August 28, 2023

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When starting out in medical aesthetics, there are many situations that can arise which can leave you struggling for answers – Should you treat patients over 65 years old with botulinum toxin? Are so-called ‘Botox parties’ a good or bad idea? Can you become resistant to botulinum toxins? Do redheads get poor longevity from Botox treatments?

In this blog, Dr Tim Pearce answers these common questions posed by aesthetic clinicians about botulinum toxin or Botox® treatments.

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Should we treat patients over 65 years old with botulinum toxin?

Many over-65-year-olds ask aesthetic clinicians for botulinum toxin treatment to look fresher or younger. Dr Tim explains that you can treat them; the difference is that treatment with this prescription medicine is regarded as off-label.

older patient lip fillersOff-label, in this instance, means that there is data to support the use of botulinum toxin type A in patients below the age of 65 for the indications that are licensed for various brands, including forehead lines, lateral canthal lines (crow’s feet), and glabellar creases. But, in those patients who are older than 65, there is not sufficient data to support use, thus the manufacturers do not claim it and it is not part of the license. This does not mean that botulinum toxin magically stops working at 65 years old, nor does it mean that any patients over 65 that you treat will end up with an unacceptable side effect. Treating a 66-year-old patient will be the same as treating a 65-year-old, for example. However, the difference is that you are making the decision as a practitioner to take on that responsibility and would need to defend your decision-making for going off-label by presenting evidence that based on accepted clinical practice, the treatment was in the realm of normal treatments carried out by other aesthetic clinicians, were there ever to be a court case or a patient claim of harm against you. There is plenty of evidence to support older patients being routinely treated with botulinum toxins, usually with good results.

One note of caution from Dr Tim is that you are more likely to get some of the known side effects from botulinum toxin with an older patient cohort because the skin in older patients tends to be less forgiving. It is more likely to drop. The skin is less resistant to muscle movement, but also less resistant to gravity. If you use the expected dose for those under 65, you are more likely to see heaviness or asymmetry in those over that age because of the position of the muscle and the relative strength of the botulinum toxin, alongside the fat and skin elasticity which is lacking compared to younger faces.

Learn more on how to get a great result with Botox in older patients.

Botox parties – a good or bad idea?

This is a very contentious topic, explains Dr Tim, because from a healthcare practitioner’s perspective, it boils down to having a party to carry out non-elective medical interventions, and these two concepts do not go well together, even though they do happen within the aesthetic sector. The reason why they are not a good idea is because patient autonomy is eroded.

As healthcare practitioners, we have different standards of practice, and we must protect our patients’ decision-making processes. Treating patients in the environment of a typical ‘Botox party’ is likely unethical and likely against professional standards. If you are going to perform a medical procedure on someone, you need them to have made that decision in a clear frame of mind, without any external influences such as a friend encouraging them and applying peer pressure or the imbibing of alcoholic drinks at the party which alters their mental state; these are not good ways to make a decision to go ahead with dermal filler or botulinum toxin treatments.

However, there is nothing wrong with gathering people/potential patients together for an evening event to perform a demonstration (on an already consulted model), so you can educate the audience about treatment, and then take bookings if they are interested in a personal consultation. This gives them a cooling off period to give it some thought – some may cancel the appointment after the event – and means that when you do consult them for treatment, they have autonomy over their decision to proceed.

Can you become resistant to botulinum toxins?

The simple answer is, yes; but it is probably rarer than most people think.

Resistance means that you develop an antibody to a component of the active molecule. The botulinum toxin molecule comes wrapped in an envelope of other molecules that are not part of the active component. In fact, one brand (Bocouture®) has removed the stabilising proteins, and the product works well. Many believe that botulinum toxin resistance is causal to the antibody picking up activity and responding to the supporting proteins rather than the active part of the botulinum toxin. This can mean that if you switch brands, you get efficacy back for some patients, although there is little science available to support these theories.

Resistance to botulinum toxin can be a real problem for both patient and practitioner when they develop an antibody to the active component of the botulinum toxin molecule. This means the antibodies stick to the molecule before it has a chance to act on the nerve, resulting in no effect on inactivating muscles. Sometimes, there is an in-between action which results in a dulled effect, with a small proportion of patients who get a short-lived result from treatment, perhaps where some of the botulinum toxin molecules can get to work and some are nullified.

To solve this, sometimes all you need is a higher dose, but quite often it ends up in none of the products working. Dr Tim admits that he has had a small number of patients who do not respond to any of the type A botulinum toxins, which is unfortunately sad. As an aesthetic clinician, you must look at other means to treat them because it is futile to keep adding more and more in those people who are truly resistant. However, data suggests that truly resistant people are in the minority and most benefit from higher doses. You must have an open, honest discussion with your patients, as soon as possible, if they appear resistant, so you can establish whether you both want to persist with the uncertainty of trying different brands and approaches, based on the costs involved and the potential for failure.

Do redheads get less time out of Botox treatments?

This is an interesting question that broadly relates to whether there are genetic predispositions that can impact the longevity of a botulinum toxin treatment.

Dr Tim surmises that there are probably many genes or genetic components involved in restoring the function of a nerve after botulinum toxin treatment – supporting regrowth, rebuilding receptors, nerve generation, and muscle hypertrophy – all contributing to the rate of achieving a full recovery after relaxation of a muscle. Whether being a redhead is one of them, he simply does not know. Anecdotally, he has not experienced any marked difference in patients with red hair in his clinic but notes that if anyone would like to gather 30 to 40 red-headed patients for a small study, he would be interested to hear if there are any significant results compared to non-red heads. He is aware of generic differences for those with red hair in relation to sensitivity to pain and spicy food, but the jury is out on any impact on botulinum toxin treatments.

For more information and insight on botulinum toxin injections, why not check out:

You can find Dr Tim Pearce on Instagram if you have any common questions about medical aesthetic treatments, or wish to comment on any top tips you are going to implement; he loves to hear from you all..

Botox® is a registered trademark of Allergan Aesthetics plc.

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Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

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