Ask Adeela: Should I Have Botox?

I am often asked if I recommend Botox. My answer? It can be great, if used judiciously.

What is that?
Botulinum toxin was first exploited by scientists in the 1970s to treat strabismus (cross-eyed eyes) and, in the 1980s, blepharospasm (uncontrollable blinking), and was approved by the FDA in 1989. It is a versatile agent and is now used to “treat” many types of wrinkles, from crow’s feet to smile lines or frown lines. FDA-approved brands include Botox Cosmetic, Dysport, Jeuveau, Daxxify, and Xeomin.

How does it work
Deep wrinkles are caused by muscle wear, not skin (think of your skin as shrink wrap over the muscle). Botox is given as an injection that temporarily “paralyzes” the muscle causing wrinkles: It blocks the neurotransmitter signals from the nerves that cause muscles to contract. This prevents expression lines from going from dynamic (present only when muscles contract and then disappear) to static (always present). The most common areas to be treated are the expressive sites on the upper face, including the frown, forehead, vertical “11”s between the eyebrows, and crow’s feet. There’s also the “Nefertiti Lift,” which consists of Botox across the platysma (neck) muscles and jawline to reduce sagging jowls, and can be followed by dermal fillers along the jawline to add volume and definition.

How long does it last?
The effects wear off over time, usually three to six months. After initially blocking the nerve’s communication “keyhole,” the nerve endings sprout or regenerate, opening a new keyhole, and muscle movement is restored.

How much and often?
All people’s experience is not the same with Botox – it depends on age, depth of wrinkles, genetic predisposition and facial expressions. As a facialist, I estimate that three out of five of my clients have had Botox. On movie sets I see actors eager to preserve their facial expressions and agents eager to preserve their clients’ careers; the pressure to conform to expectations is immense and it’s a tug of war between how much to do and how to maintain one’s natural brilliance. The ultimate goal is not to look too “done”. I’m always baffled when patients don’t know how much is being injected. My advice: Ask your doctor about the number of units, so you don’t stray too far from point A as you continue Botox over the years. Also, give your face a break from Botox — your muscles may atrophy from lack of use if it’s used long-term.

Where to find it?
I always recommend choosing a certified plastic surgeon who is knowledgeable in craniofacial anatomy. Tales of Botox fails are rife among poorly trained providers: Injecting too close to the brow bone can lead to ptosis (drooping eyelids); too close to the middle of the brows can lead to “Mephisto Effect” aka “Spock brows”. Understanding the placement, depth, and dose of Botox and its impact on surrounding muscle groups is critical to achieving proper results and long-term efficacy. Although more expensive, a certified professional is worth it. In the UK, you can check a professional’s qualifications at the Professional Standards Authority (professionalstandards.org.uk) and for cosmetic surgeons, the British Association of Aesthetic Plastic Surgeons (BAAP extension).

Is there a welcome house?
Dr. Edouard Manassa, a plastic surgeon with practices in Munich and Dusseldorf, has seen a steady increase in both male and female patients requiring “Baby Botox” to eliminate signs of work-related fatigue and stress. “Baby Botox is a good preventative approach,” he says, “or for those who dip their toes. Low-dose ‘barely there’ injections soften the imprint of wrinkles but maintain a level of movement.” Placed between the skin and muscle, at about 25% of a normal dose, results usually last up to three months. If you’re in your early 30s, that’s a good place to start if you’re trying to prevent fine lines from becoming ingrained. If you’re older, it’s a slimmer option.

What is the difference between Botox and fillers?
I often see patients who confuse Botox with fillers. Of the two, Botox is reversible and the effect wears off, while recent studies have shown that some fillers may not always dissolve completely, as marketed, and can also lead to the buildup (stratification) and development of scar tissue driven by the inflammatory response. causing the face and expressions to transform over time.

What are the pitfalls?
The tendency to have a visibly enhanced, frosty waxy look — Botox Face — isn’t particularly youthful. A face that is completely free of lines creates what I call a “Botox paradox” – a contradictory appearance of looking young and old. Added to this, long-term users often have fronts that look like freshly waxed bonnets. But I don’t like to judge, and if someone feels better from injecting their forehead, then I say do what makes you feel happy. With strategically injected units it is possible to smooth out some lines and appear refreshed, without erasing your personality.