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Botox Unfurrowed

It turns out the shots aren't so simple after all. The problem lies in the 'one size fits all' tack.

September 30, 2007|Stacie Stukin | Special to The Times

YOU'VE seen them at the mall, in line at the grocery store, even on television. Their foreheads are crease-free islands of taut skin. They smile, yet their upper face stays frozen. An upturned mouth signals happiness, but the expression reveals nothing.

You wonder: Are they asking a question? Are they concerned? And then it registers: You're looking at bad Botox.

In the worst circumstances, it's called the "joker face" or the "Mr. Spock," and it's just one of the many facial follies -- drooping eye lids, asymmetrical eyebrows (or brows that slope too low and create a sleepy look) and the ever-feared "mask face" (an inability to squint, frown or maintain a facial expression) -- that has been immortalized in medical journals by aesthetic dermatologists and plastic surgeons as cases of when good Botox gets botched. And it's become more conspicuous as Botox becomes more ubiquitous.

Twenty years ago, a handful of doctors began experimenting with the miracle protein for cosmetic purposes, and 20 years later, we're well beyond worrying about whether or not injecting a bacterium, derived from the toxin botulism, is safe.

According to the American Society of Plastic Surgeons, more than 4 million Botox injections were performed in 2006 for about a million men and women who chose the minimally invasive and temporary treatment to diminish wrinkling and frown lines.

Now that the protocols for how and where to inject Botox have been established and tested by time, the conversation has shifted toward fine-tuning the technique, and it's become clear that not all injectors (or patients) are the same.

The problem is this: Botox is no longer the luxurious domain of those with flush bank accounts and access to Beverly Hills dermatologists or plastic surgeons. Treatment can cost anywhere from $200 in the mall to $500 in the office per area injected. Thanks to an aggressive marketing campaign by Allergan, the Irvine-based company that manufactures the protein, along with its certified injection courses, Botox is available at the mall and at medi-spas and can be administered by nonaesthetic specialists: gynecologists, family practitioners, a variety of other medical professionals, as well as nonphysicians.

The result: a one-size-fits-all approach by nonspecialists who may not have intimate knowledge of facial anatomy. That shortcoming is complicated by the discovery that Botox diffuses throughout the muscles surrounding the injection point. Which is why Botox in the wrong hands may freeze the face in all the wrong places.

In fact, a 2002 article published in Archives of Dermatology, with the daunting title "Botulinum A Exotoxin for Hyperfunctional Facial Lines: Where Not to Inject," is one of a number of medical journal papers that analyzes mishaps such as "a quizzical or a Jack Nicholson look" that occur with improper injections.

"Botox is deceptively simple. You mix it, you inject it in a few key spots and then you've paralyzed the muscles," says Dr. Murad Alam, an associate professor of dermatology at Northwestern University's Feinberg School of Medicine. Alam is the author of a recently published article that recommends a series of Botox precautions, based mostly on facial anatomy.

When Botox is poorly administered, he adds, "It's like going to the mall and buying a designer knockoff and then when you get home, you're disappointed when you realize the quality isn't the same as the original Dior."

For Alam and other cosmetic specialists, the best Botox treatment doesn't leave a footprint and results in the patient looking more happy and rested. Because there is such a significant range in response to Botox and can take some people up to two weeks to see the results, a follow-up visit about 10 days later helps fine-tune the treatment. But not everyone has that patience.

Finding a cause

Explaining why we're seeing so much bad Botox is not simple. Some blame the popularity of the treatment, which is now considered a routine part of a beauty regimen. Others point at less than scrupulous technicians who realize that the more they inject, the more they can be compensated.

But it is also argued that the injection protocols developed by physicians and Allergan are inadequate. Although they are legally sound by Food and Drug Administration standards (and easily found on the Internet, DVDs and in medical textbooks), some consider these guidelines too general to produce customized, natural-looking results.

Dr. Jean Carruthers, a Vancouver-based ophthalmologist, is considered one of the pioneers of using Botox as a cosmetic treatment and was one of the original authors of those protocols. Today, she believes that the best application is an individualized approach that factors in the subtle features of the face.

"Everyone is different," she says. "Some people have very strong facial muscles that require more Botox, and others are weaker and require less."

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