Sam Corban New Zealand Register of Acupuncturists member 2007-2013
Foreword by Heiko Lade:
This journal article was originally entitled Acupuncture vs Botox: How does Acupuncture compare to Botulinum Neurotoxin A for cosmetic purposes and was written by Sam Corban who became an New Zealand Register of Aupuncturists member in 2007 and wrote this article for the Journal of the New Zealand Register of Acupuncturists.
Sam had a background in research with a Bachelor of Science from the University of Auckland. He later continued his studies and went on to obtain an additional acupuncture degree and had an interest in facial rejuvenation and using acupuncture and Chinese medicine to prevent disease and promote wellness.
Sam Corban sadly passed away in September 2013.
Below is the original article in full.
Recently, acupuncture has gained popularity as a cosmetic treatment for the face. The strongest action of acupuncture is said to be the smoothing out of fine lines and wrinkles. In this sense it is comparable to medicine containing botulinum neurotoxin A, the most popular and well known brand of which is Botox. Patients investigating cosmetic acupuncture are often interested in how acupuncture compares to botulinum neurotoxin A and what scientific evidence there is for the efficacy of cosmetic acupuncture. At present, there are just a few clinical trials investigating acupuncture for cosmetic purposes. However, the basis of its use can be posited from: what is known about the general mechanisms of acupuncture; trials of acupuncture used in other facial disorders; and importantly from clinical experience.
Background
Botox is one of a number of agents derived from botulinum neurotoxin A. It comes from the bacteria Clostridium Botulinum, which grows in incorrectly handled or prepared meat products. Although it is one of the most toxic natural substances in the world, like many other neurotoxins, it was found to have useful medicinal properties. In 1949, scientists discovered that botulinum neurotoxin A blocks the activity of the neurotransmitter acetylcholine at the neuromuscular junction, preventing muscle contraction. Subsequently, in the 1970’s and 1980’s, botulinum neurotoxin A underwent clinical trials for the treatment of muscle spasms. Success in these trials lead to its indication in a wide variety of muscular disorders including: migraine; involuntary blinking (blepharospasm), excessive sweating (hyperhidrosis); cervical dystonia; temporal mandibular pain disorders; and CNS spastic disorders such as Parkinson’s disease and multiple sclerosis. During these trials people noticed that botulinum neurotoxin A seemed to reduce the appearance of fine lines and wrinkles, making patients’ faces appear younger. It was from here that its indications were extended to include cosmetic medicine. However, though this was recognised as early as 1987, botulinum neurotoxin A was not approved for cosmetic use in the United States and many other countries until 2002. Despite its recent widespread use as a cosmetic therapy, it is now the single most popular cosmetic procedure in countries such as the United States (Flynn 2006).
Acupuncture has a long history in the treatment of facial disorders. However, since the widespread introduction of acupuncture to the West in the 1970’s, it has been used to treat a wide variety of western classified facial diseases, such as: facial paralysis; myofacial pain; temporal mandibular disorder; migraine; headache, etc. From this list one can see that both acupuncture and botulinum neurotoxin A treat overlapping disorders. If botulinum neurotoxin A treats these conditions by temporarily paralysing muscles how does acupuncture treat these conditions according to TCM and Western Medicine? Does this also mean acupuncture has cosmetic applications?
Although it is clearly acknowledged that the health of the skin depends on the function of the viscera in Western Medicine, this is often not integrated in cosmetic treatment. A fundamental principle of TCM is that the body is an integrated system; therefore treating the zangfu organs is an integral part of any treatment protocol for the face. Dysregulation of the zangfu organs will have a direct effect on the quality of the skin, to give a brief (but not complete) example: the spleen transports clean fluid to the lungs, the lungs then moisten the skin and control pores; the liver blood moistens the skin and the hair. Thus dysfunction of the zangfu organs can be seen in the quality of the skin, for instance: lung dryness will lead to early/increased wrinkling, or damp heat in the liver could lead to acne. Furthermore, pathogenic factors can obstruct function of the zangfu, such as dampness obstructs the function of the spleen and can lead to fluid filled lesions/vesicles and “puffiness” of the skin. Each sense organ of the face is nourished by a different zang organ, e.g. the liver blood moistens the eyes. Also, from a channel perspective all the yang channels pass along the face. In treating the appropriate channels one can regulate the qi and blood of the face. It is also important to use local points in the face to circulate qi and blood in both the main channels and collaterals.
However, treating western patients and western classified diseases means that it is important to provide information about the mechanism of acupuncture from a Western Medical perspective. The general effects acupuncture has on the body can help to explain the rationale for using acupuncture to treat the face, specifically the regulation of: blood circulation/microcirculation, the immune response, and neuromuscular function. In terms of blood circulation, a recent trial measured cutaneous blood flow changes at Hegu LI4 and Quchi LI 11 using Laser Doppler Flowmetry. Results showed that when an acupuncture needle was manipulated or an acupuncture needle was not manipulated but a patient felt soreness/numbness, there was a significant increase in cutaneous blood flow. In contrast, non acupuncture points next to Hegu LI4 and Quchi LI 11 only showed a small increase in blood flow (Kuo, 2004). When applied to the face, an increase in cutaneous blood flow may increase oxygenation of tissues and improve the immune/repair response. More specific studies have demonstrated that the application of electroacupuncture stimulation regulates the immune response by decreasing pro inflammatory cytokines (Sung 2005). However, this is only one of a number of ways acupuncture may exert an anti inflammatory response. As well as reducing pain and regulating the immune response, acupuncture has been shown to have a regulatory effect on the neuromuscular system. There have been a significant number of clinical trials investigating the use of acupuncture for facial disorders. Currently the World Health organization rates acupuncture as an effective treatment for chronic facial pain (including craniomanibular disorder), migraine, tension headache, general headache, and temporomandibular joint pain and dysfunction (WHO 2003). These trials demonstrate the ability of acupuncture to regulate nerve and muscle function. This is particularly relevant to cosmetic acupuncture as regulating muscle tone should lead to a decrease in lines and wrinkles.
Research specifically relating to acupuncture for cosmetic purposes is very limited. A recent animal study which looked at the effect of surrounding needling on rat skin found that surrounding needling had a significant cosmetic effect, by increasing fibroblast activity and increasing the amount of soluble collagen in the skin (Lu 2008). A second study from The Journal of Clinical Acupuncture in 1996 is referenced by many websites marketing Cosmetic Acupuncture. It found that with Cosmetic Acupuncture, 90% of patients had “marked improvement” in their faces as well as experiencing an overall rejuvenation that was not confined to the face. These results seem unusually high and need to be replicated to determine efficacy.
Discussion
Acupuncture, like botulinum neurotoxin A is used to treat medical disorders of the face. The mechanism of botulinum neurotoxin A is to interrupt nerve signals, which paralyses or “relaxes” specific facial muscles. For cosmetic purposes, decrease in muscle tension means that lines and wrinkles in the treated muscle decrease or temporarily disappear. This also prevents the formation of new lines as without muscle tension new lines are unable to form. It is theorised that botulinum neurotoxin A muscle paralysis also increases collagen production. Conversely, acupuncture reduces lines and wrinkles by increasing the tone of facial muscles, literally flattening them out. Lines which disappear when pulled apart, are likely to disappear after a course of treatment. Deeper lines which are reduced but not gone when the skin is pulled apart, are likely to be reduced with treatment.
Both acupuncture and botulinum neurotoxin A should have comparable efficacy, but it is likely that the effect of muscle paralysis exerted by botulinum neurotoxin A has a stronger effect in reducing lines and wrinkles. However, the key advantage of acupuncture is that it can reduce lines and wrinkles whilst preserving the ability of the patient to use their facial muscles/make facial expressions. Furthermore, there is evidence that acupuncture also increases the production of collagen (Lu 2008). This may help fill lines and increase the overall skin tone of the face over a longer period of time.
Acupuncture has number of other therapeutic actions botulinum neurotoxin A does not have. In strengthening facial muscles, acupuncture may reduce the age related sagging because increased muscle tension should “pull up” the brow and jowls. Due to the fact TCM is an integrated system; it also examines the function of the internal organs when looking at the health of the skin. Regulation of the zangfu organs eliminates obstructions such as dampness, qi and blood stagnation as well as tonifying deficiencies such as qi and blood deficiency. In Western Medicine, this relates to the systemic effects of acupuncture: regulation of the autonomic nervous system, e.g. digestion; increased blood circulation and microcirculation; regulation of immune function and inflammation; and regulation of the neuromuscular system. When applied to the face this should improve the patient’s complexion and the tone of their skin. In regulating the functions of the internal organs the patient should also notice an improvement in their general condition, for example energy levels and sleep.
The effect of cosmetic acupuncture like botulinum neurotoxin A are only temporary, approximately 3- 6 months. Lifestyle factors such as sleep, diet, stress, and smoking will affect the length of the treatment effect. A patient undergoing a course of treatment should notice after 1-3 sessions an improvement in their complexion as a result of improved circulation as well as general health benefits such as better energy levels, sleep and digestion. Lines and wrinkles will gradually improve over the course of treatment but the extent of these improvements varies from patient to patient. In terms of time, acupuncture and botulinum neurotoxin A are significantly different. A course of botulinum neurotoxin A consists of only one treatment, which lasts from a couple of minutes to twenty minutes (if treating many face areas). A course of acupuncture would be approximately ten treatments lasting forty minutes to one hour each. However, this is offset by the additional benefits from cosmetic acupuncture mentioned previously for both the face and the patient’s general heath. In terms of cost, a treatment of botulinum neurotoxin A is similar to a course of treatment using acupuncture.
Treatment Protocol
Diagnose patient and treat any underlying conditions:
-8 principle syndrome differentiation: e.g. yin or yang deficiency
-Qi/Blood/Body fluids: e.g. qi and blood deficiency -Zangfu theory: e.g. lung dryness -Pathogenic Factors: e.g. damp obstruction
Basic Treatment
Distal Points:
-Xuehai SP10 to tonify blood -Zusanli ST36 to tonify qi
Local points:
-Yangbai GB 14 – to reduce wrinkles on the forehead
-Jingming BL1 – to reduce wrinkles around eyes
-Quanliao SI18 – to reduce wrinkles around the cheeks
-Jiache ST8 – to lift the jowls
-Touwei ST 8, Baihui DU20 – to lift the forehead
-Dichang ST4 towards Xiaguan ST7 – to rejuvenate the
lips
* All points assist in circulating qi and blood in the face Manipulation:
-Depth and manipulation as per acupuncture guidelines also:
-Use fine needles .18mm or .20 gauge to prevent bleeding
-The face has extensive vascular supply, avoid strong manipulation to prevent bleeding, and when there is bleeding quickly apply pressure for 30-60 seconds to prevent bruising.
-Be very careful to avoid deep puncture with points near cranial nerves
-Contraindications: same as for standard acupuncture.
Different techniques:
-Wrinkles: Insert intradermal needles along the wrinkles (remove after treatment) -Electroacupuncture: Lower frequency 2-5/s continuous wave, to cause a slight twitch around the face, maximum lOmins.
Summary
In conclusion, patients are often interested in what scientific evidence there is about cosmetic acupuncture and how effective it is in comparison to botulinum neurotoxin A. Though at present there are few clinical trials of acupuncture for cosmetic applications, there is a basis from what is known about the general mechanisms of acupuncture; trials of acupuncture used in other facial disorders and from clinical experience. With this information it can be posited that whilst acupuncture is comparable to botulinum neurotoxin A for lines and wrinkles, its action are not as dramatic because it increases muscle tone rather than causing muscle paralysis. However, acupuncture may have a much broader range of effects including: lifting the bow and jowls; improving complexion and skin tone; and improving the general health of patients.
Biography
Sam Corban graduated from the New Zealand College of Chinese Medicine in 2006. He is currently practicing as an acupuncturist in Westmere, Auckland New Zealand.
References
Carruthers A, Cohen JL, Cox SE, De Boulle K, Fagien S, Finn CJ, Flynn T, Lowe NJ, Raspaldo H, Sommer B, de Almeida AT. Facial aesthetics: achieving the natural, relaxed look.J Cosmet Laser Ther. 2007;9 Suppl 1:6-10.
Fagien S, Raspaldo H. Facial rejuvenation with botulinum neurotoxin: an anatomical and experiential perspective. J Cosmet Laser Ther. 2007;9 Suppl 1:23-31
Flynn TC. Update on botulinum toxin.Semin Cutan Med Surg. 2006 Sep;25(3):l 15-21.
He L, Zhou MK, Zhou D, Wu B, Li N, Kong SY, Zhang DP, Li QF, Yang J, Zhang X. Acupuncture for Bell’s palsy. Cochrane Database Syst Rev. 2007 Oct 17;(4):
Kuo TC, Lin CW, Ho FM.The soreness and numbness effect of acupuncture on skin blood flow. Am J Chin Med. 2004;32(1): 117-29.
