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Botox A or Botulinum A Exotoxin

Botulinum A Exotoxin (hereinafter Botox A) has been available in Croatia since 2000. The first injection of Botox A was applied in the “Polyclinic Ostojić”. Therefore we feel that we have the right to claim that we have most experience in applying Botox A for the aesthetic purposes. Botox A is a neurotoxin or nerve poison which produces bacteria Clostridium Botulinum. There are seven different serotypes of Botox, and Botox A is used for the medical purposes. The first doctor who has applied Botox A for the aesthetic purposes was Dr Caruthers who, when treating the spasms of the eye muscles (blepharospasm), noticed that the wrinkles around eyes completely disappear or become less visible. That happened fifteen years ago. The American organization Food and Drug Administration (FDA), which controls the quality and safety of the food and medicines, approved the application of Botox A for the cosmetic purposes in 2002.

Botox A Activity

Botox A blocks the connection between the motoric nerve and the muscles of the face and neck (the neuromuscular combination). The blockade usually lasts from 3 to 6 months, and after that the contact between the nerve and the muscles re-establishes (thus renewing the function of the muscle) by forming the new neural fibers or axons from the blocking nerve which form the neuromuscular connection. It is therefore extremely important that Botox A is being applied directly into the muscles of the face and neck because only Botox applied this way can ensure the maximum effect. Therefore, we feel that Botox can be only applied by a qualified doctor who knows excellently the anatomy of the mimic muscles which are responsible for the appearance of the wrinkles. The facial wrinkles appear as the result of three basic factors: the mimic and neck muscle activity, the aging process and exposure to the sun, wind and dry air. Botox A can eliminate only one component of the wrinkle which appeared as the result of intensified activities of the mimic muscles, but the results of applying Botox A are better with younger people whose facial wrinkles appear almost exclusively because of the mimic muscles activity, where one can expect a complete disappearance of the treated wrinkles. Applying Botox A in the elderly leads to the mitigation of the wrinkles, but not the complete disappearance, because Botox A can not eliminate the wrinkles which were the result of the skin aging or excessive exposure to the sun and wind.

Indications for using Botox A for the cosmetic purposes

In Croatia, Botox A is being used almost exclusively for the treatment of the upper third of the facial wrinkles:

• horizontal forehead lines
• vertical glabellar lines or “frown lines”
• laugh lines or periorbital lines (“crow’s feet”)
• treating of excessive perspiration or hyperhidrosis

However, Botox A can be applied in the lower parts of the face and neck. So Botox A can treat:

• shallow lines of the lower eyelids (Botox A is applied in a small dose in the middle of the lower eyelid)
• nasolabial folds (Botox A is applied along the line of the lower jaw to block the activity of the superfitial platysma neck muscle and prevent withdrawal of the soft facial tissues towards the neck, which contributes to the appearance of the deep nasolabial folds)
• shallow vertical lines around the lips
• horizontal lines of the neck arising from the activities of the platysma muscle and which can not be removed by facelift
• a few centimetres below the lip corners to achieve raising of the corners

Contraindications for using Botox A

• hypersensitivity to any of the ingredients of the product (Botox A allergies are very rare)
• generalized interference of the muscle activity (for example: myastenia gravis)
• simultaneous application of aminoglykozid antibiotics (for example: gentamicin)
• the presence of infection in the place or around the place of injection
• with bleeding disorders when receiving anticoagulant therapy or if the patient suffers from hemophilia
• during pregnancy and breastfeeding period

Botox  A Experience at the “Polyclinic Ostojić”

The “Polyclinic Ostojić” is the first cosmetic surgery clinic in Croatia in which Botox A was used. In the past 8 years we have gained great experience in applying Botox A in this area, and we only had a small number of complications. In the “Polyclinic Ostojić” we have been applying Botox A in almost all areas of the face and neck as well as for the treatment of excessive perspiration. Botox A treatments can be repeated any number of times because there is no danger for the health of the patient. The time distance between the treatments must be at least 3 months. Usually the effect of Botox A lasts from 3 to 6 months, although we have several patients with who the effect of Botox lasted up to 10 months after multiple applications. Applying Botox A is almost painless. Botox A is applied intramuscularly using the insuline injections. The mild swelling or bruises may appear in the place of application and usually last for a day or two. Our experience with the application of Botox A for the aesthetic purposes or for the treatment of excessive perspiration have been extremely positive. This means that Botox A completely erases or reduces the facial wrinkles. The only disadvantage of Botox A is that the effect lasts for a relatively short period of time.

Procedure

The first step is preoperative medical examination. During the examination it is necessary to carefully check all the wrinkles in the upper third of the face and estimate the percentage of the wrinkles which could disappear after the application of Botox A. The data concerning the possible allergies of the patient must be noted. Certain neurological diseases (miasthenia gravis), or pregnancy and breastfeeding must be recorded as well, because such states exclude the patients from the treatment with Botox A. With the application of Botox A a patient does not have to go through the standard preoperative examination. If a patient chronically uses acetylsalicyl acid preparations (Aspirin, Andol), then more visible bruises in the place of Botox A application can be expected. The patient must be aware of the potential Botox A application complications which are rare if the right principles of Botox A applications are observed.

Surgical procedure

The application of Botox A for the correction of the upper third of the facial wrinkles

The pictures show the horizontal forehead lines  in the sleep mode and when furrowing the forehead. A part of the face which will be treated with Botox A must be disinfected with the skin disinfectant which does not contain alcohol because it is considered that locally applied alcohol inactivates Botox A. For this purpose we use Octenisept. Botox A must be applied with a patient sitting or in a half-recumbent position because in these positions there are small chances of Botox A getting into the orbit and paralising the eye muscles.

The preoperative marking with a surgical marker. V pattern of Botox A application is shown, which will create the youthful eyebrows with the raised lateral parts of the eyebrows and eliminate the shallow horizontal forehead lines. The spacing between the horizontal injections of  Botox A should be about 2 cm, and vertically about 1 cm. Botox A should be applied directly into the horizontal forehead lines, or into the forehead or frontalis muscle.

A bottle of Botox A of 100 IU (International Units) is shown, which is diluted with 1 ml of saline solution. Based on the long experience, in the “Polyclinic Ostojić”  we dilute Botox A with minimum amount of saline solution, so it would be the most concentrated and thus the most effective. One bottle of 100 IU is usually the sufficient treatment for not more than two patients, and if we treat excessive perspiration, then only one bottle of 100 IU is sufficient for one patient.

The pictures show the injection  application of Botox A. With every needle injection 2 – 3 IU of Botox A is injected. A needle must be oriented vertically on the surface skin of the forehead, and in depth to the frontal bone. Once the needle reaches the frontal bone, about 1 mm should be drawn out and then Botox A is applied in the frontalis muscle, which is responsible for the appearance of the horizontal forehead lines.

The application of Botox A into the horizontal forehead lines is completed. For the correction of the given wrinkles about 25 to 30 IU of Botox A is needed. In the end the treated area of the face should be disinfected to cleanse the skin. We encourage the patients to furrow the forehead in the next 3-4 hours so Botox A would affect mostly the muscles that form the wrinkles. The patient must not be in a horizontal position or touch the treated parts of the face with fingers in the same period. The first visible signs of Botox A effect can be seen only after 3 days, and a maximum effect after 7-10 days.

The application of Botox A into the periorbital lines or smile lines (“crow’s feet”)

The smile lines can be seen in the picture.

Botox A is applied on the four points that need to be at least 1 cm away from the lateral orbital bone. With every injection 3-4 IU (International Units) of Botox A is applied. A needle has to be directed towards outside, while Botox is applied shallow, to the depth of about 2 mm, because the orbicular muscle is located just below the skin.

The patient with the deep vertical glabellar lines (“frown lines”), which can be treated efficiently with Botox A, is shown in the picture.

Applying Botox A in the frown lines. With every injection 4-7 IU (International Units) of Botox A is applied. The precise application of Botox A into the mimic muscles is extremely important because this way the optimal aesthetic results are ensured, and the chances of complications such as the lowered position of the eyebrows (ptosis) and the upper eyelids are minimized.

Postoperative period

Since Botox A is applied in a sitting or half-sitting position, patients should be advised not to be in a horizontal position for the next 3-4 hours. The patient must not touch the treated area of the face with fingers for at least 4 hours. In the mentioned period, the patients must often make grimaces which form the wrinkles we want to eliminate, so Botox A could precisely block the targeted facial muscles. The patients may have minimal swelling and/or bruises of the upper third of the face, which usually disappear in 1-2 days.

Complications

Complications with the application of Botox A are very rare. So far no alergic anaphylactic reaction to Botox A has been described. The side-effects may occur if Botox A is applied in the wrong spot, which can result with the paralysis of these muscles, and giving high doses can cause a muscle paralysis remote from the place of injecting. The basic rule is that the injection of Botox A should be made at least 1 cm from the bone edges of the orbit. Some patients can suffer from mild headaches, dizziness and nausea for several days after the application of Botox A. The lowered position of the eyebrows (ptosis) and the upper eyelids are also rare side-effects. When applying Botox A into the neck area, the swallowing or breathing disorders can appear, as well as hoarseness, but such complications are very rare.