Botulinum toxin Type A (Botox) has been getting a lot of press lately about its expanding aesthetic applications.

Although it was officially approved by the FDA in 2002 for the temporary treatment of frown lines between the eyebrows, the product has been used by plastic surgeons for a number of other treatments—off-label uses—including brow lifts, to relieve migraine headaches, to stop excessive sweating, and the latest application—breast lifts?

According to Patricia Wexler, MD, a board-certified dermatologist who practices in New York City, botulinum toxin Type A injections in the breast are a quick fix for women who want to noninvasively give the breasts a temporary lift.

“Botox is a yin and yang of muscle movement,” Wexler says. “If you weaken a muscle that’s pulling something down, the muscle which is pulling up has nothing to oppose it. So, if you weaken the pectoralis minor muscle, which is pulling the breast down, the rhomboid muscle in the back is going to have nothing to oppose it, so it’s actually going to pull up your back and give you better posture and actually lift your breasts up.”

The breast lift procedure using botulinum toxin Type A requires three injections on each breast and is performed with a tiny needle. According to Wexler, the effect lasts anywhere between 10 and 12 weeks.

“There is no anatomic basis to the breast lift procedure using botulinum toxin Type A, and patients could anticipate several possible complications,” says Jane Petro, MD, a plastic and reconstructive surgeon who practices in Mount Kisco and Purchase, NY, and is editor of the American Journal of Cosmetic Surgery.

“The pectoralis minor muscle is not connected to the breast, but lies under the pec major,” Petro says. “The pec major is connected to the breast by loose areolar tissue, which offers a surgical plane for inserting breast implants, but has no relationship to the position of the nipple areolar complex and the inframammary fold. It is the relation between the nipple and the fold that defines ptosis, or drooping of the breast. The rhomboid muscle is a shoulder muscle and has no relationship to the breast or its ligaments whatsoever. Therefore, it could not play a role in ‘lifting’ the breast.”

In February, the FDA issued a warning regarding the possible side effects of off-label use of botulinum toxin Type A injections, stating that it had caused botulism—a rare but serious illness caused by botulinum toxin that leads to respiratory and muscular paralysis—even death—in some patients.

“Off-label is something that is created by the FDA regulatory system,” Petro says. “Many of the most commonly used botulinum toxin Type A procedures can still be considered off-label, even though they are widely accepted. “

According to Leslie Bryant, manager of corporate communications at Allergan Inc (maker of botulinum toxin Type A), the use of botulinum toxin Type A injections for off-label use are within a physician’s medical discretion, and many plastic surgeons use it to treat many different conditions.

IS COTTON THE CULPRIT ON THE CAPSULE?

Regarding “Solid Strategies in Revisional Breast Surgery” by Robert Oliver, Jr, MD (PSP, April 2008): Nine years ago, I heard Dr [John] Tebbetts present unpublished material on a serendipitous finding during routine capsular studies with SEM. Cotton fibrils were seen as double refractile bodies throughout the capsular tissue being studied.

I have since stopped using any cotton products in the operating field in any of my submammary augmentations to either help the dissection or absorb excess bleeding. I have seen a dramatic drop in my incidence of capsular contracture from 10% to less than 0.5%.

We were taught to use Raytec sponges to dissect the subglandular prosthetic pocket in residency 30 years ago. Submuscular space was dissected bluntly with instruments or fingers without using cotton because it would induce too much raw surface bleeding.

In my opinion, it is the difference in technique, plus or minus cotton, that is to blame for the contracture, not the placement of the prosthesis (subglandular versus submuscular), silicone gel, or the prosthetic surface texture.

If you want to see for yourself, wrap a smooth gel prosthesis in a stockinette, massage it for a couple of minutes, and remove it. You’ll see hundreds of cotton flecks adherent to the prosthetic surface.

We have blamed silicone gel for too many years as the cause of capsular contracture without paying attention to the cotton in the field. We quit using cotton sutures 30 years ago because of their degree of tissue reactivity.

Why should we ignore the obvious any further?

Antonio Carbonell, MD
Viserage Plastic Surgery Center
Raleigh, NC

Robert Oliver, Jr, MD, replies:

While plausible, Dr Carbonell’s hypothesis is somewhat of a leap in logic—if cotton is in the capsule on SEM, it must, therefore, be the cause of the capsule. Many agents have purported to be the main nidus of capsules, backed with experimental models and clinical trials. I remain skeptical without more compelling evidence.