Clostridium botulinum is the microorganism responsible for the production of botulinum toxin. This microorganism is capable of producing highly resistant spores. Extreme conditions such as boiling, salting or smoking do not alter its survival! Famous are our grandmothers’ jams and preserves where clostridium botulinum thrives and produces large amounts of toxin then deadly to the unfortunate taster! The spores are also and easily found in wet environments such as soils and stagnant nonpotable waters (including marine) and can contaminate certain types of foods that are canned cooked incompletely, or in cured meats and hams. The resulting disease is Botulism, obviously foodborne, which causes death mainly from respiratory paralysis.
What is it and how does botulinum toxin work?
Botulinum toxin thus has a great impact on muscle movement. In fact, it penetrates the muscles and enters the neuromuscular plate, preventing the release of acetylcholine and effectively preventing neuromuscular transmission. In Italy, the product with an aesthetic indication is called Vistabex, Azzalure or Bocouture. Vistabex was approved for aesthetic use in Italy in 2004, and that approval covers only the glabella. That is, on the package insert it is recommended for the reduction of glabellar wrinkles and periocular wrinkles.
A new botulinum toxin has recently come on the market that is expected to be useful in patients who have proven to be poor responders. It is called Letybo.
In addition, a ready-diluted botulinum toxin has also been put on the market. It is called Alluzience. It is very useful if physicians have little experience. This avoids all the problems inherent in dilution.
Botulinum toxin A is also used in other body districts, therefore, it is used “off label,” as indeed are about 40 percent of the drugs in circulation in Italy. So to conclude, the toxin acts by relaxing the muscles that cause wrinkles, and we are obviously talking about mimic wrinkles. Specifically, those of the upper III of the face. But increasingly, great results are also being achieved in different districts such as the lower III of the face, the neck and the décolleté.
Can botulinum toxin be dangerous to my health?
Effects of systemic intoxication with botulinum toxin after cosmetic treatments are not reported. The amount used in cosmetics is many times less than the dangerous doses.
Different is whether the toxin can give undesirable effects: if injected into muscles other than the target muscles, the toxin does not go wrong and invariably causes the desired muscle weakening. But, as I always say, it is not the toxin that goes wrong: she does her job! It has been injected in the vast majority of cases overdone or at dangerous or wrong injection sites! However, to date, no definitive cases of Botulinum lesions have been reported.
Contacting an experienced and knowledgeable physician is very important, however, and I remind everyone that in Italy it can only be used by physicians.
Is the toxin ready-to-use or is it freshly prepared?
The toxin is lyophilized and is prepared at the time of infiltration. This is the first important moment for minimizing side effects.
In fact, if it is diluted too much, the same amount of toxin will be diluted in too much water and migration of substance into neighboring muscles will be possible.
If, on the contrary, it is diluted too little, the effect will be too limited in extent and short in duration.
The skill of the user physician will be to tailor this particular one to the specific patient.
How is botulinum toxin injected?
The toxin is injected via insulin syringes. This will also be a very important moment because different syringes allow absolutely different implantation accuracies. I personally use 50 U. syringes (0.3 ml insulin syringe x diabetes).
Is the depth of injection important?
Absolutely! It is critical that the muscle be injected precisely, and deep muscles will need deep injections, superficial muscles superficial injections. And where there are deep and superficial muscles within a very short distance, precision of implantation will be critical!
Is the patient’s study important?
This is another very important aspect in order to avoid the occurrence of side effects and to have remarkable results. The patient should absolutely be studied well before treating and should be marked with a make-up pencil to determine the injection site well. Every patient is different and the injection should be studied exactly.
For what indications can we think of using Botulinum Toxin?
In the strictly cosmetic field, for wrinkles! The toxin has a great effect on wrinkles, as we all know.
In recent years the increase in the use of Vistabex has really been exponential, in some years greater than 1000%.
The main indication remains the wrinkles of the upper III of the face.
Increasingly, however, the lower III of the face is also being treated. In fact, one of the most important actions of the toxin remains that of modulating the balance between agonist and antagonist muscles. And this is the most important mechanism of action in the modulation of mandibular rim sagging and in the treatment of so-called platysmal bands.
Finally, botulinum toxin is widely used by some authors, in the treatment of décolletage wrinkles. In fact, muscle myofibrils are documented to reach the skin from the deep muscle plane. With very few units of toxin diluted in revitalizing substances, it is possible to reduce this phenomenon and obtain excellent results in this district as well.
For sweating: you don’t know how many patients come to my practice because of the great experience in treating hand sweating where we do a special anesthesia that resets the otherwise unbearable pain to zero. And also for cab or truck drivers when their backs sweat a lot. Botulinum toxin has a truly extraordinary effect in the limitation, indeed, abolition, of excessive sweating.
This effect is visible to everyone who tries the toxin on the forehead for cosmetic reasons: for many months forehead sweating will be nonexistent. In the treatment of
In addition, the injections, especially for the armpits, are not particularly painful, and the effects are absolutely natural. If the session then is done at the beginning of the summer period, the results will be of great duration, the winter period being less exposed to the problem.
This is one of the fields where toxin truly represents a Copernican revolution!
Is the toxin eternal or does it have to be repeated over time?
The toxin tends to be repeated every six months. To date, no definitive side effects are described after use of botulinum toxin by injection.
Invariably then after a few months, the cosmetic effect of the toxin goes to zero. It is obvious then that even the side effects will not last forever, and they too, in time, will fade and totally disappear. On average, the toxin should be repeated every 6 months, and I personally never repeat it before at least 4 months. In fact, repeating the infiltration too frequently may expose you to the risk of sensitization and production of antibodies that could inactivate the toxin.
Can botulinum toxin be done with other treatments?
In my opinion, toxin is best done alone, that is, in a stand-alone session for two reasons:
Because already there are many punctures that are done. And the toxin certainly can’t be done where other treatments are being done at the same time. I mean we can’t do in the same session on the glabellar wrinkles the toxin and a filler like hyaluronic acid.
However, we could do toxin in the upper III of the face and a filler for nasogenic wrinkles. However … many wrinkles on the face after toxin improve dramatically, and the amount of correction needed with the other methods is dramatically reduced. For example, nasogenic wrinkles after botulinum toxin treatment of the mandibular rim can improve greatly.
For these reasons, I tend to do the toxin in a separate session from other techniques, evaluate the results, and finish with the other corrections after well evaluating the benefits obtained.
In different sessions, however, there are absolutely no problems. Combination with hyaluronic acid fillers, revitalizations and peels is practically the rule.
Very interesting is the association with fractional lasers. However, I do not use nonabsorbable materials such as silicone, polyacrylamide or methyl methacrylate, which in my opinion are inherently more dangerous.
What advice can be given after a Botox session?
Saunas, steam baths, showers that are too hot, and baths that are too hot on facility day are prohibited. In addition, strenuous physical activity is also best avoided. Finally, facial massages of cosmetic or any other kind are to be avoided. Otherwise, it is possible to lead an absolutely normal life, and you can resume your work activities immediately.
When can a cosmetic doctor be asked to undergo a botulinum toxin session?
On average 30 to 65 years old, but in my experience even older ladies have responded to the toxin very well, and even in very select cases, small defects in very young girls have benefited very well without any risk. As always, common sense prevails!
Conclusions
I have always been a great advocate of the use of botulinum toxin, as moreover evidenced by some of my publications in years past.
To proscribe its administration by non-expert personnel. In fact, the toxin has to follow very precise rules and an absolute knowledge of anatomy, inceptive sites and dilution is indispensable for good results.
The advice, therefore, remains to go to experienced medical personnel. As I always tell my patients, much of the cost of the session is due to the experience of the user!
I would also say to avoid “do-it-yourself” injections, which are very dangerous. Also to avoid the search for exaggerated results: often the sight of striking side effects that we sometimes see even on television are due to the search for aesthetic results that are impossible to achieve.
If, on the other hand, done within the bounds of prudence, pursuing the “natural look,” and seeking the reduction of movement and not its complete abolition, botulinum toxin can be an extremely powerful weapon in the hands of the aesthetic physician.
An exact knowledge of modern botulinum toxins is also essential in order to know how to choose the best product for the individual patient.
Always turn to experienced and well-known personnel.