Holger G. Gassner, M.D., Board Certified Facial Plastic Surgeon (USA)

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The treatment of facial wrinkles with botulinum toxin (Botox, Vistabel and others) has for many years been the gold standard for the treatment of certain types of wrinkles in the skin. Botulinum toxin is regarded a safe medication with a low side effect profile when administered by an experienced provider. It acts by targeted injection of key muscles.  These key muscles cause the overlying skin to wrinkle.  Once they are treated, the activity of the musculature is reduced and the overlying skin becomes smoother.

Facial wrinkles have multiple causes.

A lack of elasticity of the skin, redundancy of the skin, a absorption or reduction of the naturally occurring fat under the skin as well as the activity of the facial musculature all play a role in the generation of facial wrinkles.  Each factor influences the development of wrinkles to a variable degree depending on the skin type and anatomic area of the face.  Therefore the treatment of facial wrinkles is variable and requires different methods.

Fillers such as hyaluronic acid or hydroxylapatite are typically used around the cheek and the nasolabial fold.  Pills and laser treatment are frequently applied to wrinkles around the lips or across the entire surface of the face.  Wrinkles which are the result of redundant skin for example around the neck, may often only be corrected with a face and neck lift.

In the area of the forehead and on the sides of the eyes wrinkles typically develop as a result of the activity of the underlying musculature.  This applies to the horizontal forehead lines as well as the vertical lines between the eyebrows and the crow’s feet on the sides of the eyelids.  These types of wrinkles are best treated with an injection of botulinum toxin.  This medication weakens the activity of the underlying musculature for about 3 months.  It is important not to completely eliminate the activity of the musculature.  This can result in an immobile and paralyzed appearance which may look unnatural.  The weakening of the underlying musculature allows the overlying skin to recover and the skin wrinkles to smoothen.  This effect may persist sometime after the musculature has recovered its activity.

Botulinum toxin is a medication which is sold under various names, including, Botox, Vistabel or Xeomin.  The active substance is injected into the muscle.  The small nerve cells within the muscle selective absorb the medication and transport it into the inside of the cell.

Botulinum toxin does not cause cell death.  It rather acts as an intelligent enzyme that interferes with the metabolism of the cell.  Botulinum toxin avoids that a certain signal protein can be transported to the outside of the cell.  Therefore the electrical impulse of the nerve cannot be transported to the muscle.  Hence the muscle does not contract.  The action of botulinum toxin fades after about 3 months.  After this period of time the metabolism of the cell resumes its normal function.  The signals are transported to the muscle again which regains its ability to contract.  Botulinum toxin which consists of proteins, is taken apart into smaller pieces and digested inside the cell.

The action of botulinum toxin is always temporary.  Therefore possible side effects are typically only temporary as well.  Poisoning with botulinum toxin, which has been described in the middle ages, can happen when very large amounts of botulinum toxin are ingested with rotten food.  This can cause paralysis of the musculature of breathing.  The amount that is required for such a poisoning is very much larger than what is typically administered in the face.  At least 30 vials of Botox would be required until a systemic poisoning of botulinum toxin could begin.  Systemic or other extensive poisonings with botulinum toxin have never been described in the literature after treatment of facial wrinkles.  Botulinum toxin is regarded a very safe medication with a low side effect profile.

Botulinum toxin becomes effective once a sufficient amount of a transport protein has been deactivated within the cell.  This typically occurs after 24 to 72 hours.  At this time the conduction of signals from the nerve to the muscle is interrupted and the muscle no longer contracts.  This becomes clinically evident for example on the skin when the overlying skin does not wrinkle anymore. The effects can last up to 3 months.

Botulinum toxin reduces the activity of the mimetic musculature.  For example the forehead muscle under the forehead skin runs in a vertical direction.  This muscle pulls the overlying skin into horizontal wrinkles.  With repeat contractions of the muscle the wrinkles in the skin become permanent as the soft tissue composition of the overlying skin changes.  Thus the wrinkles remain visible even when the muscle does not contract.  These changes in the texture of the skin are at least partly reversible.  Once the activity of the underlying musculature is reduced, the overlying skin can recover and the wrinkles become less visible.  Very deep wrinkles can be improved by about 70%, finer wrinkles can sometimes be completely eliminated.

The muscle weakening effect of Botox fades after about 3 months.  However, the indirect effect of botulinum toxin on the overlying wrinkles lasts a little longer.  The exact duration of effect varies from patient to patient and is typically around 4 to 7 months.  This effect may be intensified if a repeat injection after about 3 to 4 months is performed.
The modern treatment of facial wrinkles with botulinum toxin aims at avoiding a too marked [ph] paralysis of the facial musculature.  The goal is to avoid an immobile or mask like appearance.  Here the expertise and experience of the provider becomes important.  Injections are applied with the exact dosage that results in sufficient immobilization of the musculature while preserving a residual activity that maintains the mimetic expression of the face, for example, allowing for a natural eyebrow movement while the upper forehead portions are weakened significantly enough for the forehead wrinkles to diminish. 
No treatment and medicine is without side effect or risk.  However, botulinum toxin is regarded as a medication with a low risk and side effect profile.  Before the first treatment the provider will ask you a number of important questions in order to understand whether there are any reasons in your medical history that would preclude you from botulinum toxin treatment.  These may include other diseases, allergies or the use of other medications.

Dr. Gassner has performed extensive research over more than a decade with botulinum toxin.  He has published extensively on botulinum toxin.  His scientific publications are widely referenced in the scientific community.  Dr. Gassner was the first to describe the beneficial effect of botulinum toxin on healing wounds.  This method has been adopted worldwide in major centers.