You can make botox injections last longer

Botox: use, effects and risks

Above all, facial wrinkles can be gently smoothed out with a botox treatment. © hedgehog94, Fotolia

Botox or botulinum toxin A is a highly effective neurotoxin that previously caused a sensation as a cause of food poisoning. Today, the protein produced by bacteria is a blessing for many people: a well-dosed Botox treatment smoothes wrinkles in a gentle way, relieves muscle spasms in spastic people and relieves migraines and depression.

Where is botox used?

From sausage poison to wrinkle smoother: the steep career of botulinum toxin

A Swabian bites himself

Botulinum toxin was discovered more than 200 years ago: in 1817, the Swabian country doctor and poet Justinus Kerner described the connection between a puzzling fatal paralysis and a previous sausage poisoning in the Tübinger Blätter für Naturwissenschaft und Medizinikunde. And the Swabian did not let go of the subject: He researched well over 200 cases and carried out countless experiments on animals. He administered the poison extracted from spoiled sausage products to cats, birds and rabbits and meticulously observed and described their signs of intoxication. In both the deceased people and the animals, he found that the muscles, but not the brain itself, were damaged by the poisoning - that is, those affected were fully conscious until they died. Kerner did not even shy away from a daring self-experiment: he drank from his aqueous sausage poison solution and thus triggered mild symptoms of sausage poisoning in himself.

Finally, through his research, Kerner realized that the said sausage poison blocks the nerve conduction. As a clairvoyant doctor, he immediately suggested the use of what he called a “fatty poison” against nervous disorders in another specialist article. These considerations were not taken up by the professional world at that time, nor was the name “Fettgift”. But at least the sausage poisoning described by Kerner was included in Latinized medical terminology: Since 1868 the food poisoning caused by the “fat or sausage poison” has been called “botulism” - after “botulus”, Latin for “sausage”.

Treasonous ham

The sausage poison was discovered - but its producer was able to remain hidden for many years. It was not until 1895 that the Belgian microbiologist Emile Pierre Marie van Ermengem discovered him. The occasion was a memorial service at which a 34-member music association played. The musicians had a good time in the village restaurant after the festivities. Thirteen of them developed the symptoms of what is now known as botulism, and three of them died. A rotten ham, which all 13 had eaten, was identified as a corpus delicti. In this and in the autopsied remains of the dead, the microbiologist found a suspicious, rod-shaped bacterium and named it - following the sausage theme - Bacillus botulinus. A short time later, Robert Koch's laboratory succeeded in developing an antitoxin from the pathogen isolated by Ermengem.

The producer of botulinum toxin, the rod-shaped bacterium Clostridium botulinum colored in this picture. © royaltystockphoto / stock.adobe.com

Illustrious kinship

Some time after its discovery, Bacillus botulinus became “Clostridium botulinum” because it turned out that the bacterium belongs to the large family of Clostridia. Clostridia live everywhere in the earth, there are both pathogenic and harmless representatives of their kind. Clostridium botulinum produces by far the most dangerous poison. But other relatives are also not without, such as the tetanus-causing Clostridium tetani or Clostridium difficile, which causes intestinal inflammation that is difficult to treat.

Botulinum toxin research in full swing

In the early 20th century there was great interest in the deadly active ingredient, and the USA in particular invested a lot of money in research into the poison. In this way, it was possible to produce large quantities of it as early as the 1920s. The production of the antidote was also in full swing. In 1946, an American recognized the chemical structure of the neurotoxin, and in 1949 British researchers discovered how it worked in the nerve cell. Seven different variants of the neurotoxin (A, B, C1, D, E, F and G) have now been isolated, two of which, A and B, are used therapeutically.

Botulinum toxin: from poison to medicine

Since Justinus Kerner, doctors have wondered whether the muscle-paralyzing effect could also be used medicinally. After all, the neurotoxin was used as a medicinal substance for the first time in 1980 - in ophthalmology to treat strabismus. Soon the ophthalmologists took advantage of the muscle-paralyzing effect for other diseases. In 1989 it was approved in the USA under the name Oculinum (from oculus, eye) for the treatment of eyelid cramps and eye tremors. A change of manufacturer also led to a change of name: Oculinum became Botox. Other areas of application were quickly added. Botulin injections were used to alleviate the most varied forms of spasticity, for example those of the legs in childhood cerebral palsy, the spastic cramps in torticollis (cervical dystonia) or writing cramps. In 1992, approval for various neurological diseases was also granted in Germany, namely for Botox and its first competitor, Dysport.

Many names, one active ingredient

Botulinum toxin, abbreviated to BTX, occurs under many names, for example as botulinum toxin A or B. Otherwise, the nerve toxin is also known as botulinum, botulinum neurotoxin (BoNT), botulin or botulinum toxin. The best known is, of course, the trade name Botox®. But there are other representatives on the German market: These include, for example, Azzalure®, Bocouture®, Dysport®, Neurobloc®, Vistabel® and Xeomin®.

Side effect: smooth skin

With the increasing use of botulinum toxin, doctors and patients noticed an interesting “side effect” of the treatment: the skin folds around the injection site were temporarily weakened. During the treatment of eyelid cramp, not only did the eyelid cramp disappear with the botulinum injection, but also the crow's feet sitting next to it. With these observations the triumph of Botox & Co. in the world of aesthetic medicine began. Only for ten years off-label and since 2002 with approval, dermatologists, ophthalmologists, plastic and aesthetic surgeons all over the world smoothed the wrinkles of their clients in a gentle way - with a syringe instead of a scalpel.

But botox has not done its duty with this alone: ​​Its dosed muscle-paralyzing effect is now used in many other diseases. The spectrum ranges from depression to heel spurs - and it is unlikely to end there.

Botulinum toxin: Warlike potential quickly recognized

Scientists and statesmen recognized the deadly potential of botulinum toxin early on. As a potent poison, it was the ideal candidate for a biological weapon, which is why both the Japanese and the Americans had it in their arsenal. The antidote was also in the luggage: For example, the US soldiers are said to have carried around a million doses of an antiserum with them when they landed in Normandy. Whether injected, swallowed or inhaled - the amount that corresponds to a grain of salt is said to be able to kill half a million people. Today the neurotoxin is one of the six most dangerous biological weapons in the world. It is feared that botulinum toxin is manufactured and stored by the military and terrorists in numerous laboratories around the world.

What is botox (botulinum toxin) and how does it work?

Nerve cell with the acetylcholine-filled vesicles (above). If botulinum toxin gets into the nerve, it prevents it from being released from the vesicles and acetylcholine no longer reaches the muscle fiber. © Reitemann

The protein botulinum toxin produced by the bacterium Clostridium botulinum is one of the neurotoxins or nerve toxins. It inhibits the transmission of signals from nerve cells to muscle cells and thus leads to paralysis. Such paralysis has very different consequences depending on the muscle: If a small dose of it is injected into a facial muscle, the facial muscle relaxes and can no longer be contracted, and the skin over it becomes smooth. If the nerve poison reaches the respiratory muscles, they are paralyzed - the person dies of respiratory paralysis.

Acetylcholine as a signal generator

How this paralysis comes about has been known since 1950. The nerve cell communicates with the muscle cell via the motor endplate. There it releases the neurotransmitter acetylcholine from its terminal, which diffuses through the tiny gap between the nerve end and the muscle cell and docks at its receptors. This is the signal for the muscle skin to open special ion channels - which ultimately triggers the contraction (i.e. the contraction of the muscle fibers).

This signal transmission is prevented by botulinum toxin. As soon as it gets into the nerve cells, it inhibits the release of acetylcholine from the reservoirs filled with it, the vesicles. The nerve cell can no longer emit acetylcholine and therefore no longer a signal. The switch for the muscle contraction remains “switched off”, resulting in paralysis. However, this paralysis is only temporary. As soon as the active substance is broken down by the body and the nerve endings have regenerated, acetylcholine is released again and the muscle is stimulated again. For this reason, repeated applications are necessary to achieve a lasting effect.

Is Botox Treatment Safe?

One nanogram - i.e. one billionth of a gram per kilogram of body weight is fatal in mammals. For a person weighing 70 kg, this is about 90 to 150 ng for intravenous administration, about 700 ng for inhalation and about 70 micrograms for oral ingestion. In contrast, the amounts administered during botox treatment are in the picogram range: a vial of commercially available botulinum toxin contains only 0.005% of the amount that would be fatal for an adult if it were taken orally. © Pixel-Shot / stock.adobe.com

Don't be afraid of poisoning

Even if botulinum toxin is a highly potent poison - nobody needs to be afraid of botulinum poisoning through treatment with botox. Because, as Paracelsus said, “the dose alone makes the poison”. The botox doses that are used therapeutically in medicine are so extremely low that there is no need to worry about symptoms of poisoning such as botulism. In addition, Botox injections may only be made by doctors.

Risks and side effects of botox treatment

Nevertheless - as with all medical interventions - there are risks such as side effects or possible complications with a Botox treatment, which the reputable doctor always draws attention to. In order to rule out these rare, undesirable effects as far as possible, the injections should only be carried out by an experienced specialist.

The injection can cause the following side effects:

The following complications are rarely possible:

  • Asymmetries in the face
  • Too much restriction of facial expressions
  • Drooping of the eyebrow or eyelid (drooping eyelid)
  • New wrinkles elsewhere
  • Dry mouth, difficulty swallowing (if the dose is too high).

Wrinkles away - completely without animal testing!

Mice no longer have to suffer for the production of most of the medicinally used botulinum toxins. © leli / stock.adobe.com

Botulinum toxin is not produced synthetically, but obtained from living bacteria under laboratory conditions. The potency can vary once. To prevent too much botulinum toxin from getting into the ampoules, each production unit (batch) must be tested. The strength of the active ingredient used to be tested by poisoning around 100 mice per batch to death by suffocation and thereby determining the LD 50 (dose at which 50% of the animals die). After global protests by animal rights activists, first the market leader Allergan, and later the Merz and Ipsen companies, developed new, animal-free tests. These tests are based on cell cultures and are recognized throughout Europe. Anyone who is treated with Azzalure®, Botox®, Vistabel®, Xeomin®, Dysport® or Bocouture® today can do so with a clear conscience.

Also safe in the long term

According to current knowledge, long-term consequences after Botox treatment can be ruled out. In the more than 30 years in which the active ingredient has been used against spasticity, muscle cramps and in aesthetic medicine, there has so far been no evidence of any damage. Microscopic examinations have also shown that after the active ingredient has been broken down, no changes remain in the nerve or muscle fibers.

Who should do without botox?

  • Pregnant and breastfeeding women
  • Patients with myasthenia gravis, Lambert-Eaton syndrome, amyotrophic lateral sclerosis, or motor neuropathies
  • Patients with a history of swallowing disorders and aspiration
  • Patients who are allergic to botulinum toxin or other components of the injection solution
  • Patients who have a tendency to bleed or have bleeding disorders (due to the injections).

What are the uses of botulinum toxin (Botox)?

Botox treatment in Wiesbaden

Dr. med. Günther Riedel, specialist in plastic and aesthetic surgery with additional qualification in hand surgery, is an expert in botox treatment, both for combating wrinkles and for use against depression and migraines. In addition, Dr. Riedel offers a wide range of aesthetic facial and breast surgery, hand surgery and aesthetic medicine in his private practice in Wiesbaden.

Botox against wrinkles

More and more men are also using Botox treatment for crow's feet or other wrinkles.
© focusandblur / stock.adobe.com

Wrinkles are a natural aging process that increases between 40 and 50 years. Depending on their predisposition and lifestyle, they are more pronounced in some people and less pronounced in others. Forehead and frown lines, for example, develop particularly strongly in people with lively facial expressions. Once there are wrinkles, they often make us look older or more surly than we feel. Unfortunately, there is little that can be done against wrinkles with creams. Botox is much more successful in smoothing the skin: Botox injections alleviate existing expression lines and can even delay their emergence.

Special article on the subject of botox against wrinkles

Botox against excessive sweating (hyperhidrosis)

To treat hyperhidrosis (excessive sweating), Botox is injected into the skin of the affected area of ​​the body. Usually around 20 injections are necessary per armpit. © Leonid, Fotolia

About 1 to 2% of the population is affected by excessive sweating. The stress from constantly wet hands and feet or huge patches of sweat under the armpits is enormous for those affected. There are a few options for controlling the excess flow of sweat - one of them is treatment with botulinum toxin injections. The neurotoxin blocks the release of acetylcholine and thereby inhibits the sweat glands. Botox is approved for the treatment of axillary hyperhidrosis, but it is also effective for sweaty hands, sweaty feet and in the head area.

Botox for depression

Botox treatment can significantly reduce symptoms of depression. © StockPhotoPro, Fotolia

Many people with depression no longer respond to conventional treatment methods using psychotropic drugs or psychotherapy. Botox offers a new therapeutic approach for these cases: Several studies have shown that injections into the area between the eyebrows (glabellar region) achieved good results in the treatment of some types of depression. Even if the botox treatment for depression is not yet officially approved, it can be used off-label by an experienced doctor.

Special article on the subject of botox against depression.

Botox for migraines

Migraines are most common in women between the ages of 20 and 50. Treatment with botox is a new therapy option. © Syda Productions, Fotolia © Syda Productions, Fotolia

Migraine is a widespread disease, around 10% of the population suffer from headache attacks, with women being more frequently affected than men (Obermann / Katsarava 2008). Treatment is often difficult. Here, too, botulinum toxin A is a therapy option: studies in which botox was injected into the pericranial muscles (e.g. neck and forehead muscles) using a fixed injection scheme show that the agent is more effective than the placebo group. The treatment has a preventive effect, i.e. it can reduce the number of migraine days - botox is unsuitable for stopping an acute attack. In 2011, botulinum toxin A was approved for the treatment of chronic migraines.

Botox against heel spurs

Sharp pain when putting weight on the heel is typical of the heel spur. In addition to cortisone injections and shock waves, the one-time injection of botulinum toxin is a promising treatment option. © Siniehina / stock.adobe.com

Injecting botulinum toxin is also a promising new treatment for heel spurs (plantar tendinitis). After injecting a few milliliters of botulinum toxin, the thickened tendon relaxes and becomes thinner again over time. Previous studies have shown that patients with painful heel spurs can be relieved of their pain quickly and sustainably by a single injection of botulinum toxin into the plantar tendon attachment on the heel.

Botox against grinding teeth (bruxism) and CMD

Women are significantly more likely to be affected by bruxism. The symptoms can be alleviated for up to 6 months with botox injections.
© Aldeca Productions / stock.adobe.com

Many people suffer from bruxism, i.e. the unconscious tensing of their chewing muscles - with or without grinding their teeth, during the day or at night while sleeping. The cause of this has not yet been clarified, suspected are emotional stress, sleep disorders, anxiety disorders or genetic influences. Continuous jaw clenching can also lead to dysregulation of the temporomandibular joints (craniomandibular dysfunction, CMD), the consequences of which can range from cracking and rubbing when opening the mouth to chewing pain, headaches and tinnitus to migraines. One of the many treatment options for bruxism is the injection of botox into the massage muscle. It does not reduce the number of bruxism attacks, but it does reduce the pain and the strength of the masticatory muscle activity.

Frequently asked questions about botox

How long does it take for a wrinkle treatment with Botox to work?

Botox begins to work 2 to 3 days after the injection, the maximum is reached after about 1 to 2 weeks.

How quickly can I get back to society after botox treatment?

As a rule, after a Botox treatment, you will no longer see small puncture sites, rarely also small bruises. These tiny changes can usually be easily painted over and disappear within a few hours or a few days.

What shouldn't you do immediately after a Botox treatment?

So that the active ingredient stays in place and does not migrate into unplanned areas of the skin, you should avoid sleep for the first four hours after the treatment and, if possible, not lie on your stomach or side for the first night afterwards. For the same reason, physical exertion with bowed head and sport should be avoided for a few days after the treatment. Facial massages and professional facial cleansing are also better postponed so that the active ingredient remains in the desired region. The face should not be exposed to direct UV radiation from sunlight or tanning beds for ten days. Visits to the sauna should also be avoided during this time.

How long does the effect of a botox treatment last?

The duration of the effect varies from person to person and also depends on what the botox is used for. In wrinkle treatment, the blockage of signal transmission and thus the smoothing effect lasts for about 4 months. Botox injections for excessive sweating are often effective for up to 6 months. In the case of heel spurs, the effect lasts even longer: many of those affected were symptom-free for a year after the botox injection.

Are Botox Injections Painful?

The doctor uses very thin needles to inject Botox. Nevertheless you can feel the prick, sometimes a short burning sensation after the injection. If you are very sensitive to pain, the doctor can also apply an anesthetic ointment in front of the injection; if the armpit is injected, it is sometimes iced up beforehand. If the palms of the hands or the soles of the feet are injected in the case of hyperhidrosis, there is also the option of numbing these sensitive regions with the help of regional anesthesia.

What does a botox treatment cost?

The prices for wrinkle treatment with Botox depend on how much active ingredient is needed. If the frown line above the bridge of the nose is only treated selectively, it will cost around 300 euros. If several regions are injected, the effort is greater and more Botox is used. This also increases the fee for the treatment, usually between 300 and 600 euros.

The treatment of hyperhidrosis in the armpit area takes about an hour and requires a larger amount of active ingredient. Here the treatment costs amount to around 500 to 800 euros.

Which regions of the face are particularly suitable for wrinkle treatment with botox?

Especially worry or frown lines between the eyebrows, horizontal lines on the forehead and crows' feet (fine lines next to the eyes) can be alleviated very effectively and naturally with botox. Wrinkles in the mouth region can only be improved to a limited extent with botox, since the muscles in the mouth region are essential for everyday movements such as speaking and eating. However, an experienced specialist in plastic and aesthetic surgery can also achieve beautiful results here through the targeted and well-dosed use of Botox.

On the Botox anti-wrinkle special page, we explain what kind of wrinkles which treatment helps.

Who shouldn't be treated with botox?

Patients with neuromuscular diseases such as myasthenia gravis or Lambert-Eaton syndrome must not be treated with botox. The same applies to pregnant women, breastfeeding women and people who are hypersensitive to botox or other components of the injection solution. Injections are unfavorable in the case of a blood clotting disorder, which is why botox treatment should be avoided. In cases in which aspirin or other preparations containing acetylsalicyl are taken regularly, these are - after consultation with the attending physician! - stop two weeks before treatment. If there is infection in the injection area, it is better to postpone treatment until it has healed. If in doubt, the attending physician will decide whether treatment with botulinum toxin is possible.

  • From nature: the latest discoveries [SK4] in the field of natural sciences. 1868, 31-34: 346.
  • Biological weapons, Wikiedia.org, https://de.wikipedia.org/wiki/Biologische_Waffe
  • Carruthers J, Carruthers A (1992): Treatment of Glabellar Frown Lines with [SK5] C. Botulinum-A Exotoxin, J Dermatol Surge Oncol 18 (1992): 17-21.
  • Feldmeier H (2002), “Bioterrorism: Botulinum as a biological weapon”; Tagesspiegel https://www.tagesspiegel.de/themen/gesundheit/bioterrorismus-botulinum-als-biowaffe/288694.html, accessed on January 28, 2021
  • Grüsser OJ (1986): The first systematic descriptions and animal experiments [SK2] investigations of botulism: On the 200th birthday of Justinus Kerner on September 18, 1986, Sudhoffs Archiv, 70 (2): 167-187.
  • Häfner S (2009): Justinus Kerner's Heroic Experiments with Botulinum Toxin [SK3], Current Neurology 36 (8): 412-417.
  • Kerner J, (1822): The fatty poison or fatty acid and its effect [SK1] on the animal organism ”, Cotta, Stuttgart and Tübingen
  • Kerner J, (1820): New observations on the fatal poisonings that so frequently occur in Württemberg from the consumption of smoked sausages, Osiander, Tübingen, PDF at http://idb.ub.uni-tuebingen.de/opendigi/JiI36a/pdf/ JiI36a.pdf
  • Kerner J (1817): Ueber das Wurstgift, Tübinger Blätter für Naturwissenschaft und Medizinikunde, Vol. III
  • Langbein K et al, (2002): Bioterror. The most dangerous weapons in the world. Who owns them, what they do, how you can protect yourself. Stuttgart / Munich ISBN 3-421-05639-0.
  • Messelhäuser U (2015): Clostridium botulinum I, Pathogenic Microorganisms, Volume I: Occurrence, Significance and Forms of Disease, Behr's Verlag, 2nd edition 2015
  • Moore P, Naumann M (2003): Handbook of botulinum toxin treatment. 2nd edition, Wiley-Blackwell
  • Neue Zürcher Zeitung (2002): Botulinum toxin - a possible B weapon, https://www.nzz.ch/article7SC7Z-1.354180, accessed on January 28, 2021
  • Pinza M, Botox is the strongest poison in the world. A terrorism risk, VgT Switzerland, https://www.vgt.ch/doc/botox/terrorismus.html, accessed on January 28, 2021

What is botox (botulinum toxin) and how does it work?

Is Botox Treatment Safe?

  • Doctors against animal experiments, doctors against animal experiments starts protest action, https://www.aerzte-gegen-tierversuche.de/de/neuheiten/3018-sloan-pharma-erstickt-46-800-maeuse-fuer-botox-produkt, accessed on German Animal Welfare Association, Botox: Mice suffer and die for beauty, Botox (tierschutzbund.de), accessed on January 28, 2021
  • Stahlmann R, (2012): Botulinum toxins. From [SK7] sausage poisoning to aesthetic medicine, Dtsch Apoth Ztg, 34: 46.
  • Kerscher M et al., Botulinum Toxin A in Wrinkle Treatment: Overview and Differentiation to Alternative Methods, Dtsch Arztebl 2001; 98 (26): A-1758 / B-1508 / C-1400.
  • Sommer B et al, (2020): Botulinum toxin in aesthetic medicine, 3rd edition, Georg Thieme Verlag.

What are the uses of botulinum toxin (Botox)?

  • Babcock MS et al, (2005): Treatment of pain attributed to plantar fasciitis with botulinum toxin a: a short-term, randomized, placebo-controlled, double-blind study, American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, 84 (9) 649-54.
  • Becker-Wegerich P, (2008) Wrinkle treatment with botulinum toxin A and special indications. In: Krutmann J. et al, (eds) Skin Aging. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-76821-0_6.
  • Bushara KO, et al, (1996): Botulinum toxin - a possible new treatment for axillary hyperhidrosis, Clin Exp Dermatol, 21 (4): 276-278.
  • Cotchett MP et al, (2010): Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: a systematic review, Journal of foot and ankle research, 3 (1): 18.
  • Fritz K, Fackel N, (2003): Botulinum toxin in the treatment of facial wrinkles, in: Akt Dermatol, 29: 33-42.
  • Heckmann M et al, (1999): Side-controlled intradermal injection of botulinum toxin A in recalcitrant axillary hyperhidrosis, J Am Acad Dermatol, 41 (6): 987-990.
  • Huang YC et al (2010): Ultrasonographic guided botulinum toxin type A treatment for plantar fasciitis: an outcome-based investigation for treating pain and gait changes, Journal of rehabilitation medicine: official journal of the UEMS European Board of Physical and Rehabilitation Medicine 42 ( 2): 136-40.
  • Logan LR et al, (2006): Autologous blood injection and botulinum toxin for resistant plantar fasciitis accompanied by spasticity, American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, 85 (8): 699-703.
  • Obermann M, Katsarava Z, (2008): Epidemiology of unilateral headaches, in: Expert Rev Neurother, 8 (9): 1313-1320.
  • Plewig G, Heckmann M, (2000): Treatment of hyperhidrosis with botulinum toxin-A, Dtsch Ärztebl, 97 (43): A-2850.
  • Peroz I, (2019): Bruxism - the S3 guideline for diagnosis and therapy, ZMK, 35 (7-8): 486.
  • Placzek R et al, (2006): Treatment of chronic plantar fasciitis with botulinum toxin A – an open pilot study on 25 patients with a 14-week follow-up, Zeitschrift für Orthopädie und seine Grenzgebiete, 144 (4) 405-9 .
  • Placzek R et al, (2005): Treatment of chronic plantar fasciitis with botulinum toxin A: an open case series with a 1 year follow up, Annals of the rheumatic diseases, 64 (11): 1659-61.
  • Roggenkämper P et al, (2005): Dtsch Arztebl 2005; 102 (41): A-2782
  • Ruscheweyh R. et al., (2018): Therapy of chronic migraine with botulinum neurotoxin A, in: Der Nervenarzt, 89 (12): 1355-1364.
  • Rzany B et al., 2018: Update of the S1 guideline on the definition and treatment of primary hyperhidrosis, Journal of the German Society of Dermatology, 16 (7): 945-953
  • Seyler ™ et al, (2008): Botulinum neurotoxin as a therapeutic modality in orthopedic surgery: more than twenty years of experience, The Journal of bone and joint surgery. American volume, 90 (Suppl 4): 133-45.
  • Wabbels B (2016): On the use of botulinum toxin in strabology, Der Ophthalmologe, 7.
  • Zamanian A. et al, (2017): Efficacy of botox versus placebo for treatment of patients with major depression, Iranian journal of public health, 46 (7): 982.

 

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