Medical Examiner

Against “Preventative” Botox

The face-freezing injections are starting younger and younger.

A young woman receives a Botox injection in her forehead.
dimid_86/iStock/Getty Images Plus

There comes a time in every middle- to upper-class American woman’s life when she must ask herself if it’s time to start doing Botox. This time is coming earlier and earlier, according to the American Society of Plastic Surgeons, which found that 19 percent of the roughly 4.4 million cosmetic Botox injections preformed in 2020 are going into the faces of women under 40—and a startling 12,000 of those procedures are in girls ages 13 to 19. That is: Botox is being used by those who have just barely developed lines on their faces, if they even have them at all.

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Unlike traditional Botox, which freezes muscles in order to smooth over wrinkles, so-called preventative Botox promises to stop them from ever forming. For the young women pursuing this and related treatments (such as “baby Botox”—so named for the smaller amounts typically used in younger patients), the logic is clear: “This is the most beautiful I’ll ever be, so I have to hold myself in place,” says Dana Berkowitz, an associate professor of sociology at Louisiana State University and author of the 2017 book Botox Nation: Changing the Face of America.

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These days, it’s almost unfashionable to be against Botox, which in recent years has managed to reposition itself as a choice feminist-approved form of personal empowerment. The beauty ideal is demanding more of all genders than perhaps ever before (just look at any picture of the 53-year-old Jennifer Lopez), and pointing out these trends suck hasn’t stopped them from taking hold. But in the 20th anniversary year of Botox, it’s worth returning to the topic, and in particular the irony at the heart of the increasingly broad use of these injections.

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The truth is that “preventative” Botox can cause almost as many “problems” as it fixes—it’s not necessarily good, cosmetically speaking, to freeze your facial muscles for decade after decade. At the same time, preventative Botox ushers young consumers onto a treadmill of expensive treatments that never really ends. It’s time to draw, well, a line: Preventative Botox is little more than a marketing ploy, and we should not be putting up with it.

Botulinum toxin has been wreaking havoc among humans for millennia—typically by killing off friends and family whose food or open wounds were infected by certain spore-forming bacteria. But by the late 1970s, ophthalmologists were testing a diluted form in patients with cross eyes, painful eyelid spasms, and more, because of its unique ability to weaken overzealous muscles. Pretty soon, patients and providers noticed botulinum’s cosmetic potential. Dr. Jean Carruthers, a Botox “pioneer,” recalls a patient who was frustrated at the end of a routine visit, because Carruthers hadn’t injected between her eyes. “I apologized to her, saying, ‘I’m sorry but I didn’t think you were spasming there,’ ” Carruthers has said. “And she responded, ‘I know. I’m not spasming there, but every time you treat me there I get this beautiful untroubled expression.’ ”

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That beautiful, untroubled expression would eventually become a $3 billion dollar industry. In 1991, the pharmaceutical company Allergan purchased the rights to the neurotoxin and renamed it Botox. While the cosmetic injectable was used by dermatologists and plastic surgeons from the moment of discovery, there was still a lot of hesitation among prospective consumers by the time it formally came to market in 2002. Stories of poisoned patients and black-market Botox scared plenty of people off, Berkowitz writes in Botox Nation. But Allergan, doctors, and patient ambassadors like Vanessa Williams made a concerted effort to prove Botox was safe to use. It worked. In the decades since, Botox has not only frozen foreheads in time but paved the way to a whole new world of nonsurgical cosmetic enhancements, a booming med spa industry, and more.

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Perhaps the greatest ad ever created for Botox is a 2006 paper, published in the journal Archives of Facial Plastic Surgery, in which Los Angeles plastic surgeon Dr. William Binder administered Botox to Twin A regularly for 13 years and only twice to Twin B. Using side-by-side photos of the sisters—taken four and seven months after Twin A’s last injections—Binder argued that the twin who had regularly received Botox had a more youthful appearance overall, even though her Botox was wearing off. By preventing her from using certain facial muscles, and perhaps even teaching her “to avoid even trying to contract” them, Binder argued, Botox had saved Twin A from years of natural aging. While he could still try to make Twin B look young, with preventative Botox, Twin A had never gotten old. A decade and change later, plenty of twentysomethings are attempting to replicate her results.

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Yet some plastic surgeons remain hesitant to administering Botox to the young—and even appearance-focused publications like Harper’s Bazaar and Vogue have warned that too much Botox too early can backfire. Like any medical intervention, the neurotoxin can have short-term side effects, from “hourglass deformities” (when the temple temporarily collapses) to brow ptosis (in which the eyebrow drops down onto the eyelid). But with repeated and consistent use—the kind recommended to pause the clock—Botox can lead to more permanent muscle atrophy. It makes sense: You’re asking your muscles, over and over again, to stop doing their jobs; eventually, they do. This can cause your skin to become thinner and looser, and discolored or “crepe-y,” and veins may become more visible, says Dr. Patricia Wexler, a dermatological surgeon in New York City who has been injecting Botox in patients for more than 30 years. The immobilization of certain muscles can also mean other parts of the face are recruited when a person inevitably makes a facial expression. As these other muscles get a workout, they may start to wrinkle, resulting in “bunny lines” around the nose and creases beneath the eyes. “There’s a consequence to everything we do,” Wexler tells me.

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To the horror of many patients, Botox can also simply stop working. Somewhere around 1 to 3 percent of patients may develop autoimmunity to the toxin, which makes it impossible for the injection to do its brow-busting work. Dr. Loretta Ciraldo told the New York Times earlier this year about patients who “took a break” from Botox after years of injections. When they tried to get back to it, “it did not help whatsoever. Once it wore off, it wore off.” This speaks to perhaps the most concerning side effect of Botox: dependence. Despite all the promises of “prevention,” to keep wrinkles away, people must inject every four months or so for the rest of their lives. “You’re going to want to,” says Dr. Caroline Chang, founder of the Rhode Island Dermatology Institute. “You’re going to like it.”

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What’s more, the cost of a regular Botox regimen is steep. The average treatment is about $400, depending primarily on the prestige of your injector. If you do it three times a year, that’s at least $1,200. For those who start at, say, age 25 and continue until 85, that’s $72,000 over the course of a lifetime. That money could represent a substantial amount of education, child care, travel, or even charity. If you choose to spend it on Botox, great, but only as long as the real cost is clear. And most people don’t stop with Botox. Injectors today seek to “balance” the face and make “tweakments” appear natural, which usually means combining the smoothing effect of Botox with lip and cheek fillers, fat-freezing treatments for the chin, and more. Unless you’re a celebrity (who, it must be noted, are literally dependent on their appearance for future work), it’s a “ludicrous proposition financially,” Wexler says.

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I’ll put my cards on the table here: I’m fascinated by cosmetic injections, but I feel they aren’t right for me. I’m squeamish about side effects. And while I do think that everyone is allowed to modify their faces, I also think the ever-expanding use cases for Botox play into larger social harms that disproportionately affect women, especially as we grow old. Preventative Botox in particular seems like a rip-off. Consider the twins: If Twin B decided to start a regular Botox regimen, her face would more or less match her sister’s in the three to 10 days it takes for a Botox injection to immobilize the upper face muscles. That means Twin A hasn’t been sold “prevention” so much as an insurance policy—and one that she’ll have to keep paying into, lest she let the consequences of sun exposure, pollution, teleological aging, and basic movement take hold.

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Ironically, repeated continuous use of Botox might end up working against Twin A’s efforts to meet the beauty standard. In addition to the possible side effects of cosmetic injections, the definition of “attractive” is always shifting—a feature, not a bug, designed to keep the aesthetics of the wealthy ever out of reach, and the average consumer always striving. While it’s hard to imagine wrinkles making a comeback, trends are anything but ageless. Remember that ’90s “it” girls plucked their eyebrows into obscurity and have had to hire “brow whisperers” to get their bushy brows back. Or consider the same crowd that embraced “pillow face” in the mid-2010s, including Kylie Jenner herself, is already desperate to dissolve their fillers in favor of a more “natural” look. The truth is, if you stay frozen in place, you can just end up looking really, really stuck.

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