Botox Is 15 Years Old This Week: What Have We Learned?

Illustration: Assa Ariyoshi
In the fifteen years since Botox was granted a license for cosmetic use, the public's perception has changed significantly. It’s been whispered in upper-middle-class circles about friends (‘Do you think she’s had...Botox?’). It’s been denounced by the neo-Luddite movement as an alien substance that turns women (and men) into stony-faced, unreadable blank canvases (remember the furore around Nicole Kidman’s expressionless face in the early Noughties?) And it’s also been used disdainfully as a catch-all term for someone who looks a little bit too Real Housewives – regardless of whether their slightly unnerving new face really is the result of too much Botox. "The cultural reaction to Botox is very pronounced and complex," mused Dr Maryam Zamani, an oculoplastic surgeon and aesthetic doctor. "Some women really see it as a moral failing to have it done. That’s very strange to me."
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Botox has received more than its fair share of bad press. Of course, every procedure carries risks, but there does seem to be a formula at work in the media. Famous actress of a certain age decries Botox, saying her mother/grandmother is so beautiful, and those lines she has make her beautiful, plus or minus an anecdote about having it done in the past and hating it, and hey presto! sooner or later the actress gets a contract hawking face cream, or at least a dozen listicles extolling all the times she ‘kept it real’. Of course, it’s possible to age fabulously and gracefully without injectables but why is our society so insistent on scrutinising women who do go under the needle?
First: the basics. Botox is the brand name given to botulinum toxin by Allergan (there are a handful of other brands who make the injectable). Botulinum toxin is, you guessed it, very toxic and can quickly cause paralysis and respiratory failure if inhaled or ingested. It’s extracted from spores and has a range of uses both medically and cosmetically: "Botox has been used for medical purposes since the 1970s", explained Mr Kambiz Golchin, Facial Plastic Surgeon. "It’s been used to treat people who suffer all kinds of spasmodic conditions, from children who have cerebral palsy or adults who’ve suffered a stroke, or Bell’s palsy. Other than the fact that it’s no longer tested on live animals, the technology behind Botox hasn’t changed much since then. It’s an incredibly reliable and consistent procedure." It works by relaxing muscles under the skin that have been used to the point of forming wrinkles, and can take as little as fifteen minutes to administer, with results lasting up to nine months. While the cosmetic use is still relatively new, Botox’s safety has been proven over decades of medical use: "Children who receive Botox for cerebral palsy treatment will have about five or six times the amount an adult would have for line-smoothing a year, every few months. It’s incredibly safe." added Mr Golchin.
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In fifteen years, mobile phone technology, for example, has advanced at a rate of knots. Think about the bricks we all carried around circa 2002 that made typing a short text take about twenty minutes, versus the sleek, sophisticated pocket-size devices we have now. A few swipes, and you can pay your credit card bill, tap through the Oyster gates and even land a date on a modern-day smartphone. So how has Botox developed? Not so much. "There’s little room for improvement," noted Dr Zamani. "Botox has great efficacy with a very high safety profile. We know that it works, so it’s hard to find reasons to deviate from that. Perhaps if Allergan could find a way of needing to use less of it, or the effects lasting longer perhaps. Some areas, like the hands, can be uncomfortable to inject, so a topical option would be good in that instance, but even then, that would still need to be applied by a skilled practitioner."
One thing that has changed is consumer appetites. One of my friends, Sally, has been having Botox for two years, since she turned 25. "I know that might sound young, but I had these stubborn forehead lines that nothing would seem to alleviate. I drank buckets of water, wore SPF, generally took care of my skin...but nothing worked! Those lines persisted so I decided to go under the needle." Though Sally might not be as much of an anomaly as she thinks: "Most of my Botox clients are in their late 20s to early 30s", said Mr Golchin. "I am generally getting younger clients in my practice, but that’s more for fillers than Botox." Dr Zamani echoed this sentiment: "There is no right time for Botox as a rule – it differs from patient to patient. I don’t really advocate ‘preventative Botox’, as it’s much easier to work on a line that’s already there, and 90% of the time we have very good success rates with decreasing it. Also, remember that muscle tone gives you volume which is youthful, so you don’t want to necessarily diminish that with injectables as well."
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If there’s one common complaint that scares women away from Botox, it’s the fear of looking frozen. "If you think back to the '80s, it was Dynasty era where everyone was all about more is more. Shoulder pads, crazy lipstick, Aquanet hair, that sort of thing and aesthetics followed that trend, people had super dramatic facelifts and peels so potent they looked transparent," explained Dr Zamani. In fact, as early as 2003, when Botox had only been available cosmetically for about a year, Martin Scorsese complained it was impossible to find an actress whose face still conveyed emotion. "Medicine follows trends just like fashion," noted Mr Golchin. "That frozen look that was really popular in the early days isn’t really a thing anymore. In fact, I developed something I like to call “Emotional Botox”, where patients can lose the lines but still keep the movement in their face." Dr Zamani has a similar philosophy: "I’m not a big fan of the term ‘Baby Botox’ because it doesn’t really mean anything, but in terms of giving much smaller amounts of Botox than used to be popular, more of a sprinkling, that’s definitely something I offer. It’s more about a little tweak than a drastic change – too much of a good thing is not a good thing, you know?"
Illustration: Assa Ariyoshi
There’s also the fact that Botox has become something of a catch-all term. When we see a photo of a celebrity looking a little odd, the headlines that run usually feature something about ‘Botox gone wrong!’ – even if that effect couldn’t have been created by something that simply removes lines. "I have patients say to me, ‘I don’t want any Botox in my lips'", said Mr Golchin, "Botox never goes in the lips! They’re thinking of lip fillers gone wrong." Dr Zamani has experienced similar confusion: "In a snapshot, it’s really hard to tell if someone’s had Botox. If they’re smiling and not grimacing or making any weird faces, it could be the light, it could be contouring, it could be makeup, it’s actually very hard to tell, but people clump it under Botox." Fillers, where a substance (usually plumping hyaluronic acid) is injected into the skin or lips to give it volume, are what can make the face look puffy or unnatural when incorrectly administered - or administered over-zealously. ‘As consumer education grows around aesthetic treatments like fillers, which is largely due to social media and people actually live-streaming their treatments, hopefully some of this confusion will dissipate.’ added Dr Zamani.
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Botox at 15 isn’t so dissimilar to Botox when it was born - at least in terms of the nitty-gritty. Our tastes might have changed, the desired effect might have changed but it’s still very much the same product and neither of the experts I spoke to saw the formula changing much. "Right now, we know that Botox has over 800 applications", explained Dr Zamani. "It can help with migraines, with excessive sweating, with aesthetic dental problems like a gummy smile. I’m sure there are still more applications to be discovered."
While Botox has hundreds of applications, when it comes to anti-ageing, its primary function is minimising wrinkles. It doesn’t address slack skin, like Profhilo, or loss of volume, like Juvederm. But Botox has become synonymous with ‘dramatic anti-ageing’, and perhaps that’s why it’s ended up both an umbrella term for a whole raft of treatments, and also, the gold standard of youthfulness. As a beauty journalist, I’ve lost count of how many brands have breathlessly told me their newest serum is ‘Botox in a bottle’ - but do they really mean it freezes lines and wrinkles? (Spoiler alert: I doubt it does). Or do they just mean, ‘your skin will look a lot, lot fresher’? (Which is possible. Try NIOD’s Copper Amino Isolate 5% and get a good retinol, thank me later).
Remember, lines and wrinkles aren’t the be all and end all of looking youthful. As Dr Zamani explained, "You can have a fiftysomething woman who has lots of lines and wrinkles, and who still looks fresher than say someone who’s younger but has a lot of sun spots. At the end of the day, taking care of your skin holistically through lots of sleep, sunscreen and good skincare, not to mention your diet, is of paramount importance." I’ll add a few weekly glasses of red to that note there, for the antioxidants, of course.
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