Artificial beauty and a long-lasting youthful appearance are no longer solely the result of aesthetic surgeries. The magical knife and aesthetic operations have been replaced by non-surgical treatments unified under the term tweakments, involving facial enhancement with Botox and dermal fillers, which are increasingly being used by men as well as women. In the last decade, Botox injection treatments, botulinum toxin, a neurotoxin produced by the bacterium Clostridium botulinum, which temporarily paralyzes muscles to reduce wrinkles and other signs of aging on the face, neck, and forehead, have become one of the most popular non-surgical cosmetic treatments in the world. Until three years ago, women accounted for 85 percent of its use, but today that percentage is decreasing in favor of men. Of the nine million Botox treatments performed in 2022, according to the International Society of Aesthetic Plastic Surgery (ISAPS), 42 percent were conducted in North America, nine percent in Japan, and the remainder was shared between South America and Europe.
The Magic of Botox and Dermal Fillers
Men have recently discovered the magic of Botox and dermal fillers and are undergoing treatments that erase wrinkles and make the skin look younger. However, unlike women, they are not willing to undergo major facial procedures as they want to look as natural as possible. This is aided by exosome therapy, tiny substances that connect and transport proteins and lipids between cells, which is performed through microneedling that activates the skin’s natural self-renewal through tiny punctures. Although the use of exosomes has not been approved by regulatory agencies in the USA, the UK, and Europe, they are marketed as miraculous treatments for hair loss, skin aging, acne, eczema, and even pain… Such treatments are becoming increasingly popular. The global market for exosome skin care products was valued at $256 million in 2023, and it is projected to grow to 674 million dollars by 2030. However, this is a small amount compared to the Botox market, which, according to SNS Insider research, is expected to reach a value of $13.74 billion by 2032. It is beneficial as long as these treatments are performed by professionals, but there is an increasing number of improvised practitioners, leading to a rise in complaints.
– Botulinum toxin type A (BoNT-A) is a purified protein complex of neurotoxin produced by the fermentation of the bacterium Clostridium botulinum type A (strain Hall). All BoNT-A complexes approved by the FDA are produced from the same bacterial strain, but each manufacturer uses similar procedures for further purification and preparation of the toxin for clinical use. Seven different botulinum neurotoxins have been isolated and described: A, B, C1, D, E, F, and G. The different serotypes of this toxin vary depending on the species they affect and the severity and duration of paralysis they cause. For example, it has been found that botulinum toxin type A is five hundred times more potent than type B when measured by the degree of paralysis induced in rats. The commercially available pharmaceutical preparation contains botulinum toxin and is sold under the trademark BOTOX® by Allergan, Inc. It consists of a purified complex of botulinum toxin type A, human serum albumin, and sodium chloride, which is packaged in a sterile, dry form. It is reconstituted with sterile saline solution without preservatives before injection. There are also different formulations of BoNT-A from other manufacturers,” explains Prof. Dr. Ruža Frkanec from the Center for Research and Knowledge Transfer in Biotechnology at the University of Zagreb, emphasizing that each of these products has specific indications, dosages, and methods of application, which is why users should familiarize themselves with the specifics of the products they use.
How It Works
According to her, these products are not interchangeable. Their units of biological activity are different, as are their characteristics, and they may have different safety profiles.
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—– Although there are differences in production and formulation, all BoNT-A products share an identical mechanism of action. Botulinum toxins bind with high affinity to cholinergic motor neurons and block the release of the neurotransmitter acetylcholine in the synaptic cleft at the nerve endings of muscles, thereby causing muscle paralysis. The clinical effects of peripheral injection, whether intramuscular or subcutaneous, of botulinum toxin type A are usually observed within one week of treatment, often within a few hours after injection. The most common effect lasts from three to six months, but it can be up to twelve months, depending on the indication. Frequent use of Botox can lead to the production of antibodies to Btx-A, which may compromise the effectiveness of long-term treatment,” explains Frkanec.
Filler Networking
According to her, the most well-known dermal filler used to fill wrinkles, increase the volume of cheeks, chin, reshape the nose, and enhance lips is hyaluronic acid (HA) because there are enzymes in the body that completely break it down over time. A person weighing seventy kilograms has about 15 grams of HA, and approximately half of that is contained in the skin.
– Currently, there are several commercial injectable fillers based on HA available. The main differences lie in their parameters such as origin, concentration, particle size, molecular weight, crosslinking agent, HA crosslinking technology, and the presence of non-crosslinked phases of HA. It is believed that crosslinked HA fillers increase the volume of soft tissues due to their water-binding and space-filling characteristics,” notes Frkanec.
She adds that the history of dermal fillers is long, as medical professionals discovered that taking fat tissue from one part of the body and injecting it into another area is very useful for treating various facial defects and scars resulting from trauma.
Risks and Duration
Bovine collagen was very useful for this purpose, and later human collagen was obtained, which is non-immunogenic, does not cause hypersensitivity, and allergic reactions.
– The duration of results from dermal filler treatments depends on the type of filler used, but they can be temporary, lasting less than six months, semi-permanent, from two to five years, and permanent. Biostimulating fillers provide results that improve over time, often over two years,” notes Frkanec.
She further explains that the risks associated with the use of dermal fillers can be short-term but also long-term with complications. Most of these side effects are mild and transient, but more serious side effects with long-term or even permanent aesthetic defects can occur.
– Every application can cause bruising and edema, which are most commonly observed after application and disappear after a few days. However, edema can also occur after injection as a result of hypersensitivity to the filler and can last for weeks. Chronic angioedema, deep dermal edema, and edema of subcutaneous tissues can also occur due to hypersensitivity to fillers. Similarly, malarial edema can occur on the cheekbones due to lymphatic drainage disorders and the formation of swelling. Vascular complications arise if fillers are injected into blood vessels, arteries, or veins. Complications are accompanied by reduced capillary blood flow due to obstruction, causing a blue-red discoloration of the skin. All of this can also lead to skin necrosis in the injection area. Symptoms may not appear immediately in the case of venous circulation compression but develop slowly and gradually over several hours. The skin at the injection sites is prone to hyperpigmentation. The biggest problem is the possibility of infection if the skin is damaged or if the injection site is not properly disinfected or due to unprofessional handling of the needle,” explains Frkanec.
Digital Shaming
She adds that individuals under the age of eighteen should not undergo these aesthetic treatments. Botox is also not recommended during pregnancy or breastfeeding due to a lack of detailed studies on its safety in these conditions, and it should be avoided by those allergic to botulinum toxin type A, patients with neuromuscular conditions such as myasthenia gravis or amyotrophic lateral sclerosis (ALS)…
– Many side effects have been observed in recent years, and an increase in their number is expected. This may be due to a combination of various factors, such as a lack of regulations and licensing in many countries, meaning that people with minimal or no formal training are administering injections of botulinum toxin and skin fillers. Unfortunately, this includes non-healthcare workers who lack a basic understanding of anatomy, physiology, pharmacology, procedures, complication prevention, and general patient management…,” lists Frkanec, adding that it is interesting that unrealistic expectations of users are also mentioned in the literature as a negative consequence of resorting to aesthetic procedures, so it is important to consider this, especially for young people undergoing procedures.
Another important aspect, considering social media and those who use it, is the phenomenon of ‘digital shaming’, the online ridicule of a person, or bullying. As the number of non-surgical aesthetic treatments increases, so does the number of complaints. According to data from Save Face, the UK register of accredited aesthetic doctors, there were 2,824 complaints in 2022, more than two-thirds of which related to dermal fillers, and the rest to Botox treatments. That unqualified therapists are not the only ones responsible for the negative consequences of these treatments but also their frequent repetition is demonstrated by an example from Australia. According to Dr. Gavin Chan, founder of the Victorian Cosmetic Institute, who spent a significant part of his medical career injecting dermal fillers, patients began returning to him a few years ago due to swelling around the eyes from treatments they had received as far back as seven years ago. MRI showed that long-injected fillers were still present in their tissue, even though their shelf life was supposed to be eighteen months. The cause lies in the frequent repetition of treatments.
