Myths about botulinum toxin in the practice of a cosmetologist

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Magdalena Al-Nagash, aesthetic surgeon, chief physician of the NUCU Cosmetic laser technology center, full member of ISD (USA) (Ukraine, Kharkov)

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The awkwardness of the situation itself is perplexing: on the one hand, sometimes there is neither the strength nor the desire to answer such questions seriously, on the other hand, a banal disregard can easily result in serious problems in the future. One of my friends even drew a parallel: after all, I sometimes drive service station mechanics into a stupor, asking questions that are far from the smartest, from their point of view, and, having not received an answer, I feel offended and ignored and, as a rule, change the mechanic. Our patients sometimes have it a hundred times worse: the number of cosmetic procedures has grown exponentially in recent years, the Internet is overflowing with information that is both incomprehensible to them, written in scientific professional language, and the most unpretentiously scandalous, designed only to attract attention to the site page.

The need to speak the same language with the patient and help him overcome his fears has long been part of the work of a doctor of aesthetic medicine, who is often obliged to combine in his practice the skills of not only a professional cosmetologist and diagnostician, but also a psychologist...

First of all, I would like to touch upon the most frequently asked questions regarding the top procedure – botulinum therapy.

The idea of ​​“beauty injections” arose more than ten years ago, when Jean Carruthers noticed that after Botox injections, patients with strabismus had a curious effect: the wrinkles on the bridge of the nose were smoothed out. Since then, Botox has come a long way and is now considered the number one procedure for good reason. It is this popularity that sometimes plays a cruel joke: the name Botox has become a household word for many procedures – and this is sometimes the reason for the incidents and misunderstandings that arise in our work.

The second unsightly side of the popularity of this wonderful drug was the desire of some dishonest and unprofessional journalists to promote themselves at the expense of the fame of the world-famous brand. And then frightened patients come with strange questions...

Let me give you a number of these “myths” and my answers to them.

>Myth 1: Botox injections destroy the brain

Some time ago, Internet resources were full of scandalous headlines like “Botox injections destroy the brain.”

All these conversations certainly attracted attention to the articles and websites. However, a more detailed analysis of the texts revealed a surprising pattern: they were all based on the assumption made by an Italian scientist after a short experiment on rats. Subsequent numerous studies on the safety of medical botulinum toxins did not provide any grounds for disseminating this information, while the publishers modestly ignored the need for refutation. But if this wave passed through Europe back in 2007-2008, it reached us somewhat later, in 2009 and 2010.

The authors' goal was the same - to promote themselves and attract attention to their resources. After all, against the backdrop of scandalous statements, there is always an unhealthy, but PR frenzy. In this regard, I would like to dot the i's

Quote from the instructions for the drug: "Botulinum toxin concentrates for some time at the site of its intramuscular injection before entering the systemic bloodstream. When administered in therapeutic doses, it does not penetrate the blood-brain barrier and does not cause systemic effects. It is rapidly metabolized to form simpler molecular structures. It is excreted by the kidneys in the form of metabolites."

Note that the information on therapeutic doses assumes the use of the drug in neurology, which means the injection into one muscle sometimes amounts to about 200 units!

As for the ban on use during pregnancy and lactation, it is, as in the case of all large pharmaceutical companies, based on the lack of experimental data in this group of patients! Moreover, a return study of "random" patients who did not know about the pregnancy and underwent the procedure, and then continued the pregnancy, does not demonstrate a single statistically significant difference in the vital signs of the mother and child compared to those who did not receive botulinum toxin.

Note that I am not at all calling for the use of the drug during pregnancy and lactation, – I just want you to think logically. The drug consists of two components: the first is a shell of hemagglutinin and non-hemagglutinin proteins, which is destroyed within a few hours from the moment the botulinum toxin is injected into the muscle until it reaches the axon of the target nerve. Naturally, these proteins are utilized in the same way as all other blood plasma proteins: through the kidneys as metabolites.

As for the second component - the neurotoxin itself, after entering the axon it interacts with the acetylcholine receptors of the presynaptic membrane, roughly speaking, it is built into them, completely blocking them, which explains the effect of botulinum toxin. After four months, as a result of the sprouting, new motor fibers sprout, and the old ones are utilized by the body in a completely natural way for living beings. After all, you and I do not think about how many muscle, nerve fibers, epithelial cells, etc. have been renewed in our body over the course of six months. Self-renewal of the body is a fundamental factor in the vital activity of living beings, the regenerative function is one of the main features of all living things.

And to finally dispel doubts, I would like to give an example of an experiment on the metabolism of botulinum toxins.

“The animals studied were injected with a radiolabeled toxin. Distribution studies performed on animals demonstrated slow diffusion of the 125I-complex of botulinum neurotoxin A into the gastrocnemius muscle after injection, followed by rapid systemic metabolism and excretion in the urine. The amount of radiolabeled material in the muscle decreased with a half-life of about 10 hours. At the injection site, the radioactivity was limited to large protein molecules and in the blood plasma to small molecules, indicating rapid systemic metabolism of the substrate. Within 24 hours after dosing, 60% of the radioactivity was excreted in the urine. The toxin is metabolized by proteases and molecular components that are recycled through normal metabolic pathways.” This study once again confirms my words: already in the first day all the “debris” toxin sheaths, and the toxin chain itself is metabolized along with the aging axon.

Thus, talking about the “accumulation” of the drug in the brain is pure manipulation of facts and phrases taken out of the context of the research.

Myth two: Botox makes you stupid

Again, screaming Internet headlines make worried patients ask the question: “Doesn’t the drug smooth out the convolutions?” I’d like to smile, but the number of such questions rather brings sadness.
I turned to the same resources, conducted my own “investigation” and found out that the articles that patients talk about demonstrate some possible connection between a decrease in brain activity against the background of blocking facial hyperactivity.

As an example, scientists cite the opinions that facial expressions stimulate the thought process, and after injections, the activity of facial muscles decreases.

Approximately the same thing happens in children when they develop fine motor skills of their hands: the more dexterously the fingers move, the faster the child begins to clearly and correctly pronounce sounds and words, master sentences, etc.

So maybe people with unemotional faces who can control their facial expressions are idiots? And monkeys who are rich in facial expressions are, in turn, hidden geniuses? These are the conclusions that come to mind after reading such articles.

Therefore, I kindly ask you to be critical of the information received from incompetent sources: most often it hides a banal desire to get publicity, stir up public opinion and, against this background, skim off your share of the cream. And as a result, it turns out that the long-suffering Oksana Pushkina and others like her get Botox in their lips and "nasolabial folds".

A third theme naturally arises.

Myth three: Botox ruined Oksana Pushkina

And not only her, judging by these articles. Having read the small print of the tabloids, as a rule, you understand that the procedure performed and the resulting side effects have nothing to do with the said procedure. The same unfortunate Pushkina, instead of the declared hyaluronic acid filler, was injected with a permanent filler in the nasolabial folds, which is “famous” for its high level of extremely severe side effects and at the same time for being cheap.

The only way to protect yourself from such fraud in life is to contact professional cosmetologists, high-level specialists working with registered drugs and world-famous brands.

Believe me, none of them will hide the probability of occurrence of this or that side effect and will help to assess the real long-term consequences of the procedures. Therefore, be critical when evaluating the article information.

Myth 4: You can get 10 injections in your entire life, then the drug doesn’t work

Who, when and how came up with this wonderful number? Why not 3, not 5, not 7 and not 15? What is the sacred deep meaning?

Theoretically, such a myth would make sense if the issue of the formation of specific antibodies that would accumulate after each injection and “eat” Botox when administered again were raised.

In this situation, I am forced to turn to a more scientific explanation: I try to convey to the patient that the Botox molecule is protected from the outside by transport proteins that prevent the formation of antibodies. I often cite data from American colleagues who have been managing a group of patients for more than ten years, receiving Botox and not recording a decrease in effectiveness. Sometimes – information from studies provided by the company, which demonstrate an improvement in results from time to time, which is explained by a simple fact: in the process of being in a “relaxed” state, the muscle “forgets” about its habits, hypertonicity, hypertrophied facial expressions already bother these patients less, therefore, each subsequent injection improves the result, makes the period of effectiveness longer.

In addition, a study has recently been published that examined the development of antibodies after Botox treatment (1. Carruthers A. et al. Journal of Clinical Research. – 2004. – 7: 1–20; 2. Naumann M. et al. Movement Disorders. – 2010. – 25: 2 211–18). This meta-analysis of large clinical trials in five indications in several thousand patients found that of the patients treated for nasal wrinkles, only 0.28% tested positive for neutralizing antibodies to botulinum toxin. At the time of their last medical examination, these patients had no neutralizing antibodies at all. This study demonstrated that the incidence of specific antibodies is simply negligible.

Therefore, on the one hand, it is important to achieve realistic patient expectations regarding what result can be achieved, and on the other hand, there is clinical evidence that with each repeat application of Botox, the result is stable and even improved. Importantly, this study provides level 1a evidence to support the very low incidence of neutralizing antibodies to botulinum toxin and the absence of a clinically significant decrease in treatment efficacy due to neutralizing antibodies over time.

So you can calmly assure the patient that he is not limited to the amazing number 10 in the number of procedures performed.

And finally, one of the most controversial issues.

Myth number five: Botox for lips

What can you answer to a patient who comes with the question: “Do you do Botox on the lips?”

As a professional with many years of experience, I certainly perform correction of lip asymmetry and gummy smile.

Quite often in the complex therapy of these problems I use papular injection of Botox in microdoses to weaken the muscle fibrils intertwined with the skin, or to relieve hypertonicity of the muscle that lifts the upper lip. However, patients, as a rule, are interested in completely different procedures, and the impersonal expression "Botox in the lips" can mean both correction of the volume and contour of the lips, performed with hyaluronic acid fillers, and correction of the skin structure of the upper lip, removal of pigment spots, etc. Therefore, it is important to correctly identify the patient's needs.

Thus, I would like to draw your attention to the need to talk to the client, give him true information, help him fight fears, look for answers to the most seemingly unexpected questions. It is this behavior that will become the key to a successful career, trusting long-term relationships with the patient and excellent work results.

First published: KOSMETIK international journal, №4/2013, pp. 52-56