Botox common, but safety can be concern

Q: The lines on my forehead and around my eyes look more pronounced every year. I'd like to look younger, but I don't want to have surgery. Is Botox the way to go?

A: Over time, laughing, smiling, frowning, wincing, squinting and pursing your lips etch lines in the forehead, between the brows and around the eyes. Injections of Botox Cosmetic, which can smooth lines and wrinkles, have become the most common cosmetic procedure in the U.S. According to the American Society of Plastic Surgeons, doctors delivered more than 4 million Botox Cosmetic treatments in 2006, up 420 percent from 2000. Most people are satisfied with results, but that doesn't mean Botox is right for you.

The ASPS reports a treatment costs almost $500 on average, which sounds pricey. But compared with the average fee of nearly $5,000 for a surgical facelift, the injections seem relatively affordable. Plus, they require no recovery time and have few risks, although concerns raised by a consumer advocacy group recently sparked a Food and Drug Administration safety review.

If food contaminated with botulinum toxin is ingested, it causes botulism, a potentially fatal disease. But tiny doses of sterile, purified botulinum toxin should not enter the bloodstream or cause harm when injected into specific muscle sites. Three botulinum toxin products have earned FDA approval:

--Botox, which treats eyelid and neck-muscle spasms, as well as excessive sweating.

--Myobloc, which also treats severe neck spasms.

--Botox Cosmetic, which improves the appearance of lines and wrinkles.

A skilled physician can use Botox Cosmetic to approximate the results you'd get from a facelift or other surgical procedure. However, injections need to be repeated regularly to maintain the effect.

Botox Cosmetic, also called botulism toxin Type A, blocks the release of a chemical called acetylcholine, which is responsible for muscle contractions. When contractions in a few strategic areas are blocked, the muscles relax, and creases in the skin smooth out. Since the muscles can't contract, new creases don't form.

Injections take just minutes and don't cause much discomfort. You may notice mild redness for a few hours or occasionally minor bruising. You should notice a change in your appearance in three to seven days. The results usually last about three or four months. With continued use, the muscles thin, and the effects tend to last longer.

Botox Cosmetic does not smooth all wrinkles. It isn't effective for treating the deep creases from nose to mouth. Sometimes a dynamic scowl line is too deep and entrenched to relax. In these cases, you may need fillers to raise the depressed surface area left by the lines. Botox Cosmetic doesn't wipe away static wrinkles formed from years of overexposure to sun. Laser resurfacing techniques do a better job of erasing these lines.

Many people worry injections will leave them with an unnatural expression, or with frozen or asymmetrical features. But when done well, Botox Cosmetic treatments shouldn't drastically alter your facial expressions. In rare cases, injections near the upper eyelids may make them droop temporarily. If you have an injection in your forehead, you may get a temporary headache. But side effects are typically uncommon and minimal.

However, safety is a real concern when poorly trained, unlicensed practitioners inject botulinum toxins. Experts warn that a "Botox party" in someone's home or office is not an appropriate or safe way to receive a medical treatment, even a cosmetic one. The FDA also cautions that clinical doses are not comparable from one product to the next.

In February, the FDA announced an ongoing safety review of botulinum toxins following reports of deaths and hospitalizations. The most serious cases occurred in children with cerebral palsy who were given botulinum toxins to treat severe arm and leg muscle spasms.

Botulinum toxins have not been approved for treatment of any condition in children under age 12. Some serious reactions have occurred in adults using these products, but none were fatal, according to the FDA report.

Some people have had success reducing the appearance of fine lines and wrinkles with over-the-counter creams and products that contain alpha-hydroxy acids.

You might try these products first, however, improvements in appearance may take longer and aren't likely to be as dramatic.

For more information on the FDA safety review, log on to www.fda.gov. To learn more about minimally invasive cosmetic procedures, visit www.plasticsurgery.org.

The Harvard Medical School Adviser is researched and written by the faculty and staff of Harvard Medical School. Visit www.health.harvard.edu/adviser.