Biology 103
2002 Second Paper
On Serendip

To Botox or Not to Botox

Brie Farley

Where does our plight for perfection end? Self-improvement, especially in the area of personal appearance, is applauded in American culture. In April 2002, the FDA announced the approval of Botulinum Toxin Type A to temporarily improve the appearance of moderate to severe frown lines between the eyebrows (glabellar lines), a medical condition that is not serious. Botulinum Toxin Type A, better known as Botox, was first approved in December 1989 to treat eye muscle disorders (blepharospasm and strabismus) and in December 2000 to treat cervical dystonia, a neurological movement disorder causing severe neck and shoulder contractions. (1).

Botox is a protein produced by the bacterium Clostridium botulinum. In medical settings, it is used as an injectible form or sterile, purified botulinum toxin. In 1895, Emile P. Van Ermengem first isolated the Botulinum microbe. He discovered that this bacterium produced a toxin, and understood that this was what caused disease. However, it wasn't until 1946 that the toxin was isolated in a crystal form by Edward J. Schantz. In the early 70's, Dr. Alan Scott began investigating the use of botulinum toxin injections to treat crossed eyes (also called strabismus). Clinical studies for this purpose were initiated in 1977. (6).

Shortly after these studies, Dr. Jean Carruthers, a Canadian opthalmologist, noted a marked decrease in the appearance of frown lines on a patient that was receiving botulinum toxin injections to relieve twitching of the eye (blepharospasm). Soon after, Dr. Carruthers teamed up with husband Dr. Alastair Carruthers, a Canadian dermatologist, to use the botulinum toxin to treat frown lines and crow's feet. The results of these treatments were published in 1989, laying the foundation for a revolution in cosmetic surgery. (6).

Small doses of toxin are injected into the affected muscles and block the release of the chemical acetylcholine that would otherwise signal the muscle to contract. Thus, the toxin paralyzes the injected muscle. Botox worked so well to help medical conditions, it was tested as a cosmetic procedure. (1).

"In placebo-controlled, multi-center, randomized clinical trials involving a total of 405 patients with moderate to severe glabellar lines who were injected with Botox Cosmetic, data from both the investigators' and the patients' ratings of the improvement of the frown lines were evaluated. After 30 days, the great majority of investigators and patients rated frown lines as improved or nonexistent. Very few patients in the placebo group saw similar improvement." (1).

Within a few hours to a couple of days after the botulinum toxin is injected into the affected muscle(s), the spasms or contractions are reduced or eliminated altogether. The effects of the treatment are not permanent, reportedly lasting anywhere from three to eight months. By injecting the toxin directly into a certain muscle or muscle group, the risk of it spreading to other areas of the body is greatly diminished. (2). When Botox is injected into the muscles surrounding the eyes, those muscles can not "scrunch up" for a period of time. The wrinkles in that area, often referred to as "crow's-feet," temporarily go away. (2). (For before and after pictures, see (7))

Most of the patients in the study were women, under the age of 50. The most common side effects were headache, respiratory infection, flu syndrome, blepharoptosis (droopy eyelids) and nausea. Less frequent adverse reactions (less than 3% of patients) included pain in the face, redness at the injection site and muscle weakness. (1). In June 2002, the American Headache Society released findings of 13 studies that indicate Botox rid a number of patients of severe headaches. (3).

One particular project suggests that people plagued with headaches who also had Botox injections for cosmetic reasons suffered from fewer migraines, experienced a reduction in the disabling effects of migraines and used less pain medication. (3).

The headache and Botox connection began emerging in 1992 when a California physician noted his patients who got Botox injections said they were having fewer headaches. (3). "The biggest advantage to Botox is its lack of side effects, especially compared to other medications," Dr. William Ondo of the Baylor College of Medicine said in an AHS press release. "It really is extremely safe and appears to be very effective for some people." (3). Researchers think Botox blocks sensory nerves that relay pain messages to the brain in order to relax muscles, making them less sensitive to pain. (3).

"Scrunching" your eyebrows in a concerned or angered expression relays these messages and may cause headaches.

"More than half of the 48 patients in a study at a Mayo Clinic in Scottsdale, Arizona, said their migraine occurrences dropped by 50 percent or more. Of the ones who had a positive response, 61 percent said they had headaches less frequently and almost 30 percent said the headaches were less severe. At the Baylor College of Medicine Headache Clinic, 58 patients participated in a controlled trial. Some received Botox and others had placebos. After three months, 55 percent of the patients who received Botox reported at least moderate improvement in their headaches. Two of the 29 who got the placebo water injections reported the same results." (3).

What's the worst that can happen, you might ask, from having a toxic substance injected into your face?? According to results from a study conducted at Wake Forest, Botox side effects are minimal. Doctors found a small risk the skin around the injection site would droop temporarily. (3). This is known as blepharoptosis and occurs in about 5% of patients. It usually appears 7 to 14 days after the injection and can last 4 to 6 weeks. A more speedy method of treating it is the application of prescription eye drops (iopidine). In many cases, these drops will help resolve the droop within a few days. To reduce the risk of blepharoptosis, it is recommended that patients obtain Botox from a physician who is experienced in its use. It is also important for a patient to remain vertical for 4-6 hours after the injection. This allows the Botox to be taken up in the treated area and reduces the chance of displacement to other muscles. The injected site should not be touched for two to three hours following injection. (4). Botox sounds like a miracle drug for those desiring a wrinkle-free face. It has minimal side effects and is relatively inexpensive to other forms of cosmetic alterations such as surgery. Different patients will require different amounts of Botox treatment, which can vary the cost. According to recent information, Botox treatment can cost anywhere from $300 to $700 per treatment. (6). However, what should we anticipate is the future of Botox? Botulinum Toxin Type A, Botox, is related to botulism. Botulism is a form of food poisoning that occurs when someone eats something containing a neurotoxin produced by the bacterium Clostridium botulinum. Botulinum toxin A is one of the neurotoxins produced by Clostridium botulinum. (2). Thus, muscle paralysis is the most serious symptom of botulism, which in some cases has proven to be fatal. The botulinum toxins attach themselves to nerve endings. Once this happens, acetylcholine, the neurotransmitter responsible for triggering muscle contractions, cannot be released. Essentially, the botulinum toxins block the signals that would normally tell your muscles to contract. If, for example, it attacks the muscles in your chest, this could have a profound impact on your breathing. When people die from botulism, this is often the cause; the respiratory muscles are paralyzed so it is impossible to breathe. (2).

Said in this way, Botox may not sound so harmless. It is a serious toxin, and although the side effects from facial injections do not sound lethal, its users should realize the lethal properties of the substance. Furthermore, what will happen to all of the Botox enthusiasts when they decide to discontinue Botox injections? The current recommended 'dosage' is to return once every three months for new injections between the eyebrows. These muscles are paralyzed and weakened. Over time, will these muscles be able to function properly without Botox injections or will the toxin have weakened their natural capabilities to the point of destruction? When all of the women from the study are eighty years old, will their eyes be visible under permanent blepharoptosis? We are living in an era of self-manipulation and self-perfection. Is it not ironic that many of the same individuals who do their grocery shopping exclusively at the organic market are off having poison injected into their face to look healthy? The newest rage of self-improvement enthusiasts is Botox Parties. Botox parties are one of the newer, more controversial ways to administer Botox. Typically, Botox party guests will get a quick lecture on the risks before receiving Botox treatments in a private area. Alcohol is sometimes served, although it should never be served prior to the treatments (and many doctors will say that alcohol should never be involved in any medical procedure, before or after). (6).

"Some people enjoy Botox parties because of the support they receive from other guests. In addition, a Botox party can be a more economical way to have treatment, since the prices for the actual toxin are usually lower in large groups. At any rate, these occasions have been growing ever more popular, and many highly qualified physicians look upon them with disfavor." (6).

There are many physicians who refuse to do Botox parties. They believe that no medical procedure should be administered in a social setting. They also argue that it is impossible to meet the specialized needs of each individual Botox patient in a party setting where the doctor is administering up to ten Botox treatments in an hour. (6). It almost sounds as if Botox is comparable to an addictive drug; a qualified dealer, a group of high paying clients, and a social setting complete with food and alcohol to make it more acceptable and more fun.

So far, Botox has been approved to help with cross-eyes, uncontrollable blinking, cervical dystonia, and now moderate to severe frown lines between eyebrows It is being studied to help excessive sweating, spasticity after a stroke, back spasms, and headaches. (2) Is Botox a problem or is the newest and best cure to a myriad of medical and cosmetic concerns? Apparently, the risks of Botox injections, and the unknown future effects of Botox, are not enough to discourage Botox enthusiasts.

It is a difficult generation who can no longer find a distinction between potential inflictions of self-harm and striving to look the best. In Hollywood, the treatments are so popular that some directors complain that their leading actors can no longer convincingly perform a full range of facial expressions. (5)

Doctors knowledgeable in Botox are in high demand. This increases the possibility that not all doctors know all they should. This includes knowing when Botox won't be useful at all. "Muscles cause some wrinkles, but many result simply from the loss of elasticity that goes naturally with aging (or, less naturally, with smoking and sun exposure), causing the skin to sag and crumple". (5)

There are treatments for this sort of wrinkle, but Botox isn't one of them, says Dr. David L. Fledman, director of plastic surgery at Maimonides Medical Center in Brooklyn New York. "I had a patient recently who came in asking for Botox." He says. "It would have done no good at all. In fact, she might have ended up looking worse." (5)

Botox isn't a cure-all, and it is accompanied by some strange side effects. In September 2002, the company that distributes Botox, Allergan Inc., was asked to revise their advertising. Thus, all advertisements for Botox will disappear until Botox is advertised seriously and realistically as a medical procedure and not as a simple method to destroy, "those tough lines between your eyebrows." (8)

...."If you don't mind getting shot up with poison and you don't mind paralyzing parts of your face-well, you've got plenty of company."(5)

References

1) FDA , an article posted by the FDA upon approving Botox
2) How Stuff Works , A great site with explanations on how everything works!
3) CNN , an article regarding the helpful effects of Botox on headaches.
4) www.ebody.com , Details about the side effects of different medical procedures
5) Vreflect.com, Talks about Botox as a cultural phenomenon
6) Botox Injections Information , A professional site with information and links to doctors
7) Botox Injections Information, Go here to see pictures!
8) Sunwellness Magazine, An article from September 2002 announcing the FDA's notice to Allergan Inc. to halt advertising



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