The Basics of Botox

Botlinum toxin is one of the cornerstones of aesthetic medicine. It is a treatment that has been made famous by celebrities, and has been portrayed in various ways by the media - not always kindly or accurately. Most people know vaguely what toxin is, and probably have some sort of preconception of it. But we’re going to cover the basics of this wonderful treatment.

What are all the different types of “Botox?”

Everyone seems to refer to botulinum toxin as “Botox,” but Botox itself it actually a brand, developed by Allergan. Here is a brief round-up of the different types of botulinum toxin that you will encounter. They all have slightly different characteristics, but basically work the same way. It will be up to you and the expertise of your clinician to choose which product will be the best for your treatment.

In all these formulations (except Bocouture), botulinum toxin is prepared by surrounding it by a protective protein complex, which differs in mass between products. However, the toxin itself is identical - consisting of a light chain and heavy chain joined by a disulfide bond.

The Original Three Toxins

• Botox by Allergan - this has been around since the 90s and has been in use the longest, and therefore has the most research behind its use. This is the product that everyone knows about and names when they think about the use of botulinum toxin for cosmetic and medical purposes. The stabilisers used in Botox are human albumin and sodium chloride.

• Azzalure by Galderma - this product reportedly kicks in a bit more quickly than the others, which can be great for patients who like to see a good result as soon as possible. However, it is a smaller protein and therefore will diffuse more easily, meaning that it can spread a bit further than its counterparts, which your aesthetic medical professional should be aware of when injecting. The stabilisers used in Azzalure are human albumin and lactose monohydrate. Azzalure was adapted from and is identical to Dysport (the name most commonly used in the USA), and the units (Speywood) are interchangeable.

• Bocouture by Mertz - this has the least amount of stabilising proteins, which some take to mean it is a more “pure” product. I don’t think this is a meaningful distinction to make, because at the end of the day what makes it work is the botulinum toxin which is identical to all the others. Theoretically, there might be a smaller chance of developing resistance to Bocouture, although this has not been proven. One of the benefits of this is that, unlike Botox and Azzalure, this product does not need to be refrigerated which can be more convenient for practitioners. The stabilisers used in Bocouture are human albumin and sucrose (sugar). Bocouture’s sister toxin is known as Xeomin.

  There are other botulinum toxins available in the world, such as Neuronox and Prosigne, however these are not used in the UK. Be careful in the UK that you are not being administered an illegal or counterfeit product from a non-medic who does not have a legitimate means to get a prescription. Check out our article on the legalities around getting Botox if you are a patient.

The New Generation

These are the new kids on the block in the UK as of the year 2022. Some of these are in the process of getting approval are brand new to market, or have been around for a few years but only in the States or Asia. We have written individual articles explaining each one, with a quick summary below!

• Nucevia by Evolus

• Daaxify by Revance

• Letybo by Croma-Pharma

• Alluzience by Galderma

For a quick summary, go to our Which Toxin is Which article.

Is Botox a poison?

No, it definitely isn’t - but this is something that I hear said quite often (and usually derisively).

Botox is a purified protein.

It is derived from botulinum toxin, a neurotoxin that is naturally produced by the bacteria Clostridium botulinum.

There are various different serotypes in existence, but Serotype A is the most potent and the only one that is used in a clinical context.

How does it work?

The science: Neurons that innervate skeletal muscle fibres directly are called motor neurons. The axons of these motor neurons divide into many branches and each innervate a muscle fibre (known as a motor unit). These axon terminals contain synaptic vesicles (small fluid-filled sacs that transport substances within the cell), and these vesicles contains a neurotransmitter known as acetylcholine (ACh). Between the pre- and postsynaptic neuron is a synaptic cleft, which typically operates in only one direction, and the postsynaptic neuron will contain the receptors for the neurotransmitter. Once the neurotransmitters reach the postsynaptic membrane, they bind to their target receptors. These receptors may be ion channels, or second messenger proteins, allowing the message or signal to propagate along to the next neuron.

What normally happens in a neuromuscular junction is that the neurotransmitters (ACh) are released when an action potential (an electrical impulse travelling along a neuron) reaches the presynaptic membrane, which causes the opening of a number of calcium channels. The influx of calcium ions in turn binds a protein called a synaptotagmin, triggering a change in the SNARE protein that anchors the vesicles in place. This process leads to the vesicles containing the neurotransmitter to fuse with the presynaptic membrane, releasing the neurotransmitter so it can diffuse across the synaptic cleft

ACh diffuses across the axon terminal to the motor end plate, binds a receptor, and causes a cascade of singlas that eventually leads to muscle fibre contraction. Within the synaptic junction is an enzyme known as acetylcholinesterase, which breaks down ACh. When the receptors no longer contain any ACh, the signal to contract the muscle fibre ends.

Botulinum toxin works by breaking down the proteins of the SNARE complex, which is required for the binding of the vesicles containing the neurotransmitter ACh with the plasma membrane at the axon terminal of the motor neuron. In other words, it prevents the release of ACh entirely by blocking the vesticles that transports it, which prevents the signal from reaching the motor end plate and therefore the muscle fibre does not contract.

These results are completely temporary, as new neuromuscular junction will form (a process known as “sprouting”), which typically takes 2-4 months. The cosmetic effect of this is a softening of dynamic wrinkles on the surface of the skin.

The History of Botox

Botox was originally used by ophthalmologists in the late 1980s for the treatment of eye disorders - namely strabismus, a condition where the eyes do not align with one another when gazing at an object. It was also licensed for the treatment of blepharospasm, a condition where there is uncontrollable muscle twitching of the eyelid.

However, while injecting Botox around the eyes, the doctors and patients both noticed that the patients were having a very noticeable (and desirable) side effect. There were gorgeous cosmetic results, with the softening of dynamic wrinkles around the eyes, and doctors found that patients were clamouring for repeated injections because they liked the way they looked so much!

Scientific papers were quickly published, detailing the exciting results that were seen with the cosmetic use of botulinum toxin. From there, the field took off rapidly! It is now one of the most popular non-surgical cosmetic procedures in the world.

What you should know as a patient

What are the side effects?

Botox is not a permanent treatment, and both its effects and side effects are temporary. Common initial side effects include bleeding/bruising, some swelling, and a mild post-treatment headache. These are normal and will go away on their own. More moderate side effects include drooping of the eyelids and eyebrows, but this can usually be avoided by careful and appropriate placement of the treatment and understanding of the anatomy of the muscles being targeted. Even in the rare instance that this does occur, steps can be taken to correct or improve it, and the effects will wear off on their own.

Is there anyone who shouldn't have these treatments?

You cannot have anti-wrinkle injections if you are trying to get pregnant, are pregnant, or are breastfeeding. Botox is also contraindicated in certain muscular diseases (for example Myasthenia Gravis), blood disorders, patients taking medication that effects blood clotting, or if there are any psychological concerns.

What should I do after my treatment?

For the next four hours after the treatment, do not lie down or do any exercise that would involve bending forward or being upside down (like yoga). Avoid touching the treatment area to prevent any irritation, and do not put anything on your skin including makeup.

For the next 24 hours, you should also avoid any strenuous exercise that would cause you to be flushed or sweat, and avoid any heat (no saunas or steam rooms). Also avoid drinking any alcohol or taking any tablets that could increase risk of bleeding and bruising (like aspirin or NSAIDs) for the next 24 hours.

Using your muscles of facial expression over the next two days will help the treatment gain its maximum effect. Remember, it takes a couple of days for the treatment to take full effect. Be vigilant about wearing SPF and protecting your skin (good skin makes any cosmetic treatment look even better).

For the next two weeks you cannot have any other cosmetic procedures, no chemical peels, and no tanning beds.

Remember everyone’s physiology and biology is slightly different, and their body may metabolise the toxin in slightly different ways. You should always have a two-week review appointment available so that any concerns can be discussed or adjustments can be made.

Final thoughts

Botulinum toxin is a wonderful medical product that has been used for a variety of medical indications for decades now. This includes the ophthalmological applications described above, as well as medical issues like migraines or hyperhydrosis (excessive sweating).

The cosmetic effects that it has - when used by the medical professional with an eye and understanding of anatomy, ageing, and aesthetics - are impressive and can have a massive positive impact on patients’ lives.

*At Ashley Aesthetics, we use Botox as our preferred product in clinic.

Check out Glowday’s excellent treatment guide here.