The Good, The Bad and The Ugly of Botox® Injections

Publication: HospitalDoctor.Net | 17/10/2002

When patients ask Mr Dai Davies, a consultant plastic surgeon at Charing Cross Hospital, about Botox®, he tells them: 'It is nature's most poisonous toxin.' But this does not deter the increasing numbers of people opting to have the cosmetic treatment.

The formation of lines and wrinkles is attributed to repeated muscle activity over time. Botox® or botulinum toxin type A, a neurotoxin derived from the bacterium Clostridium botulinum, works by blocking the release of acetylcholine from the nerve ending to the motor end plate, thereby locally reducing muscle contraction.

Serious issue

The most important thing for GPs to understand is that 'it is a serious issue for many patients', says Dr Patrick Bowler, chairman of the British Association of Cosmetic Doctors. 'They [GPs] need to understand and appreciate that both women and men feel the need to make themselves look as good as they can.' If used correctly, the treatment is safe and effective in the majority of cases. Its other attraction is that it is less invasive and painful than surgery.

Essex GP Dr Paul Myers, who uses Botox® in private practice at the Court House Clinic, says: 'It is a very, very effective treatment and there are no serious problems associated with it.'

However, there are concerns about the widespread availability of Botox®. At one extreme, it is administered by plastic surgeons in private hospitals, but at the other by nurses at beauty salons on the high street. The treatment costs £200 to £300.

'GPs should encourage people to see someone who knows what they are doing,' Dr Bowler says. 'There are some beauty salons where nurses have 15-minute slots to assess the patient and administer the treatment, and this is not enough time. Nurses should not be doing it unsupervised.' He recommends that patients should be referred to a private hospital or clinic where doctors either carry out or supervise the procedure. They should also be told to check how long the practitioner has been administering the treatment and how many patients he or she has treated, as well as ask to see photographs. Dr Myers adds: 'Problems with cosmetic use only arise if it [Botox®] is not administered correctly.'

Side-effects associated with the cosmetic use of Botox® include ptosis (drooping of the eyelid), weakness around the mouth and asymmetric eyebrows, but these only occur if the correct dose is not used or if the injections are not sited accurately. If used correctly, the product is backed up with long-term safety data from its use in other indications such as eyelid spasms and squints, where Botox® is used at much higher doses than for wrinkles.

Long-term problems

'For a 70kg adult, a lethal dose of Botox® would be 3,000 units. Between 100 and 200 units are used for other indications,' Mr Davies says. 'But for cosmetic procedures, I never use more than 20 units. In truth, it is pretty safe stuff,' he adds.

Birmingham GP Dr David Eccleston, who has been administering Botox® for five years, says: 'If there are any side-effects, they always get better. There are no documented long-term problems.' However, Botox® is contraindicated in those who are pregnant, breastfeeding or have a long-standing neurological disorder. It should not be used if patients are taking certain drugs, including some antibiotics and calcium channel blockers.

But there are pitfalls other than side-effects. Dr Eccleston stresses the importance of assessing patients and their expectations before carrying out the treatment, to pick up underlying conditions such as depression or dysmorphophobia.

Poor self-image

'If a patient has a poor self-image, they will never be satisfied with the results of treatment,' he says. If a patient is dysmorphophobic 'you have to reassure the patient but tell them that it is not a miracle treatment'. He suggests saying: 'Although it is an effective treatment in the right cases, in your case it will not give you what you are looking for.'

The doctors agree that if a GP suspects other conditions such as dysmorphophobia, he or she should refer the patient to a psychologist or psychiatrist, but should also give advice on Botox® because of its wide accessibility. Providing Botox® can be a lucrative sideline for GPs, but there are cautions to remember. The treatment is not actually licensed in the UK for use on wrinkles.

Dr Tim Callaghan, a Bradford GP who practises privately, says: 'The clients have to understand that it is being used off-label. You have to explain what this means.'

Training in administering the treatment is also vital. The key message seems to be that Botox® is a safe and effective procedure, but only if administered by someone who has undergone training and gained experience. Although it works in the majority of patients, it is not a miracle cure. Patient expectations of the treatment have to be realistic and not all are suitable for it.