How Botox Injections Work: Understanding the Popular Cosmetic Treatment

Botox is an excellent reparative process to start using if you are witnessing the signs of aging on your face. Botox is known for its capability to reduce the appearance of face wrinkles. While Botox is typically used cosmetically, doctors have also used this procedure to correct neck spasms, lazy eyes, frequent urination, and chronic sweating. It also helps with the frequency of chronic migraines.

Botox is created with onobotulinumtoxinA to temporarily prevent muscles from moving. This toxin is made by a botulism causing microbe. Botox was the first drug to use the botulinum toxin for any purpose. Botox works by blocking the chemical signs nerves send that allow your muscles to contract. Botox is injected, and these injections are typically used on the face. [Ref. 1] If ingested through food, it can stop the working of key muscles in the body and cause paralysis and eventually death. [Ref. 2]

Botulinum toxin has 7 different neurotoxins composing it, but only the A and B neurotoxins can be used in a clinical setting. The toxin itself is created by the bacteria Clostridium botulinum and it blocks acetylcholine release. The first type of Botox released to a general market was Botox using the A neurotoxin. Botox is particularly useful for treating glabellar frown lines, and other small facial lines that development due to facial expression movement. The toxin first binds to specific receptors on presynaptic cells and then internalizes. During internalization, the membrane of nerve cells surrounds the toxin-receptor system and forms a vesicle to put the toxin in a nerve terminal. After internalization, the disulfide bond is separated, and the toxin is released across the membrane into the nerve terminal. After this, serotype A and E stop the release of acetylcholine and this inhibits face muscle contractions. [Ref. 5]

Botox carries risks as well as great potential rewards. These risks can include swelling at the injection site, substantial pain, bruising at the injection point, headache, droopy facial expressions, dry eyes, and flu-like symptoms. [Ref. 1] In addition to the positive aesthetic benefits of Botox, there may also be striking psychological benefits as well. In 2014, two D.C. doctors, Dr. Eric Finzi and Dr. Rosenthal, published a study showing that individuals with severe depression who get Botox reported fewer symptoms a month later than individuals given placebo injections. A speculation as to why it may have such a positive impact on depression is that facial-feedback hypothesis, originally postulated by Darwin, and later refined by American psychologist William James. This theory promotes the concept that positive facial expressions can have an impact on mental health. However, Italian researcher Matteo Caleo ran a study on rats where after injecting Botox in rat muscles he found evidence of the drug itself in the brain stem. [Ref. 2]

For Botox to work successfully, it must be administered correctly by a doctor. You may choose to go to either a board-certified doctor or dermatologist. It is a short ten-minute treatment that is possible to do on a lunch break. [Ref. 9] Your skin must be numbed prior to the procedure, and the number of injections you will receive must be determined beforehand by a doctor. The standard dosage for Botox is 20 unites. After the procedure, you cannot touch your face for a day. It will start working about three days after injection and will last for about three months. [Ref. 1] [Ref. 5]

Assessment for getting treated with Botox involves an analysis of your facial structure and how hard and soft tissues interact in your face. Your doctor may complete a skin snap and/or stretch test. This will allow your doctor to analyze how your specific needs can be addressed while also minimizing potential harm and any potential negative aesthetic outcomes. Botox originally was intended to paralyze certain facial muscles, but now, dosage is used as minimally as possible to prioritize muscle modulation over paralysis.

This type of assessment requires an observation that is both static and dynamic. This means that spontaneous facial expressions must be observed in addition to facial expressions shown under directive. [Ref. 6] Your doctor must determine whether your facial lines are considered dynamic or static. Facial lines are considered dynamic when they express emotion, whereas facial lines are considered dynamic when they exist without muscle contraction. [Ref. 12]

Additionally, it is important that your doctor treat two adjacent areas with lower dosages. This prevents possible overcorrection of one area which could cause a negative impact on the surrounding areas of the face. It is also critical that your doctor does not repeatedly overdose one specific muscle of the face; this can cause what is called “compensatory hypertrophy” and it will make the muscles of the face interact in a discordant manner. [Ref. 6]

There are three SNARE proteins involved in this process. These proteins are synaptobrevin, syntaxin, and SNAP-25. The first anchors the protein and targets the vesicle, the second marks the spot where fusion occurs, and the final protein acts as a connector between the two proteins. [Ref. 12]

Botulinum toxin was first used in biochemical warfare experiments during World War II, both by the American and Japanese military. [Ref. 12] Botox began as a therapy for people dealing with a medical condition that made them cross eyed. It was originally promoted in the 1970s by Dr. Alan B. Scott. Scott initially named the drug Oculinum and Allergan later bought rights to the drug. Later, in 1998, David E.I. Pyott became CEO of Allergan, and promoted further study of potential uses for the drug. Allergan now has a research and development budget of about 1.5 million to develop and refine uses for Botox. [Ref. 2] In 2015, therapeutic uses of Botox by the pharmaceutical company Allergan exceeded aesthetic uses by over half, due to their ability to invest in research and development. [Ref. 2] In addition to having therapeutic uses for mild conditions, it can also be used for a series of serious conditions, including laryngeal dystonia, stuttering, and vocal tics. Additionally, it has had positive results when used in a clinical setting for temporomandibular joint disorders, in eliminating pain and improving patient quality of life. It also has been shown to improve facial and nasal conditions, like rhinitis and hemifacial spasms. [Ref. 7]

Botox has also been shown to help individuals who are suffering from cerebral palsy. Cerebral palsy typically causes uncontrollable muscles spasms, and Botox can be used to limit these movements, which reduces pain. The reduction of spasticity is another positive benefit that the use of Botox can provide. While Botox is not a long-term solution for muscle disorders, it does have potential to improve the lives of users in the short term when it comes to pain thresholds and ability to move naturally. [Ref. 8]

Botox is a great option for someone who is new to plastic surgery because it is widely considered safe. A 2014 study in JAMA Dermatology provided data that there is about one negative side effect per each 3,333 procedures. [Ref. 3] Botox has gained notoriety in Hollywood circles and from people like Dr. Frederic Brandt, who have made Botox a norm. In Justine Harman’s podcast about the life of Dr. Frederic Brandt, Harman recounts how he was able to minimize the stigmas surrounding Botox and promote Botox to a broader audience. [Ref. 4] Doctors like Brandt have been at the forefront of an effort to popularize Botox as both a therapeutic and aesthetic treatment.

Another means through which Botox has become popularized is that it is now being marketed to young people through Instagram advertisements rather than directly through doctor or dermatologist offices. As a result of cross-marketing to multiple demographics, the use of Botox has increased 800% from 2002 to 2018 in the United States. While Botox sales continue to rise, the use of Botox does raise concerns about the pressure to remain youthful today. While many other plastic surgery options are specific to repairing a certain problem, Botox’s main use is preventing the appearance of aging. [Ref. 13] However, aesthetic uses do not just have to concentrate on aging- Botox can also have a positive impact on improving oily skin. This can improve the ability for makeup to remain on skin and improve acne levels. [Ref. 14]

Botox is not limited as an aesthetic choice for women only; in 2014, over 10% of Botox procedures in the United States were provided to men. [Ref. 6] The drug Botox also has a wide variety of brand variations and names, which include, Botox Vista, Vistabex, Botox Cosmetic, and Vistabel. [Ref. 6]

The future of Botox is the ability to use it in conjunction with fillers and other treatments. Now, instead of purely using Botox to induce facial paralysis on the upper face, individuals and surgeons are using it throughout the face to provide a positive impact on aging skin. In 2016, the Global Aesthetics Consensus Group published recommendations for future uses of Botox. The group recommended that Botox be used with an integrative approach. They recommended that dosage and placement not be based on a routine standard but based on target muscles and associated soft and hard tissues. [Ref. 6]

If you are considering Botox, there is not necessarily a right or wrong time to start using it. However, if you do choose to start using Botox at a younger age, it can have a preventative effect when it comes to the presence of wrinkles as you begin to age. It is also necessary to consider how medications or supplements you take may impact how thin your blood is; Botox can lead to facial bruising if your blood is particularly thin. It is also of utmost important not to exercise after receiving Botox. Additionally, you may find that your doctor will use a vibrating tool on your face to see how your facial muscles interact. You may also require a follow-up appointment with your surgeon or dermatologist, to determine if any touchups or refinement are necessary [Ref. 9]

The best path forward is to develop a plan with your dermatologist or doctor based on their assessment beforehand. They may decide not to inject certain areas due to the issue of compensatory movement. For example, if you have heady eyelids, there is a good chance you are prone to raising your eyebrows often to compensate for your heavy lids. Now, if Botox is injected around your eyelids, it could make the muscles surrounding the lids weaker. As a result, it can end up having the opposite of the intended effect in the long run, even if you are seeing immediate effects in the short term. Additionally, it is good to know how often you would like to do treatments in advance, which can depend upon not only your financial situation but your doctor’s assessment. [Ref. 15]

If the thought of using a lot of Botox is scary to you, you can also try micro-dosing your face with Botox. Micro-Botox is used in the same way as normative Botox but is significantly less invasive. It primarily targets the skin, rather than the muscles underneath the skin. Despite not paralyzing the muscles, this trend of micro-Botox can significantly improve redness, oil production, and the appearance of acne. Your doctor can potentially minimize the impact to your facial muscles while still lightly injecting them. Your options will change depending on what your dermatologist or doctor is willing or able to offer. [Ref. 16]

While you can choose to get preventative Botox, it is important to realize that it cannot reduce facial issues that come from living an unhealthy lifestyle, i.e., too much sun exposure or cigarette smoking. Botox is not necessarily a means through which to reduce lines that form from damage and misuse, but a way to prevent and slow the formation of wrinkles that you are genetically predisposed to have. [Ref. 10]

Botox is also not as expensive as you may expect. A unit of Botox can cost anywhere from ten to fifteen dollars in major cities in the United States. The standard for a localized spot on the face is about twenty units, which means you are only paying about two hundred dollars overall. [Ref. 11]

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