responses. Their conclusions were that feedback from facial expressions is not necessary to have an emotional experience, but it may modify the intensity of that emotional experience.

Considering the number one reason people have Botox is to decrease the frowning or scowling between their eyebrows, this may also help people feel less angry and irritated. So maybe Botox, and its cousins Dysport and Xeomin, really are tranquility drugs as well.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background:  Frown lines are a major concern for many people as they make them look like they are scowling and angry. The frown lines are one of the major undesired facial features that have accounted for the meteoric rise in Botox sales and for making it a household name. Unknown to most, frown lines are actually the only FDA-approved cosmetic indication for Botox, even though it is widely off-label for other facial areas.

Despite the success of Botox in reducing the undesired actions on the skin between the eyebrows (aka glabella) of the corrugator and procerus muscles, one’s frown lines may not go completely away. Once the long-term actions of the muscles have permanently etched lines or grooves into the skin, muscle weakening along will reduce but not eliminate them. Botox is successful for the treatment of dynamic wrinkling (lines that appear when the face moves), static wrinkling (even when one is not moving muscles) requires a different or companion approach.

This is a case of a 50 year-old female who was bothered by her scowling and the unhappy expression that the lines into between her eyebrows gave. She has received Botox injections and, while it was better, still had some obvious vertical furrows in the glabellar area. She desired further efforts on reduction of these lines.

Adding some form of soft tissue filling is the next treatment strategy. Most commonly this is done with injectable fillers which are widely used. She did undergo Radiesse filler injections and was pleased with the results but wanted something that would last longer.

Other forms of soft tissue filling of facial lines and furrows are non-injectable and require a more invasive approach. (although not that much more invasive) Graft or filling options include one’s own fat, allograft dermal grafts (off-the-shelf) and a synthetic implant. (Advanta, also known as PTFE or Gore-Tex)

She desired a collagen-based implant over that of a synthetic one. Through two small nick incisions, above and below the vertical glabellar lines, the soft rehydrated dermal grafts were cut and threaded underneath. This was done as a simple in-office procedure under local anesthesia that took about 15 minutes to do. This provided her with a result that was equal to that of injectable fillers but which would last much longer. She remains with good results one year after procedure.

Adding an injectable filler or a dermal graft to glabellar furrows does not mean that one no longer needs muscle-reducing Botox injections. Deep glabellar furrows requires a double approach in some cases to get the best result, treating both the muscular hyperactivity and the skin etching.                                                                                                         

Case Highlights:

1) Deep glabellar furrows or wrinkles may be reduced by controlling the muscle action with Botox but will not be completely gone. In long-established frowning, the skin becomes permanently indented which is not responsive to reducing muscle action alone.

2) Soft tissue filling is a companion treatment to Botox for deep glabellar lines. Treatment options include temporary injectable fillers or longer-lasting implants.

3) While Botox and soft tissue fillers can be done at the same time, it is usually best to do Botox first and see what the results are. Management of the grooved skin can always be done later if further improvement is desired.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

Scars remain a common patient concern for which numerous treatments are available. One frequently used approach is that of injection therapy. This historically has been done through the use of steroids and, more recently, with a chemotherapy agent such as 5-fluorouracil. These injectional approaches are designed to disrupt how collagen bundles are formed or to disrupt or unbundled those that have formed. There has been usually reserved for the most problematic of scars such as keloids and more severe forms of hypertrophic scars.

Very recently, Botox (botulinum type A) injections have been added to the injectional agent list for scar therapy. Not only have I seen patients who have had their scars injected locally but a few clinical papers in plastic surgery journals have been reported. The logical question is…what is the connection between wrinkles treatments and scar therapy? Does the use of Botox for scar therapy make sense?

As most of the general public is aware, Botox is an anti-wrinkle injection treatment for certain facial areas particularly in the forehead and around the eyes. It works because of its local muscle paralyzing effect, decreasing the presence of dynamic wrinkling. But what does that have to do with what makes scars look bad…or prevent them from ever getting to that point? While Botox has been given some ‘magical properties’ by some, it is not a injection cure-all for anything (and it is being used for a lot of diverse medical problems) and any potential effect must have a biologic basis for its use.

One of the many factors that influences scar outcomes is tension, pulling forces placed on the wound or incisional edges. There are two main factors that cause wound tension. The first factor is how tight is the wound closure, a force that comes primarily from the skin edges themselves. That is a wound influence that the plastic surgeon has some, but not much, control over. Wound suturing techniques help but when tissue as been lost or moved, the closure is going to be under some tension. The body relaxes this tension over time through scar widening and redness. The other tension factor, probably less significant, is the pulling of the tissues from the underlying muscle. This is primarily a potential issue in facial wounds and it has to have the right combination of scar orientation to the direction of the expressive muscle movement action. (scar must be oblique or perpendicular to how the muscle moves) Herein lies the theoretical benefit of Botox scar therapy. If the muscle action is lessened during the early phases of healing, scar widening could theoretically be reduced.

While the use of Botox in scar treatments makes some theoretical sense, its clinical use at this time is far more hopeful than proven. There are numerous factors that influence how a scar will eventually look and limited muscle action around a scar is but just one of them. Such Botox use would have to be done early (within the first few months) and would not have any chance of being effective in more mature scars. But the magical perception of Botox and the understandable anxiety of having a visible scar will likely lead to a lot of useless injection treatments. But hope is eternal and, for the sake of a few hundred dollars, there is no real downside to throwing this injection approach into the alchemy of scar therapies.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

Botox is most well known for reducing facial expression activity and the wrinkles that they cause. Less known, but no less appreciated, is its use for excessive sweating or hyperhidrosis. This is another FDA-approved indication for Botox use. For those afflicted with excessive armpit or axillary hyperhidrosis, the relief from the constant wetting and staining of shorts and the embarrassment that it can cause is significant. For reasons not completely understood, the duration of action of Botox for hyperhidrosis is considerably longer than its effect on diminishing facial muscle movement.

Like its use in the axilla, Botox can be very effective for excessive scalp and forehead sweating. Injection technique is critical and should not be confused with how it is placed for forehead and glabellar wrinkles. The injection should be placed just under the skin and not deeper into the muscle or galea. If Botox is injected deeper in the muscle or too close to it, diffusion may occur causing some forehead asymmetry. This is a very minor problem and can easily be balanced out with additional Botox injections. If the injections are well placed and symmetric, however, any effect on the frontalis muscle will be balanced and not problematic.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

One of the typical features of an aging upper face are a variety of skin lines that develop between the eyebrows. The action of specific muscles combined with the effects of gravity create an abnormal skin pattern of vertical, oblique, and horizontal lines. These dynamic and eventual static wrinkles are bothersome for many patients as they create the emotional impressions of anger, grief, and age.

The non-surgical use of Botox injections and the surgical approach of browlifting or foreheadplasty are proven methods of modifying these muscles. By changing the degree or amount that these muscles move, the upper face becomes more relaxed and more youthful.

The corrugator muscle is the main culprit in this indesireable set of glabellar facial expressions. The horizontal portion of this muscle is responsible for pulling the eyebrows inward. When done enough over time, an evident pair of vertical skin creases develop. Known as the ‘11s’, they may also infrequently appear as a single large vertical crease. These vertical lines always extend significantly above the height of the eyebrows.

The oblique glabellar skin lines occur just at the level of the eyebrows, are oriented obliquely, and careful inspection will reveal they are not part of the vertical skin lines. They are caused by the medial eyebrow depressors which consist of the oblique head of the corrugators, the depressor supercilii, and the medial fibers of  the orbicularis oculi muscles.

The skin crease that sits below the eyebrows is horizontal and is often called the ‘bunny line’. It is caused by the procerus muscle which pulls down the inner eyebrows. It creates this crease as it pushes down against the  more fixed skin of the nose.

The combination of these six muscles flexing over time etches this pattern of glabellar lines between the eyebrows. In essence, dynamic wrinkles eventually become static lines if unchecked. This makes a good argument as to the benefit of early use of Botox or Dysport when one first begins to see this skin pattern appears. Such chemical prophylaxis is effective and many younger women today are embarking on this approach.

In established and deeper glabellar wrinkles, Botox and Dysport injections will make them more shallow but will not make them go completely away. In some cases, injectable fillers must be combined with muscle relaxation injections to make for a nearly complete smooth and wrinkle-free area between the eyebrows.

If one is seeking a more permanent or longer-term treatment, this is where the option of a surgical foreheadplasty comes in. Besides altering the shape and position of the eyebrows, this operation is intended to help lessen these unfavorable glabellar skin lines. This is done by weakening the actions of the aforementioned six muscles through removal or excision of some of these muscles. This is best done through an open incision (coronal or hairline browlift) but good and diligent endoscopic techniques can make a dent in their action also.

Most patients, regardless of their degree of glabellar skin lines, begins with injection therapy to see how much improvement they can achieve. In advanced cases associated with excess upper eyelid skin, the combination of a browlift and blepharoplasty can make for a satisfying forehead result.     

Barry L. Eppley, M.D., D.M.D.

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis