Botulinum toxin injECTION

Botulinum toxin, one brand being Botox, is an injectable neuromodulator derived from neurotoxins produced by Clostridium botulinum, the bacterium responsible for botulism. The toxin inhibits the neurotransmission between peripheral nerve endings and muscle fibers, this will weaken or paralyze the muscle. Initially used for medical indications, botulinum toxin injection has now become one of the most requested procedures in facial cosmetics. 

When used appropriately, botulinum toxin injection is an overwhelmingly safe method to treat different Neurological disorders, most importantly Migraines and different dystonias and spams, such as  Blepharospasm and  Hemifacial spasms. 

The clinical relevance of Clostridium botulinum, a gram-positive bacillus, was first recognized in 1897, when the toxin produced by the organism was identifies as the etiologic agent of Botulism,. There are different types of the toxin, Type A is the most common form used. 

The clinical utility of the toxin stems from the ability to prevent muscular contraction through inhibiting the release of acetylcholine from the peripheral nerve cells into the neuromuscular junctions.  The acetylcholine is needed to perform the muscle action, so its absence will result in weakness and paralysis of the muscle. 

There are different formulations, the one we use in the clinic is mostly OnabotulinumtoxinA, called BOTOX. 

The toxin is manufactured in small bottle and must be reconstituted. I use saline for reconstitution, with different dilution ratios. The dilution will all depend on the clinical application.

The dose of the toxin will depend on the clinical application. For example, treatment of Migraine will require higher dose than what is needed for Blepharospasm. Additionally, men will require higher doses than women, due to stronger and larger muscle mass.  

The injection sites will depend on the indication.  In patients with migraine for example, I inject in specific pre-determined sites on the forehead and temple, and depending on the distribution of the pain, the back head muscles can also be injected.  For chronic severe cases of Migraine, I also use follow-the-pain protocol to improve the success rate. 

For other applications, such as hemifacial spasm and Blepharospasm, different muscles will be injected, and the dose is less. 

As I mentioned above, botulinum toxin is a safe treatment.  I use special very fine needles. The treatment is very well-tolerated by many patients. I usually apply ice to the skin, and this makes the treatment even more tolerable.

Little bruising can happen, but this is not common. General recommendations will be given to the patient following the treatment. 

Many patients with migraine will improve on botulinum toxin injection. However, there are patients who will not respond. Further sessions are not recommended if the first session failed.  

If the treatment proves to be effective, then it can be repeated after 3-4 months. The good effect can sometime last for up to 6 months in some patients.