Sometime last summer, I was startled to see the onset of lines in my forehead. And I screamed, nearly smashing my magnifying mirror. I was 28! I wore sunscreen! I treated my skin like a fifth favorite pet! What had I done wrong to develop wrinkles so soon?! Descending into epidermal doom, I grabbed my phone to Google “preventative botox in twenties.”
In hindsight, I was surely suffering from what I now is a uniquely pandemic-prompted panic. “We’ve been affectionately calling it the ‘Zoom effect,’” Dr. Michelle Henry, a New York City dermatologist, tells SheKnows. “People have been staring at themselves for hours and want to make changes.”
Dr. Renée Moran, owner of Dr. Moran Medical Aesthetics in Newtown, Mass., says the same. “Everybody’s got Zoom doom. When you’re in all these meetings, you’re constantly looking at yourself.”
Hence: The COVID cosmetic procedure boom, of which I wasn’t even aware until being a part of it.
I didn’t get Botox until October, two weeks before I turned 29. The combination of “Zoom doom” and the end of my twenties pushed me past my fear of needles, and I made an appointment with an injector a friend recommended. I did no further research on the practitioner or the procedure, and looking back, I was a fool. I didn’t know what Botox was or how it worked, frequently confusing its effects with those of filler.
I didn’t even care: I’d become so irrationally obsessed with these “lines” that I just wanted to be rid of them and move on with my life…Except that’s not how Botox works, nor any injectable for that matter. Unbeknownst to previous-me, Botox lasts about ninety days, so you need to have it continually touched up if you want the results to remain. So really, injectables are a life-long commitment — the opposite of moving on.
What’s more, I was under the impression that Botox and injectables weren’t a “big deal,” mostly because of what I’d seen online. As of late, especially amid the pandemic, my feed’s been filled with twenty-somethings broadcasting seamless procedures, smiling. So I figured it was painless, something simple like getting your eyebrows waxed. And while that’s true in the sense that you can walk out right after, injecting skin always presents the possibility of bruising, swelling, and infection, no matter how skilled your injector is. Plus, sometimes, it does hurt! My first time was so excruciating I texted my friends, “you lied,” while blood streamed down my face. My second time was painless however, and I didn’t bruise or bleed. It’s weird!
Now, when friends ask for advice on injectables, I always advise doing rigorous research on desired procedures — and practitioners — before moving forward. Because while I love that social media is normalizing honesty about cosmetic work, we must simultaneously normalize doing thorough research before letting strangers inject our faces with bacteria (a subtweet at past me).
You can start now. Here are frequently asked questions about — and what I wish I knew before getting — Botox:
Is it just me, or is everyone getting Botox now?
Overall, the average number of facial aesthetic procedures has nearly doubled since 2013, and, as noted earlier, the pandemic is inspiring record numbers of people to pursue cosmetic work. That said, the more likely reason it suddenly seems so common is due to a decrease in stigma.
“It’s not taboo anymore,” says Dr. Craig Forleiter, a plastic surgeon in Palm Beach, Florida. “People used to get face lifts and not go out in public for weeks until it was healed. Now, people can’t wait to go out and show everyone their face lift.”
Kristina Kitsos, a Beverly Hills registered aesthetic nurse who’s been injecting for over 17 years, says the same — primarily of her patients in their twenties. “If you look at my Instagram you think all my clients are young, but in reality it’s only about 20 percent,” she says. “Other patients are secretive, but my younger clients have all grown up online. They’re not ashamed.”
What is Botox?
People tend to use “Botox” as an all encompassing term, but “Botox” is actually a brand name referring to its main ingredient, “Botulinum toxin,” which was first identified in 1895, and approved for medical use in 1989. “[Botox] has been safely used since the 1980s, and was originally used for blepharospasm — spasms in the eyelid,” Kitsos explains. “[Doctors] noticed people who were treated for those spasms in one eye ended up having fewer wrinkles in that eye and wanted the other eye, without the blepharospasm, treated as well, so the smooth skin would be even on both eyes.”
Thus: The birth of cosmetic Botox, which was approved for wrinkle treatment in 2002.
What does Botox do?
Like Kleenex to tissues, Botox is one brand name of many “Neuromodulators.” When injected, neuromodulators “temporarily paralyze the muscle, reducing wrinkling and pulling of the overlying skin,” says Henry of how they work. Therefore, contrary to my initial belief, neuromodulators don’t necessarily treat existing wrinkles, they prevent them from getting worse.
Other brand name neuromodulators include Dysport, Jeuveau and Xeomin.
Are Botox and filler the same thing?
No! Neuromodulators and cosmetic filler are very different, aside from both being injectable cosmetic treatments. Botox paralyzes the muscle into which it’s injected, while filler, most commonly made of hyaluronic acid, adds volume. You can think of Botox like a sports bra — holding your muscles in place so your skin can’t form wrinkles — while filler is a push-up bra, adding cushion beneath the skin. Both can also address aesthetic-aging concerns, however: If you’re concerned about a loss of volume in the face, for example, filler can help.
Can anyone inject Botox?
No. While it slightly varies by state, registered nurses (RNs), physicians assistants (PAs), nurse practitioners (NPs), and doctors (MDs) are customarily qualified to inject neuromodulators and fillers after a brief training in injectables. In most states, RNs, PAs and NPs must be supervised by an MD, though in some, like Texas, aestheticians and beauticians can inject, too.
How do you know who is a good injector?
No title is necessarily better than another in the world of injectables, and just because someone’s a doctor doesn’t mean they have adequate training in skincare and facial anatomy (as much as I love my psychiatrist, an MD, I don’t want her injecting my face). So really what it comes down to is someone’s experience and training, which you can usually find on their website. Always be sure to read reviews and find pictures of someone’s previous work, and never be scared to ask for a consultation.
“It’s so so important to go to a reputable injector and someone who has done more than just a weekend certification class,” Moran advises. “ A lot of those classes don’t even have hands-on training.”
Henry agrees. “Make sure you find an injector who is well trained and understands the dynamics of aging and anatomy,” she says. “The American Society of Dermatologic Surgery is a great source to find an excellent injector.”
How long does Botox last?
Neuromodulators last about ninety days, depending on the individual’s skin and other factors. “Three months is what companies claim,” Kitsos says. “Some [patients] say more, but those are the lucky ones.” This doesn’t mean your skin will suddenly start to sag on day ninety one. It’s a gradual process, like a “a melting ice cube,” she says. “It slowly fades away.”
Therefore Botox, unlike permanent surgery, is not a one and done deal. If you like how it looks and hope to preserve the effects, you’ll need to touch it up a few times a year, depending on how dedicated you are to the aesthetic.
How much does it cost?
Prices widely vary. One Botox session can range from around $100 to upwards of $1200, and possibly even more. My first treatment was a “Baby Botox” first-time special, costing $90 for 10 units, but the second, which was 20 units, was several hundred. Prices increase from there, depending on location (LA and New York tend to be more expensive) as well as the type of practitioner. Plastic surgeons and dermatologists are customarily more costly.
If you’re looking at these numbers and thinking they’re reasonable, be sure to remember: Injectables require maintenance and touch ups every few months. These will amount to recurring costs, like a subscription.
Are there risks associated with Botox?
Every medical procedure comes with a set of risks, so yes. “The risk of bleeding, bruising, and infection are always present, regardless of training,” Forleiter says. “There are certain steps that we take in order to decrease those risks, although we can never completely eliminate them.”
Botox injections can also cause Ptosis, which essentially means sagging, and is caused by Botox paralyzing a muscle for which it wasn’t intended. Botox most commonly results in Ptosis of the eyebrows and eyelids, making them droop. “Unfortunately for those you just have to wait it out,” Moran explains. “Within a few weeks, once you start getting muscle strength back, it will start to correct itself. There are eye drops [that can] help it out but really it’s just a wait and see.”
There are a multitude of other unlikely risks, that are pretty much on par with those of any given procedure and/or medication: Allergic reaction, headache (which I get!), itching, pain, difficulty swallowing, shortness of breath, nausea, stomach pain, muscle weakness and more. It’s also not suggested to get Botox if you’re pregnant, breastfeeding, and/or have a neurological disorder. Be sure to read up on the full list of side effects and warnings.
Why else do people use Botox?
As explained above, Botox was initially used to treat eye muscle disorders, for which it’s still used today. Botox is also used to treat chronic migraines, chronic pain, overactive bladder and excessive sweating (‘hyperhidrosis’) in various parts of the body, as well for other aesthetic enhancements, like “brow lifts” and “lip flips.”
“For brow lifts, Botox is used to relax the depressor muscles of the brow to gently relax and elevate the brow,” Henry says of neuromodulators’ alternative benefits, adding that lip flips work by relaxing the muscle area around the mouth, which can help result in poutier looking lips.
Does “Preventative Botox” really work?
There’s no guarantee that Botox will specifically help you with wrinkles, considering everyone’s skin is so different. The logic behind preventative Botox is compelling, though. “Wrinkles are the result of excessive contraction and movement — the same reason that your clothes get wrinkled when you wear them,” Kitsos explains. “By limiting excessive movement, you don’t ‘grow’ the wrinkles in the first place.”
“Early treatment may prevent the creation of deep severe wrinkles,” says Henry, adding that “pre-juvenation and tweakments – little changes to prevent the need for large treatments” are “very popular” with Gen Z and Millennial aged patients.
Is Botox vegan?
No. Botox contains egg protein, and Dysport, another neuromodulator brand, has milk protein in it, too. So if you’re vegan and/or have allergies — especially to eggs or milk — be sure to choose injectables wisely. May this be a lesson in always reading products’ ingredients before having them injected into your face!
What else can I do to prevent wrinkles?
The answers to this were pretty much a resounding chorus of “sunscreen!”
“Wear SPF every single day, no matter what,” Moran says. “Even when you’re indoors, you’re using your tablet and phone, and you can still get damage [from the blue light] that way.”
Forleiter also suggests using “SPF skincare with titanium dioxide,” as well as asking your doctor about tretinoin.“[Tretinoin] has been shown in medical literature to improve fine lines and wrinkles, thicken the dermis and increase transit time of pigment through the outer layers of the skin,” he says. “This chemical has a really great anti-aging effect.”
Otherwise, adopting and maintaining a solid skincare routine, including sunscreen and drinking plenty of water, can do wonders for the skin, no matter your age.
A version of this story was published March 2021.
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