The Facts on “How Do Botox® Injections Work?”
Botox® is a very recognizable term, with stories about Hollywood celebrities using it to erase their wrinkles coming out almost daily. In fact, according to the American Society of Plastic Surgeons, Botox® was the #1 minimally-invasive procedure, with 6.7 million procedures being done in the most recent study. If a patients ask you how do Botox® injections work, the following is a primer that covers the latest Botox® and Botox® Cosmetic FDA-approved cosmetic and medical uses. This short playbook will help you educate your patients on what results they can expect to receive from a Botox® treatment.
What Is Botox®?
According to Allergan, the maker of Botox®, “OnabotulinumtoxinA (BOTOX®) is a medical product containing tiny amounts of the highly purified botulinum toxin protein refined from the bacterium. The product is administered in small injections to reduce specific muscle activity by blocking the overactive nerve impulses that trigger excessive muscle contractions or glandular activity.”
It was originally approved by the FDA in 1989 and has since been approved for treatment of many cosmetic and medical conditions. It should also be noted that Botox® is a prescription medicine, and therefore can only be provided by a healthcare provider who can prescribe drugs, like a physician. Often physicians will delegate to other healthcare providers who are licensed to inject FDA controlled substances, like physician assistants and nurses.
One thing to keep in mind is that the effects are only temporary; they disappear after 4-6 months. On the plus, side, this is a quick procedure that typically only takes 15-20 minutes, there is no recovery time needed, and as you age, you can easily adjust the location and amounts to meet your patients anti-aging goals.
You have probably already noticed that we have been discussing Botox® and Botox® Cosmetic. There are actually two types of Botox®: Botox® and Botox® Cosmetic. They are both technically onabotulinumtoxinA, but each have their own FDA approvals. As you will see the approved uses for Botox® Cosmetic revolve around facial aesthetics, whereas the approvals for Botox® are more medically based. For example currently, Botox® Cosmetic is FDA-approved for:
- Treatment to temporarily improve the appearance of both moderate to severe frown lines between the brows and crow’s feet in adults.
- Improving the look of moderate to severe frown lines between the eyebrows (glabellar lines) in adults for a short period of time (temporary).
- Improving the look of moderate to severe crow’s feet lines in adults for a short period of time (temporary).
Botox® has the following FDA-approved indications:
- to treat overactive bladder symptoms such as a strong need to urinate with leaking or wetting accidents (urgent urinary incontinence), a strong need to urinate right away (urgency), and urinating often (frequency) in adults 18 years and older when another type of medicine (anticholinergic) does not work well enough or cannot be taken
- to treat leakage of urine (incontinence) in adults 18 years and older with overactive bladder due to neurologic disease who still have leakage or cannot tolerate the side effects after trying an anticholinergic medication
- to prevent headaches in adults with chronic migraine who have 15 or more days each month with headache lasting 4 or more hours each day in people 18 years or older
- to treat increased muscle stiffness in elbow, wrist, finger, and thumb muscles in people 18 years and older with upper limb spasticity
- to treat increased muscle stiffness in ankle and toe muscles in people 18 years and older with lower limb spasticity
- to treat the abnormal head position and neck pain that happens with cervical dystonia (CD) in people 16 years and older
- to treat certain types of eye muscle problems (strabismus) or abnormal spasm of the eyelids (blepharospasm) in people 12 years and older
- BOTOX® is also injected into the skin to treat the symptoms of severe underarm sweating (severe primary axillary hyperhidrosis) when medicines used on the skin (topical) do not work well enough in people 18 years and older.
How Botox® Works: A Quick Overview
When speaking to patients, the KISS (Keep It Short & Simple) rule is probably the best strategy. For example, you may say “Botox® works by relaxing your active facial muscles which gives the appearance of less facial wrinkles.” If you want to get a bit more technical, “Botox® blocks signals from the nerves to the muscles so that the injected muscle can no longer contract, which causes the wrinkles to relax and soften.”
Avoid using negative sounding words like: paralyze, neutralize, freeze, and of course botulism!
The results for Botox® are very quick, often showing up within days. Not everyone is the same, so for some people, it can take up to 2 weeks for the results to show up.
How Botox® Cosmetic Works: Face
Botox Cosmetic’s® popularity will account for the majority of your aesthetic patient base, so if you want to add aesthetics to your practice, you must master the injection of Botox® (or other FDA approved Botulinum Toxins, like Xeomin® and Dysport®). If you are new to offering Botox®, please make sure you complete a comprehensive hands-on CME-approved training program. If you are an experienced injector, it is important to stay up to date with the latest Botox® injection techniques.
We all use our facial muscles a lot. All of that talking and emoting and eating and everyday living gives the facial muscles a great workout all day long. This is great for the health of those muscles but can cause problems with your skin. For example, frown lines, the little lines that show up between your eyebrows, can result if you are someone who scrunches your face up when you are unhappy or very focused.
For the “Botox® Virgin,” you will need to be prepared to explain how Botox® works on the face. It is important that you understand where the most requested areas are for injections, they are: forehead lines, crow’s feet around the nose, and those “angry 11’s” between your eyebrows.
One of the most requested procedures is to remove the wrinkles in the forehead. Many times these lines are genetic and you can see them in children as well as adults (Reminder: never inject Botox Cosmetic® in anyone under 18!). Other times, they are seen in people who are very expressive with their face. It’s important to ask your patient what they want, some people don’t want any wrinkles in their forehead, others are fine with wrinkles, they just don’t want deep looking ones. You can provide any of these results by increasing or reducing the amount of the Botulinum toxin you inject in the muscles.
Allergan has done a wonderful job educating the public on the “angry 11’s,” these are the lines that appear between your eyebrows. Again, these can be genetic or caused by excessive facial movements in expressive people. Not everyone has these, but most people do not want to look angry, so if they have them, they most likely want to get rid of them! This is an easy home-run procedure, which can be done quickly, and looks great!
Crow’s feet (which are also called smile lines) are the small lines that occur around the eyes as a result of the skin wrinkling to accommodate smiling and squinting–they are the third most popular region of the face. You may find that men are fine with having these lines, but women generally want them gone! Again, this is a quick procedure that typically erases the wrinkles between 3-10 days.
It is also important to tell your patients that cosmetic injectables only treat lines that are caused by muscle movements. Explain that lines and wrinkles caused by sun damage will not respond to these treatments. As well, some patients think the deep wrinkles around their mouths (marionette lines) and nose (nasal labial fold) can be treated with Botox®, unfortunately they cannot. One will need to use a dermal filler like Allergan’s Juvederm/Voluma, Merz’s Boletero, or Galderma’s Restylane.
How Botox® Works: Other Areas of the Body
Many patients think Botox® is purely a cosmetic treatment, but botulinum toxins can also be an effective treatment option for those who suffer extreme sweating, migraines, muscle spasms, tremors, etc. Here are a few popular medical treatments and how to explain them to your patients.
Primary Hyperhidrosis can be especially difficult to cope with when it is concentrated at the patient’s palms, feet, and armpits. Botox® can shield sweat glands as well, which effectively renders the sweat glands at those injection sites inactive (for about six months). Make sure your patient understands that he or she will still sweat from other areas of their bodies but hopefully it will only be a normal amount.
First and foremost it is important that your patients understand that Botox® will not cure a migraine completely. Instead, explain that if the treatment is successful, it will reduce the symptoms of the attack like sensory sensitivity and nausea. It does this by, again, stopping the areas most affected by the migraine (forehead, temples, neck, etc.) from being able to communicate with the brain. They will still get migraines but the headaches should be much easier to manage.
Tremors and Muscle Spasms
These are probably the easiest bodily treatments for your patient to understand. Explain to them that their tremor or spasm is simply a miscommunication or “misfire” of the brain that causes the muscle to contract without outside stimuli. Since Botox® treatments will keep those misfires from reaching the affected muscle, the condition should clear up relatively quickly.
Botox® Side Effects
Like most prescription medications, Botox® and other aesthetic injections are not without potential side effects. The great news is that most of these are not very common, however it is your responsibility as the prescriber to ensure you have done your due diligence with proper patient selection, and ensure that they are aware of all the potential side effects of the drug. Some of the more common side effects include:
- pain and redness where the medicine was injected
- pain in the face
However, remember Botox® is a prescription drug, and there can be more serious side effects. Get medical help right away if you have any of these problems any time (hours to weeks) after injection of BOTOX® or BOTOX® Cosmetic:
- Problems swallowing, speaking, or breathing, due to weakening of associated muscles, can be severe and result in loss of life. You are at the highest risk if these problems are pre-existing before injection. Swallowing problems may last for several months
- Spread of toxin effects. The effect of botulinum toxin may affect areas away from the injection site and cause serious symptoms including: loss of strength and all-over muscle weakness, double vision, blurred vision and drooping eyelids, hoarseness or change or loss of voice, trouble saying words clearly, loss of bladder control, trouble breathing, trouble swallowing
There has not been a confirmed serious case of spread of toxin effect away from the injection site when BOTOX® has been used at the recommended dose to treat chronic migraine, severe underarm sweating, blepharospasm, strabismus, or when BOTOX® Cosmetic has been used at the recommended dose to treat frown lines or crow’s feet lines.
In summary, it is important to manage your patients’ expectations and to explain these treatments to them in the language with which they are the most comfortable. You learned a lot about this when you learned about bedside manner. The better your patients understand how and why a treatment is administered, the more likely they are to opt-in to the procedure.
For the best results, constantly strive to improve your injection technique. Remember, the number one reason patients don’t come back is because of injection pain, so make sure the treatment is as painless as possible for them! (check out our article on Pain Management for Botox® and other Cosmetic Injectables for more tips!).
Botox is a trademark of Allergan Inc.; Dysport is a trademark of Galderma; Xeomin is a trademark of Merz Aesthetics