If ever a miracle injectable existed, it may just be the family of neuromodulators. Best known by their brand names — Botox®, Dysport®, Jeuveau®, and Xeomin® — botulinum toxin type A injections are most celebrated and widely used as effective wrinkle reducers, but new findings point to yet another benefit.
If you are planning to go under the knife for a cosmetic surgery, don’t be surprised if your surgeon brings up Botox® and the like as both a preventative and corrective step for scar care. Here’s what you need to know about the benefits of Botox® for minimizing the appearance of scars.
What the Science Says
Scientific data is the pinnacle of measuring the capabilities of a drug (cosmetic or not). Current research on neuromodulators to improve the look of scars is looking up. The use of neuromodulators for alleviating scars first became talk when a 2018 study tested the effects. “The results showed that the scars that received Botox injections were rated higher on their appearance than those that did not receive injections," says Marina Peredo, MD, a board certified dermatologist in New York City.
The report in Plastic and Reconstructive Surgery detailed the benefits for patients who received treatment for four months, specifically after reconstructive surgery of the face (a procedure that often results in a bevy of distinct scars). The clinical trial showed that when these patients were treated with Botox early on, the injections produced narrower, better, and flatter surgical scars. However, common scar characteristics such as color and vascularity were not notably different.
How Does Botox Minimize Scarring?
Let's take it back to the basics for a moment. Surgical sutures are the option of choice when a scar or laceration requires closure. When it comes to stitches, however, it is known that tension and movement around the edges of the scar lead to less optimal scarring, says Jonathan Cabin, MD, a double board certified facial plastic and reconstructive surgeon in Arlington, VA.
Plastic surgeons have long known that certain types of facial scars naturally heal better than others. One reason is the scar's direction, and how it’s positioned compared to the underlying muscles, says Esther Yoonah Kim, MD, a board certified plastic and reconstructive surgeon and co-founder of Advanced Institute for Plastic Surgery and Bloom Spa in Temecula, CA. “If the scar lies against the pulling muscles, there is a tug-of-war across the scar,” she explains. “This tension will pull the scar apart, leading to a widened, thicker, and uglier scar.”
We know that Botox® (and other neuromodulators) temporarily reduce muscle movement to limit wrinkle formation. Dr. Cabin explains that this same theory works to help reduce the tension and movement around healing wounds, thus reducing the forces that can worsen scarring. While neuromodulators won’t totally stop the muscles from ripping at a scar, they will help create less stress and allow the scar to heal properly.
When repetitive tensile forces in any direction by muscles under or around wound edges or tissue might negatively affect the overall healing processes, botulinum toxin injections can have an impact, says Ava Shamban, MD, a board certified dermatologist in Santa Monica, CA. “Wound healing is a complex range of processes from homeostasis to inflammatory response and the dermal cell remodeling,” she explains. “Interruptions to these processes can lead to disruption and complications, such as derailing fibroblast activity or prolonging the inflammatory response, and delays in healing can result in scar hypertrophy or increased pigmentation.”
To make the most of the treatment, your surgeon should inject the to-be-operated-on area before the procedure to limit the mobility of the muscles in the region. “If I am planning to make an incision in an area, like the forehead, where Botox® can safely reduce movement, I always inject Botox® (or an equivalent toxin) two weeks before the planned procedure, since it takes that long for toxins to kick in,” Dr. Cabin shares.
This approach creates an ideal situation where most movement in that specific area is significantly reduced right at the onset of the recovery process, but the injections can also occur post-op. “The treatment works best when injected early in healing — preferably before creating a scar — but within the first few months when the wound is going through its initial healing process and is most sensitive to tension and movement," he adds. This way, the resulting scar will heal thinner and flatter.
Not All Scars Are Equal
Using neuromodulators to improve scars falls under the bucket of off-label (read: not approved by the United States Food and Drug Administration yet relatively safe and well-documented) neurotoxin uses. But unlike many of Botox® and friends’ non-FDA-approved benefits, scar improvement is one treatment that provides significant physical and emotional benefits. Scars come with memories, some of which can be debilitating or a sign of a remembered trauma.
While all neuromodulators will theoretically have the same effect on the scar, Jennifer Levine, MD, a double board certified facial plastic and reconstructive surgeon in New York City, says some patients and providers prefer Xeomin® in this case. "Xeomin® is often embraced because it is a cleaner alternative to other neuromodulators," she says. Unlike Botox®, Dysport®, Jeuveau®, it is a pure form of botulinum toxin formulated without stabilizing proteins.
Treating older scars with Botox probably won't produce the same result, but, like everything in life, there are exceptions to the rule. In some instances, scars that are mature and more than one year old may respond positively. “It really depends on the orientation of the scar,” Dr. Cabin says. “Reduction of expression through the use of Botox can temporarily reduce the repeated reinforcement of the scar and minimize its noticeability, especially in the forehead or central brow.” But, in these cases, improvements in the appearance of the said scar are more temporary in nature. Repeat treatments every few months are required.
Neuromodulators aren't compatible with every type of scar. Even if they are new and fresh, keloid scars won’t respond positively. They need to be treated with a laser or corticosteroids. When used directly on the scar, a corticosteroid solution may help improve the texture and tone of the skin where an existing mark exists due to a cut or abrasion. Furthermore, Dr. Shamban says corticosteroids may help reduce the scar's height, density, and overall size since steroids break the woven bonds between collagen fibers, thus reducing the amount of scar tissue beneath the skin.
Neurotoxins, meanwhile, works best on certain new scars, such as skin cancer removal, Mohs surgery, and reconstructive surgery, though timing is everything. In some cases, a neuromodulator alone isn’t enough to make a dramatic improvement in the appearance of the scar and additional treatments may be needed. "Some people use a combination of Botox, lasers, and skincare to get the skin in optimal condition," Dr. Peredo explains. She also stresses that using good skincare before surgery is vital to encourage better healing. “Keeping the body hydrated and reducing caffeine and alcohol intake can help with wound healing,” she says.
How Long Botox Lasts
If you get Botox® and co. for wrinkles, you are accustomed to routine maintenance sessions every three to four months. When it comes to treating fresh scars, however, Dr. Cabin says that only one appointment is needed because the treatment lasts about two to four months. “This provides a large window of activity, during which the initial phase of healing will occur,” he explains. After this period, neuromodulators are less critical.
Follow-up sessions every two to four months for the first year can be beneficial for some patients, but they’re not always necessary. “It’s about minimizing movement around the healing wound during a window of time when the scar is forming, reducing the final scar,” Dr. Cabin says. When done correctly, one initial treatment can have a lifetime impact on the outcome.
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