In the era of the “natural look”, botulinum toxin has never been so popular. Anti Age Magazine & Longevity interviewed Dr Laurie Saloner, an expert in botulinum toxin injections.
Anti Age & Longevity Magazine: How does botulinum toxin work?
Dr Laurie Saloner: Botulinum toxin is produced by a bacteria called Clostridium botulinum. Botulinum toxin type A blocks the exchange of acetylcholine by exocytosis at a neuromuscular level. This stops the muscle that is myomodulated by the toxin from contracting. It is a fully reversible effect because the body does not conserve any toxin over the long term (it is resorbed after 4 to 6 months, depending on the individual). Remember that toxin injections are a medical treatment that must only be performed by qualified doctors (dermatologists, facial surgeons, ENT, maxillofacial surgeons, ophthalmologists, neurologists).
AA&LM: Where did botulinum toxin come from?
DR. L.S.: Originally, it was used in ophthalmology to treat oculomotor muscle spasms. In France, botulinum toxin obtained market approval in 2003. It is often used in aesthetic medicine for the forehead area, though only two toxins have market approval for use in three areas
– glabella, forehead and periocular region – and Bocouture is approved for injection into all of these areas.
AA&LM: What is the best indication for toxin?
DR. L.S.: I think it is a gold-standard way of fighting aging and is the most effective product available to us in anti-aging medicine: it is aesthetic medicine’s superpower. Nowadays, when people are looking to restore, preserve or maintain their facial volumes, it is the best treatment available. It is worth noting that toxin does not alter the face’s anatomical structure, but rather it reduces the strength of the muscles to reduce the signs of aging. The idea is to preserve enough strength in the muscles so as not to freeze the facial expressions, meaning that the face can still move, but not enough that it has an adverse effect on the skin. That is what causes wrinkles: excessive muscle contractions that have an impact on the dermis, as the muscle contractions become stronger over time. The advantage of toxin is that, by reducing the strength of the muscles, it allows the skin to restore itself over time. I’d like to point out that this is also a bioresorbable product.
AA&LM: How can you explain the “frozen look” and how can we remedy it?
DR. L.S.: There was a time when the frozen look was everywhere – so many women with expressionless faces – but we soon realised that a lack of expressions does not necessarily make you look younger. When you look at some actresses – in Desperate Housewives, for example – paradoxically the one with the frozen face looks the oldest because she no longer looks natural. To avoid this effect, we need to take a subtle approach. A toxin like Bocouture not only respects the activity of the subjacent muscles, but it is also a so-called “precise” toxin, meaning that its spread is limited. For example, when I identify and mark out my injection points on the face, I choose to preserve the mobility of certain muscles, such as in the eyebrow area. We know that the frontalis muscle, the only muscle to elevate the eyebrow, is responsible for horizontal forehead lines. This is therefore a muscle we want to treat, but carefully, so that it can still move a bit. It is a delicate task! This is exactly where we need to use a “precise” toxin so that we can carefully target the neuromuscular junctions. Bocouture allows us to target the muscles very precisely, as it only spreads up to 1 cm around the injection points.
AA&LM: Do you have to be careful with agonistic and antagonistic muscles?
DR. L.S.: Yes. By reducing the activity of one muscle, we enhance the intensity of another. In the “Baby Botox” trend that we often talk about, the theory is to inject and block small areas. But these injections accentuate the effect of the nearby antagonistic muscles, which means we risk creating wrinkles where there were none before. This can be seen in young women who have glabellar lines after sun exposure and only want to treat this area, which has the consequence of increasing the strength of the frontalis muscle that lifts the eyebrow, for example.
AA&LM: What are the differences between the toxins?
DR. L.S.: In addition to their so-called precision, the main difference between the toxins is the product’s purity. For example, Bocouture does not produce any “anti-toxin” antibodies, so the patient’s body is less likely to resist its action. This feature comes in useful for any touch ups that are carried out soon after treatment, because the practitioner does not have to be careful about generating antibodies. The second difference might be its durability, but most studies have shown a similar durability for all of the toxins available on the market. Finally, with regard to Bocouture, this is a stable toxin and does not need to be kept refrigerated, so that negates the risk of the product degrading at room temperature.
AA&LM: What are the main trends and best combinations of procedures?
DR. L.S.: For me, the future of toxin lies in “full face” treatments. Before, we would mainly focus on the upper third of the face when using toxin, but today we go for a global approach to preserve the volumes, with the aim of preserving the facial structures. We realised that the muscles that pull the face downwards lead to a loss of a clear jawline, the appearance of platysma cords and even nasolabial folds, all of which get worse with age. Using toxin as a preventative tool blocks these depressor muscles and, consequently, activates the elevator muscles, particularly the zygomaticus major and minor muscles, which reduces the formation of expression lines, among others. We can combine this with hyaluronic acid, which lasts longer, and calcium hydroxyapatite, which boosts the skin’s density. The best combination, in my opinion, is toxin for prevention and tissue inducers to stimulate collagen production.
AA&LM: When should you start having toxin treatments?
DR. L.S.: As a preventative tool, you should start quite young, around age 30, but generally it should be as soon as you notice any wrinkles that cannot be erased with creams. What is good about toxin is that the skin never goes back to its original state. The more you have it, the less the muscles contract over time, which means the sessions can be spaced out more.
AA&LM: Are toxin treatments becoming more mainstream?
DR. L.S.: Yes. Since we now seek more natural-looking results, toxin injections are in fashion and are no longer demonised. What is more, we are stepping into a new era of toxin, with new studies into how it can improve the skin quality as well as the hair density and even using it to treat rosacea. This is the idea behind “mesobotox”, which allows us to myomodulate the activity of the skin and blood vessels with very superficial injections. This might even lead to a new indication for toxin in mesotherapy.
Dr Laurie Saloner
Face, neck and rhinoplasty surgeon who has taught the university diploma in facial aesthetic surgery for many years. A former hospital practitioner, she has used her experience to teach facial anatomy to generations of junior doctors through dissections and operations. Her approach aims to preserve and improve the face, to prevent aging without deforming the existing fatty volumes.
