The most popular anti-ageing treatment of all time

As Botox cosmetic celebrates its 20th birthday this year in the United States, we take a trip down memory lane with the founders of this revolutionary treatment.

Thought to be the most powerful toxin known to man and capable of causing paralysis, millions of people across the world have botulinum toxin type A injections to address the ageing effects of furrows, frowns and wrinkles. What was once the domain of the A-listers is now very much entrenched in the ‘every woman’ modern-day beauty arsenal and has become a worldwide phenomenon.

The birth of Botox

Although the cosmetic effect of botulinum toxin on wrinkles was first documented by a plastic surgeon from Sacramento, it wasn’t until Canadian husband and wife ophthalmologist and dermatologist physicians Jean and Alastair Carruthers published their research in 1992 that ‘Botox’ for cosmetic use was officially born. In 2002, it was officially approved in the US as a treatment for frown lines in adults. (Australia had already introduced Botox for cosmetic use back in 1999.)

The birth of Botox to treat wrinkles was something of an accident. As an ophthalmologist, Jean Carruthers had been using botulinum toxin type A to treat blepharospasm – an uncontrolled muscle spasm that occurs in the eye.

‘One of Jean’s patients complained that she hadn’t been treated in this area,’ Dr Alastair Carruthers told us during an exclusive interview in San Diego some years back, pointing to the region between his eyes where you’d imagine frown lines may exist had he not discovered Botox’s ‘other’ use.

“I didn’t think you were spasming there,” my wife replied, to which the patient explained, “But every time you treat me there I get this overly untroubled, unworried look and my family tells me I look so much better!”’ he recalls.

As a dermatologist, Alastair Carruthers knew first-hand the significance of this flyaway comment. In the late 1980s, his cosmetic toolbox was sadly lacking any weapon capable of improving the appearance of frown lines.

‘We didn’t have anything,’ he emphasises. ‘Collagen was about it.’ It didn’t take long for the husband and wife team to begin their exploration into the cosmetic potential of botulinum toxin type A. ‘The very next day, Jean treated our receptionist, Cathy,’ says Dr Carruthers. ‘Cathy had witnessed Jean inject hundreds of clients so she knew it was a reasonable procedure. A few days later, I saw her and remember saying, “Wow”, because I hadn’t seen anything like it before,’ he recalls.

With his cosmetic practice side by side with his wife’s ophthalmology clinic, from that point on, Alastair Carruthers would send his own patients next door for treatment, any time he met someone who wanted to improve the appearance of their forehead furrows.

Of course, without clinical evidence the use of botulinum toxin would not be the phenomenon it is today. ‘It took time, but we gradually accumulated a number of people and, in March 1991, we were able to present our data,’ he says.

The results were impressive, but the timing poor. In 1991, the US FDA (Food and Drug Administration) was in the midst of threatening jail-time for the illegal promotion of the off-label use of Retin-A. ‘And then we come along and tell the FDA we want to inject the most deadly material known to humanity in order to treat wrinkles,’ Dr Carruthers says. ‘Everyone said we were crazy.’

Cosmetic doctors the world over started to use it – off-label – to improve the appearance of frown lines, but it wasn’t until 2002, after formal clinical trials, that the FDA approved Botox Cosmetic to temporarily improve the appearance of moderate to severe frown lines between the eyebrows.

‘It took a while, but with the support of some key dermatologists, it was as if all of a sudden there was a critical mass and people started to listen to us,’ Dr Carruthers recalls.

Botox Cosmetic, as we know, went on to become a major blockbuster, estimated to bring in US$2 billion in annual sales for Allergan.

Given that Botox can be considered one of the most successful symbioses in late-20th- century cosmetic medicine, it’s understandable to assume that Jean and Alastair Carruthers went on to become billionaires.

As two people upholding an ethical position, however, they refused to cash in. Although they eventually went on to become consultants with Allergan, the multi-billion dollar company that would launch Botox Cosmetic, and which already owned the formula for medical use, they never patented their discovery.

‘We took advice from a lawyer in Toronto who was supposed to be an expert and said that he did not think this was a patentable idea. We have since learned that it was indeed,’ Dr Carruthers told a Canadian magazine back in 2010. ‘Are there any regrets? I guess so, but not major.’

What exactly is botulinum toxin and what can it treat?

Botulinum toxin is a protein produced by the bacterium Clostridium botulinum. It is a muscle relaxant that is commonly used for cosmetic facial enhancement, particularly to treat crow’s feet around the eyes, the frown lines between the eyebrows (glabellar lines) and the worry lines across the forehead. The marionette or sad lines, from the corner of the mouth to the chin, can be effectively treated with botulinum toxin. It can also be used to produce the effect of a brow lift by relaxing the muscles that drag down the brow.

In cosmetic procedures, botulinum toxin works by blocking nerve stimulation to wrinkle-causing muscles, which prevents the muscle from contracting and significantly reduces wrinkles and fine lines.

Not just a pretty face

While many people think of botulinum toxin as a modern-day treatment for wrinkles, it has actually been used since the 1960s to treat a range of medical conditions. But its discovery actually extends much further back in time.

In the 19th century, German physician Justinus Christian Kerner first recognised the potential therapeutic uses of botulinum toxin. An 1815 outbreak of botulism (a dangerous paralytic illness caused by the toxin botulin) in southern Germany among people who had eaten uncooked blood sausage led Kerner to publish a precise description of botulism’s symptoms – from blurred vision to progressive muscle weakness, culminating in respiratory failure. He postulated
that minute quantities of the disease- producing substance might be able to treat disorders of the nervous system.

In the 1970s, Dr Alan Scott of the Smith-Kettlewell Eye Institute demonstrated that botulinum toxin was a powerful therapeutic agent that could be used to treat ophthalmic disorders associated with muscle over-activity such as lazy eye or eyelid spasms (blepharospasms). Since then, it has been used to treat a variety of involuntary muscle contractions or disorders such as neck spasms (cervical dystonia), to reduce symptoms of an overactive bladder, relieve teeth clenching and grinding, and even as a migraine and tension headache preventative.

Botulinum toxin is used in much higher doses to treat children two years of age or older suffering from cerebral palsy to help them walk.

It can also be injected into the skin to block the action of the nerves that control sweat glands, and in this way treat excessive localised sweating (hyperhidrosis), especially severe underarm sweating.