Americans stuck on Botox for 10 years now

Vancouver, B.C., ophthalmologist Jean Carruthers got the first inkling of the power of Botox in 1987, when a patient being treated for facial muscle spasms complained Carruthers had missed a spot.

"It's just every time you treat me there, I get this beautiful, untroubled expression," the woman said. And a bell went off in Carruthers' head.

Married to a dermatologist, Carruthers, whose specialty was oculoplastic surgery, knew "frown lines" between the eyebrows were tough to treat. What if Botox could be used on them?

That simple question propelled the couple through several years of experiments and investigation, then, 10 years ago this week, to the U.S. Food and Drug Administration's approval of Botox for treating frown lines.

Over the course of that decade, botulinum toxin, as it is technically called, has profoundly changed the work of dermatologists and plastic surgeons, and broadly expanded the use of cosmetic procedures by the general public.

"It's really skyrocketed our practices," says Susan Weinkle, president of the American Society for Dermatologic Surgery. "It's what brings many patients into the office. Once a patient is in, you have the opportunity to tell them the breadth of what else is available, which they might not otherwise know about."

$1.8 billion this year and counting

What was a $90 million-a-year business in 1997, treating people with crossed eyes, excessive blinking and neck muscle disorders, is projected to hit $1.8 billion by the end of this year. And that may be just the beginning. Botox manufacturer Allergan Inc. of Irvine, Calif., recently received FDA approval to treat chronic migraines and urinary incontinence, and is working to get approval to treat other bladder issues. The company also is beginning to study Botox for arthritis pain in the knee, says Allergan president David E.I. Pyott.

Botox word to the wise

Getting botulinum toxin treatments �is not something I think (people) should be impulsive about,� says Malcolm Roth, president of the American Society of Plastic Surgeons. He and others recommend that patients:

Experience matters: Get the shot delivered by a doctor who has performed hundreds of such procedures.

Men vs. women: Look for someone who has knowledge of facial anatomy and an understanding of facial aesthetics, several plastic surgeons and dermatologists recommended. Different people require different amounts of the drug, with men generally needing more than women.

Keep it fresh: Ask the nurse or doctor to mix up the solution immediately before the injection to insure freshness. Botox is delivered in powdered form and once water is added it must remain refrigerated and stays fresh for only about a day.

Botox is technically a neurotoxin, a killer of nerve cells, but in very small doses it merely blocks muscles from receiving messages from the nervous system. This is tremendously helpful in medical cases where muscles are overactive, such as crossed eyes and certain muscle disorders. Immobilizing certain facial muscles prevents frowning and minimizes crow's-feet at the outer corner of eyes.

Botox, injected 5.6 million times last year, now has competition from two other, similar products, Dysport and Xeomin, but it has become the Kleenex of the field � the brand name so familiar that people think it is the generic term.

For both good and bad, Botox's effects wear off in three to six months. That means frown lines need to be treated a few times a year � which is good for its manufacturer, and for doctors who charge a few hundred to $1,000 a treatment, depending on the work done. It also means any shots delivered to the wrong place, or muscles deadened a little too much, won't last long.

Although it is made from one of deadliest known toxins, there are no significant long-term safety risks from Botox, which has now been injected millions of times, says Mathew Avram, director of the dermatology laser and cosmetic center at Massachusetts General Hospital.

"Botox truly stands out as a safe and effective treatment that has revolutionized the way we can achieve facial rejuvenation," says Avram, who adds he receives no funding from Allergan.

The Carrutherses, who also say they receive no funding from Allergan, never cashed in on their discovery because Allergan already held the patent on Botox.

Beware the bad outcomes

Although dentists, emergency room doctors, gynecologists and others offer Botox shots now, dermatologists and plastic surgeons say their specialties are best trained to deliver the shots.

Signs of bad use of Botox include visible ripples, shiny foreheads and the completely frozen look common among some celebrities.

Many people prefer botulinum toxin shots to plastic surgery because the shots are more affordable, nearly painless and do not require patients to miss work, says Malcolm Roth, president of the American Society of Plastic Surgeons. And yes, people have continued to get their Botox during the economic downturn, Roth says.

Today, the Carrutherses still believe strongly in the product they first tested on Alastair Carruthers' assistant, Cathy Bickerton Swan, whose prominent frown lines were wiped away by Botox injections. And Jean Carruthers, who is now in her 60s, says she swears by Botox herself. "I've gone around saying I haven't frowned since 1987."