The Agony and Ecstasy of Botox

America has a love/hate relationship with Botox. It’s the blockbuster drug that millions use regularly. It reduces wrinkles in the upper half of the face and has a growing list of uses that are not related to cosmetic appearance. But there are some definite risks with its use, and it’s been implicated in some dark controversies, black market purchases and even deaths. On today’s show, you saw me discussing the issues associated with Botox use. In this blog, let’s go a little further and explore the safety issues with Botox.

Posted on | Arthur Perry, MD, FACS | Comments ()

America has a love/hate relationship with Botox. It’s the blockbuster drug that millions use regularly. It reduces wrinkles in the upper half of the face and has a growing list of uses that are not related to cosmetic appearance. But there are some definite risks with its use, and it’s been implicated in some dark controversies, black market purchases and even deaths. On today’s show, you saw me discussing the issues associated with Botox use. In this blog, let’s go a little further and explore the safety issues with Botox.

Botox is a powerful drug that knocks off the connection between the nerves and muscles. While we refer to this neurotoxin as “Botox,” there are actually several companies that make nearly identical products. Like it or not, it’s similar to how “Kleenex” became the term for all paper tissues. So we’ll lump Dysport  and Xeomin, the other products, together and refer to all these drugs as “Botox."

The FDA approved Botox Cosmetic to lessen vertical frown lines between the brows. (Those are the ones that appear on your dog’s face when another dog approaches his food. They signal anger to the prospective thief, and telegraph an imminent bite if the retreat doesn’t occur.) The FDA allows drugs to be used “off-label” for purposes that they haven’t specifically approved. And so, Botox is legitimately used to reduce the horizontal forehead lines, the crow’s feet, and the bunny lines on the nose. Some daring docs have used it to decrease wrinkles around the mouth and even the bands in the neck. These areas are much less predictable than the upper face areas, and complications like drooling and asymmetric smiles are common. We won’t get into it here, but Botox has also been used to decrease hand, feet, and underarm sweating.

Botox use may seem as simple as injecting the drug in a few set locations. But the creative, artistic use of Botox is much more complex than that. Skilled physicians visualize the muscles that they want to paralyze, and pepper the muscle with many small injections of the drug. The goal of Botox is not to “carpet bomb” the forehead, but rather to preserve some motion while reducing objectionable wrinkles. 

Typically, the vertical lines between the brows are injected with 13-30 units of Botox while the horizontal forehead lines need 10-20 units, the crow’s feet need 8-20 on each side and the bunny lines need 5-10 units.

Botox is a revolutionary drug, and is so effective that it can reduce even deep wrinkles. The longer patients use it, the better they look, as the body actually “heals in” wrinkles when they are not continually recreated. Botox takes less than 15 minutes to inject and typically lasts four months. This powerhouse drug can improve appearance and restore confidence. I love Botox and so do my patients.

While you may see advertisements for Botox in salons, spas and maybe a party or two, Botox is a real medical procedure, with the potential to cause serious problems, even death. In trained hands, Botox problems are usually minor things like bruising or the occasional asymmetric eyebrow. Most of the bigger problems have resulted from injections of large amounts in the neck. This toxin can travel to the muscles that control swallowing and coughing and aspiration of food and pneumonia can result. These complications are rare, but they do underscore the fact that getting Botox is not like getting a facial or a massage. It is a medical procedure that should be performed in a medical office, a heavily regulated environment designed to assure patient safety and privacy.

So, who should perform your Botox? While plastic surgeons and dermatologists are the obvious choice, properly trained ophthalmologists and otolaryngologists are also reasonable alternatives. These four groups all receive appropriate instruction during their residency training programs.

What about family doctors, emergency medicine doctors, dentists, podiatrists, and everyone else who is trying to get into the act, courtesy of their weekend crash courses? Let’s just put it this way … I’m legally allowed to perform colonoscopies, but you wouldn’t want me doing that to you. Why? I’m not formally trained in colonoscopies. Doctors who add Botox and other cosmetic procedures to their menu of patient offerings are taking advantage of their medical licenses in this era of declining insurance reimbursement for the procedures that they were trained to do. It reminds me of Suttons Law: Why did Willie Sutton rob banks? Because that’s where the money was. 

Bottom line? Like all medical procedures, choose your doctor carefully, and don’t view Botox like you view a manicure. For more information about Botox, check out my book, Straight Talk About Cosmetic Surgery.

Blog written by Arthur Perry, MD, FACS
Dr. Perry has over 2 decades of experience as a clinical surgeon and has been named to the “Best Doctors in the NY Area” book...