Botulinum toxin has been licensed for the temporary improvement in moderate to severe lateral canthal lines (crow’s feet at the outer corners of the eyes), glabellar lines (frown lines between the eyebrows) and horizontal forehead lines. There are other areas which are less commonly treated with botulinum toxin. Although this is ‘off label’ (not specifically licensed for this treatment), these are well established and have evidence to support their use.

• Glabellar lines (frown lines)
• Lateral canthal lines (crow’s feet)
• Horizontal forehead lines
• Gummy smiles
• Bunny lines
• Smoker’s/Lip lines
• Platysmal bands (turkey neck)
• Jawline (Nefertiti Lift)
• Slimming of jaw muscles
• Chin dimpling
• Brow lifting
• Hyperhidrosis (Excessive Sweating)

Facial expressions occur when the brain sends nerve signals to the facial muscles causing them to contract in response to voluntary control, automated or emotional response. Botulinum toxin blocks the transmission of the chemical signal from the nerve reaching the target muscle. Without this signal, the muscle is unable to contract and remains in a resting state, therefore facial expressions are relaxed. It is not always possible or desirable to stop all movement as a completely frozen look may not be aesthetically pleasing. It is important to discuss your expectations with your practitioner prior to any treatment.

The effects of botulinum toxin are not instant, and most people will start to notice the results after about 4 days, having the full effect by about day 10. Most practitioners will offer a follow-up appointment at 2 weeks,  when the effects of treatment can be reviewed. Additional botulinum toxin may be administered at this time if needed.

Over approximately 3 to 4 months, the nerve terminal recovers and movement in the treated area restarts. Treatment can be repeated at this time to maintain the desired results. It is not recommended to repeat treatments at intervals of less than 3 months. Static lines that are present at rest, may soften once the botulinum toxin has taken effect and with repeated treatments may continue to improve as the skin recovers and is no longer being creased by constant muscle action. There are no known long-term side-effects from having repeated treatments, although there may be some muscle wasting (atrophy) with repeated treatments.

Botulinum toxin is injected using a fine needle, similar to the size used on an insulin pen. It is generally not painful and most people will only experience minor discomfort. Some people describe the sensation like plucking an eyebrow.

Very rarely, for people who cannot tolerate the procedure, a topical anaesthetic cream or ice may be applied prior to treatment to reduce the sensation.

Millions of botulinum toxin treatments have been performed worldwide and it has an excellent safety profile. However, as with any medical aesthetic procedure, there are certain risks and side-effects which should be discussed with you during your initial consultation.

Side-effects may be more likely due to the following factors:

• Patient factors: Poor condition of the skin, loss of elasticity, heaviness of the forehead, certain autoimmune or chronic medical conditions.
• Practitioner factors: Training, years of experience, number of procedures performed.
• Premises factors: Suitability of the premises.

We do not recommend that treatments are performed in a home environment.

Possible side-effects include:

• Injection site pain
• Bleeding and/or bruising at the injection sites
• Redness, itching, irritation at the injection site
• Swelling, including under eye puffiness
• Headache, which may last several days
• Nausea and/or hot flushes
• Poor cosmetic results
• Uneven effect on one side
• Drooping or heaviness of the brow or eyelid
• Abnormal appearance of the brows (Mephisto or Spock brow)
• Blepharitis (inflammation of the eye lids)
• Eye pain or visual disturbance
• Paraesthesia (abnormal sensation)
• Muscle twitching
• Flu-like symptoms
• Anxiety symptoms
• Rarely, muscle or joint pains

If you develop any unexpected side-effect after treatment, it is important to contact your practitioner as soon as possible, who may be able to offer advice or corrective treatment.

Prior to treatment, you should complete a medical history with your practitioner, you should also receive all of the relevant information you need to make an informed decision about whether to go ahead with treatment or not, as well as possible side-effects specific to your treatment and costs involved. It is usual to have an initial consultation and then rebook treatment for a later date, giving you the opportunity to have a cooling off period to consider all of the information provided.

Do not feel pressurised or coerced into having treatment at the same time as your consultation.

Before treatment, you should be given the opportunity to have any further questions answered and sign a consent form, either printed or electronically produced. The practitioner will examine the treatment area to determine the most appropriate injection sites and dosage required for optimum results.

Treatment usually takes about 10-15 minutes to perform and you can resume your normal activities afterwards. Photographs should be taken prior to having the procedure to compare with the outcome at a follow up appointment. Any photographs taken will form part of your medical record and should not be used for any other purpose without your explicit permission.

Botulinum toxin injections are usually undertaken with you lying on a treatment couch. Firstly, the treatment area will be cleaned and disinfected. The practitioner will examine the muscles, plan the treatment and then inject the required dose into the target muscles. Some practitioners may prefer to mark out the treatment areas prior to injection. You can expect between 3 – 6 injections per treatment area. Immediately after treatment, you may have small raised bumps on the skin where the botulinum toxin has been injected, but these should resolve within less than an hour.

If you have never had botulinum toxin treatments before, it is generally recommended to have just one area treated initially.

Treatment results are often more successful when the skin is in a good condition, with good elasticity, where facial expressions are not excessive and there are no or only minimal static lines in the area to be treated.

You may not be suitable for treatment if any of the following apply:

• Botulinum toxin is generally only recommended to those aged between 25 to 65, although it may be used off-license for people outside this age range.
• Botulinum toxin cannot be given to pregnant or breast-feeding women and is not recommended if you are actively trying to get pregnant.
• Patients with certain neurological disorders (such as myasthenia gravis).
• You are currently taking certain medicines (including antibiotics, such as clindamycin).
• You have previously experienced adverse reactions to any botulinum toxin treatment.
• Treatment is not recommended if you are suffering from any skin infection in or near the treatment area, including cold sores.
• You are unwell, including coughs and colds, on the day of treatment.
• You are taking any medicines which affect bleeding, such as aspirin or warfarin.

It is important to be honest about your medical history, previous surgery, previous or planned dental treatment and any medication taken, so that you can have a safe and effective treatment.

• Avoid taking anti-inflammatories (such as aspirin, ibuprofen, naproxen) for 3 days prior to treatment (unless this has been prescribed by your doctor) as this increases the risk of bruising.
• Alcohol, fish oils, St. John’s Wort, Gingko Biloba, garlic and Vitamin E should also be avoided for 3 days prior to treatment to lessen the risk of bruising.
• If you are prone to bruising, taking arnica orally for a few days prior to treatment may lessen the risk.
• If you are unwell on the day of your appointment, contact the practitioner to reschedule.
• Ensure your practitioner is informed if there are any changes in your medical history or medication taken before receiving any treatment.
• Do not plan to have treatment within 2 weeks of an important social event or holiday as this may not allow enough time to have some correction if the desired result is not achieved.

After treatment, most people can resume their normal daily activities. Immediately after treatment, there may be some redness, minor swelling at the injection sites and pin-prick marks, which should settle in time. If you develop any bruising, which may be apparent at the time of treatment or may even develop over the following days, it is usually minor and can be covered with make-up. Occasionally, more significant bruising can occur. Rarely, you may develop a headache after treatment which can last a few days. Simple analgesia can be taken for this if needed.

Many practitioners advise the following:

• Do not apply make-up for 12 hours after treatment to reduce the risk of infection.
• Try to avoid touching or rubbing the treated area until the following day as you may affect the results of treatment.
• Avoid extremes of hot or cold and vigorous exercise on the day of treatment.
• Contact your practitioner if you experience any unwanted side-effects.

Ensure you know the following information:

• Practitioner’s full name
• Practitioner’s profession (doctor, dentist, nurse, midwife, or pharmacist)
• Practitioner’s contact details (address, telephone number, and email)
• An emergency contact number if a complication arises.

Practitioners should be registered with their professional body (General Medical Council, General Dental Council, Nursing and Midwifery Council or General Pharmaceutical Council) and you can check their current registration status. Practitioners are accountable to these bodies and legally required to have indemnity insurance in place for all the treatments they perform.

If you are not happy with your treatment outcome, you should attempt to resolve this with your treating practitioner in the first instance. If you need to see a different practitioner, you are entitled to receive a copy of your treatment record outlining the product used, areas injected and dosage, as well as any photographs that were taken, to have your concerns addressed safely. However, remedial treatment may not always be possible. Sometimes it may be necessary to allow time for the treatment to wear off.