Hydrosis
The Origins of Botulinum Toxin for Medical and Cosmetic Use
The German doctor and poet Justinius Kerner published observations of symptoms caused by the consumption of spoiled food, mainly sausage or pickled meats. The symptoms described by Kerner were those of an illness called botulism, which stems from the Latin word “botulus” which means “sausage”. The symptoms of this illness, including double vision, drooping eyelids, slurred speech, progressive general weakness of the skeletal muscles, and finally death through paralysis of the breathing muscles. 90 years later the microbiologist Emile-Pierre van Ermengen managed to isolate the bacterium, which causes botulism and named Clostridium Botulinum. He was able to extract the bacterium from the people who had died of botulism as well as from raw, salted pork, one of the methods used to preserve meat in those days.
Only in 1946 Edward J. Schantz managed to isolate and purify the actual paralysing toxin. It is not the bacterium, which causes the symptoms of botulism but the toxin produced by the bacterium. There are 8 toxin subtypes labelled A to G with C1 and C2 of which 7 have paralysing effects. The most potent subtype is the Botulinum Toxin type A, which is widely used in its purified and diluted form for cosmetic and medical purposes and sold by Allergan under the trade name Botox®.
In the early 70ies Dr Alan Scott introduced Botulinum toxin type A for clinical use as a non-surgical treatment for strabismus. He found that when minute amounts of the drug are injected into the eye muscles of cross-eyed monkeys he could relieve the symptoms of strabismus. Further experiments extended the use of Botulinum toxin in humans.
The drug went on trial between 1977-78. Dr Scott treated patients successfully for a condition called blepharospasm a hyperactivity of the muscles surrounding the orbital rim. This condition can affect one or both eyes, causing the eyelid to spasm uncontrollably and repeatedly. The spasms can also appear on face and neck. Symptoms of blepharospasm are involuntary blinking leading to periodical complete eye closure rendering the patient temporarily blind.
The Food and Drug Administration (FDA) finally approved Botulinum toxin type A in 1989 for the treatment of strabismus and blepharospasm. Particularly in the field of neurology the use of Botulinum toxin type A extended rapidly for conditions involving muscle hyperactivity, such as Torticollus, Dystonia, Cerebral Palsy and more.
Around 1987 some of the patients treated by Dr Scott for blepharospasms noticed that the affected and successfully treated side of their face looked less lined in the area that would decades later be injected with Botulinum toxin type A for the treatment of Crowe’s feet or smile lines purely for cosmetic reasons.
Other areas on the forehead where Botulinum toxin type A was injected like the glabella region between the eyebrows, forehead lines and as mentioned above the smile lines around the eyes responded equally well in regards to the cosmetic benefits when injected for the treatment of involuntary muscle hyperactivity. This obviously led to the subsequent discovery of Botulinum toxin type A injections for the treatment of facial lines for cosmetic reasons only.
The physician couple Jean and Alastair Carruthers were particularly involved in the beginning stages of the Botulinum toxin type A use for cosmetic indications exclusively. Both Carruthers were having close links to Alan Scott and were pioneering into the cosmetic field of Botulinum toxin type A injections. Even though Alan Scott did use Botulinum toxin type A in the mid 80ties for cosmetic indications on his patients it was not until 1992 when the Carruthers started to publish their findings that things in the field of non-invasive cosmetic medicine was about to change dramatically. From that point onwards the Botox phenomenon was taking off in a way that was most probably not foreseen by any of the people who were involved in the process at that time, neither the physicians injecting it nor the company producing the drug. Since Botox was approved for the use in other medical conditions, it was possible to use it “off-label”, meaning, doctors could legally inject it for cosmetic reasons, provided the patient signed a consent form. Imagine the scenario, especially for the Carruthers couple, stockholders in Allergan, pioneering the “gold rush”, spreading their findings among mainly Dermatologists. The market for cosmetic medicine was until then mainly in the hands of Plastic and Cosmetic surgeons. Dermatologists, Ophthalmologists, ENT-Surgeons, Dentists were only able to grab a very small piece of the pie, the biggest chunk was still held by a domain impenetrable to non-surgeons. Now all of a sudden there is a drug which can be administered by a simple physician, almost no risk at all, no permanent damage to the patients health, simple, easy, just a subcutaneous injection, a nurse can do it under supervision but maybe the answer to thousands of years of super human efforts in the combat against ageing. This was a license to print money for everybody educated and clever enough to jump on the bandwagon. All of a sudden the face of cosmetic medicine has changed forever. No more bleeding and bruising, delayed wound healing, barbaric cutting and pulling, distorted facial expressions, scars and paper thin stretched out skin. Here was the answer to all the rejuvenation needs of a growing population of affluent, successful, educated and up to date people born between 1945 to 1960, who have been exposing their faces to excessive sunlight, especially on the west coast of America, (the Carruthers are based in Vancouver) who showed signs of premature ageing due to all that golf playing, skiing and tanning in the Caribbean or in Hawaii.
The runaway train has not come to a halt yet, in 2000 Cosmetic Botox treatments have outrun any other cosmetic procedure, by now leading the top ten list of cosmetic procedures. Insert table Interesting to see that surgical procedures are only managing rank 7 with breast implants and facial surgery listed much further down the line compared to non-invasive treatments like chemical peels, dermal fillers and obviously Botox injections. The trend towards non-invasive cosmetic procedures has opened a completely different market for both the customer and the provider. Injectable beauty enhancers are now available in virtually every beauty salon, a tough competitive market has grown from the Botox and dermal filler boom, with nurses and general practitioners carving deeply into the cosmetic market formerly controlled tightly by the community of plastic and cosmetic surgeons. With the onset of the Botox surge a lot of plastic surgeons had to adjust to a completely new type of customer. This type of customer did not have any patience or tolerance for down-time, bruising, discomfort or even worse, a permanent change in physical appearance. These people wanted a lunchtime facelift, something they have heard from a friend, miraculously smoothing out lines without any bloody bandages or stitches, instead quick, easy, painless and still so effective. A lot of the plastic and cosmetic surgeons were not prepared for this development and until today, the best Botox injectors are found not among the surgeons but among dermatologists, ophthalmologists or simply physicians and nurses. In fact a lot of surgeons were very sceptical towards Botox and some simply stated it does not work. This was maybe due to the fact that there was not a great deal of expertise among the surgical community when it came to simple injection treatments. Until then most of the facial procedures were operative. Another simple cause for the initial reluctance was maybe rooted in the believe that promoting a treatment that might replace or postpone a facelift was not really the best marketing strategy for a plastic surgeon.
Things have changed dramatically now. We as cosmetic doctors have a whole array of treatments to choose from, virtually all with next to no down-time and very little risk or potential side effects. Botox treatments have become somewhat a crossover between medical sience and artform. Aesthetic medicine is at least 50% art. The most important ingredient to everlasting youth and beauty is a good relationship between practitioner and patient.