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Botox has become so synonymous with the portrayal of Plastic Surgery in the media that many people are confused about how, where and indeed why it is used. In this entry, I shall try to clear up the confusion.

Both Botox (onabotulinumtoxinA) and its major competitor, Dysport (abobotulinumtoxinA), are derivatives of Botulinum Toxin A, a toxin produced in nature by the bacterium Clostridium Bolulinum and responsible for the paralyzing illness ‘Botulism.’ The action of the toxin is to paralyze muscles for lengthy periods of time (up to a year). In medical doses, specific muscles may safely be put out of action to produce a cosmetic benefit. The medication is administered by injection, using a fine needle, into or near the target muscles, which are usually muscles of facial expression. The paralysis then takes a few days to take effect. Botox is not therefore a filler (a common misunderstanding), and because it paralyses facial muscles, the physician must be very selective in its use if a blank expression is to be avoided.

Specific sites for the clinical use of Botox are as follows:

a.     The frown lines between the eyebrows. This area is known as the ‘glabella.’ It often contains vertical creases caused by repeated and intense frowning. These can be abolished or severely reduced by Botox.

b.     The ‘crow’s feet’ wrinkles extending out from the side of the eyes. Botox paralyzes the lateral part of the underlying orbicularis muscle causing these ‘smile lines’ causing them to disappear on active smiling.

c.     The transverse crease sometimes seen on the bridge of the nose can be eliminated by using Botox to paralyze the tiny procerus muscle, which causes it.

d.     The infamous ‘bunny lines’ slanting down at the sides of the upper nose. These may be a natural phenomenon and can be treated with Botox, but, paradoxically, may actually be caused by the same agent! Here’s why: with the corrugator muscles and procerus put out of action, the patient’s efforts to frown are channelled into the only muscles in the region still working and, in some people, contributing to frowning – the nasalis muscles. Bunny lines can convey a feeling of distaste, particularly if prominent. They can be treated with Botox even if caused by it.

e.     The upper lip may be rolled out so as to display more of the red portion with a few units of Botox placed into the orbicularis muscle of the lip itself. The patient does not display the bulked up ‘duck lip’ seen with fillers since no bulk is added.

f.     Some people display multiple dimples over the chin due to excessive action of the mentalis muscle. This is not age related, but is easy to treat with Botox.

g.     Marionette lines are those extending downwards from the corners of the mouth towards the mandibular border in front of the jowl. They are associated with a down-turning of the corners of the mouth caused by action of the depressor anguli oris muscles. They can be weakened by Botox so as to elevate the corners of the mouth as part of a perioral rejuvenation.


Botox lasts for a number of months up to about a year, depending on the individual, the dose and the location of the injection. Repeating the treatment every four months is said to ‘train’ the muscle not to contract and produce a long term benefit. However, this has not been proven conclusively.

Side effects include paralysis of adjacent muscles leading to mild disabilities such as ptosis (droopiness) of the upper eyelid when the glabella is injected. Fortunately, such problems are short-lived, as the action of Botox is limited.


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