Botox: Another Shot at Looking Young

First approved by the Food and Drug Administration in 1990 for treating eye muscle spasms, botox showed its cosmetic potential almost immediately, when patients with their eye on ophthalmologic gains noticed their wrinkles softening. The toxin that could block nerve impulses to temporarily paralyze certain misfiring eye muscles, it turned out, could also be directed to disable those muscles that form "crow's feet" around the eyes, wrinkle lines on the forehead and frown lines between the eyebrows.

Ten years after it initially hit the market, botox is one of the most popular cosmetic medical procedure in the United States; almost 800,000 Americans got the injections in 2000, according to the American Society of Plastic Surgeons (ASPS).

With California-based Allergan Inc. expecting approval of botox for cosmetic use shortly, the ASPS predicts that the product's popularity "could increase exponentially."

Botox can iron out wrinkles earned over years of facial movements, such as smiling and frowning, concentrating and squinting. In addition to the most popular complaints — furrows between the eyebrows, crow's feet and forehead lines — women in particular get botox injections to correct some imperfections of their lips and necks. Recently, botox has found yet another use: a "chemical brow lift" to restore the arch to falling eyebrows. (Outside the cosmetic sphere, botox is used not only for muscle control, but also to treat migraine headaches and other types of pain and to eliminate excessive sweating, or "hyperhydrosis.")

Most botox users are women (88 percent, according to the ASPS), and most are aged 35 to 50 (59 percent). Says Kevin Poitras, M.D., who treats some 100 people each year with botox injections in his Bethesda, Md., dermatology office, "My patients aren't satisfied with growing old gracefully. They say 'I don't feel old. I don't think old. Why should I look old?'"

For $300 to $1,000 per treatment — $366 on average, according to the ASPS — botox can restore a refreshed appearance to aging faces that are starting to look anxious, tired or angry. "I knew it was time to do something when people started looking at me and asking 'Are you mad'?" says 40-year-old Anna Masica, an aesthetician at a Bethesda, Md., spa who turned to botox earlier this year to get rid of bothersome frown lines between her eyes.

"I feel better about myself knowing my forehead doesn't always look scrunched up," Masica says. "I feel I look younger, and my makeup doesn't end up in the creases between my eyes like it used to by the end of the day."

Masica knows her wrinkles will return after four months. Botox is a temporary fix, lasting about that long before the lines gradually reappear, requiring another treatment to keep them at bay. (However, doctors have observed that repeated botox treatments may last progressively longer as the facial muscles atrophy from non-use.)

Although the benefits of botox injections are more fleeting than those from surgical procedures such as facelifts and laser skin resurfacing, botoxing has pluses of its own.

To name one, the injections are doled out in a five-minute to half-hour procedure, depending on the number of areas treated. Patients "come in, have it done, get off the table and go back to work," Poitras says. "There's no down time."

What's more, the injections with a tiny needle are "pretty close to pain-free," says Los Angeles plastic surgeon Brian Kinney, M.D. Botox recipient Masica is even less equivocal: "There is no pain involved."

As a rule, Kinney doesn't numb his patients while he performs the several injections (three for your basic frown lines, for example). But patients who have a low threshold for pain may opt for a pre-injection numbing agent.

To minimize the chance of complications, patients are asked to do two things: use the facial muscles so the botox is attracted to the right areas — "just make funny faces for half an hour," clarifies Poitras — and avoid lying down for up to four hours.

Having followed these pointers, the improvements should show themselves within two to five days. There's no need to worry about being left expressionless, assures Kinney, while acknowledging that post-botox expressions may be less dramatic than before. The side effect might be perfectly acceptable for a poker player, but could be a liability for, say, a hardball negotiator whose ability to intimidate is a highly prized commodity.

The basic approach for injecting botox is "really straightforward" so risks are "minimal," according to Kinney, who has five years' experience offering the wrinkle-reducer. Doctors inject about 25 to 50 units of botox to smooth patients' skin, ten times fewer than the 3,500 units that could kill.

Still...paralyzing the facial muscles: The thought could unnerve the most enthusiastic youth-seeker. As a beauty school student, the botox basics were enough to scare Masica away for a time. "I knew it was botulism that paralyzed the muscles. That's a scary thought," she says. But with her job at a spa came a better understanding of botox and a confidence in the procedure's safety.

The risks, though rare, include bruising, numbness, swelling, muscle twitching, headache, droopy eyebrow and, most commonly, a droopy eyelid. Poitras explains, "Rarely, if the botox drifts too close to the eye muscles, a person can find it impossible to open their eyelid completely."

Some people shouldn't use botox, such as women who are pregnant or breast-feeding and people with certain kinds of medical problems, including, in Kinney's view, some kinds of musculoskeletal and neurological conditions.

People contemplating the injections should choose their doctor carefully, making sure they are trained and experienced in performing the procedure and are willing to discuss expected results and risks openly.

That said, there is something for patients and doctors alike to smile about: Like its skin-smoothing benefits, botox-related problems are temporary. No need to fear botox-based lawsuits, doctors joke, because by the time the patient gets to an attorney, the side effects have worn off.

Botox might be a good starter surgery, says Kinney, for those who aren't ready to go under the knife. "Get started, get to know your surgeon, see if you have a similar approach to staying beautiful."

With all of botox's promise for patients whose wrinkles appear when they smile or raise their eyebrows, it's of no use, however, for sun-damaged skin and gravity-grown jowls. For these concerns or facial creases that have been etched permanently over years, some choose to combine botox with facelift, fat injection, laser or chemical peel or eyelid surgery.

Plans for plastic surgery aside, staying beautiful requires an overall healthy lifestyle, Kinney emphasizes, which includes giving up smoking, eating right, exercising and using sunscreen. It may be true what existentialist author Albert Camus wrote in 1957: "After a certain age every man is responsible for his face" — and in the name of taking charge of your own countenance, dermatologist Poitras exhorts the use of botox along with sunblock. But he frowns on the idea of a life sans smiling to shun those dreaded wrinkles — much too depressing a price to pay for a furrow-free brow.