Botulinum toxin (commonly known as Botox) is a chemical substance that acts on muscle cells by blocking their activity and thus paralyzing the muscle. It is a molecule present in nature, specifically produced by a bacterium (clostridium botulinum) which causes the well-known botulism, characterized precisely by muscular paralysis.
After studying the properties of this molecule and its mechanism of action, it was considered that it could be used to modulate the contractile capacity of certain muscles and thus obtain a medical benefit. From this point on, the synthesis of this molecule in the laboratory was initiated.
In the field of aesthetic medicine, botulinum toxin is used to prevent certain muscles from contracting; it blocks or minimizes mobility and thus modulates skin movements, thus preventing the formation of “expression wrinkles”.
It is mainly used to treat expression wrinkles in the upper third of the face:
- Forehead wrinkles
- Between the eyebrows
- Crow’s feet
Botox treatment takes effect from the third or fourth day of its application, reaching its maximum effect after 10 days.
How does it affect the patient?
To better understand how it works and what the patient will notice, we must begin by identifying the two types of wrinkles:
- Static wrinkles: those that occur as a result of the sagging of the tissues themselves and the loss of collagen. Facial mimicry conditions changes in them but does not make them less visible.
- Dynamic wrinkles: those that appear as a consequence of repetitive movement. Facial mimicry makes them more or less visible in such a way that they are much less visible with a relaxed facial expression.
Botulinum toxin acts on the latter. By paralyzing, to a greater or lesser extent, the selective activity of certain muscles, we limit the repeated facial mimicry and, thus, the formation and identification of these dynamic or “expression” wrinkles.
If done correctly, the patient will continue to express himself naturally but in a less intense, less forced way, which will prevent the skin from wrinkling. The action of Botox will prevent expression wrinkles from increasing and, little by little, they will soften as the patient will have a more relaxed expression.
After 4 months, Botox begins to lose its effect.
Like any biological substance, botulinum toxin loses its effect over time. Four months after its application, botulinum toxin or Botox begins to lose its effect; after 6 months it is practically non-existent. After that time, the muscle will recover its activity, the expression will restore its intensity and, with them, the wrinkles will return.
In conclusion, we will have to reapply the treatment between 4 and 6 months, if we do not do so we will recover the previous muscular mobility and, with it, the initial state of those expression wrinkles we want to treat.
Where is it applied?
It is very important to emphasize that legally the application of botulinum toxin or Botox is only approved in the upper third of the face. There are some doctors who use it to treat wrinkles around the mouth or in the neck (nefertiti neck is what we call those wrinkles that are noticed in the neck when the skin is very old). The reason why the legislation only contemplates the application in the upper third is that there are no formal studies on its application, for aesthetic purposes, in other areas of the face but, if performed by a qualified professional, also the application in those areas, the results are very satisfactory.
When we speak of the upper third we refer to the region above the eyes: “crow’s feet”, between the eyebrows and forehead. As we have said, botulinum toxin is not indicated for these areas but if the doctor and the patient reach an agreement informing about it, it can be used.
The toxin is applied by puncture, in a series of points that allow the same vehicle on the specific muscles on which we want to act. The inoculation is performed with a fine needle and is completely painless since an anesthetic cream is applied to the puncture points beforehand.
Can any patient be injected with Botox?
We must make it very clear that botulinum toxin does not give volume. Many patients get confused and think that botulinum toxin can swell their face. For this reason, it is important not to confuse botulinum toxin with hyaluronic acid; botulinum toxin never swells the face. What botulinum toxin does is to act on the muscle preventing its contraction.
Each patient is different and for that reason it is not possible to generalize. There are many types of patients, some begin to mark expression wrinkles at a very young age. Therefore, it is not surprising that we have patients who start treatment in their 30s, while others do not start until later in life.
If we take into consideration the preventive nature of the treatment, we will understand that early treatment is very appropriate, since it will help us to minimize the progression of wrinkles.
We said that the continued action of the toxin reduces wrinkles, but the more pronounced they are, the harder it will be for them to smooth out and the more difficult it will be for them to disappear. In other words, early application of the treatment allows wrinkles to be shallower and, therefore, makes their correction much easier and quicker; late treatment makes it more complicated and, sometimes, incomplete in terms of results.
In those cases where wrinkles are very very marked, I personally recommend a two-stage treatment:
- Approximately during the first year treat only with botulinum toxin to determine the degree of improvement of wrinkles.
- After one year, when we have managed to smooth these expression wrinkles, we will incorporate hyaluronic acid of very low cross-linking, to treat only the wrinkle. Previously, we will have treated with botox to avoid the contraction of the muscle that conditions the appearance of the wrinkle. No matter how much hyaluronic acid we apply, if the muscle contracts, the wrinkle will remain there.
Botox is applied with a very fine needle (30 gauges) that is practically unnoticeable. It is a painless treatment that usually does not last more than 15 minutes.
What are the puncture points?
The toxin is inoculated by fine needle puncture in a series of points. These points allow us to inject the toxin in certain muscle groups on which we want to act. During the evaluation of each patient we must identify the action of the different muscle groups and evaluate on which points we should act.
We make the patient gesticulate, we ask him to raise his eyebrows, to frown, to make an angry face or to smile strongly. Thanks to the evaluation of facial mimicry we are able to force the identification of “expression wrinkles”. We mark the different wrinkles and, based on these, we specify on which points we are going to apply the toxin.
In short, it is necessary to have a very exhaustive knowledge of the dynamic anatomy of the face and more specifically of the upper third of the face. It must be taken into account that the interaction of the frontalis, corrugator and procerus muscles, depending on the anatomical arrangement of the fascicles of fibers in the different muscles, gives rise to a good number of emotional states. For example:
- When the forehead is raised, with predominance of the medial frontalis over the procerus and corrugators, the emotion it reflects may be one of expectation, curiosity, illusion, mockery.
- The balance between the frontalis as elevator and the depressor muscles, procerus and corrugators, conveys friendliness, serenity.
- When the corrugators and procerus predominate over the frontalis, the forehead is depressed in its central portion. This can express worry, anger, tiredness …
- If the action of the lateral fibers of the frontal is predominant on the external portion of the orbicularis, surprise, happiness, enthusiasm are transmitted.
- If the action of the external fibers of the orbicularis predominates over the lateral fibers of the frontalis muscle, what is communicated is anxiety, sadness, tiredness, weariness, boredom?
After a detailed study of all the wrinkles we will be able to specify where it is necessary to infiltrate the toxin. In the case of crow’s feet, the origin derives from the contraction of the external portion of the orbicular nerve. As the years go by, the skin loses elasticity and wrinkles are marked even at rest.
The position of the eyebrows is also an important issue, so we will deal specifically with this topic in a future post. Depending on the balance of muscular “paralysis” that we condition on the muscles, we can modulate the height of the eyebrows. Thus, if we weaken excessively the action of the frontalis muscle we can generate a certain decrease in the height of the eyebrows, this is relatively accepted in the case of men. On the contrary, in women, this has a negative effect as it results in an aged appearance. The eyebrow in women should be above the supraorbital arch maintaining an upward line from the inside out; the loss of this upward line is suggestive of aging.
As we can see, where to apply botulinum toxin and why depends on the careful study of each case and the interaction of the action of the different muscle groups of each patient. Each individual is unique and should be treated according to their specific anatomy.
As always, you are the center, all thinking by and for you, because we want to take care of you.