Smoothing the Fault Lines
When it comes to cosmetic botox treatment, the devil is in the details
Wanting to erase the thin laugh lines around her eyes, Judy Patty decided two years ago to go for Botox treatment at an antiaging clinic run by Jerome Lentini, a doctor recommended by a friend of hers. Botox is a form of botulinum toxin, a powerful bacterial poison. But when given in tiny injections, it makes wrinkles disappear by temporarily paralyzing the muscles underneath the skin that cause it to fold and furrow.
After the nurse injected the skin around her eyes, Patty's wrinkles faded, but for the next three weeks she also experienced severe swelling around her eyes and clogged sinuses. "Both the doctor who treated me and my regular doctor told me that I couldn't be having this reaction from the Botox and insisted it was just a really bad cold," says the 47-year-old mother of two from Portland, Ore. When the fine lines reappeared five months later, Patty went back to Lentini and again experienced the same nasty side effects. The next time she heard about the doctor, he was in the news. In 2005, he was arrested by federal investigators for misrepresenting a highly concentrated botulinum toxin intended for laboratory use as Botox and using it on more than 800 of his patients. "I'm very worried now about the long-term effects of what was put in my body," she says.
The Food and Drug Administration has approved only one botulinum toxin for the treatment of wrinkles: Botox, manufactured by Irvine, Calif.-based Allergan. Though its only cosmetically approved use is for reducing frown lines between the eyebrows, doctors can and do inject it "off label" to smooth wrinkles elsewhere in the face: in the forehead, around the eyes, in the lines below the lips. Practitioners have found so many handy uses for this paralytic poison that it is by far the most popular cosmetic plastic surgery option, with 3.8 million procedures performed in 2005, according to the American Society of Plastic Surgeons.
Used as directed, Botox has proved to be safe and effective thus far. But as Botox's popularity has grown, so has the potential for risky, dangerous treatment, either at locations not equipped to handle a medical problem-Botox party, anyone?-or by practitioners more interested in making a quick buck than protecting your safety. The research-grade botulinum toxin that Lentini and some 200 other doctors bought through the Internet, prosecutors say, was clearly labeled "not for human use." But at about $1,000 to treat 15 to 25 patients, half the cost of Botox, the price proved irresistible. In a way, Patty was lucky: She got off with coldlike symptoms. A Florida doctor who injected himself and three friends with the drug wasn't so fortunate. They all wound up in the hospital for several months, paralyzed and hooked up to ventilators while the toxin slowly cleared from their systems.
Genuine thing. Research-grade botulinum toxin isn't the only substance practitioners are either ordering online or bringing back with them from their travels abroad. There are Chinese, South Korean, and German versions of the drug, as well as Dysport, a drug similar to Botox, that's approved in Europe and is currently under review by the FDA. Just say no to these Botox wannabes, say doctors. "You'd have to be very stupid to use anything that's not FDA-approved after the fiasco in Florida," says Alastair Carruthers, president of the American Society for Dermatologic Surgery, referring to the four patients who were hospitalized there.
Since the federal investigation, Allergan has made it easy for patients to make sure they're getting the genuine thing. Every Botox vial now has a hologram that says "Allergan" on it and a flip-top cap emblazoned with the company's name. If you decide to go under the needle, do your own quality check. "Ask to see the bottle," says Richard Glogau, a clinical professor of dermatology at the University of California-San Francisco, "then watch the doctor draw the medicine in front of you."
In addition to using authentic Botox, picking the right practitioner to administer the injections is critical to achieving a safe and aesthetically pleasing result. You can't trust someone just because he or she has a medical degree, though there are plenty to choose from these days. Doctors of all types, from dermatologists to gynecologists, are hanging out a shingle and offering cosmetic procedures from chemical peels to laser resurfacing to Botox. In general, doctors aren't required to undergo any special training before performing these procedures. What's more, in many offices, nurse practitioners, registered nurses, physician assistants, and other non-M.D. staffers may be giving treatments.
The good news is that even if you are treated by an inept technician, you'll almost certainly suffer no permanent harm, though you may have to deal with a droopy eyelid or frozen forehead for a couple of months until the Botox wears off. But why spend an average of $300 to $500 a treatment to look like a Stepford wife? Achieving a natural look that allows expressiveness while smoothing away wrinkles is your goal, and the more familiarity your practitioner has with how faces work, the better your chances of attaining it.
Those with the most extensive training in the musculature of the face are M.D.'s in the specialties of dermatology, ophthalmology, and facial and general plastic surgery. Ask your doctor what training he or she has had in the specific procedure you're considering, how many years the doctor has been performing it, and how many patients he or she has treated with it in the past year. Ideally, you want someone with extensive training (more than a weekend course) who has been performing the procedure routinely for at least a couple of years, say experts.
Nurse practitioners, registered nurses, and physician assistants who've taken courses in cosmetic procedures and trained extensively with a doctor may be competent practitioners as well. Ask the same questions about experience, and make sure a doctor will be on the premises when you're having a treatment, says Glogau. Although side effects are rare, people sometimes get lightheaded or faint during the procedure, have an allergic reaction, or bruise or bleed.
If Dysport is approved in the United States as expected in the next couple of years, patients will be able to pick their poison, and the price will probably come down. But for now, choosing an experienced professional and making sure the real thing is being used are your best bets for ensuring that your Botox treatment succeeds without a wrinkle.
This story appears in the January 22, 2007 print edition of U.S. News & World Report.