Is Preventative Botox a Scam?

Preventative Botox
Photo: Uyen Cao

I often find myself in front of my mirror making facial expressions and then inspecting whether my wrinkles are still there when I stop. At 30 years old, I have faint lines at the outer corners of my eyes and a couple of creases around my mouth whenever I smile, but they quickly disappear once I relax my face. When the day comes that my crows feet and laugh lines have settled in, there's a good chance I'll get Botox — but until then, no way.

I think preventative Botox is kind of a scam.

Preventative Botox is used to prevent wrinkles and fine lines from forming, or injected during the early stages of fine lines and wrinkles to stop them in their tracks. Many doctors recommend it as a preemptive solution to a problem.

"I usually say that the time to really start preventative Botox is when you see a faint line starting to form when your face is at rest," says Dara Liotta, double board certified cosmetic and reconstructive plastic surgeon in New York City. "Anyone without Botox will have lines when they animate their face, but if you rest your face, and you start to see a faint line in the area, that's the beginning of a wrinkle, and preventative Botox can help before the line becomes more permanent."

I'm not against preventative Botox because I think that getting injections will make my face look frozen or fake, or because I'm scared of needles. Instead, my aversion stems from not knowing what Botox will do over time — if I ever decide to stop getting it, I worry about the adverse effects it could have.

As it turns out, some doctors agree.

"Typically, botulinum toxin injections [like Botox] are started when lines and wrinkles start to form, not prior to the appearance of any symptoms," says Patricia Wexler, M.D., dermatologist and founder of Wexler Dermatology in New York City. "If the toxin is started too early, before any lines or wrinkles exist, the muscles and skin overlying the muscles can eventually become atrophic (thin), and look prematurely aged."

According to Dr. Wexler, this is especially true of the forehead. Injecting Botox for many years can lead to muscle loss in the area that's being treated, and flattening of the forehead muscle — and, importantly, the skin on top of it. This means you can end up with even more wrinkles than you originally had, plus visibly protruding veins. Hers is just one of many professional opinions on the subject — I spoke with numerous dermatologists, and all of them made slightly different arguments for or against preventative Botox.

"When I first started teaching this to resident physicians nearly 25 years ago, I injected some young physicians since they wanted to experience the treatment themselves even though they didn't have wrinkles yet," says Loretta Ciraldo, MD, FAAD, a Miami-based dermatologist and co-founder of Dr. Loretta Skincare. "Many of these young physicians have wrinkled much less than expected and I do believe this is based on the 'preventative nature,' but there really aren't any studies on this yet, so it is just anecdotal at this point."

Dr. Ciraldo also says that she's seen the muscles weaken around the frown line in some patients she's been treating with Botox for 24 years, although it isn't always obvious. Ava Shamban, MD, Beverly Hills dermatologist and founder of SKIN FIVE, agrees.

"We do see the frown muscles weaken if treated three to four times a year," she says. "It isn't seen around the eyes or in the forehead. If the treatments with Botox stop, the muscle movement begins again." This means that when the muscles move again, it's possible the wrinkles will return, or fully form if they hadn't before. So, "preventative" Botox only prevents wrinkles as long as it's kept up.

As Dr. Ciraldo mentioned, the reason that it's impossible to nail down one concrete medical opinion on preventative Botox is because the evidence of its efficacy is all anecdotal. Although there have been studies on using Botox preventatively, using the toxin this way isn't actually FDA-approved. Botox has FDA approval to be used for existing wrinkles on just three facial areas (crows feet, forehead lines, and frown lines between the eyebrows) — and this limited approval took almost 15 years.

"When companies get things FDA-approved it takes many years, thousands of subjects, and is very expensive," says Nicci Levy, founder of Alchemy 43, a chain of medi spas. "Typically what these companies do with getting cosmetic approval is that they pick one thing to get approval on and add other things later."

Even without hard evidence, the interest in preventative Botox is growing. More than half of Alchemy 43's customers are under the age of 35, according to Levy. The American Society of Plastic Surgeons reports that Botox procedures in general have increased 28% since 2010 among 20- to 29-year-olds. The West Coast chain known as the "Drybar of Botox" in the beauty industry, offers an inviting, social-media friendly space to get "microtreatments," a stark contrast from getting injections in sterile doctors' offices. The locations feature pastel pink furniture, marble tables, and neon signs. It looks like the average millennial's Instagram feed in real life.

InStyle beauty editor Dianna Mazzone, 25, gets preventative Botox to minimize frown lines, and considers the injectible part of her skincare routine. "I started to see very faint vertical lines between my brows," she told me. "I think about it like anti-aging skincare — it's easier to be proactive than reactive."

However, being proactive can be costly. According to the American Society of Plastic Surgeons' 2017 Plastic Surgery Report, the average nationwide cost for Botulinum Type A toxin injections is $385. Considering that Botox's results aren't permanent, years of getting injections doesn't come cheap. In the case of a cautionary treatment like preventative Botox, you're adding years of spending money to maintain the treatment results before the problem truly exists.

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"Cost is a factor, but this is actually my only real 'indulgence' or frivolous expense," says Dana, 27, who gets Botox to reduce and prevent the appearance of forehead lines. "The cost isn't too hard to swallow if you think about how much it costs per month based on the frequency I receive the treatment (less than $100). That's not to say it's not a lot of money, but it's worth it for me."

Then, of course, there's the risk factor. Generally, the risks of getting Botox are pretty minimal — common side effects include bruising, or a mild headache immediately following the procedure. The fact that doctors confirm it's relative safety probably lends to the low-key attitude millennials have toward getting injectables, and why they're willing to pay the price for the treatment. However, Botox — preventative or otherwise — can go awry when it's injected incorrectly or the wrong amount is used. A few examples Dr. Ciraldo has seen include droopy eyelids or eyebrows after being injected too closely to both areas, and an uneven smile after receiving crows feet injections slightly lower in the cheeks. It can also cause non-cosmetic reactions, including dry mouth from getting too much Botox in the neck, and dry eyes from getting it too close to the orbital area.

Without any concrete studies that prove preventative Botox stops wrinkles from developing or delays early stage wrinkles from becoming more noticeable over time, I can't help but see this as continuously receiving potentially risky injections with the hope I might preserve my appearance. I liken it to my ability to do a plank in Pilates class. When I go to class a couple times a week, I can hold a plank for a minute without dropping my knees or breaking a sweat. If I skip a week, I only last about 30 seconds in my plank before I have to take a break. If I were to quit going to Pilates, soon enough it would be like I'd never been able to plank at all; I'd lose the ability completely. To maintain a wrinkle-free complexion, I'd have to keep on getting Botox — starting before I even have distinct wrinkles. And I'm just not ready to sign on for 60 years of needles to the face, based on hope alone.

Like any other cosmetic treatment — from hair dye to body waxing; lash extensions to gel manicures — the choice to commit to the expense, plus the risk of long term Botox use is totally up to the individual. So for now, I'm gonna stick to my Caudalie serum, my Pilates, and squishing my face up in the mirror to check for wrinkles. Maybe I'll reconsider once they actually appear.

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