From botulism outbreak to eliminating crow’s feet and chronic pain, we investigate whether Botox injections are the elixir of youth, a medical panacea, or a toxic epidemic
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On November 20, pharmaceutical company Allergan celebrated its first ever National Botox Cosmetic Day. The holiday, admittedly nothing more than a marketing ploy, was chosen to commemorate the most popular treatment day on record in the US. First introduced on the market in 1989, the original injectable has become ubiquitous for its ability to “freeze” faces and hold back time – or at least look like it. In the decades since its introduction, Botox has quite literally changed the face of humanity.
While technically a brand name, Botox may refer to any injectable form of botulinum toxin type A. Botulinum toxin is a protein derived from the bacterium Clostridium botulinum. Heavily diluted and highly purified, it’s generally safe in the hands of a trained medical professional. Other common brand names include Dysport/Azzalure, Xeomin/Bocouture, and Jeuveau (in the US and UK, respectively). The injections have become one of the most popular minimally-invasive cosmetic treatments.
Culturally, the rise of Botox went hand-in-hand with the birth of Bravo’s Real Housewives reality TV franchise. In 2006, the third ever episode featured the women of Orange County receiving a Botox housecall. The wrinkle relaxer was a public accessory for housewives like Vicki Gunvalson and Lauri Waring Peterson, only to be questioned or actively ridiculed by the rest of the world. For a time, it seemed that injectors were heavy handed and techniques lacked finesse. Shiny, frozen faces were deemed trashy in line with the reality TV platforms that featured them most – think ABC’s Extreme Makeover and Fox’s The Swan.
If a decade ago it was easy to poo-poo Botox as a hobby of the super-wealthy and supremely vain, today it is not. Botulinum toxin is becoming one of the world’s most versatile medical therapies. According to the American Society of Plastic Surgeons (ASPS), over 7.4 million botulinum toxin type A (Botox, Xeomin, and Dysport) treatments were performed last year, up 845 per cent from the year 2000. In the UK, figures hover around 100,000 Botox injections per year, according to the BBC. With statistics like these, it’s clear that we’ve reached the era of peak Botox. Cosmetic injectables and their (three- to four-month) promise of youth are now standard practice, rather than tabloid fodder, as they once were. A couple of jabs a few times a year – in the privacy of your injector’s office – and you’re good to go.
Celebrities have long been fans and devotees. Simon Cowell reportedly said that Botox added a decade to his on-screen career. Steven Tyler has been open about having regular wrinkle-relaxing injections, as have Cindy Crawford, Kim Kardashian West, Kelly Ripa, Vanessa Williams, and Sarah, Duchess of York. On the other hand, big names like Courteney Cox, Gwyneth Paltrow, and Cameron Diaz have all spoken about their negative experiences with the injectable. Too much of the stuff made them look odd, unnatural, or unfamiliar, they say. Celebrities praise botulinum toxin for its medical applications as well. Bethenny Frankel gets her jaw injected to ease the symptoms of bruxism (teeth grinding), and actor Kristin Chenoweth uses Botox to deal with her migraines.
The origins of everyone’s favourite elixir of youth are decidedly less glamorous than the lunchtime tweakment we’ve come to know. Beyond the cosmetic world, botulinum toxins are best known for causing botulism, a rare and sometimes fatal illness that can lead to muscle paralysis. In the 1820s, German poet and physician Justinus Kerner published the first comprehensive and medically accurate study of what would later be known as food-borne botulism. The study revolved around “sausage poison”– named after the German food staple at the heart of the outbreak – and dealt with prevention and treatment of the illness, while also suggesting that the poison could be therapeutic in small doses. In 1895, Belgian bacteriologist Emile van Ermengem was first to pinpoint the bacterium responsible for botulism, after studying a fatal outbreak that was linked to a batch of tainted ham served at a funeral.
“The origins of everyone’s favourite elixir of youth are decidedly less glamorous than the lunchtime tweakment we’ve come to know. In 1895, Belgian bacteriologist Emile van Ermengem was first to pinpoint the bacterium responsible for botulism (a rare and sometimes fatal illness that can lead to muscle paralysis), after studying a fatal outbreak that was linked to a batch of tainted ham served at a funeral”
The next major advancement came in 1928, when the purified form of botulinum toxin type A was first isolated by Dr Herman Sommer at the University of California, San Francisco. From the 1930s, the toxin formerly known as “sausage poison” became an agent of biological warfare. Japan first used C. botulinum cultures on their prisoners of war, and the biological threat of weaponised neurotoxins pervaded throughout World War II. The US researched and produced capsules of botulinum toxin with the aim of enlisting Chinese sex workers to administer the toxin to Japanese officials. The capsules were never used and later destroyed. However, these less-than-friendly wartime innovations paved the way for what was to come.
Edward J. Schantz, who had been instrumental in botulinum toxin research and production during the war, went on to produce the toxin for use in scientific studies during the 1960s. In 1978, ophthalmologist Alan B Scott began Food and Drug Administration (FDA) trials for the use of botulinum toxin to treat crossed eyes. The drug, which Scott called Oculinum, received its first FDA approval to treat crossed eyes (strabismus) and eye twitching (blepharospasm) in 1989. Allergan acquired Oculinum from Scott just a couple of years later, renaming it Botox.
Discovery of the toxin’s cosmetic applications were a happy accident. In 1987, Canadian eye doctor Jean Carruthers was using Botox to treat blepharospasm in a patient. The woman complained when Jean didn’t inject her forehead, because she said the injections made her lines disappear. Jean brought the discovery to her husband, dermatologist Alastair Carruthers. The couple devoted their time to experimenting with their wrinkle-relaxing discovery, and published their first study in 1992. Above all else, the modern history of Botox is a tale of off-label innovation. “Drought Over, Botox Is Back,” heralded a New York Times headline from 1997. By that time, Botox for off-label (meaning not FDA approved) wrinkle-smoothing was so popular that demand outweighed supply, resulting in a national shortage.
In the early 2000s, cosmetic applications for the injectable neurotoxin were functional if not inconspicuous. Botox Cosmetic was innovative for its ability to treat wrinkles, not the elegance with which it did so. Botox was first approved by the FDA for cosmetic use in 2002 for treatment of glabellar lines (“eleven” lines between the brows). Though the same formula as its medical counterpart, it was marketed as Botox Cosmetic.
The neurotoxic effects of cosmetic Botox work by interfering with nerve signals to prevent muscle contraction. In doing so, it can temporarily diminish the appearance of wrinkles and fine lines. Botox is most commonly used to treat glabellar lines, crow’s feet (around the eyes), and forehead creases. But these don’t even begin to touch on the toxin’s myriad cosmetic and medical applications – from treating overactive bladder, chronic migraine, excessive sweating (hyperhidrosis), and neck spasms (cervical dystonia). The average cost of a single wrinkle-relaxing Botox treatment is $397 in the US and around £100 to £350 in the UK, though figures vary significantly based on treatment zone, concentration, and provider.
In the UK, botulinum toxin injections need to be prescribed in person by a pharmacist, nurse, doctor, or dentist. However, prescriber doesn’t necessarily mean injector. The medical professional who prescribes your toxin is responsible for ensuring that it’s safely injected by a properly-trained professional, but the injector doesn’t legally need any special certifications to administer the drug. In the US, laws regarding who can administer Botox are different from state to state. California law, for example, dictates the drug can be injected by a physician directly, or by a registered nurse or physician’s assistant while under the supervision of a doctor. Therefore, it’s critical to know who will be prescribing the drug and administering it.
As with all cosmetic injections, artistry and style should be top of mind. We’ve all seen the immobile, tight, waxy-looking faces that can come from a generous dose of toxin. It’s the look that made Botox famous, but has since gone out of style in favour of a softer, subtler approach. More recently, a new generation of young influencer-types began discussing their injections in a way that makes the cosmetic procedure feel commonplace. Allergan enlisted brand ambassadors like 33-year-old Lo Bosworth to help attract millennial consumers. Instagrammers like @botoxbunny use memes and TikTok to target a younger audience. “You’ll always have the ones who are obsessed with having no movement on their face,” says Dr Wassim Taktouk, an advanced aesthetic doctor who specialises in Botox. But generally speaking, the majority of his patients want a more natural look.
“The problem is that if you start immobilising someone’s face entirely – which I know is quite popular in LA – I think it actually ages someone.” To be fair, lack of facial movement isn’t a particularly youthful quality. Young faces are dynamic and full of expression. So a lineless, but frozen face presents the interesting paradox of looking not exactly young but also not exactly old.” Taktouk circumvents this by injecting very small quantities of Botox into key areas. The goal is, “to soften the muscle, but not to knock out its movement entirely.” This low-dose approach, sometimes referred to as “baby Botox,” is becoming a popular trend among those in favour of a more natural look.
“We’ve all seen the immobile, tight, waxy-looking faces that can come from a generous dose of toxin. It’s the look that made Botox famous, but has since gone out of style in favour of a softer, subtler approach”
Another major trend to hit the cosmetic toxin industry is what people are calling “preventative Botox”. Not all doctors believe in using botulinum toxin as a preventative. However, advocates argue that strategically relaxing certain facial muscles can interfere with the formation of wrinkles in their earliest stages, usually the mid 20s to early 30s. When it comes to preventative Botox, Taktouk takes a case-by-case approach. Skin type is a major factor.
“Darker skins we know wrinkle less, lighter skin tends to wrinkle prematurely,” explains Taktouk. He believes that paler skins with a tendency to freckle can sometimes benefit from preventative toxins, but he’s careful to add: “I don’t think that it should be a rule that everyone should start in their mid-20s. At the end of the day, it’s still a toxin, and I don’t think that you need to be unnecessarily injecting people who don’t necessarily need it. We review the patients case by case.” Botox is becoming increasingly popular among male consumers as well – Taktouk estimates around 30 per cent of his clients are men. Jax Taylor, Tom Sandoval, and Gene Simmons are just a few male celebrities who’ve spoken openly about getting Botox.
Jackie*, is a camera operator. She was 27 when she got Botox for the first time. She’d been working on location in Alaska, on and off for about four years. The conditions were harsh, and she got in the habit of furrowing her brows while looking through the viewfinder. “I started to notice those ‘eleven’ lines.” While back home in California, Jackie went in for a consultation with the nurse practitioner who does her mom’s injections and she recommended a very minimal dose of Botox. Within a couple of days, Jackie says: “There were no lines to be seen. I mean, it wasn’t crazy to begin with, but it went away completely.”
Now 30, Jackie has gotten Botox four times, typically every six months, save for the one-year hiatus before her last injection which she attributes laziness. For her, getting Botox between her brows twice a year is a preventative thing. “It was more the feeling of not being able to use those muscles that I like. It’s a good reminder to be like, ‘Hey, don’t squint when you’re looking through a camera!’” Jackie has gotten out of the habit of contorting her face while looking through the viewfinder, even when the Botox wears off (which, for most people takes about three to six months). She wears SPF and takes good care of her pale skin, but knows she’s still predisposed to premature wrinkling.
A treatment once regarded as desperately vain is now seen as little more than body maintenance. You may not be ready to dive head-first into preventative Botox but are you bo-curious? With botulinum toxin treatment so widely available, it’s difficult to know when is the best time to start. When is Botox prevention, treatment, and (if ever) just too late? Most of Taktouk’s Botox patients start around their mid to late-30s. In recent years, however, he’s noticed a worrying influx of young girls (sometimes only 18), coming in and asking for Botox.
When it comes to the younger age group, Taktouk’s approach is to steer them away from Botox altogether. He advocates for prevention via topical skin care, rather than injectable toxins. “Really good quality skin care – antioxidants, vitamin C in the morning, SPF in the day, retinols possibly in the evening – I think it’s preventative. Their skin care will decelerate the aging process of the skin. We should be pushing them to do that.”
From fatal food poisoning and bio-weapon, to eye spasms and crow’s feet, it almost feels greedy to expect Botox to have any more tricks up its sleeves. And yet, new and innovative medical applications continue to pop up. Taktouk sees the future of Botox as a renewed focus on its therapeutic roots. “It’s definitely finding a place in medical treatments for a variety of conditions, whether esophageal spasms or anal sphincter spasms. So we’re using a lot more of it in much more integrated and complicated areas. That’s quite exciting.” One of the most hyped potential uses is the treatment of depression. The effects of Botox on depression are still being studied, and the medical community isn’t exactly clear on the mechanism at play, but it may have to do with how facial expressions communicate with the brain.
In the faces of friends and family and on the pages of magazines, botulinum toxin is everywhere. The number of people who haven’t had Botox still greatly exceeds those who have, but the faces we see in the media are overwhelmingly skewed toward the latter. Past the point of being newsworthy, we continue to internalise these ageless faces but teenagers asking for anti-ageing injections takes prevention to a new and unhealthy realm. Ultimately overzealous attitudes toward Botox shouldn’t replace good skincare practices.