Botox: What You Need To Know
By Noha Aboelata, MD
It is estimated that Americans spend around 14 billion dollars per year on cosmetic procedures. Our society has always placed a high value on physical appearance, and now, with all of the choices out there, from repositioning fat to injecting chemicals and paralyzing muscles, it can be rather confusing knowing what options, if any, are right for you.
Today, Botox (Botulinum Toxin, Type A) injection is the most commonly performed cosmetic procedure in the world. Botox works by paralyzing the facial muscles, thereby stopping the expressions that formed the facial wrinkles such as lines of the forehead or those between the eyebrow. The effects of Botox typically last two to six months, at which point another injection would be needed to again paralyze the muscle. There have been some side effects and complications with Botox, but these are generally rare. The cases of death associated with Botox seem to have been in those being treated for muscle spasticity, so larger amounts of the toxin were injected. And the risk of contracting a blood-borne illness because of the Human Albumin contained in it is quite remote since donor screening is performed. Occasionally the body may produce "neutralizing antibodies" to the injection making Botox injections ineffective. Also, wrinkles not caused specifically by facial expressions will not respond to Botox injections.
Safety and results with Botox injections are quite technique-dependent. This means that with an experienced provider, you are much less likely to experience some of the more common side effects like droopy eyes or an expressionless face. Still, these potential complications are not uncommon, and may take months to wear off. We have seen clients who have experienced drooping eyes and were understandably distraught, stating that they looked better with the wrinkles! Also, going to someone reputable should decrease the chances that the Botox itself is fake or has been adulterated or diluted, situations which could lead to significant complications.
Even without the side effects, remember that Botox works by paralyzing the muscles, so there will be a reduction of facial expression. This means that those expressions that may characterize you or denote how you are feeling may suddenly stop being part of your repertoire. On a practical note, this could pose a real issue if you are an actor or otherwise in the public eye. And in personal relationships, parenting, and social situations, this could interfere as well. Recent evidence suggests that the use of Botox actually decreases one's ability to empathize with others. Users of Botox were discovered by USC and Duke University researchers to have a diminished capacity to read the emotions of others. This seems to be because we naturally mimic the expressions of others which helps us to decode their meaning. Since users of Botox are unable to use all of their facial muscles to make expressions, their ability to perceive another person's emotions and therefore empathize with them is significantly diminished. And, of course, since their ability to display emotion through facial expression is impaired, this may lead to a perception of indifference as well.
It is also important to consider all of the things that are contributing to looking older, aside from just the deep expression lines. Factors that contribute to older-looking skin include rough texture, enlarged pores, skin laxity, uneven pigmentation, fine line wrinkles, age or sunspots, and acne or other scars. So keep in mind that Botox does absolutely nothing to improve elasticity, tone or health of the skin, all critical in enjoying a more youthful appearance.
Although many non-invasive procedures will not erase your lines instantly, they can improve the elasticity of the skin, meaning that the skin bounces back more quickly. Most people who have deep wrinkles can look back at pictures from their youth and see that they have been making the expressions that led to the deep lines, perhaps their whole life. It is only as the skin ages and elasticity decreases that the lines tend to stay visible even when you are no longer making the expression. Products and procedures designed to improve the health and elasticity of the skin, and increase collagen production will turn back the clock, so to speak, so that the skin "behaves" as though it were younger. So, instead of looking different than you ever did (no longer able to make your expressions), you will look more like you did when you were younger.
Lastly, it is important to assess your own expectations and outlook on age management. Some will place a priority on immediately getting rid of a bothersome line, and do not mind repeatedly seeking an injection for that purpose. In those cases, Botox may be an appropriate method. For others, the preference will be to implement changes to their skincare, and perhaps their lifestyle that bring about only slow changes. Many will fall somewhere in the middle, wanting to make dramatic changes that are enduring as well. Skin rejuvenation, chemical exfoliation, and skin tightening procedures are amongst those that will build collagen and improve elasticity, but results are typically not immediate. It is important to remember that lines and wrinkles did not appear overnight, so methods that rid them overnight will typically not be lasting, and when they wear off, the result may not be desirable.
The effects of Botox injection generally wear off between two and six months. It is important to note that generally, the maximum improvement with Botox occurs right after the injection and then wears off as time goes on. Therefore, many will opt for regular injections of the substance to regain the look they initially achieved. This is a major reason for the profitability of offering Botox injections. However, there is growing concern that this phenomenon creates a kind of dependence on getting the injections that has been likened to an addiction. It has also been suggested that the anticipation itself of getting the next injection, or the fear of looking ugly (actually coined 'Imagined ugly syndrome' in a British study) leads to an addiction phenomenon that seems to lead to an increase in injections and other invasive procedures, including cosmetic surgery.
There is probably not enough evidence to say that Botox itself is any more addictive that other "quick-fix" or temporary solutions to aging, or that those who are seemingly hooked on Botox wouldn't have gotten hooked on something else. And certainly there are many people who can take advantage of a procedure like Botox injections while maintaining a realistic and positive outlook on age management and their own appearance. However, we have seen cases of individuals whose self-image has been affected by this cycle, whereby the patient seems to become increasingly concerned by the presence of the lines and want to do more, intervene more, and get more injections more frequently. Certainly, we have seen cases of those seeking Botox at multiple locations to avoid being told that they have come back "too soon" for their next injection. We have also seen those whose self-esteem has seemingly gone down after using Botox for a period of time. This seems to be related to the expectation that is formed over time. That is, the idea that being dissatisfied with one's appearance can be cured instantaneously by an injection. When there is an unwanted side effect of the Botox, the Botox "stops working" or seems to be less effective, or the patient's expectations are higher than what the injection can produce, symptoms of depression may arise. Of course it is of concern when, over time, we see a decrease in self-esteem and a negative impact on self-image from a process which is designed to improve one's appearance. By contrast, processes which improve the appearance daily, even if it is more gradually, seem to have a positive affect on self-image and self-esteem, and seem to contribute to an overall healthier approach to improving one's appearance.
In summary, there are many ways to approach age management, and the number of available options is rapidly expanding. Anyone planning to embark on a regimen aimed at restoring a more youthful experience must consider many factors. It is recommended that you first examine your own goals and expectations, and seek an establishment whose philosophy is aligned with yours. It is also important to consider not only the physical but the emotional effects, both positive and negative, of any approach you decide to take. Lastly, it is most critical that whatever you choose to do, that you feel comfortable and positive about your decision, and that during the course of your treatment you are looking and feeling better every day!
About Dr. Aboelata Dr. Noha Aboelata, MD is a Board Certified Family Physician and Medical Director of Isis Skin & Body in Oakland, California. Dr. Aboelata established Isis in 2004 with the clear intent of providing safe alternatives to improving the health and appearance of all skin tones. It was critical to Dr. Aboelata that the treatments she offered promoted a positive, healthy and holistic approach to skincare, while minimizing the risks of complications as well as those of dependency or distorted self-image. During her residency training, Dr. Aboelata noted that laser therapies were available only to the fairest skin tones, while plastic surgery and injectibles were becoming more popular methods for looking younger. Dr. Aboelata was motivated to find the best alternatives available that would be safe and effective for people of all tones. Once she was satisfied that these objectives could be met without compromise, Isis was founded. All products and procedures offered at Isis are non-invasive and are suitable for people of all skin tones and ethnicities.