Botulinum toxin, a.k.a. Botox, is the world’s most potent known neurotoxin. It’s lethal in doses as small as five one-hundredths of a millionth of a gram; for a rough dilutional comparison, imagine dumping a case of beer into Mille Lacs and rendering every walleye in the lake blind drunk. The hard part, of course, would be stirring it all in—and the sad part, for many, would be the wasted beer.
For centuries, the only purveyor of the paralyzing botulinum toxin was the bacterium Clostridium botulinum. You could pick up a dose by ingesting it in bad food or by growing it yourself in a contaminated wound. Long since isolated in the lab, the toxin is now commercially available and is quantified in what may be my favorite dosing measure: the mouse unit. This is the amount of toxin it takes to kill 50 percent of a group of 18- to 22-gram female Swiss-Webster mice. My apologies to those of you who breed, show, and are emotionally involved with Swiss-Webster mice. It’s just a funny unit.
Looking to expand beyond the Swiss-Webster mouse euthanasia market, the purveyors of botulinum toxin won FDA approval in 1989 for use of the drug in the treatment of strabismus, commonly known as “lazy eye.” The eye is under the control of six distinct muscles, and adjusting the tension on one or more of them can straighten things out, eyeball-aim-wise. When injected into a muscle, botulinum toxin permanently blocks the adjacent nerve terminals from releasing the chemical that stimulates said muscle to contract. Voilá—paralysis! This blockage is irreversible, but in two to three months, new nerve terminals will sprout, replacing those that have been decommissioned. This is why patients treated with Botox generally need additional injections at regular intervals.
Botox hit the big time in 2000, when it was approved for the treatment of facial wrinkles—what cosmetic surgeons whimsically refer to as “hyperfunctional facial lines.” While most of us tend to blame wrinkles on the skin, they’re actually caused by the tiny facial muscles that tug on the skin, like sash cords moving drapes. These are the muscles that make our faces expressive, that keep us from walking around like emotionless zombies or Norwegian bachelor farmers.
The frontalis muscle is called the “surprise muscle” because it lifts the eyebrows and the skin of the forehead toward the scalp. Seinfeld’s Kramer gave his frontalis a workout, as did Democrats watching the 2004 presidential election returns.
It takes three muscles—the procerus, the corrugator, and the orbicularis—to form a scowl. Parents, almost without exception, have hyperfunctioning scowl muscles that, when stimulated, reflexively prompt such standardized phrases as “You did what to your sister?” and “What does the word no mean to you?”
The orbicularis oculi muscle makes a lap around each eyeball and can produce wrinkles near the outside edges of the eye. These lines are commonly referred to as crow’s-feet—as if crows, having recently become the canaries-in-a-coal-mine for the West Nile virus, don’t have enough PR problems.
Plastic surgeons and dermatologists can paralyze any of these muscles and watch the wrinkles melt away. The key to a successful Botox treatment is moderation: if the dose is too big or too potent, or if it’s placed too deep, the botulinum toxin can ooze into adjacent tissue and knock out some deeper facial muscles that you’re really gonna miss while they’re gone. An eyelid might not be able to close, or open; sagging eyebrows might give you a sleepy, Walter Matthau look; an inadvertently paralyzed eye muscle might cause double vision. An inexpert injection around the mouth can lead to the signature Dick Cheney/Popeye lopsided smile (Popeye shovels cans of spinach into his; Cheney, bottles of Lipitor).
In the hands of an experienced Botox practitioner, these complications are rare. Since the effects of Botox don’t peak for a month, problems are best avoided by erring on the side of undertreatment; the patient can always come back for a touchup if needed. The most common side effects of a wrinkle wrangle are bruising at the injection site, a mild headache (or, for reasons that aren’t well understood, headache relief), and flu-like symptoms that can persist for several days to a few weeks. Though botulinum toxin can be lethal, it takes about 2,500 to 3,000 units to kill an average-sized human. (Relax—the usual cosmetic dose is around 30 units. Yes, that’s Swiss-Webster mouse units.)
If relaxing the wrinkles of the cosmetically insecure strikes you as a trivial pursuit, you’ll be glad to know that Botox has other uses. Many people suffer from dystonia, a condition in which an overactive muscle group produces abnormal movements and postures. Botox can help them. Blepharospasm, a dystonia of the eyelid that leads to a kind of intermittent, involuntary wink, can be successfully treated with Botox, as can torticollis, a dystonia in which muscles on one side of the neck pull the head in that direction, as if the patient has watched too many NASCAR races from turn three.
In the aftermath of a stroke or spinal-cord injury, a patient’s muscles go flaccid. With time, however, the affected muscles become spastic—they move to a contracted position that stiffens the limb and compromises what little remaining movement the patient has. Botox injections force these muscle groups to relax, restoring lost range of motion and improving limb function. In children with cerebral palsy, Botox can relax tightened calf muscles, enabling the kids to convert from toe walking to a normal, flat-footed gait.
The benefits of botulinum toxin injections aren’t limited to skeletal muscles. If the muscles of the gastrointestinal tract become spastic, swallowing can be impaired. Enter Botox. On the other end of things, the anal door can become, functionally speaking, rusted shut, in which case Botox can be the WD-40.
So think of Botox as the blonde bombshell who’s made a name for herself by splashing her high-definition bosom across our plasma-screen nation, but who spends her off-hours binding the wounds of the injured. Jessica Simpson with a Mother Teresa side.
If you hate your wrinkles but can’t stand the sight of needles, particularly when they’re aimed at you, I’ve got a suggestion: sing those hyperfunctioning facial creases away! That’s right, sing!
(To the tune of “Garden Party” by Rick Nelson)
I went to a Botox party to youth-enize with my old friends
A chance to flatten all the wrinkles out and look alive again
When I got to the Botox party, the plastic surgeon knew my name
He said, “A few cc’s and I guarantee—you won’t look the same.”
But my face is all right now, the wrinkles just up and fell
You see, you can’t please everyone, so you got to please yourself.
People came from miles around, everyone was there
Dame Edna brought Bob Dylan, there was magic in the air
And over in the corner, much to my surprise
Martha Stewart with a new tattoo and liposuctioned thighs.
When the doctor called out “Ready!” Mick Jagger was first in line
With Keith Richards and Barbra Streisand just a step behind
As the doctor leaned in slowly to begin his plastic deed
Mick said, “I hope I get what I want,” and Keith said, “or what you need.”
Someone opened up a closet door and there Bob Barker stood
But the doctor bent his needles—Bob’s face was wood
Well, that night the crows feet fell, and as we chatted in the atrium,
We liked our looks and we tried to smile, but our faces all were numb.
Craig Bowron is a Twin Cities internist who frequently displays hyperfunctionality of the smartaleckus muscle group.