Lines and Wrinkles

Introduction
Facial lines are caused by the repeated use of the underlying facial muscles which over time results in a permanent crease or wrinkle. As an alternative to surgery in younger patients it is possible to reduce these lines by relaxing the action of the underlying muscle using botulinum (Botox). This temporarily reduces the action of the underlying muscle. Where botox is injected it reduces the facial movements which result in wrinkling. This gives a smoother, more rested appearance to the face. Botox also has a preventative effect when used repeatedly to reduce the onset of wrinkles forming in the long term. This is partly due to the effect of re-educating the facial muscles not to make expressions which result in wrinkling. To achieve the best results botox is injected to a level which does not cause complete freezing of the muscles but relaxes them so that some movement is still possible.

Mr Grover has a particular interest in Botox injections and was the lead clinician in the UK coordinating an international multicentre trial on safe dosage of Botulinum toxin which eventually lead to it being issued a license for cosmetic use in Europe and the United Kingdom. He has a strong interest in improving safety and is responsible for the UK National Audit of Cosmetic Surgery & Safety for the Royal College of Surgeons.



What areas can be treated?
Is Botox safe?
What should be expected after Botox therapy?
How long does Botox last?
How often is Botox needed?
What are the alternatives to Botox?
What unexpected benefits have come from Botox?
How painful are the injections?
Who should not receive Botox?
What are the risks?
What do I do after the treatment?

Commonly Asked Questions

What areas can be treated?
Botox is most commonly performed in the upper face. The most common areas requested are the horizontal forehead lines, vertical frown lines between the eyebrows, and crow’s feet (or laughter lines) radiating away from the eyes. While it would probably work around the mouth and chin, it would almost undoubtedly weaken the smile and Mr Grover does not recommend its use around the mouth. Creases around the mouth may however be improved by filling them out with a dermal filler such as Restylane.

Is Botox safe?
Botox injection is currently the most popular cosmetic procedure with over 1.6 million Botox injections being performed last year. The treatment is now 21 years old and therefore has a well established safety record.  In the USA the Food and Drug Administration (FDA) now licenses Botox for cosmetic use as does the  british Government and European Union. For many people, Botox treatment represents their first experience with cosmetic surgery. As a quick and effective treatment, with excellent results and virtually no downtime, it is perfect for those patients who have minimal signs of facial aging such as forehead furrows and crow's feet. Whilst Botox can often delay the need for more extensive surgery, it is important to stress that it does not achieve the same results as surgical procedures.

What should be expected after Botox therapy?
Botox is a remarkably safe treatment for wrinkles with little down time associated with the treatment. Occasionally slight bruising may occur where botox is injected and a mild headache may follow. Bruising may be greater in patients who are taking aspirin or any blood thinning medicines. These products should be avoided if possible prior to the injection. Muscle relaxation is first noted at between the 3rd and 10th day after injection; it is not immediate.

How long does Botox last?
Successful therapy is signalled by muscle weakness that begins 3 and 10 days after injection with the main effect visible at about 7 days. The effect after the initial injection lasts between 3 and 5 months for most patients.

How often is Botox needed?
Repeat treatment is suggested every 4-5 months to keep the muscles sufficiently frozen to allow the furrows to smooth out. In practice this means coming three times in the first year.  After using botox for one year the intervals between injections may be a little longer so that you need it only twice a year. 

What are the alternatives to Botox?
Filling agents including Restylane and Hyaluronic acid may help to eliminate the finer expression lines. Depending on the severity of the skin changes it may be more appropriate to recommend lifting operations of the forehead, temporal region or face which would also have the longest lasting effect.

What unexpected benefits have come from Botox?
Tension headaches and migraine for some patients have disappeared. These occurred in patients who were recruiting forehead and brow muscles during periods of stress and tension. When these muscles were relaxed, the headaches faded. It has been found to help wit headache in about 30% of migraine sufferers.

How painful are the injections?
The smallest needles are used and the medicine itself does not tend to sting as much as injections of local anaesthetic. Most patients feel it as painful as having their eyebrows plucked. It is advised not to use aspirin as this can increase the risk of bruising.

Who should not receive Botox? 

  • Pregnant women; although there have been no reports of birth defects with this medicine, no pregnant patients will be treated.
  • Breastfeeding; similarly, there is no evidence that Botox is expressed in breast milk but it is best avoided if breastfeeding.
  • Patients with a history of neuromuscular disease (multiple sclerosis and myasthenia gravis) or other types of diseases involving neurotransmission should avoid this medicine.
  • Patients taking the following medicines should not receive Botox: aminoglycoside antibiotics, penicillamine, and calcium channel blockers (Calan, Cardizem, Dilactor, Norvasc, Procardia, Verelan).
  • Known allergy to human albumin (egg white) or Botox; currently there are no documented cases of allergy to Botox.  

What are the risks?
As with any sort of injection there can be some bruising and minor swelling although this is not severe and usually settles within a few days.  Very rarely if the botox reaches the upper eyelid muscle there may be transient drooping.  This is the most significant risk and occurs in about 1 in 1000 injections. It occurs from local spread of the botox from the injection site and can be minimised by accurate dosage, proper placement, as well as keeping in an upright position for three to four hours after the injection. If drooping eyelids occur, it usually resolves over a few weeks. Special eye drops may temporarily reduce eyelid droop if it occurs.

What do I do after the treatment?
Do not massage the area of the injection. Do not lie down for a nap – keep upright for about 3-4 hours.  Do not take any aspirin for two or three days either side of the injections as this may help to reduce the chance of bruising.  It is also advised not to perform any vigorous exercise for 24-48 hours after the treatment. Anything that could move the botox from where it has been injected in the first couple of days should be avoided. In practice this means avoiding having any facials or massages where you might lie face down on a circular pillow for 48 hours.

© 2005-2017 Rajiv Grover 94 Harley Street London W1G 7HX Tel 020 7486 4301