Treatment with botulinum toxin (“Botox”) is one of the most common aesthetic procedures worldwide. It is particularly suitable for so-called expression lines, which are caused by repeated muscle movements – such as the frown line between the eyebrows, forehead lines or crow’s feet around the eyes.
How does botulinum toxin work?
Botulinum toxin is a protein that temporarily inhibits the transmission of nerve signals to the muscle. It blocks the release of the messenger substance acetylcholine at the nerve endings. The treated muscle relaxes, and the overlying skin is smoothed. Because only very small amounts are injected selectively into individual muscles, the rest of the facial expression is preserved when the treatment is carried out correctly.
The effect usually begins after two to three days, reaches its maximum after about two weeks and generally lasts three to four months, sometimes longer. The body then forms new nerve connections and muscle activity returns. The treatment can be repeated.
Approval
Botulinum toxin is a prescription-only medicine. In addition to products for neurological and other medical uses, several products are expressly approved in Germany for the treatment of certain facial wrinkles, for example Vistabel, Bocouture and Azzalure. They are approved mainly for the frown line (glabellar line), and some also for crow’s feet and forehead lines. The exact indications differ from product to product. Treatments of other regions, such as the neck, are sometimes carried out outside the approval (“off-label”) and require appropriate patient information.
How does the treatment work?
- Consultation and informed consent: the doctor analyses your facial expressions and discusses realistic goals, risks and alternatives.
- Injection: using a very fine needle, the product is injected at several points into the muscles concerned. The treatment usually takes only 10 to 20 minutes; anaesthesia is generally not necessary.
- Afterwards: small areas of redness or wheals usually disappear after a short time. On the day of treatment, the area should not be massaged, and sauna and intensive exercise should be avoided for a short time. Everyday life is otherwise not restricted.
- Follow-up: after about two weeks, the result can be assessed and touched up if necessary. Particularly at the first treatment, dosing tends to be cautious.
Possible side effects
When carried out correctly, the treatment is considered well tolerated. Possible side effects include:
- slight pain, redness, swelling or small bruises at the injection sites,
- temporary headache or a feeling of tightness,
- temporary drooping of the eyebrow or upper eyelid if the active substance spreads to neighbouring muscles,
- asymmetry or a facial expression perceived as “frozen” if the dose is too high,
- rarely, dry eyes, double vision or allergic reactions.
Most side effects are temporary and subside as the effect wears off. Some products contain small amounts of human albumin as an excipient; no transmission of infections as a result is known.
When should treatment not be given?
- Pregnancy and breastfeeding
- Disorders of neuromuscular transmission, e.g. myasthenia gravis or Lambert-Eaton syndrome
- Inflammation or infection in the treatment area
- Known allergy to botulinum toxin or one of the excipients
- Caution with coagulation disorders or anticoagulant medicines and with certain medicines that affect neuromuscular transmission (e.g. some antibiotics)
Alternatives
Static wrinkles that are visible even at rest often respond only partially to botulinum toxin alone. Here, a combination with hyaluronic acid filler injections, laser or other skin-improving procedures may be useful. In cases of pronounced skin laxity, surgical procedures such as a facelift may be considered.
Costs
Aesthetic treatments with botulinum toxin are not covered by German health insurance funds; billing is in accordance with the German medical fee schedule (GOÄ). The costs of treating possible complications may also have to be borne by the patient – it can be worth discussing insurance against follow-up costs.
What to look out for
Botulinum toxin is a medicine and belongs in the hands of doctors. Make sure you receive detailed information, choose a specialist with experience in aesthetic medicine (e.g. plastic and aesthetic surgery or dermatology) and insist on the use of approved original products.
Note: This article is for general information only and does not replace medical advice.
