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The New York Times
Even those who know all about [botox] will be intrigued.
“Even those who know all about [botox] will be intrigued.”—The New York Times
“A cool new book…there are real lessons to be learned.”—Self magazine
“A fascinating and entertaining survey of how our faces contribute to our emotions… important.”—Publishers Weekly
"Facial expressions drive our feelings, as Dr. Eric Finzi persuasively describes in The Face of Emotion. Brace yourself: this enlightening, uplifting book will exercise your zygomatic major (smile).”—Jena Pincott, author of Do Gentlemen Really Prefer Blondes?: The Science Behind Love, Sex, and Attraction
“This groundbreaking book about the relationship between facial expressions and emotions is likely to provoke great interest. Eric Finzi — researcher, dermatologist and artist— has crossed traditional barriers to take us on a journey that starts with Charles Darwin, who first suggested an influence of the muscles of the face on the passions of the mind, and leads all the way to Botox as an unexpected potential treatment for depression.” —Norman E. Rosenthal, author of the New York Times bestseller Transcendence
Verdict A great read for armchair psychologists and those interested in unforeseen side effects of plastic surgery. This will make for an interesting read for undergraduate students in psychology, especially those interested in mood and emotion.—Rachel M. Minkin, Michigan State Univ. Libs., Lansing
(c) Copyright 2013. Library Journals LLC, a wholly owned subsidiary of Media Source, Inc. No redistribution permitted.
A POISON TO SOME A MIRACLE TO OTHERS
What is now proved was once only imagined.
We are bombarded on a daily basis with flawless images of women and men. Whether these images are real or enhanced digitally and/or surgically, the young movie stars and models become idols whose looks and actions are emulated by millions. From style to parenting to cosmetic procedures, these demigods provide an elusive standard to which many aspire.
The desire to look like these icons goes hand in hand with the wish to prevent or reverse the ravages of aging, a part of human behavior for as long as we have had records. For millennia we have searched for simple, quick, and effective ways of treating aging. Today, Botox has become the most popular cosmetic procedure in the world. What attributes of Botox account for its immense popularity?
Perhaps it is because Botox injections are quick, affordable (as cosmetic procedures go), almost painless, and effective at reducing lines and wrinkles. In addition, treatment with Botox is non-invasive, is safe, causes minimal bruising, and requires only a short recovery period. All of these features add up to a drug used by millions.
How surprising then is the vitriolic reaction that the discussion of Botox can elicit! What is it about this molecule that brings out big partisan guns at the dinner table? How many other small proteins have such strong emotions attached to them?
What Is Botox?
Botox is a trademarked name for one type of chemical whose scientific name is botulinum toxin A. It is derived from a bacterium that lives best under conditions where there is no oxygen. Before there were safety standards for the canning of food, it was not rare for people to die from the ingestion of this bacteria and its toxin after eating a can of improperly prepared food. Botulinum toxin is the most powerful poison made by nature. A single gram of the purified toxin, widely dispersed and inhaled, could kill a million people.
How Botox Was Discovered
In 1822, Justinus Kerner published his insights on the clinical course of botulism, including physical findings such as lack of tear fluid and muscle paralysis. Amazingly enough, he also speculated on the potential therapeutic value of botulinum toxin, including its possible use to prevent abnormal muscle movements. Subsequently, the bacterium responsible for botulism was identified and cultured. Long before any of the current uses, research was focused on purifying the toxin for use in warfare. Fortunately, botulinum toxin did not prove to be an easily applied weapon; it was more suited as a medicine. It wasn't until 1973, when Dr. Alan Scott first published his work on the treatment of strabismus (a disorder in which the eyes are not properly aligned with one another, usually resulting from a lack of coordination from muscles controlling eye movements) in monkeys with botulinum toxin, that the possibilities for botulinum toxin being used medically began to be explored.
Botulinum toxin's cosmetic uses were discovered when Jean Carruthers, a Canadian ophthalmologist, was treating a patient in 1987 for a rare eye disorder known as blepharospasm that causes excessive blinking of the eyes and, in some, causes the eyelids to slam shut. Dr. Carruthers treated the woman with botulinum toxin, then a largely unknown substance. Application of botulinum toxin in small amounts worked well and stopped Dr. Carruthers's patient's debilitating eye disorder. But, even with no symptoms, the patient kept coming back, telling her doctor that each time she received a botulinum toxin injection, the wrinkles between her brows seemed to disappear, giving her a relaxed, untroubled expression.
Dr. Carruthers's husband, Alastair, a dermatologist, found the story of the blepharospasm patient intriguing and began to explore how botulinum toxin could be used to enhance a person's appearance. Alastair and Jean's seminal research helped bring botulinum toxin into wide usage. Since then, millions have been treated with botulinum toxin for both cosmetic and non-cosmetic reasons.
The toxin prevents neurons from releasing the chemical that allows us to use our muscles. A tiny amount prevents muscles from performing their normal duties, such as swallowing and breathing. If you ingest enough of the toxin, it paralyzes all the muscles in your body, including the ones necessary for moving the diaphragm, which is a required part of breathing. Unless you are hooked up to a breathing machine, you do not survive long after ingesting that bad can of food. In the 1800s, eating a contaminated sausage would cause a slow and agonizing death as one's whole body became progressively weaker until, finally, one was unable to breathe. But injected locally, in tiny doses, the toxin paralyzes only a small area of muscle. The effect is temporary, lasting 3 to 12 months depending on where it is injected. In the face it is usually injected into the upper third to diminish forehead lines, crow's feet, and frowning between the eyebrows. Any lines on the face that are caused by underlying facial muscle movement are helped by Botox. The ability to smile with your mouth is not affected, and you look younger from the softening of lines and creases and the absence of a scowl between your eyebrows.
It sounds pretty nasty that you are injecting a poison—until you realize that almost all drugs, in the wrong dose, are poisons. What really matters is the difference between the effective and lethal doses of the drug. The bigger the difference, the safer the drug. Conversely, if there is not much distinction between the dangerous and the effective dose, one must be very careful. Let us take the example of the drug acetaminophen, known most commonly by its brand name Tylenol. It is a safe drug when used properly, as evidenced by the millions of children who take it every year (who would give a poison to their child?). But what happens if you ingest ten times as many Tylenol as recommended? This is one of the more common reasons that young people require liver transplantation.
Or how about trying to push away some anxiety with a few Valium and a couple of drinks to further numb the pain? Another very bad idea. This sort of combination has accidently killed quite a few in Hollywood because the ratio between the lethal dose and the effective dose of anti-anxiety pills is not very high to begin with and is lowered significantly when combined with alcohol. Quite a few drugs have dangerous interactions with other medicines that can alter their safety profile. Botox is not among them. The difference between effective and lethal doses of botulinum toxin is huge.
If someone accidentally injected 20 times as much botulinum toxin as needed into your face, it would not kill you (although your face would look frozen). The fact that botulinum toxin is such a powerful and specific poison actually makes it a relatively safer drug. If you take 20 times the proper dose of aspirin, the pain in your shoulder may go away only to be replaced by more severe stomach pain caused by a bleeding ulcer, one of the unfortunate side effects of aspirin. In order for aspirin to help your shoulder, it needs to enter your bloodstream. But for it to get there, you need to eat it. And 20 pills can make quite a hole in your stomach.
Even normal doses of certain drugs can occasionally have unpleasant side effects. Take the popular drug Bactrim, which is commonly used to treat urinary tract infections. Occasionally it causes a serious reaction called Stevens-Johnson syndrome. The rash can be life threatening and may appear after one normal dose.
Many of my skin cancer patients are older and are taking blood thinners for their cardiovascular disease. One of the most common is Coumadin (Warfarin). This drug does a beautiful job of inhibiting your ability to form a clot, which is helpful when trying to prevent heart attacks or strokes. But Warfarin is a tricky molecule. If you take three times as much as you need for your heart, you might bleed to death. It is also, for the same reason, one of the most effective poisons for rats. But I don't think that most of my patients know that every day they are swallowing a rat poison. If they did, they would probably be put off by it. One can just imagine how well the pills would sell if the bottle had a boxed warning about the danger of feeding the pills to rats. Warfarin is such a useful drug because it is such a good poison.
Botulinum toxin does indeed derive from a poison. But then so do many of our great drugs. Penicillin, the magical wonder drug that helped introduce the antibiotic revolution to modern medicine, is actually a poison made by a certain fungus that wished to kill the bacteria around it. The fungus makes it to "poison" its enemy, the bacteria. No one would deny the lifesaving features of antibiotics. But I have had patients who were perfectly rational in every other facet of their care, who, when I bring up the possibility of using Botox, said, "Oh no, I could never use that." They have heard that it is a toxin, a poison. They wanted other alternatives to soften a crease or a furrow.
Some of our best blood pressure medicines are derived from plant poisons that Stone Age tribes of humans living in tropical rain forests discovered to be powerful when placed at the end of their blow darts. When their prey or tribal enemy was hit by a poison dart, their blood pressure lowered enough that they collapsed and died. Their poison darts led to the discovery of a whole class of medicines that lower blood pressure. But personal risk assessment, unless you are a statistician, usually does not reflect reality. How otherwise to explain why many prefer to drive rather than fly 900 miles because it feels safer?
In contrast with most other drugs, botulinum toxin in normal doses stays where it is put: an injection into the forehead will have no effect anywhere else in your body. The fear that botulinum toxin generates because of its poisonous origins is understandable, but it does not entirely explain the disdain some express for this molecule. Perhaps its ability to travel on both sides of the medical road plays a role. How many drugs are able to make you look younger and also help alleviate a wide variety of medical diseases? Only one: Botox. There are no other role models for Botox—nothing else that works well cosmetically and medically. There are no other medicines that can help your migraine headaches, reduce unwanted sweating, help you pee when you want to, help cerebral palsy sufferers, improve your mood, and make you look younger. It sounds a lot like one of those magic tonics sold by traveling salesman at the end of the nineteenth century, but this medicine is real. Let us review some of the many diseases for which Botox is important.
Parkinson's disease (PD) is a complex and progressive movement disorder that can cause symptoms such as tremors, pain, and difficulty with walking and balance. Patients can suffer uncontrollable rigidity in their posture from sustained abnormal activity of their muscles. For example, a PD patient may have a foot that is twisted or pushed down because of a muscle that won't stop working. In addition to pain, this may lead to many falls as a dragged leg gets caught in cracks in a path. To correct this, Botox is injected in a targeted way into the muscles that are distorting the leg, releasing it from the grip of muscle spasms and pain. Within a week of injections, muscle relaxation allows many patients to walk normally again. Botox has been FDA approved to treat PD patients.
Sometimes a PD patient can develop a twisted or tilted neck. Not only is this painful, but it makes it difficult to turn one's head for driving. Botox can help restore the normal neck position, allowing PD patients to continue driving and remain independent.
Similarly, Botox is now approved for cervical dystonia, a condition that causes the neck to twitch, twist, go through repetitive movements, and carry the head in abnormal postures. It happens because involuntary muscle contractions hinder normal movement and cause severe, chronic neck pain.
Cerebral palsy represents another group of movement and muscle disorders that can be helped by Botox injections. Muscle tightness and spasticity caused by the disorder make walking difficult and can worsen over time as muscle spasms increase in severity. Writing can also be difficult. By injecting Botox into the stronger, spastic muscles, the weaker muscles can be strengthened and stretched, and normal movement can be partially restored. Children who were previously bound to wheelchairs have been able to walk. While not a cure for cerebral palsy, Botox injections can dramatically improve the quality of life for young children suffering from this disease.
Sometimes the benefits of botulinum toxin have been discovered by serendipity. An Atlanta plastic surgeon noticed that many of the patients on whom he had used botulinum toxin cosmetically reported back to him that botulinum toxin had not only removed their facial wrinkles but their migraine headaches as well. Word spread quickly, and many doctors began using botulinum toxin "off-label" for headache treatment. Years ago my operating room nurse Sharon suffered from severe and frequent migraines. They weren't hard to recognize. Her head would become slightly tilted, one eye would be bloodshot, and it was easy to see that she was in pain. Botox completely prevented her headaches for three months at a time. As soon as the Botox wore off, the headaches would reemerge, but fortunately, like clockwork, a new round of injections suppressed the migraines.
Migraine headaches were originally thought to be primarily a disorder of blood vessels, but the effective prevention of many a migraine by botulinum toxin has opened a new window into the role that facial and scalp muscles play in the disorder. Few would have predicted that botulinum toxin would become a standard treatment for migraines. But controlled studies have now been done, and Botox is currently FDA approved for injection into the forehead and scalp to treat and prevent migraine headaches.
Botulinum toxin has also been approved for treating underarm sweating. It sounds trivial until you learn that some sufferers sweat so much that they are forced to carry several changes of clothing with them daily. They can't take their jackets off without disturbing their coworkers. The excessive sweating is caused by overstimulation of sweat glands. Botulinum toxin injection into the armpits quiets the glands responsible for those drenched shirts. Botulinum toxin is also being used to combat sweaty palms, which, as any salesman can tell you, are not good for business.
In some patients with multiple sclerosis or a spinal cord injury, the bladder may not communicate normally with the brain, leading to overactive bladder muscles. Instead of filling with urine and relaxing, the bladder muscles contract, decreasing the normal volume of urine that the bladder can hold. This leads to unwanted leakage of urine or urinary incontinence. Injections of Botox can relax the overactive bladder muscle and have now been FDA approved for this condition.
The diversity of clinical uses for botulinum toxin will only increase as we discover more maladies that can be remedied by treating a specific muscle. Research around the world has led to the discovery of an ever-expanding list of medical uses for botulinum toxin. Many disorders are caused by muscles that contract when they shouldn't or muscles whose use worsens the disease, and botulinum toxin halts the nerve impulses that fire the muscle into action.
What is surprising is how many different diseases can be helped by botulinum toxin. Since botulinum toxin is specific for its inhibition of muscle contraction, we have learned how important a role muscles play in different diseases. In addition, for many diseases, muscles provide a suitable entry point for treatment. For example, underarm sweating is not caused by a problem with the tiny muscles around the sweat glands in your armpits. But you need those little muscles to propel your sweat from under your skin to the skin surface. Therefore, if you inhibit those muscles from working, you can no longer sweat in those areas.
Some do not believe in the concept of cosmetic surgery and thus distrust anything that can change one's appearance. But the distinction between reconstructive and aesthetic surgery has always been a blurry one. How does one judge a rhinoplasty that corrects a deviated septum, allowing one to breathe better while simultaneously refining the tip of the nose? The surgery clearly helps breathing, but what pleases the patient more—better breathing or a better profile?
But is more and more of a good thing still good? Like any powerful tool, botulinum toxin can be overused. Every dermatologist has occasionally seen patients look frozen because of the injudicious use of too much botulinum toxin. However, that is definitely not the norm. When used at proper doses and proper injection sites, the effects of botulinum toxin A are more subtle. We need our faces to communicate with others: if you can't move your forehead or your eyebrows, you can't give all those visual cues, mostly unconscious, that help others understand what you're trying to say. For the same reason that most of us would prefer to discuss serious emotional issues in person rather than over the telephone, movement in our faces helps us "talk" to others. Think about all those misunderstandings that begin with casual chatting on the Internet, chatting that deprives one of evaluating all the clues of communication, including the tone and timbre of voice, body posture, and facial expression. The same applies to plastic surgery: we have all seen that face-lift gone awry. There may be an ideal in beauty, but there are many ways to get to Rome, none of which requires casting our faces from the same mold.
Excerpted from The Face of Emotion by Eric Finzi. Copyright © 2013 Eric Finzi. Excerpted by permission of Palgrave Macmillan.
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