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Normal skin is well able to protect itself from the elements, but if you have rosacea your skin can get inflamed much more easily. One important component of this is the ability of the skin to deal with free oxygen radicals. These are potentially damaging and could lead to damage to blood vessels, particularly the small capillaries in the skin, which could worsen the facial and nasal redness.
Vitamin C is one of the most powerful anti-oxidants that the body has available. If you have rosacea you need to be sure that your vitamin C levels are kept at adequate levels. This might mean taking vitamin C supplements if your diet is likely to be low in Vitamin C. Vitamin C is also needed to help the body make collagen, the essential binding protein that holds all the cells together. The skin of people with rosacea tends to be more fragile so again it is important that the there are adequate levels of Vitamin C so that collagen production is optimized.
It is also a good idea to use a moisturizer which contains Vitamin C. As well as protecting the skin from free radicals, there is evidence to suggest that the topical application of Vitamin C can also help to reduce redness in people with rosacea. Care needs to be taken to ensure that the formulation of the moisturizer doesn’t contain any irritants which people with rosacea are much more susceptible to.
An important aspect of protecting the skin is to use a good quality sunblock. Everyone should use a sunblock and it is even more important if you have rosacea as the ultraviolet radiation can lead to higher levels of free radicals in the skin which in turn damage already fragile blood vessels. The highest sun protection factor should be used, preferably at least a factor 30. Watch out for any alcohol content in the formulation of the sun block as this can irritate the skin.
The final aspect of protecting your skin is to avoid products that cause irritation. This can be very difficult as so many soaps, shampoos, moisturizers and cosmetics have ingredients that are likely to cause irritation. The usual suspects are the alcohol and fragrances used in these products. If you stick to products that are free from fragrance and cosmetics that are water-based or oil in water based you are less likely to run into problems with irritation.
What matters when you have your Botulinum toxin (Botox) is the overall number of units that you are given. Practitioners may choose to dilute their Botox with varying amounts of saline, and this will affect how far the Botox diffuses away from the injection site. Personally, when I am treating frown lines between the eyebrows in the frown line (Glabella) region I like to use it in quite a concentrated form (100 units of Botox diluted in 1 ml of saline, giving 10 units per 0.1ml), as I want the Botox diffusion to be quite limited. When I am treating horizontal forehead lines I prefer to use it in a more dilute form (100 units in 2mls of saline) so that I can achieve more diffusion of the botox over a wider area of muscle.
So why does the total number of units that you are given matter so much? Because studies have shown a clear dose-response relationship between the duration of effect and the dosage that you are given. If you are given 20 units of Botox into your glabella frown line region it will last about 16 weeks in 75% percent of clients, whereas if clients are given half that dose it will only last that long 35% of the time, and you will therefore probably be needing more treatment well before the end of four months after your last treatment with this dosage.
So if you are of average build and normal facial muscles mass, and you are having the frown line and your forehead treated with Botox you should probably be getting a total dosage of around 40-50 units. This will reliably achieve an effect that is going to last you for the next four months or so. Clearly if you are exceptionally lean or exceptionally well endowed with facial muscles then the dosage will need to be altered accordingly.
Don’t forget that if your if your doctor is using Dysport (marketed under the name of Azzalure in Europe) then the number of units will be different. It will be about 3 times higher than with Botox or Xeomin as Dysport/Azzalure, unit for unit, is only one third as powerful as Botox. So one unit of Botox is equivalent to around 3 units of Dysport / Azzalure. When given in appropriate dosage studies have shown that Dysport/Azzalure is as effective as Botox. So ask your practitioner about the total dosage they are planning to use. If it’s a lot less or a lot more than the quantities mentioned above for the forehead and frown line areas, ask them why.
Botulinum toxin (Botox, produced by Allergan, is the most commonly used form of the medication) is a powerful drug. When given by an expert it can take years off your appearance, and used correctly you will be able to retain a natural look. However, in some countries regulation of who can provide Botox is not very strict and you may find that you have a bad Botox experience. So what is a bad Botox experience and how can you avoid it?
You can have a bad botox experience if you are given too much or too little Botox, if it’s given in the wrong place, or if your provider is unscrupulous and using something other than one of the regulated forms of Botulinum Toxin (the main ones at the time of writing are Botox, Azzalure (Dysport in the United States), and Xeomin.
You can tell if you’ve had a bad Botox experience if one of the following has happened after your treatment:
- drooping of one eyelid, which means that your provider may have given the botox too close to your eyelid muscle. Having said that, other factors can lead to migration of botox into the eyelid muscles, such as having a facial or lying down after Botox or vigorous exercise immediately after Botox
- drooping of both eyebrows (feels like you are looking out under the peak of a baseball cap). Usually means that your Botox provider hasn’t properly evaluated your forehead musculature and given the Botox too low down or has been too aggressive dosage or a combination of the two.
- completely frozen expression (unless, of course, you specifically requested it, some people do like this look!) which suggests that you might have had too much botox.
- drooping of one side of the face. The botox has probably been given too close to the cheek muscles.
- inability to close your mouth properly. Too much botox has probably been given into your lip muscles when trying to treat those upper lip lines and wrinkles.
- voice hoarseness or difficulty in swallowing. This is a potentially serious complication that can occur after Botox treatment in the neck. If you get this seek medical advice immediately.
So how can you reduce the chance of having a bad botox experience? The answer is to choose your Botox provider with care. Ask the following questions:
1. What is their training, experience, accreditation and qualifications? They should have been trained by an accredited Botox trainer. They should be thoroughly experienced in doing Botox injections and have an adequate number of patients each week with which to maintain their skills (ask them how many patients they treat in an average week, if it’s less than four or five you should be concerned).
2. Ask your provider what their complication rate is. Anyone doing regular Botox will experience occasional complications. If they are a UK doctor then they should know as one of the requirements of medical appraisal is audit. If they say they never have any complications then either they are not seeing enough patients or they are not being truthful and you should consider changing your provider.
3. Ask them what their on-going supervision and validation requirements are. As part of medical quality control (known in England as clinical governance) All UK and US doctors have to have strict annual appraisal requirements where the quality of their work is reviewed by an external expert.
4. Ask them which brand of Botulinum Toxin they use. All of the major brands (Botox, Azzalure (Dysport) and Xeomin work just as well as each other if given in the correct strength, but one unit of Azzalure does not equal one unit of Xeomin or one unit of Botox. Around two and a half to three times as many Azzalure units need to be used for every unit of Botox or Xeomin. So if your provider uses Azzalure ask them how many units they use for their treatment.
So you can see there are major advantages in choosing a fully registered doctor to provide your Botox treatment. It guarantees quality assurance in terms of knowledge, training, on-going experience and appraisal as this is needed to maintain registration as a doctor and validation to provide medical cosmetic treatment.
Botox has been available for medical purposes ever since the mid 1980′s, but it was not until the mid 1990′s that it has been used for cosmetic medical treatments. Since then people have come to realize its fantastic potential for turning back the clock. It can literally take years off your appearance, softening lines and wrinkles that you might have thought were now a permanent feature of your face.
But Botox needs to be respected. You need to choose a provider who is properly trained and regulated. It’s a powerful drug and it can be used in a way that produces a balanced and harmonious look. But if used in the wrong places it can cause problems. These can range from cosmetic problems like an eyelid droop, to functional problems like not being able to form a proper seal around your spoon or fork when you eat, or not being able to swallow your food. These types of problems can arise from incorrect administration of Botox, which might mean too a high a dose for your particular muscles, or incorrect site of injection, or both.
The safest and best places to use Botox for cosmetic purposes are on the forehead, between the eyebrows and at the sides of the eyes. This will soften lines and wrinkles, and if given correctly, can also produce a subtle eyebrow lift. In these areas there is more leeway (particularly on the forehead and between the eyebrows) in terms of the dosage or injection points. Plenty of research has been done about using Botox on the forehead to define the correct average dose range and the optimal points for the injections. Botox for “crow’s feet” lines that extend out from the corners of the eyes can also be very effective.
Care needs to be taken about injecting Botox around the corners of the eyes because if it is given too low down on your face it can affect the cheek muscles that hold up the side of the mouth. If these are affected by the Botox on both sides you could end up with down-turned corners of your mouth and difficulty smiling. A rather sad, sallow expression. On the other hand, if only one side of your mouth is affected you could end up with an asymmetrical facial appearance, rather like after a stroke or Bell’s palsy. Fortunately with Botox none of these adverse events are permanent and the effect will wear off within three to six months.
Moving down the face another effective area for Botox treatment is the top lip, where fine vertical lines can develop. Here the margin for error is much less, and a lot of expertise and experience is required to get a good response and at the same time minimize the risk of lip incontinence. Particular care needs to taken when treating people who use their mouth muscles for the work, notably musicians. Loss of the fine motor coordination that they need from their lips might mean loss of their livelihood.
Some people have Masseter muscle hypertrophy, giving rise to a square-faced appearance. Injection of Botox here can produce subtle but worthwhile improvements if your appearance.
Botox can also be used in the chin area to reduce dimpling, and also to lift the corners of the mouth. This can be very effective but again a precise knowledge of the local muscle anatomy is required to avoid problems with lower lip weakness from incorrect injection.
Finally, Botox has been used in the neck to treat Platysmal bands. These are vertical bands that stretch up to the chin. Care needs to be taken with the dosage and injection site to avoid inadvertently affecting the muscles that are used to swallow.
We can think about the ways the dermal fillers can be used from the top down. The wonderful thing about the current generation of synthetic hyaluronic acid fillers is that you don’t have to wait for them to take effect as the results are instant. You will literally see your wrinkles and lines soften and sometimes disappear before your eyes. Modern dermal fillers last for a good length of time, that is, about six to nine months, and they also promote a small amount of new collagen production in the areas that have been filled which results in a progressive smoothing and rejuvenation of the filled area.
So if we think about the face, we can start with those deep forehead lines that can develop as we age. They do respond to Botox treatment, but sometimes Botox isn’t enough and some dermal filler can make all the difference. Deep lines between the eyebrows usually need filler treatment as well as Botox, and this can produce a dramatically effective cosmetic result.
Moving down the face we can think about the dark circles that people can get underneath the eyes. When these are permanent, that is, not just after a bad night’s sleep it can be due to thin skin which shows up the dark blue veins underneath. Dermal filling here can produce a very satisfactory correction.
Next there are those lines between the cheeks and the mouth and from the corners of the mouth sagging down producing a somewhat sad expression. They tend to deepen with time and become overly pronounced. Again, dermal fillers can soften these and even correct down-turned lip corners.
Jaw lines can become quite pointed due to jowl formation. It used to be thought that the only way to correct that was by means of a face lift. Nowadays it is appreciated that correction of the loss of volume along the front of the jaw line itself can give a dramatic improvement in appearance.
The skin of the hands can become excessively thin with age, and this is often a give-away even when the face still looks quite young. Some filler volume injected under the skin of the hands can correct this instantaneously.
Finally there is the chest area between the breasts and the neck. Often this area is neglected when sun screen is applied and the skin suffers from thinning due to loss of elasticity as a result of ultraviolet radiation exposure from the sun. Injection of small volumes of filler over this area can make a big difference.
Botox is a wonderful drug that can really help people to look younger. But it is important to have an honest discussion with your client to make sure that their expectations and your treatment objectives are in line. Often times I will come across clients who feel that their previous experience with Botox was too heavy handed, leaving them with a fixed, frozen and totally unnatural expression, or sometimes a droopy brow which interferes with their vision.
I will explain to my clients that I like to give Botox in a dose that will soften their lines and wrinkles but at the same time retain a degree of facial expression. This means a more youthful look but retains the natural balance and harmony of the face. While some clients do want the ‘frozen’ forehead look, they are in the minority and most would rather avoid this.
Choosing the correct dose for a particular patient is not as straightforward as your Botox course tutor might have you think. Although some of the Botulinum Toxin manufacturers do provide dosage recommendations, these should be used as a guideline rather than a one-size fits all formula. If you go down this road you will find that your customers will look for a more bespoke service elsewhere.
So how do you work out the correct dose? It requires a deep understanding of the anatomy and function of the facial anatomy, and an appreciation that everyone is different. So when I see a new patient who is thinking about Botox treatment I will carefully evaluate that persons facial musculature. I will look at the strength of their musculature by examining their muscle bulk. I will determine the anatomy of their muscles, which is often different from the description in textbooks. I will determine the impact of relaxing those muscles, particularly the frontalis and orbicularis oculi muscles.
In considering the impact I am thinking not only about the aesthetics but also what will happen to the visual function of my patient once their brow is relaxed. They are not going to be best pleased if you paralyze their brow muscles which they are using to keep their heavy upper eyelids elevated and out of the field of their vision
Some areas of Botox treatment are also more difficult to get right than others. In this context I am thinking particularly about Botox treatment for fine lines around the lips. In this area one has to be particularly respectful of the power of Botox and tread very cautiously as overdosage can lead to lip incontinence that can last for several months.
Botox works by relaxing your facial muscles, but how does this affect your wrinkles? The reason is that your facial skin is attached to your facial muscles. Except when you are asleep (though some of my patients tell me that they also frown in their sleep!) these muscles are constantly in a state of dynamic tension and activity. This activity wrinkles the skin and can eventually cause quite deep lines, especially as we age and the skin loses its elasticity. Botox works by immobilizing the muscles of facial expression. It does this by blocking the action of the neurotransmitter called acetyl choline at the point where the nerves from your brain meet your facial muscles.
The Botox therefore only acts in your skin, it doesn’t have any systemic effects in the rest of your body at the dosage that is used for cosmetic treatment. The actual injection of the Botox causes some local redness and possibly some bruising if a vein or (unusually) a small artery is accidentally hit by the needles. The redness will subside within a few hours, but bruising can take considerably longer to dissipate, sometime a week or two if it is really deep.
After the injection the Botox binds to the acetyl choline receptors on the muscle end of the neuromuscular junction, thereby blocking the nerve transmission. This binding can take a few days to take effect, and so the full effect of the Botox treatment usually takes seven to ten days to reach its maximum. Thereafter the Botox is gradually metabolized and dissipated.
So what you will notice after the injection of your Botox is that the redness from the injection will fade, usually over a few hours, and after two or three days you will see a softening of your lines and wrinkles. Of course, this is based on the assumption that the treatment has been provided at the correct dosage and injected in the right place. The other assumption is that the wrinkles that you have are amenable to treatment with Botox. Some lines and wrinkles are too deep for Botox alone, and need additional filler treatment to make a really good cosmetic improvement.
Regular treatment with Botox has been shown to have a very beneficial cosmetic effect on treatment. In effect, it puts your skin into hibernation by taking away all the stress caused by the constant activity of the underlying facial muscles. The end result is that after years of treatment, people who have had regular Botox look significantly younger than those who haven’t had the benefit of Botox.
Acne Rosacea is a long term skin condition that causes facial redness, thread veins and spider veins (known medically as telangiectasias), and in some cases, papules and pustules. These symptoms can be very troublesome psychologically, and lead to social withdrawal and isolation in some people who are severely affected. However, treatments are available that will help get rid of the redness, thread veins and papules. The question is which treatment is the most effective? The answer requires a strict scientific approach where groups of comparable patients are given different treatments and compared in a standardised way. Fortunately, this has been done for patients with rosacea.
The results of these clinical comparisons has shown that Azelaic acid cream is an effective topical treatment (that is, a cream that can be rubbed into the skin rather than a medication that has to be taken orally) that reduces nearly all the symptoms of rosacea in the majority of patients who are prescribed it. The only thing that it doesn’t help is established spider or thread veins (telangiectasia). These can be treated with Intense Pulsed Light or the newer Veinwave technique, which is based on radio frequency energy.
In the United Kingdom Azelaic acid is available as Skinoren cream. In rosacea it is thought to work by reducing the quantity of free oxygen radicals. It also has an exfoliative and anti-comedonic affect that works well for people who also have acne vulgaris, the common form of acne. Metronidazole antibiotic gel is an alternative treatment but it doesn’t work as well as Azelaic acid. Both are well-tolerated by most people, though some do have to stop treatment with Azelaic acid due to excessive dryness or irritation.
Azelaic acid has other advantages in terms of it being probably non-teratogenic, unlike the Vitamin A preparations like Tretinoin (although all medications should be avoided during pregnancy where safe and practical).
Botox/Vistabel (Allergan pharmaceuticals) and Dysport / Azzalure (distributed by Galderma in Europe) and Xeomin (Merz Pharmaceuticals) are different molecular formulations of Botulinum Toxin type A. It is known that one unit of Botox is not equivalent to 1 unit of Dysport /Azzalure. In Europe the recommendation is to use 2.5 units of Dysport / Azzalure for every 1 unit of Botox. Botox and Xeomin are equivalent in strength. The main advantages of Xeomin over Botox are a) Xeomin doesn’t need to be kept at low temperatures for storage and is therefore more likely to be used in pristine condition when it gets opened by your doctor because even with the best will in the world it is diffcult to maintain a cold chain for all parts of transportation especially in the summer months and b) your body is less likely to form neutralizing antibodies to Xeomin as it carries less molecular baggage than Botox.
In terms of the comparison of Botox and Azzalure a study of 62 patients in 2006 showed that both treatments were effective in treating wrinkles. However it showed that Botox was better in terms of wrinkle improvement and the duration of effect at 16 weeks than Dysport for forehead wrinkles when the ratio of Botox to Dysport/Azzalure was 1:2.5. The authors said that this study was financially supported by Allergan, the makers of Botox.
However, another study was done in 2007 on 26 people. This time a 1:3 ratio of Botox to Dysport/Azzalure was used so unfortunately it is not directly comparable with the 2006 study. However, this study showed that Dysport/Azzalure was superior to Botox with better duration of effect at 20 weeks after injection. The authors said that this study did not receive financial backing from any of the manufacturers. This study also included electrical measurements of muscle activity as well as digital photographic appraisals done by an independent panel of 3 examiners who assessed with forehead wrinkles of the people in the study.
The conclusions that can be drawn from these studies is that there is no clear best type of Botulinum toxin for cosmetic use. The efficacy of both products in terms of their cosmetic effects is well proven as is their safety record. The duration of action depends to a large extent on how many units are administered. If 3 units of Dysport/Azzalure are used for every one unit of Botox, then the research suggests a slightly longer duration of effect than Botox, and the opposite seems to be true when the recommended 2.5:1 ratio is used.
In terms of other aspects of patient satisfaction, particularly the rapidity of onset of effect and relative incidence of side effects they both have similar ratings. Median time to onset of effect is from day 3 for both products and reaches maximal effect at day 30.
My own preference is for Azzalure. It has a long, smooth duration of action. My patient satisfaction with treatment with this product is extremely high.
Botulinum toxin (Botox) anti-ageing treatment has been around for about 20 years now. It works by blocking the electrical signals that come from the nerves where they meet the muscles. This means that the muscle loses its normal tone and ability to contract. This translates into the skin over the muscle becoming smoother, wrinkle lines becoming softer and often disappearing altogether. But wait a moment, Botulinum toxin is a toxic substance, right? Surely it must be harmful to have a chemical toxin pumped into your system? Well, let’s have a close look at the evidence.
Firstly, Botulinum toxin is indeed a potentially harmful substance. Weight for weight it is one of the most poisonous substances on the planet. If you are given enough, it will kill you by paralysing the muscles that you use when you breathe. But because it acts in such a unique and totally specific way it can be useful too. In fact, it was through the genius and lateral thinking of a doctor that the medically useful properties of Botox were first discovered. Alan B Scott, MD, an ophthalmologist and founder of the Smith-Kettlewell Eye Research Institute in San Francisco, first developed and manufactured Botulinum Type A neurotoxin (BTX-A) for therapeutic use in eye muscles. So, in the right dose, Botox is an incredibly powerful and safe medication.
Exactly how safe is Botox? Well, over all the years that it has been used no deaths have reported to have been caused by cosmetic use of Botox. This is not surprising as the estimated lethal dose of Botulinum toxin would be approximately 3500 units, and the amount used in cosmetic treatment is usually around 100 units as a maximum. So there is a huge margin of safety.
What about the safety of long term repeated injections of Botulinum toxin? Botox wears off completely after 3 to 4 months, and so repeated injections are necessary to maintain an effect. There is no evidence from long term studies that repeated doses of Botox have any harmful effect. In fact, there is now evidence to suggest that regular Botox has a hibernating effect on the skin, so that people who have regular Botox end up looking younger than those who haven’t had the injections.
So the question as to whether you can be too old or too young to have Botox is not really a question of safety. It is really a judgement call on the part of the patient and the treating physician. I have found that some very young people, in their early twenties, can have quite deep lines, often hereditary. These can respond very well to Botox and will slow their progression. This can have very profound beneficial psychological effects for the patient. Similarly, older people with deep lines can usually see some benefit from Botox although their lines probably won’t disappear altogether.
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