BOTOX:
GETTING THE WRINKLES OUT OF BUFFALO
BY JAMIE MOSES

Cosmetic surgery has come a long way in the past few decades. Gone are the days of men walking around with lopsided “rugs” on their heads or “plugs” that made their scalps look like a peg board stuffed with imitation horse hair. Now microsurgical implants of thousands of natural hairs placed one by one dress previously naked crowns. 
Gone, too, are the face lifts that pulled the skin into a bizarre mask reminiscent of a Vincent Price horror flick. The array of tools available to dermatologists, cosmetic and plastic surgeons has grown immensely. In fact, surgery is often the last resort. Peels, microdermabrasions, collagen shots and, most recently, Botox are all part of the new non-surgical approach to delivering a youthful appearance to the growing number of baby boomers seeking cosmetic help. Only a few weeks ago, over 12,000 people attended an anti-aging show in Toronto.
Here’s a short list of relatively mild procedures:
Botox: An injectable drug made from botulism bacteria that works by paralyzing small areas of muscle in order to decrease the ability to frown or squint. 
Collagen: Purified bovine collagen is injected below the surface of the skin to temporarily smooth the appearance of wrinkles and facial lines. 
Chemical Peel: Resurfacing skin with chemical solutions that range in strength from mild, like alpha-hydroxy acid, to strong, like carbolic acid. 
Endermology: Using a vacuum-like device to break up and smooth the appearance of cellulite. 

Microfat Injections
: Fat is extracted from one area of the body and injected into another area to help restore fullness. 
Botox is getting most of the attention these days. On April 15, 2002, the FDA announced the approval of Botulinum Toxin Type A (Botox Cosmetic) for the temporary relief of frown lines between the eyebrows (it can also be used on “crows feet” around the eyes). Although the drug already was frequently being used for cosmetic purposes (off label use), Botox only had FDA approval to treat eye-muscle and neurological-movement disorders. It first won FDA approval in 1989 as a treatment for crossed eyes and uncontrollable blinking. 
The small amounts of Botox used by doctors block the chemical released by the nerves that would normally tell your muscles to contract. 
In large doses it can cause botulism food-poisoning, characterized by paralysis. Doctors and the FDA insist that it is safe in small doses. They have been prescribing it to sufferers from migraine and cerebral palsy for at least 20 years. Botox’s cosmetic potential was first discovered when it was used to treat people with dystonia-involuntary muscular spasms. Not only did the twitches subside but the patients also began to look smooth-skinned and wrinkle-free. 
Many years before its current popularity as a miracle wrinkle remover, a Williamsville cosmetic surgeon, Dr. Riyaz Hassanali who works at Advanced Cosmetic Surgery Center on Maple Rd., thought about using Botox for his patients.
“When I was in medical school in 1985,” says Hassanali, “I was rotating through ophthalmology. We were using Botox back then to inject into individuals who had a lazy eye. With Botox we would slightly paralyze the muscle of the opposing eye and this would force the lazy eye to repair itself and become strong enough to move. 
“I asked the doctor I was working under at the time what the side effects were of this treatment. He said, ‘well, if the Botox gets into surrounding muscles the wrinkles go away.’ I thought that was interesting. But this was before I got into cosmetic surgery, I was just a student. 
“Then as I got into dermatology, one of the rotations I did was in plastic surgery. I remember the surgeon I was working with was going to inject somebody with collagen and he said to me ‘I wish there was something better than collagen.’ And I said ‘I have an idea, Botox.’ He said ‘Botox? You mean botulism?’ I said, yeah. 
“He said ‘are you kidding me?’ You’re going to inject poison into people’s faces? Nobody’s going to go for that.’
“He had a lot more experience and wisdom than I did, so I just let go of the idea.”
But the married couple Alastair and Jean Carruthers in the dermatology division at the University of British Columbia made a similar observation and did not let go of the idea. After performing a study, they wrote a paper in 1996 based on the following premise: The idea of using botulism toxin for purely cosmetic purposes arose from the observation that therapy for facial dystonias markedly decreased lines and wrinkles in the treated areas. 
The rest, as they say, is (a short) history. The Carruthers are famous and Botox is the toast of the aging.
Even without the Carruthers Botox would have soon found its cosmetic place. Many physicians noticed that the injections smoothed wrinkles that form with the concentrated muscle pull of a frown or smile. Botox corrected crow’s feet, softened scowly forehead lines, sullen downturned mouths and too-tight muscles that cause a ropy-looking “chicken neck.” 
Injections also are used to stop excessive sweating in the palms and underarms. Botox has shown benefit as a treatment for chronic migraine and tension headaches. It is used for backache and chronic pain. Not all practitioners use it in all its potential applications. 
The ease of application, high safety profile, and impressive results have led to its rapid acceptance by many clinicians. But that very ease of application, a couple of minutes spent with a small needle, has also moved the procedure from the clinic into people’s homes. “Botox parties” are the rage in many cities.
“In California and in New York City,” says Hassanali, “women have these Botox parties.You go with your girlfriends, you all have a nice meal, chat, and you all get your Botox injections and little collagen injections and Viola! And it was done in a non-intimidating setting like a doctor’s office.”
However, Christine Cassiano, PR manager for Botox manufacturer Allergan, somewhat indirectly suggested that Allergan does not support these parties. Cassiano told the Wall Street Journal last week, “Our long-term research has shown that satisfied customers are the ones who receive treatments in professional settings.” 
That may be the official Allergan position but women are nonetheless flocking to the home parties.
“We’ve been doing Botox parties in Rochester for the past year,” says Hassanali. “Albeit, it’s a very upscale clientele that we have there. They’re people who travel to NYC, who travel to Los Angeles and they’ve come to realize, ‘hey, I can get this right in my backyard. I’d rather go here.’ And actually, they get the same quality of care locally for a fraction of the cost of going to NY or LA.” 
Compared to plastic surgery procedures Botox at a few hundred bucks is already very affordable, but with the recent FDA approval, Hassanali is hoping the prices will come down further because of increased volume. In fact, he predicts in a few years it will become the number one cosmetic procedure in the country.
Actually, it is already. In Monday’s April 29 USA Today, Botox was reported No. 1 U.S. cosmetic treatment, with 1.6 million of the 8.5 million procedures, according to the American Society for Aesthetic Plastic Surgery. The growth rate of Botox has been-46 percent last year, 2,356 percent since 1997.
“Allergan, the company who makes Botox, did close to $400 million in off-label use of the drug,” says Hassanali, “meaning uses not FDA approved, like cosmetics purposes. Now that it’s been approved it will probably skyrocket.” 
With FDA approval word is that Botox manufacturer Allergan will launch a $50 million print and television advertising campaign through ad agency Grey Worldwide. But the national media attention already given to Botox has been instrumental in getting the word out. The New York Times, USA Today, CNN, FOX, and every major network has been talking about Botox. 
“A couple of weeks before the Oscars, says Hassanali, “all the networks were talking about it. Which movie stars were using Botox or who was planning on using it. They were interviewing producers and directors who were complaining about the overuse of Botox among the stars. They felt that Botox was impairing actors’ abilities to express themselves because it reduced the degree of certain facial expressions. like frowning. And the emotions they want their actors to display on screen was being limited by the slight paralysis from Botox.” 
Television actors are jumping on board, as well. The desirable demographics that major networks battle over are the under-30. Consequently, several network shows feature characters without a trace of the tiny wrinkles that begin to appear around, say, age 32. Many television actors are hitting the Botox before they even turn 30, so that they can maintain their 20s look as long as possible. Hassanali’s youngest Botox patient is only 28. 
But as Dr. Hassanali has pointed out, producers and directors are complaining at the cost to facial expression. Martin Scorsese has complained bitterly about the increasing use of Botox in the entertainment industry. And Robert Redford is also on the record as saying that women who use plastic surgery to smooth out their wrinkles “end up looking body-snatched.” 
Indeed, a New York Times Botox article in February said the drug has made it “rare in certain social enclaves to see a woman over the age of 35 with the ability to look angry.” 
According to Hassanali, the percentage of loss of expression is different with each case. “It depends on the severity of the problem,” he says. “If somebody has minor lines, after one treatment you’ll see a significant improvement. Somone who has significant lines on their face, it may take several sessions to get resolution of those lines. Certainly with even one session you’ll see improvement, but you’ll notice right away that you’re not able to frown as severely because those frown muscles have been somewhat immobilized. But then what happens over time is that because you’re not able to use that frown muscle it gradually atrophies. And as that muscle beneath your skin softens up, the lines on your face, which are above the muscle, begin to flatten out and disappear. 
“The key is in the musculature. Think of the skin on your face as a carpet and the muscle underneath as the floor. If the floor is buckling then the carpet will buckle with it. If you smooth the floor out beneath the carpet, the carpet lays flat. It’s the same with the muscles under your skin. If, with Botox, we relax those muscles and keep them from contracting into ridges of frowns and squints, eventually the skin will lay flat and lines begin to recede. There’s nothing wrong with the skin, it’s what’s happening beneath the skin that’s the source of the problem. But for years we used to attack the problem by treating the surface, we peel it off, we dermabrade it off, we laser it off, but we’re just working on the surface. We didn’t understand until Botox came along that the problem was not the surface. There are other more permanent procedures you can do, cut the scalp, pull the skin and actually cut the muscles, but then you’ll never be able to move your forehead. And when you start describing these procedures to people, many of them are not interested in anything like that.”
Undoubtedly, one of the most appealing features of Botox is the fact that if you don’t like it, it goes away in a few months and you can just forget it. So while Botox is less then surgery, and is in fact reversible, it also appears to be more than other popular skin treatments.
“There’s no comparison between Botox and microdermabrasion,” says Hassanali. “Microdermabrasion is basically a deep cleanser. It helps to smooth out surface irregularities of the skin, the dead skin. It’s more like an exfoliative treatment, a freshening. As a doctor I have some criticism of the claims of microdermabrasion reducing wrinkles. It may reduce very, very fine lines, that’s it. 
“But I’m not against microdermabrasion. I think it definitely has a role to play for individuals who want to have healthier looking skin. It’s fine for that.
“Collagen is probably going to have a tough time, sales are going to go down,” says Hassanali. “For a time it enjoyed great popularity among individuals who wanted to remove, say some lines on their forehead but did not want to have surgery or did not have the time it takes to recover from surgery. Collagen injections, which basically fill in the furrows or lines, provided a convenient solution. But it has its drawbacks; it doesn’t last very long; it’s expensive; and seven percent of people who try it are allergic to it-which means they have to wait for results from a skin test before they can receive treatment. But there’s a new similar product out of Sweden being tested right now and awaiting FDA approval which lasts twice as long as collagen and doesn’t require a skin test.”
Before the media got on to Botox, doctors performing the procedure had very little marketing assistance.
“In my situation,” says Hassanali, “the first patients who received Botox treatments were patients who were already coming to me for other procedures. Eventually news spread by word of mouth. Two ladies I did today heard about me from a fitness center.”
The ratio of men to women using Botox is heavily weighted to women. No surprise there! A typical day of Botox procedures in Hassanali’s office reflects this clearly.
“Today I did eight people,” says Hassanali, “seven women, one guy. So more women are getting it done than men, and that’s true for all cosmetic procedures. But I think baby boomers and generation X males will probably seek out cosmetic procedures more than previous generations. But right now, if I look at the patients who come in here for Botox treatment, the overwhelming majority are women, at least 75 percent.”
That figure is consistent with other reports, including attendance at the previously mentioned anti-aging show in Toronto, which was 75 percent women. 
“Part of the reason for that ratio is lack of knowledge on the part of men,” says Hassanali. “You won’t see Botox articles in magazines that cater to men or Botox ads in sports sections of newspapers. Whereas you’ll see a lot of articles on Botox in magazines that focus on women. So women are more aware of these things.”
The procedure takes less than five minutes and Hassanali says a person will start seeing results within five days, and that within several weeks they’ll see significant improvement-because they are no longer contracting those muscles.
As mentioned before, immobilizing those expressive frowns is a trade off-youthful looks at the expense of personal character. But Hassanali says that can be controlled to a degree.
“I don’t inject such a volume of Botox that you lose too much muscle movement. Clearly, you are still able to express yourself. The level of expression will be less than pre-Botox treatment. But the level can be controlled by the degree of how much is injected. For example, I have one patient I only inject a small amount in the area at the bridge of her nose, right where the eyebrows meet in a frown. Other patients I may go completely across the forehead and along the sides. If someone comes to me with dramatically severe lines (like the Old Man of the Sea) we might not be able to erase those lines. So I may tell them that I’m not sure this is the right procedure. There are always options available. However, with Botox, it’s rare to find someone who cannot benefit from it.”
So how long does Botox last and how many times must one have treatment? Hassanli says it’s recommended that it not be done more than once every three months. However, he says that once results have been achieved there’s no need to do more than maintenance booster shots twice a year as opposed to four times a year. He also points out that if the treatments are eventually stopped there may still be long-term benefits.
“These wrinkles are the result of habit. If after a lengthy period you stop Botox treatments, when full movement returns you will likely use other muscles as well, rather than just relying on these few muscles of habit. You might even use a totally different set of muscles, in which case those old lines may not return.”
The age range of people turning to Botox is fairly wide.
“Of the eight patients I did today,” says Hassanali, “one was 51, three were 50, the others were 42, 44, 45 and 60.
“But it’s not based on age, it’s based on the severity of the problem. For example, we’ve have seen older people who just don’t use these frowning muscles that much and don’t have that many wrinkles. By the same token we’ve seen younger people who by the time they’re 31 they’ve got significant marks of formity in their foreheads.”
PASS THE MARGARITAS AND THE HYPODERMICS!
For Hassanali his youngest patient is 28 and his oldest is 72, and they both want the same thing-to look young. Is that unreasonable? Times are changing, appearances are changing, and our expectations are changing. When old Hollywood actors like Spencer Tracy turned 50 or 60, they looked like old men, white hair, deeply wrinkled faces, a slight stoop. Today’s aging men don’t accept this; Donald Trump, Bill Clinton, Ted Turner, John McEnroe or Michael Jordan. Elton John and Bruce Willis have both spent enormous sums of money on capturing as youthful an appearance as possible.
As for the women, as New York Times columnist Maureen Dowd put it recently, there are now four stages in the life span of a woman: Pre-Babe, Babe, Botox-Babe and, finally, Cher.


For more information, go to www.botox.com.

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