Passages
Relaxing those wrinkles

By Katherine Nichols
Advertiser Staff Writer

It's the most poisonous substance known. But people line up to have it injected into their faces to lessen the appearance of wrinkles. Doctors say there are minimal side effects. Patients are happy; so pleased, in fact, that often they return several times a year for treatments.

An injection of BOTOX is used to smooth creases by paralyzing, or "relaxing," the facial muscles. It lasts for about six months. Deborah Booker • The Honolulu Advertiser

It is, of course, toxic, but for medical and cosmetic purposes, the doses are miniscule and diluted, making an overdose on an adult nearly impossible (there is more risk associated with use in children). Said Dr. Robert Schulz: "The secret in life is the right amount."

A small enough dose, he said, "will have a good local effect, but won't create a systemic (involving the entire body) response."

Preparing to administer BOTOX treatments, Schulz, a Straub Clinic and Hospital plastic surgeon with more than 23 years of experience, studied a patient's "before" photograph. It was a black-and-white closeup of the upper half of her scowling face. Arlene, a 57-year-old company manager who declined to use her last name, was instructed to frown for the picture to help Schulz see exactly where he needed to inject, because the structure of every face — the muscles used and the lines that result — is a little different.

In the small treatment room, Schulz hummed as he drew dots between Arlene's eyebrows while she reclined in something akin to a dentist's chair. The needle followed the dots. It barely pierced the skin. Blood rose in tiny spheres, quickly blotted away by an attentive nurse. It was over in five minutes.

"It felt like little stings," said Arlene. "But it wasn't bad."

A few minutes later in another room, Schulz completed the same procedure on Toni, a flight attendant. When he finished, she looked at him and asked, "That's it? Really?" She described the pain as "a little bit worse than plucking your eyebrows."

So how does it work?

Repeated muscular action in a facial area causes wrinkles. "Botulinum A exotoxin produces weakness or paralysis of limited areas of the facial musculature and offers a superb alternative for selected facial (surgeries)," according to an article in the medical journal Dermatologic Clinics. In essence, the toxin destroys the neuromuscular junction, causing muscular paralysis (though some doctors prefer "relax" to "paralyze"). Patients who have a problem with excessive scowling that creates creases between their brows simply will not be able to corrugate any more. As a result, the furrows will begin to disappear. "The only way we could get to it for many years was to do a forehead lift," said Schulz. Now, said his staff, Botox can delay the need for a forehead lift.

The treatment has few side effects and lasts for about six months, said Schulz (though some physicians say less); when the effects wear off, injections can be repeated.

The most dramatic results occur in people who frown or squint when they concentrate. "It's a natural thing to do," Schulz said of squinting. "We intensify all of our facial expressions with a squint. What the BOTOX does is help you lose that unthinking activation of the muscle." As a result, some people — if they don't fight the temporary paralysis to see if they can work the muscles again — can train themselves not to squint.

The public did not know much about BOTOX before it was used for cosmetic purposes, but its origins had little to do with looking better. "BOTOX started off with a medical indication," said Schulz, "and all of a sudden somebody found an aesthetic use for it, and it went crazy."

The Federal Drug Administration approved BOTOX for medical indications like blepharospasm (twitching eye), spasmodic dysphonia (vocal spasms) and several other disorders. It also helped patients who, from trauma or infection, suffered paralysis on one side of the face. In these cases, the other side often becomes hyperactive, and BOTOX can be used as an effective treatment. Insurance will often cover these medical therapies, including in some instances alleviating cluster and muscle spasm headaches, but will not cover elective cosmetic use.

Aesthetically, BOTOX is most commonly used to alleviate glabellar furrows (scowl lines between the eyebrows), crow's feet (lines around the eyes) and horizontal forehead lines. According to the American Society of Aesthetic Plastic Surgery Inc., about 65,000 people were injected with BOTOX in 1997. But Schulz estimates those numbers are much higher now. "I bet there are clinics (in Los Angeles, New York and Florida) that do 50 or 100 per day," he said. Christine Cassiano, manager of public relations at Allergan, the company that manufactures botulinum toxin type A, reported Allergan's worldwide sales for the year 2000 at $239.5 million. It's unclear, however, how much of this is medical and how much is cosmetic. In any case, the popularity and acceptance in the medical community of BOTOX for aesthetic use is extremely high. In fact, Cassiano said Allergan anticipates FDA approval for the cosmetic use of BOTOX by the end of the fourth quarter of this year.

Each treatment, regardless of how many injections the physician makes, costs approximately $400. Patients don't feel anything when they walk out of the office, and the toxin doesn't take effect for about 24 hours. Many plastic surgeons and dermatologists offer this service.

Possible side effects might include a small amount of bruising at the injection site, or a headache for a few hours after treatment, though Schulz said only one of his patients has suffered a headache. He also said bruising is more common around the eyes, where the skin is thinner. But this can be covered with green makeup until it disappears a few days later.

Another potential danger is that a doctor could inadvertently inject a nerve. This can result in forehead numbness for up to 6 months. But the beauty of BOTOX, said Schulz (who has never had this happen) is that nothing is permanent.

Patients should also be aware of the risks associated with injecting the horizontal forehead lines. "These are the brow elevators," said Schulz. "These anti-gravity muscles are our friends." If the treatment of the brow isn't absolutely uniform, the patient may have trouble raising his or her eyebrows together, creating an undesirable expression. He advocates treating active horizontal forehead lines only in certain circumstances. "You're reasonably safe with a toe-in-the-water approach."

Schulz's entire staff has had BOTOX treatments and recommends them. If done properly by a trained and skilled physician, the treatment "doesn't change you," said Donna Sasaki, a nurse in Schulz's office. "It has a nice, lasting effect; it doesn't make you look fake." Ann McKenzie, a nurse, and Laurie Kimura, the patient counselor, agreed.

Patients related subtle but encouraging results. Two days after her treatment, Arlene said she "had no aftereffects or discomfort. It was like nothing."

Toni concurred: "I really didn't have any kind of pain or sensation. And it definitely looks better already."

The line between her brows is still there, she said, but doesn't appear to be as deep.

Confident she would do it again, Toni reflected on the simplicity and absence of side effects: "Gee," she said. "That's the way to go."