Botox is a trademarked protein derived from a rod-shaped, Gram-positive bacterium called Clostridium botulinum. In fact, the substance is botulinum toxin. An American company coined the term “BOTOX” by abbreviating “botulinum toxin,” and since then, this term has become synonymous with botulinum toxin.
Mechanism of Action of Botulinum Toxin:
This toxin is a complex protein molecule that acts at the neuromuscular junction, where the motor nerve connects to the voluntary (skeletal) muscle. It inhibits the release of acetylcholine from the motor nerve terminals. Acetylcholine is a neurotransmitter released from the axon terminals of motor nerves, which causes contraction of muscle fibers. By blocking this process, botulinum toxin prevents muscle stimulation, resulting in muscle paralysis or relaxation. Since botulinum toxin is a foreign protein antigen, over time it is recognized and eliminated by the immune system. After elimination, the muscle regains function as acetylcholine secretion resumes, and paralysis resolves.
To date, seven different types of botulinum toxin have been identified, but only types A, B, and E cause paralysis in humans.
Historical Background:
Before the 1960s, botulinum toxin was considered one of the most lethal poisons. Most cases of poisoning occurred through consumption of contaminated canned or prepared foods. The toxin is heat-sensitive; boiling foods at proper temperatures and durations could prevent infection. Ingesting a significant amount of contaminated food caused paralysis of the intercostal muscles, leading to respiratory failure and death due to loss of chest wall movement and breathing ability. Prompt diagnosis and mechanical ventilation could save the patient.
In 1960, after the molecular structure of the botulinum toxin protein chain was elucidated, two American ophthalmologists, Allen Scott and Edward Schantz, at the Smith-Kettlewell Eye Research Institute, studied its use for reducing strabismus through neurosurgical methods. About 18 years later, the U.S. Food and Drug Administration (FDA) approved botulinum toxin type A injection for patients with strabismus.
In 1987, ophthalmologists Jean and Alastair Carruthers discovered that injecting botulinum toxin type A in patients with blepharospasm (involuntary eyelid contraction) also reduced glabellar frown lines between the eyebrows. This breakthrough opened the door for botulinum toxin in aesthetic medicine, leading to FDA approval for cosmetic use in 1992.
Since 1992, despite the relatively shorter history of Botox injections compared to dermal fillers, Botox injection rates have doubled those of fillers.
Applications of Botox:
Today, with precise understanding of botulinum toxin’s structure and accurate dosing, Botox is no longer regarded as a lethal toxin but as a widely accepted aesthetic and therapeutic agent.
Botox is used to improve migraine headaches, treat glabellar frown lines and forehead wrinkles, periorbital wrinkles (crow’s feet), eyebrow shaping and lifting, gummy smile correction, facial symmetry, neck wrinkles, neck lifting (Nefertiti lift), and hyperhidrosis (excessive sweating) in the armpits, palms, and soles.
Botox for Migraines:
In patients with severe migraine attacks, Botox injections in specific head regions can reduce headache intensity and prolong intervals between attacks. It is also effective for tension headaches affecting the forehead or occiput. Some patients can identify initial trigger points for pain, which are targeted first in treatment protocols.
Botox for Forehead Wrinkles:
For a natural appearance, all relevant areas involved in forehead movements—glabellar lines, horizontal forehead lines, crow’s feet around the eyes, and bunny lines on the nose—should be treated. Injecting the glabellar region not only smooths frown lines but also elevates the eyebrow arch, imparting a more cheerful appearance. Combined injections into horizontal forehead and crow’s feet lines soften wrinkles and allow eyebrow reshaping to adjust eye-to-brow distance and elevate the outer eye corner (“cat eye” effect).
Botox for Neck Wrinkles:
The platysma muscle, a superficial neck muscle, weakens over time, causing vertical bands visible at rest or during neck contraction or jaw opening. Botox is an effective and safe alternative for young patients who are not surgical candidates and older patients who prefer non-surgical treatments.
Botox for Neck Lift (Nefertiti Lift):
The ancient Egyptian Queen Nefertiti is renowned for her elegant neck and defined jawline. Botox-induced neck lifting, which elongates the neck and sharpens the jawline, is thus named the “Nefertiti lift.”
Treatment of Gummy Smile:
Some individuals elevate their upper lip excessively when smiling, exposing a large portion of the gums—a condition called gummy smile. This results from hyperactivity of the levator labii superioris muscle, which can be effectively corrected with just two Botox injections.
Botox for Chin:
Some people unconsciously wrinkle their chin at rest or while talking. Others have a recessed chin either congenitally or post-implant surgery. Botox injections can alleviate these issues.
Facial Symmetry with Botox:
Botox can also be used to correct facial asymmetry by balancing muscle activity.
Hyperhidrosis Treatment:
Acetylcholine, besides triggering muscle contraction, stimulates sweat glands. Injecting Botox in the armpits reduces excessive sweating, minimizing underarm moisture and clothing stains. The effect typically lasts up to one year.
Botox for Palmar and Plantar Hyperhidrosis:
Using the same mechanism, Botox reduces excessive sweating in the palms and soles. However, injections in the hands must be performed by skilled practitioners to avoid diffusion into the interosseous muscles, which could impair hand movement and strength.
Botox for Scalp Hyperhidrosis:
Excessive scalp sweating, especially in menopausal women, can be bothersome. Botox injections at the frontal scalp and above the forehead can provide relief.
Pre- and Post-Injection Care:
Prior to any injection, avoid medications, supplements, and substances that thin the blood. If blood thinners are medically necessary, consult your physician.
After Botox injection, avoid manipulating, massaging, or pressing the injection site. Refrain from heavy exercise for one week. Avoid exposure to heat, sun, and tanning systems. If injected in the face, avoid direct hot air from hairdryers to the forehead and face for one week.
Duration of Botox Effect:
Typically, Botox effects last between 4 to 6 months, varying among individuals. The onset begins about 2 hours post-injection, but visible results emerge after 3 days and reach maximum effect by day 21. Smaller, weaker muscles are paralyzed first, followed by larger, stronger muscles.
Side Effects of Botox Injection:
Short-term: bruising, swelling, mild pain at injection sites, asymmetry, muscle twitching, headache (due to gradual drug effect up to day 14).
Temporary (up to one month): double vision, eyelid drooping, light sensitivity, eye fatigue, eyelid puffiness.
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