Botox injections

Many people think of botulinum toxin type A (known by the brand names Botox, Dysport and Xeomin) as just a treatment for wrinkles. However, it has actually been used for many years to treat several medical conditions. Its use as a cosmetic treatment was only realised when people using it to treat facial muscle spasms noticed an improvement in their facial wrinkles.

What is Botox?

Botox is one brand of a purified form of botulinum toxin type A, a chemical toxin that is produced by Clostridium botulinum bacteria. Other brands available in Australia include Dysport and Xeomin.

Although these medicines are made up of the same toxin that causes botulism (a type of infection that can result in life-threatening muscle paralysis) they are generally safe to use as an injectable medicine. That’s because they are used in very small quantities and injected directly into specific sites.

What are Botox injections used for?

The Therapeutic Goods Administration (the Australian drug regulatory agency) first approved injections of botulinum toxin type A for medical use in 1999. The injections were approved for cosmetic use in 2002 (at that time, specifically for the treatment of vertical frown lines).

Current cosmetic uses

Botulinum toxin type A injections are now approved for the cosmetic treatment of several types of facial wrinkles.

Botox can be used in adults to temporarily improve the appearance of:

  • vertical frown lines (also called glabellar lines — lines between the eyebrows that are caused by the muscles that contract when you frown, squint or concentrate);
  • horizontal forehead lines; and
  • lines radiating from the corners of the eyes (crow's feet).

Dysport has been approved for the treatment of moderate to severe vertical frown lines between the eyebrows and crow’s feet in adults.

Xeomin can be used to treat upper facial lines, vertical frown lines, horizontal forehead lines and crow’s feet in adults.

Medical uses

Botulinum toxin type A injections can be used to treat several medical conditions. Not all brands have the same approved uses - your doctor will use the brand of botulinum toxin that is appropriate.

Muscular conditions that can be treated include:

  • blepharospasm (twitching or spasm of the eyelid);
  • cervical dystonia, or spasmodic torticollis (a type of muscle spasm in the neck);
  • facial or other localised muscle spasms;
  • muscle spasticity due to cerebral palsy; and
  • strabismus (a condition where the eyes are not properly aligned).

Botulinum toxin type A can also be injected into the bladder muscle to help treat certain cases of incontinence due to overactive bladder.

Excessive localised sweating (hyperhidrosis), especially severe underarm sweating, can also be treated with Botulinum toxin type A injections.

And Botox can be used to help prevent migraine headaches in people with chronic migraine. That includes people who have headaches on at least 15 days each month, of which at least 8 days are with migraine. When used to treat migraine, Botox is injected into muscles in the head and neck.

How does Botox treatment work?

Botulinum toxin type A works by stopping the release of a chemical messenger (a neurotransmitter called acetylcholine) from nerve cells. The effects are restricted to the area being treated, and because the nerve fibres usually regenerate after a couple of months, the effects are only temporary.

When injected into a muscle, the toxin blocks the signals between nerves and the muscle. The muscle loses the ability to contract and becomes weakened or temporarily paralysed. When injected into the skin, botulinum toxin type A can block the action of the nerves that control your sweat glands.

Exactly how it works to reduce the frequency of migraines is not known.

How are Botox injections used to treat wrinkles?

Botulinum toxin type A can be used to weaken or paralyse some of the facial muscles that pull on your skin and cause wrinkles. When the muscles are relaxed, they smooth out, allowing the overlying skin to flatten out too.

Lines and wrinkles caused by certain facial expressions start to disappear about 2 to 7 days after the injections.

Because the therapy targets specific, individual muscles, the ability to form most facial expressions should not be affected.

How long does the effect last?

The improvement in the appearance of your wrinkles usually lasts for 3 to 6 months. Repeated injections are required to maintain the effect. With continued use, the effects may start to last longer.

A small number of people develop neutralising antibodies to Botox injections after repeated therapy, which results in the treatment no longer being effective.

Can Botox injections be used to prevent wrinkles developing?

There is increasing interest among younger people in the possibility of using Botox injections to prevent wrinkles. The idea is that by starting young you could prevent the development of wrinkles in the first place.

Currently, Botox injections are not indicated for this purpose, and there is a lack of evidence to show what the long-term outcomes would be. Also, it should be noted that Botulinum toxin type A is only indicated for cosmetic use in adults.

What do Botox injections feel like?

When injections are to be given into the skin or muscles just under the skin, most people are able to have them without any local anaesthetic, as they are not too painful. They have been described as feeling a bit like an ant bite. However, it depends on the area being injected, so ask your doctor.

The injections are done using a very fine needle. The number of injections will depend on why you are being treated and the size of the area being treated.

Are Botox injections safe?

Botox injections are relatively safe when administered by a medical professional who is trained in their use. However, as with all treatments, there are some possible side effects.

What are the side effects?

Most side effects of botulinum toxin type A are mild and temporary. Pain, tenderness and bruising may be associated with the injections, and some people have reported a slight headache after treatment. Some people also have dry eyes or tearing after facial injections.

Nausea and a flu-like syndrome are rare side effects. It’s also rare, but not unheard of, for the toxin to spread and cause weakness or paralysis of other muscles. This can be dangerous if it affects swallowing or breathing.

There is only a small risk of significant side effects, such as a drooping eyelid or uneven eyebrows (which usually only lasts a few days, but can last longer).

It's important to remember that that all medical procedures carry risks as well as benefits, and you need to discuss these with your doctor.

Who should not have botulinum toxin type A injections?

Botulinum toxin type A injections should not be used in women who are pregnant or breast feeding. They should also not be used if:

  • you have a known allergy to the treatment;
  • there is an infection in the area that’s to be treated; or
  • you have myasthenia gravis or Eaton Lambert syndrome (neuromuscular conditions).

Where can I get Botox treatment?

Injection therapy with botulinum toxin type A is only available on prescription from a doctor. It should always be given by a trained medical professional who is familiar with the correct technique. Your doctor will be able to let you know whether this treatment is suitable for you.

Cosmetic procedures can be performed by various health professionals, including plastic surgeons, cosmetic surgeons and physicians, dermatologists and nurses. It is possible to go directly to some of these professionals for treatment, but it is preferable to have a referral from your GP.

References

1. Botox Prescribing Information. Allergan. Accessed via eMIMS. TGA approval date: 8 Feb 2018.
2. Dysport Prescribing Information. Ipsen. Accessed via eMIMS. Date of revision: 8 Jun 2018.
3. Xeomin Prescribing Information. Merz. Accessed via eMIMS. Date of revision: 15 Mar 2018.
4. Australasian College of Dermatologists. Neurotoxins (updated 2 Jun 2015). https://www.dermcoll.edu.au/atoz/neurotoxins/ (accessed Sep 2018).
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