Definition, Types And Mechanism Of Action: Botox

BOTOX is taken from a bacteria known as Clostridium botulinum bacterium in which this microbe produces a protein and neurotoxin necessary for the formation of this material and it was discovered by Emaile van in 1897. Since then, BOTOX has been experimented for therapeutic uses and approved for certain medical treatment tell 2002 where Food and drug administration (FDA) has approved the use of Botox for cosmetic and therapeutic application. Currently, there are seven recognized serotypes of botulinum neurotoxin which is (A, B, C1, D, E, F and G). For commercially use, Botox, Dysport and Xeomin are the only three forms of type A that are available and one type of B which is MyoBloc.

Type A Botulinum toxin works by inhibiting the release of acetylcholine on cholinergic nerve endings (neuromuscular junction) of motor nerves thus resulting in flaccid paralysis of the overactive muscle.

Fillers

In regard to filler, there is four major category that it falls in (autologous implants, collagens, HAs and biosynthetic polymers). For the first category, it was introduced in 1893 by Neuber’s for soft-tissue augmentation. However, due to the limitation in the reproducibility of the effect and the Immunologic concerns the use of this type of filler has declined until the late 1970s. Nevertheless, after improving lipectomy suction and harvesting techniques the autologous fat graft has increased in demand in the market.

Collagen in injectable form has a variable concentration of purified bovine or human collagen and before the introduction of Hyaluronic Acid fillers, it was the ‘gold standard’ injectable filler. One of its advantages over the lateral is that it is less viscous and less likely to produce irregularities for treatment and correction of fine lines and wrinkles. Hyaluronic Acid is naturally present in the extracellular matrix of the body where it offers a framework for collagen development. HA is a polysaccharide with hydrophilic properties, so it has a high affinity for binding with water molecules. So, it is main function involve lubrication, hydration and maintaining the equilibrium of connective tissue. Due to their hydrophilic properties, it can attain considerable soft tissue augmentation and when a suitable amount of volume is injected it cannot be distinguished either visually or by palpation. Compared to collagen fillers, Hyaluronic Acid can last up to 6-9 months or longer depending on the type used. whereas collagen fillers can only remain for a few weeks or months.

Synthetic fillers are generally composed of one of the biosynthetic polymers such as (e.g., poly-L-lactic acid, calcium hydroxyapatite and polymethylmethacralate) that are joint with injectable carriers. Synthetic polymers are preferred over the other types of filler due to their ability for more permanent results which earned them popularity among plastic surgeons. However, that would also raise the concern over the high rate of long term adverse effects or unwanted events.

Complication and side effects

As with any invasive or non-invasive surgical procedure, BOTOX and filler injection are not without any risks. Nevertheless, BOTOX and fillers are generally a highly safe treatment for most patient with few complications when administered correctly. Therefore to minimize the unwanted event a correct injection technique is needed.

Reported contraindications for BOTOX include the use of (quinine, calcium channel blockers, penicillamine, or aminoglycoside antibiotics). BOTOX is also a relative contraindication for patient with neuromuscular diseases and it’s a C category for pregnant women which include: women who are attempting pregnancy, pregnant or lactating women. The physician should also be aware of the patient allergic reaction to any of the BOTOX component. The ten main errors when injecting BOTOX are:

• Using an excessive amount of BOTOX will lead to lack of expression, some would advise using less amount than the recommended dose in the articles and textbooks for more natural appearance. However, patients should be informed that the effect will last for a shorter period of time than the usual.
• Mephisto effect or ‘devil eyebrow’ which result of injecting the Frontalis Muscle Instead of the Corrugator Supercilii Muscle and that will lead to a relaxation in the middle portion of the eyebrows and compensatory contraction on the lateral side.
• Excessively elevated eyebrows due to the injecting of botulinum toxin into the superior lateral portion of the orbicularis oculi muscle leading to relaxation of the fibers and in result the eyebrows will be lifted.
• eyebrow and/or eyelid Ptosis resulting from injection of the BOTOX into the frontalis muscle with patient who use it to lift their eyelids and it is usually observed with elderly patient how are 65 years or older.
• Exacerbation of undereye bags happens with patient who as a result of herniated fat or fluid retention have undereye bags and are injected with botulinum toxin in the most inferior portion of the orbicularis oculi muscle.
• Failure to include the lower third of the face when injecting BOTOX will result in less efficient overall result.
• Unnatural wrinkles happens when BOTOX is injected into the desirable muscle and the adjacent muscle compensate by contraction, in some cases that leads to new unwanted telltale wrinkles. ‘Bunny lines’ are one of the classic wrinkles that are caused by botulinum toxin injection.
• Lack of understanding of muscle contraction patterns for each individual patient will result in an unnatural appearance.
• Masculinization of women’s appearance by injecting the wrong area will give more straight and sharp future and it also can feminize a men’s appearance by the same way.
• Suboptimal result could happen if the case needs a combination of BOTOX and other cosmetic treatments as the case of lost facial fat volume.

Plenty amount of people believe that fillers only serve to increase their satisfaction of their appearance regardless of their possible side effect, one of the major complications of filler injection is intravascular and or perivascular injections that produce a compression of the vessels leading to tissue necrosis. Nicking of the blood vessels and deposition filler particle are a combined with pain and tissue blanching. Regardless, those symptoms are usually present after filler injection and it cannot be distinguished from intravascular injection. In rare cases intravascular injection in the area proximal to the glabella progress to the central retinal artery by retrograde movement of the particle scattering micro-emboli inside the retina that leads to complete unilateral vision loss which could be permanent if not recognized and treated instantly. Slow and superficial injection could minimize the possibility of these episodes, compinged with the back pressure withdrawal of the syringe that reveals if the tip has perforated the blood vessel. However, the absences of blood does not in piratically mean that the vessel was not compromised due to the high viscosity of the filler particles and the small caliber of the needle.