What is botox?
In the late 18th century, many people died in southern Germany from eating spoiled meat and sausages, and they showed progressive mydriasis and muscle flaccidity. German scientist Justinus Kerner named this 'sausage poisoning' and after studying the substance extracted from spoiled sausages, he hypothesized that this toxin interfered with the signal transmission of the motor nerves and suggested that it could be used therapeutically for hypersensitivity of the nervous system in small doses. Later, botulism broke out again in Belgium, and the causative strain was first isolated and named Bacillus botulinus. It is now called Clostridium botulinum. Botulinum means sausage in Latin. The toxin produced by this strain is a neurotoxin (a substance that is toxic to nerves) and is called botulinum toxin.
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| Justinus Kerner, known as the godfather of botulinum toxin |
Botox Mechanism of Action
Motorneurons at the neuromuscular junction terminals of peripheral nerves release acetylcholine (ACh, neurotransmitter) to transmit signals, allowing muscles to function and maintain muscle tone. The mechanism of action of botulinum toxin is to specifically and irreversibly bind to target tissues (①), enter cells (endocytosis) (②), and then interfere with the function of SNARE proteins that play an important role in releasing acetylcholine (③,④). At this time, the type of SNARE protein complex affected varies depending on the serotype of botulinum toxin.
Botulinum toxin has seven forms (A, B, C, D, E, F, G) depending on the serotype, and this is a difference depending on the strain variant. There are five types, A, B, E, F, and G, that act on the nervous system of the human body, and types A and B are widely used in clinical practice because their effects last longer than other serotypes. In general, type A is known to be more effective (toxic) than type B and to have a stronger effect on muscles. Botulinum toxin is widely known as a wrinkle-removing injection under the product name Botox, but it is currently used in various fields such as for cosmetic treatment as well as for the treatment of blepharospasm, strabismus, hyperhidrosis, migraine, cerebral palsy, bruxism, and neuropathic pain.
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| Mechanism of action of botulinum toxin at the neuromuscular junction terminal |
Differences in Effects by Type of Botox
Currently commercialized botulinum toxin type A preparations include Botox®, Dysport®, and Xeomin®, while type B preparations include Myobloc®. Among these, Botox® is the original botulinum toxin that was first approved by the US FDA and sold by Allergan Inc., an American pharmaceutical company, in 1989, and thus has an exclusive position in the market, and is also expensive. So, is Allergan the most effective?
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| Botox from Allergan |
The potency of all commercially available botulinum toxin finished products is expressed in units, with 1 unit corresponding to the lethal dose (LD50, the dose that causes 50% of the administered group to die) calculated in a specific mouse. It is expressed by measuring the content of the toxin, not the dose that produces physiological effects such as smoothing out wrinkles.
Botulinum toxin is a biological product, not a synthetic drug, and is produced by living cells, and although the strains are the same for each product, the strains are different. Accordingly, small genetic variations exist, and even if they are the same serotype A toxin, there are differences in biological metabolic processes, etc. In addition, clinical profiles can change depending on the manufacturing method even for the same strain. In addition, they are slightly affected by the ingredients of the product, such as diluents and stabilizers. Therefore, even if the unit is the same for each product, there are differences in the in vivo profiles such as efficacy, maintenance period, safety, and side effects, as well as in storage methods, shelf life, and stability. However, the toxin produced by the botulinum strain is not strain-specific and is a species-specific characteristic. Since it is considered to be the most potent toxin in existence, there appears to be little difference depending on the strain and manufacturing method.
The composition of commercialized botulinum toxin is composed of the toxin part that directly performs physiological actions and additives, and the toxin part is composed of a complex of neurotoxin and non-toxin proteins. First of all, Allergan, Xeomin, and Dysport have the same strain and only slightly different manufacturing methods. In the case of Xeomin, it is said that the non-toxin protein is removed and only the pure toxin is purified. I don't know about Dysport because I've never tried it, and I recently switched to Xeomin after receiving Allergan for a long time because the price was burdensome, and although it may vary from person to person, the effect and duration were the same as Allergan.
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| Allergan's Botox |
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| Mertz's Geomin |
This is a product called Liztox, manufactured in Korea, and there are many other types of Korean botox. I haven't tried many types, but based solely on my personal experience, for the cosmetic aspect, I think you can get sufficient results from botulinum products without having to insist on Allergan.
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| Liztox, a Korean-made product |
Botox side effects
Botulinum toxin is a relatively safe drug, and when used for cosmetic purposes, small amounts are used locally, so the frequency of side effects is significantly lower than when used for therapeutic purposes. However, local side effects such as temporary headaches, ecchymosis, mouthweakness (weakened ability to chew when injected into cheek muscles), ptosis, bruising, difficulty speaking, and paresthesia may occur. The disadvantage is that the effect does not last permanently and the price is relatively high, but the side effects are temporary, so they can be considered advantages.
If there is a side effect that is most concerning when receiving cosmetic treatment, it is expected to be botulinum toxin resistance, which reduces the effectiveness of botulinum toxin. Since botulinum toxin contains a protein component that does not exist in the human body, it can cause an immune response in our body and produce antibodies (neutralizing antibodies) that block the therapeutic effect. Antibodies are easily produced when high doses (more than 200 units for one treatment) are used or when injected frequently (within 3 months). When used for skin beauty purposes, the problem of antibody production can be ignored because a low dose of less than 100 units is used at a time. In the case of Xeomin, it is advertised that there is no resistance as it is a pure toxin, but if it is used in a dermatology clinic, there is no need to insist on Xeomin. However, if you are receiving regular botox treatment, it is best to receive it at as long an interval as possible.
When does botox work?
It takes 24-72 hours for the toxin to take effect after injection, and the effects of botulinum toxin peak in about 10 days and last for about 2-3 months. After that, muscle contraction gradually recovers, and you can feel it gradually returning after 4 months. After 6 months, it returns more, but it is not the same as before, so it is safe to receive the treatment once every 6 months in terms of maintaining the effect and the side effects of developing tolerance.