Risks and limits of the procedure
I want Botox but I am worried about my face becoming mask-like and immobile?

In the media we are bombarded by images of celebrities and other people who have had various treatments leaving them with a mask-like appearance to their face with hardly any movement. My opinion is that facial movement is one of the most important things for maintaining character and beauty. The aim of my Botox is anti-aging but I target muscles in a balanced way to achieve a natural mobile look to your face. The doses that I use are appropriate for this and not excessive.

I have heard Botox can be dangerous?

To date there have been no long term adverse effects from regular Botox use recorded. This gives it a safety profile much better than that of Paracetamol. There have been two reported fatalities and there is some debate about the role of Botox in one of these. In both cases the doses used were not the typical doses that are used for aesthetic purposes and there remain questions about the administration and the pre-existing medical conditions in the patients that were treated.

Why cannot I have Botox for lines in my cheeks?

Very small doses of Botox can be used in the lower part of the face but my view is that they have a very limited effect and there are alternative treatments such as facial fat transfer, platelet rich plasma and surgical treatments such as face lifting that give much better results. Using stronger doses of Botox in the lower third of the face carries real risks of altering the shape and function of the mouth which clearly would be a very unappealing result.

I would like to have Botox but I am worried about my eyebrows going too high?

Balancing the muscles that pull the brow up and down is a key part of giving Botox and requires experience and skill by your practitioner. I have been carrying out Botox for many years now and there is no doubt that there is a group of patients who get a strong upward spring of their brow following Botox treatment. This tends to be younger patients. In this group of patients I tend to give a small dose of Botox in the brow above the arch to counteract this effect.

As we age laxity develops in the soft tissues of the face. In the forehead, the brow starts to drop. In an effort to counteract this and sometimes from facial expression, patients pull their brow up with the forehead muscles. This creates horizontal lines across the brow and over time instead of just appearing when the face is moved (dynamic lines) they become present even when the forehead is not moved (fixed lines). Facial concentration or frowning can lead to vertical lines in the middle of the forehead (glabellar lines) and we are all familiar with the lines from  muscles that narrow the eye when concentrating , laughing or when shielding our eyes from sunlight or cigarette smoke (laughter lines).

Lines also form across the lower eyelids as the skin loses elasticity as well as around the nose (bunny lines) and around the lips, particularly in smokers and those who have had unprotected sun exposure.

All these creates an aged look to the face and one of the ways to combat this is to weaken the muscles that create these lines. The agent used for these is Botox and my own preference is to use the original Botox as I am familiar with its dosage and effects from many years of use. Botox (Botulinum Toxin Type – A) is a toxin produced by bacteria and purified for therapeutic use. It works by blocking the signal from a nerve to a given muscle thus preventing or reducing the contraction of that muscle. Once Botox is administered the body responds by neutralising the toxin, displacing it from its site of action and by growing new nerve endings. As a result, the effect is temporary, typically lasting around three months to target muscles (muscles at which treatment is directed) and much shorter intervals to non-target muscles (muscles affected because of their being near to the target muscle). The effect normally takes around five days to appear.

Botox should be used to carefully balance the face, keeping the muscles that are important active to achieve a natural look. My philosophy is that a face that does not move can never be aesthetically pleasing and I aim to maintain some degree of natural expression in the face.

The effect of Botox varies from individual and treatment should be tailored to your face – it should not be hurried.

Botox has been used medically for many years to treat a variety of conditions ranging from involuntary eyelid spasms (its original use) to the relief of spasticity in conditions such as cerebral palsy. Botox can also be used very effectively to treat excessive sweating in the armpits (hyperhidrosis). To date there have been only extremely rare serious complications from Botox treatment for aesthetic purposes and to date there is no evidence of long-term adverse physical effects from treatment with Botox.

Botox to the Face and Neck

When I give patients Botox to the face it is usually part of a treatment programme designed for facial rejuvenation and for those who have had surgery to maintain the effects of that surgery. In the upper third of the face, the most important aspect of Botox treatment is to maintain the position of the brow. Sagging eyebrows give a very aging appearance and lead to a constant effort to lift them. This creates horizontal lines across the forehead. The brow is pulled down by a number of muscles including those around the outside of the eyes and those in between the eyebrows. It is pulled up by two strap muscles (the frontalis) which run up the forehead on each side. To lift the brow the Botox is given to the muscles around the outer aspect of the eye to stop the downward pull from here and to the muscles in between the eyebrows to stop the downward pull at this point. This allows the brow the spring back up to varying degrees depending on the amount that it has dropped. It also has the advantage of reducing laughter lines around the eyes and vertical lines on the forehead. At the same time I give Botox directly to the side of the nose to treat bunny lines and in the lower eyelid to treat lines here. For these areas, small doses are used. Patients frequently ask for Botox treatment to the rest of the forehead in order to address fixed or dynamic horizontal lines. This has to be done carefully and I tend to use a lower dose for this area so that I do not weaken the muscle that pulls the brow up. In my opinion, a brow that is smooth in which the eyebrows are sagging does not look particularly appealing. The patient may have a smooth forehead but still will look old. On the other hand, a brow that is in a perky young position with few soft lines across the forehead will give a younger appearance to the face.

The other area where Botox has a good effect is the upper lip. Small doses given into the upper lip over a period of time will gradually reduce the depth of vertical lines and give a more youthful appearance to this area.

In the neck, the superficial muscle (platysma) runs from the collar bones up to the chin on each side. In youth, the front edges of this muscle are close together but over time they start to separate and sag. This gives vertical bands extending from the chin down into the neck. In addition contraction of the neck muscles gives rise to horizontal lines across the neck. These areas can also be treated with Botox to gradually improve their appearance.

It is important to understand that Botox works very differently from filler. It does not restore any volume rather directly acts to reduce the power of the muscles that create lines. For severe changes and long-standing deep lines other techniques can also be used including fillers – either commercially available absorbable fillers like Juvederm or your own fat (a fat transfer to the face).

In addition, for very severe changes, surgical dermabrasion can be used to reduce the impact.

Other areas treated with Botox

Botox can also be used in the face to reduce the bulk of the jaw muscles (masseters) in those who have a very wide and bulky jaw. Over time the bulk reduces but several treatments are often necessary to achieve an effect.

Excessive sweating from the armpits can be crippling for many people. Apart from the obvious social aspects, it can interfere with occupation and many of my patients over the years have been in situations where they have to change their clothing or shower several times a day to keep on top of it. Botox treatment is one of the available treatments for this condition. Doses are given to the armpits and the effect typically last four to six months. There is some evidence that with regular use of Botox less is required but this does not typically give a long term cure for the condition. Other techniques such as Body-Jet liposuction and curettage of the sweat glands in the armpit are alternatives that do give a high chance of a permanent correction of the problem.

Migraine treatment. For those suffering from severe migraines, I have used Botox to good effect. This treatment uses larger doses that are distributed into the muscles of the scalp and shoulders as well as the face.

Botox is carried out as an outpatient procedure and typically takes 15 to 20 minutes. In the treatment room I will apply a local anaesthetic spray to your face and allow this a few minutes to work. Botox is then injected using a very fine needle at various points. Most patients tolerate this procedure easily. Afterwards a soothing moisturiser is applied to the face.

With all my Botox patients I start off with a full medical history and assessment. It is important that you let me know of any medical conditions that affect you and in particular any nerve or muscle disorders. It is very useful to have information about previous Botox that you have had as Botox if done properly should be tailored to each individual and the more information I have about how you respond to Botox the quicker we can find the optimum formula for you. I carry out a full assessment of your face looking at all aspects of facial aging and will advise you of any adjunctive treatments that may be beneficial in addition. It is very useful if you bring photographs of yourself from your late teens through late 20s and 30s so that I can see how your face has changed. These do not have to be professional quality as long as they give a clear shot of the face.

Once I have gone through this and discussed your aims we formulate a plan for you and I will go through the procedure itself, aftercare and recovery time and discuss any risks. If you have previously had Botox under my care you can merely attend for your Botox treatment at three to six monthly intervals are required.

After your treatment you can go about your normal day to day business with a few precautions. My recommendation is that when washing your face, you massage only very gently for the first five days and always away from the eyes and mouth. For the first few days you should avoid anything with high G forces eg fairground rides, bungee jumping etc). After a few hours you may apply makeup but again use the same precautions when massaging the face. After around five days your Botox is fixed and you may carry on as normal. After your first Botox treatment my usual practice is to see you at around the two-week mark to assess the effect. This is very important as it allows me to fine-tune the individual dose to particular areas to optimise the effect. If you are one of my regular patients, once we have established your treatment plan, I am happy to see you at three months or whenever your next Botox treatment is due.