By Carol Lewis

The promise of a more youthful look was too tempting for 53-year-old Mary Schwallenberg to pass up. So, when the Food and Drug Administration approved a product that temporarily improves the appearance of frown lines between the eyebrows, the Orlando, Fla., resident took a shot at it. And it wasn't long before she became one of many people clamoring for regular treatments that often include refreshments and friendly conversation, as well as injections.

Botulinum Toxin Type A (BOTOX® Cosmetic) is a protein complex produced by the bacterium Clostridium botulinum, which contains the same toxin that causes food poisoning. When used in a medical setting as an injectable form of sterile, purified botulinum toxin, small doses block the release of a chemical called acetylcholine by nerve cells that signal muscle contraction. By selectively interfering with the underlying muscles' ability to contract, existing frown lines are smoothed out and, in most cases, are nearly invisible in a week.

BOTOX® injections are the fastest-growing cosmetic procedure in the industry, according to the American Society for Aesthetic Plastic Surgery (ASAPS). In 2001, more than 1.6 million people received injections, an increase of 46 percent over the previous year. More popular than breast enhancement surgery and a potential blockbuster, BOTOX® is regarded by some as the ultimate fountain of youth.

Schwallenberg, a pharmaceutical sales representative who is excited about her next round of injections, says she wants to look her best for her job. "That's corporate America for you," she says. "I have a lot of energy and I just wanted to look good."

BOTOX® was first approved in 1989 to treat two eye muscle disorders--uncontrollable blinking (blepharospasm) and misaligned eyes (strabismus). In 2000, the toxin was approved to treat a neurological movement disorder that causes severe neck and shoulder contractions, known as cervical dystonia. As an unusual side effect of the eye disorder treatment, doctors observed that BOTOX® softened the vertical frown (glabellar) lines between the eyebrows that tend to make people look tired, angry or displeased. But until this improvement was actually demonstrated in clinical studies, Allergan Inc., of Irvine, Calif., was prohibited from making this claim for the product.

By April 2002, the FDA was satisfied by its review of studies indicating that BOTOX® reduced the severity of frown lines for up to 120 days. The agency then granted approval to use the drug for this condition.

The FDA regulates products, but not how they are used. Approved products are sometimes used by a licensed practitioner for uses other than those stated in the product label. BOTOX® Cosmetic, for example, is currently being used by physicians to treat facial wrinkles other than those specified by the FDA. Consumers should be aware, however, that this "off-label" use has not been independently reviewed by the agency, and the safety and effectiveness of BOTOX® injections into other regions of the face and neck, alone or in combination with the frown-lines region, have not been clinically evaluated.

Ella L. Toombs, M.D., a dermatologic medical officer in the FDA's Office of Cosmetics and Colors, says, "Careful deliberation, investigation and evaluation is undertaken by the agency before any prescription product is approved." Drugs such as BOTOX®, which are not indicated for serious or life-threatening conditions, "are subject to a greater level of scrutiny because of the benefit-to-risk ratio." Toombs says this means that the FDA may allow someone to incur a greater risk from products that treat medical conditions, rather than from those that are approved for cosmetic purposes.

BOTOX® 'Parties'

The recent rise in the popularity of BOTOX® has much to do with the manner in which it is frequently marketed. Some practitioners buy the toxin in bulk and arrange get-togethers for people receiving their treatments. As in business, volume discounts can be found in medicine.

Plastic surgery events known as BOTOX® parties--also seminars, evenings and socials--are a key element of BOTOX® marketing in much of the United States. The gatherings are thought to be a convenient means of providing BOTOX® treatments more economically, and may help reduce the anxiety that normally goes along with getting an injection. Doctors are finding that treating people in groups allows them to make the procedure more affordable to their patients.

Here's how a "party" typically works: A group of often nervous, but excited, middle-aged men and women mingle in a common area. Sometimes refreshments are served. One by one, as their name is called, each slips away for about 15 minutes to a private exam room. He or she pays a fee and signs an informed consent agreement. Anesthesia is rarely needed, but sedatives and numbing agents may be available. The practitioner injects about one-tenth of a teaspoon of toxin into specific muscles of the forehead most often targeted for the effect. The person then rejoins the group.

Scott A. Greenberg, M.D., a board-certified plastic surgeon in Winter Park, Fla., has been hosting monthly "BOTOX® Happy Hours" in his medical office since the drug's approval in April. Greenberg feels that these by-invitation-only events to previous patients "are an opportunity to treat a lot of people at one time in a relaxed but professional atmosphere." Greenberg says there is no difference between treating 10 people during individual office visits throughout the day and treating 10 people individually, but in a more socialized setting. "The important thing is that the identical standards of medical care are maintained at these gatherings as in a routine daytime office consultation."

Julianne Clifford, Ph.D., of the FDA's Division of Vaccines and Related Products Applications, explains that "BOTOX® is licensed for marketing and distribution as single-use vials." This means that as packaged, "each vial is intended to be used for a single patient in a single treatment session." BOTOX® does not contain a preservative against potential contamination of the product through repeated use of a single vial. Once opened and diluted, BOTOX® must be used within four hours. Treating multiple people with one vial violates product labeling, which is stated on the package insert, the vial and the carton.

"We lose something when we mass treat," says Franklin L. DiSpaltro, M.D., president of the ASAPS. "One of my concerns is that these parties are a marketing tool--gathering as many patients as possible trivializes a medical treatment, which could deteriorate over time into a nonprofessional environment." DiSpaltro says there's more to medicine "than just dispensing drugs."

Schwallenberg, however, insists that "Dr. Greenberg was very professional. It wasn't a cattle call," she says. "And I don't think I'd go to a doctor I didn't know."

The FDA is concerned that BOTOX® has the potential for being abused. The ASAPS recently reported that unqualified people are dispensing BOTOX® in salons, gyms, hotel rooms, home-based offices, and other retail venues. In such cases, people run the risks of improper technique, inappropriate dosages, and unsanitary conditions. "BOTOX® is a prescription drug that should be administered by a qualified physician in an appropriate medical setting," says Toombs.

Greenberg agrees. "Patient safety has to be of prime concern," he says. "People need to be in the right hands when complications arise." That's why Greenberg does not allow his staff to administer BOTOX® treatments. Even the most skilled health-care providers, he says, can have complications as well as dissatisfied customers.

Although there is no chance of contracting botulism from BOTOX® injections, there are some risks associated with the procedure. If too much toxin is injected, for example, or if it is injected into the wrong facial area, a person can end up with droopy eyelid muscles (ptosis) that could last for weeks. This particular complication was observed in clinical trials.

Other common side effects following injection were headache, respiratory infection, flu syndrome, and nausea. Less frequent adverse reactions included pain in the face, redness at the injection site, and muscle weakness. These reactions were generally temporary, but could last several months.

While the effects of BOTOX® Cosmetic don't last, still, people don't seem to mind repeating the procedure every four to six months in order to maintain a wrinkle-free look. Battling the signs of aging in a non-invasive way, after all, is part of the allure of the product--that and the fact that there are no unsightly scars, and that there is very little recovery time with the procedure.

The FDA recommends that Botox Cosmetic be injected no more frequently than once every three months, and that the lowest effective dose should be used.