Leading cosmetic injectables expert Dr Sarah Hart answers all of our burning questions about Botox, from when to start, to what can go wrong, and how much it costs.
For those who are considering it, the most important advice is to find a practitioner who knows what they’re doing. Book a consultation session first. And ask lots of questions.
To get the ball rolling we asked leading cosmetic medicine doctor Sarah Hart some of the most common — and important — questions, to help give you a better understanding of what is involved.
First up, what’s the difference between Botox and botulinum toxin?
Botox is a brand name and has become so well known it’s used in a generic way, like Xerox or Hoover. The generic name is botulinum toxin which, like photocopier and vacuum cleaner, isn’t nearly as catchy.
Botulinum toxin sounds scary. But toxins are just biomolecules produced by plants, bacteria and animals, usually for defensive purposes. They make great medicines. For example, digitoxin from the foxglove plant is a heart medicine. Botulinum toxin is produced by a bacteria found in soil, Clostridium botulinum.
The botulinum toxin protein has a very specific function. It stops nerves releasing a neurotransmitter called acetylcholine by snipping a receptor protein called SNAP-25. This relaxes the muscle. It is very precise, so you can use tiny amounts to target individual muscles. It also affects sweat and salivary glands, as they too are controlled by acetylcholine.
It was first used for relaxing eye muscles to stop crossed eyes and eye muscle spasms. Patients being treated for eye conditions noticed it improved their wrinkles. Thus, cosmetic use was discovered by chance. Before Botox, plastic surgeons used to physically cut the frown muscles to improve frown lines. It makes more sense to temporarily relax the muscles with a few quick injections instead. It caught on quickly and now, millions of people have had their wrinkles treated with Botox.
It is used for a huge number of conditions, from migraines to spasticity, incontinence to erectile dysfunction. It’s an incredibly useful and versatile medicine.
Why are so many people — women and men — getting Botox?
I think it’s become so popular because it’s easy and effective with minimal recovery time. All you need to do is have tiny injections three or four times a year, then you can go straight back to work (or play) with a little concealer. It’s very efficient, and really works for wrinkles. It’s much more effective at smoothing lines than skin creams, as confirmed by hundreds of academic research papers.
Botox also has extra effects that other skin treatments don’t have. My patients report that relaxing their frown muscles often improves their mood and makes them feel happier. Looking more cheerful and approachable can improve how others respond to you socially. Some patients report improved headaches too, which makes sense, because the areas we treat with Botox for preventing headaches are similar.
Sounds positive. What are the negatives?
You have to choose your practitioner carefully. If done poorly, Botox can make you look a bit weird. For example, too much Botox in the crow’s feet can cause “shelving” where the cheek drops when you smile, leaving a hollow at the lower corner of the eye. The wrong placement in the forehead can give you wonky brows, or Spock eyebrows.
Too high a dose can leave you looking frozen and shiny, or shrink your muscles too much. It shouldn’t be like this. Good Botox is both an art and a science, and I think finding the right practitioner is like finding a great hairdresser! Word of mouth is best.
Which areas of the face respond best to Botox?
Botox is fabulous for frown lines, horizontal forehead lines and crow’s feet. It works better than anything else for these wrinkles. It can lift the brows, or even lower them, if that’s your goal. We can also use Botox “off label” to relax muscles in other areas of the face, although regulations mean I can’t publicise these. However, your practitioner can discuss this in a private consultation.
Is it true it can weaken your facial muscles?
Yes, that’s how it works. Weakening the muscle that causes the wrinkle is the goal. I prioritise relaxing the muscles that pull down on your face, to encourage a gentle lift.
It lasts about 3-6 months, depending on what dose you have. A bigger dose lasts longer. It can also last longer after you’ve had regular treatments for a couple of years. Usually you’d have treatment every four months, but it varies from three to six months, as it often lasts longer when you’ve been having it for a few years, while small doses don’t last as long.
How much is it going to cost?
Cosmetic Botox is charged by the unit. The price per unit varies from $15-30 depending on the experience and skill of the person administering it.
What rules govern the use of Botox in New Zealand?
Botox is a prescription medicine. Doctors and dentists can prescribe and administer it. Cosmetic nurses can also administer it under a ‘Standing Order’ from a doctor or dentist, who is responsible for making sure the nurse is competent.
In New Zealand, there is recognised training for doctors who perform cosmetic botulinum toxin treatments called the NZSCM Diploma of Cosmetic Medicine. This two-year course is the only qualification recognised by the Medical Council of NZ. The NZ Society of Cosmetic Medicine (NZSCM) was established 21 years ago to ensure high standards for doctors doing Cosmetic Medicine treatments like cosmetic injectables.
The Diploma is a comprehensive course with over 200 hours of lectures, demonstrations, hands-on workshops, and practical and written exams. All NZSCM members have the Diploma and follow specific standards of ethics and practice when treating cosmetic patients.
Dermatologists and surgeons may perform cosmetic Botox treatments after completing specific extra training. Non-dermatologist, non-surgeon, non-NZSCM doctors may perform cosmetic Botox, but must have the supervision of a “collegial relationship” with a dermatologist, surgeon or NZSCM member.
There are no recognised qualifications in Cosmetic Medicine for dentists or cosmetic nurses yet.
A bruise, headache or tenderness is always possible where injections are involved, but done well, Botox has a very low rate of adverse events. However, sometimes it can weaken a nearby muscle that’s not the intended target. It might weaken the lid muscle, giving a droopy eyelid, or a smile muscle, giving a narrowed or crooked smile.
The rarest complication is double vision, where the muscles that move the eyeball are inadvertently weakened. That requires Botox to spread a couple of centimetres from the correct location, which is a long way, so it’s incredibly rare. Muscles affected by Botox always regain their strength, so all adverse effects will wear off. Most people don’t get adverse effects from Botox — that’s why it’s so popular.
You should also be aware that we’re starting to see counterfeit toxins which have unpredictable effects, so make sure you find a reputable practitioner. The only qualification recognised by the Medical Council of NZ is the two-year NZSCM Diploma of Cosmetic Medicine. You can find NZSCM Cosmetic Medicine doctors here. Nzscm.co.nz/members-directory
What follow-up is needed?
I ask my patients to come back for photos a couple of weeks after treating any new area. It takes two weeks for Botox to settle completely, so follow-up is essential to find out whether the treatment looks great. I can tweak the result with more Botox if needed. Once we’ve created the perfect injection pattern for your face, you don’t need to return each time.
Is it true if Botox is used on young skin, it can prevent wrinkles from forming in the first place? What evidence is there to support this idea? Is it really a preventative measure for future wrinkles?
Short answer – there is no hard evidence to confirm it, but it makes intuitive sense. If the skin isn’t being creased repeatedly by the muscle, it is hard to form a wrinkle. In daily practice, we see that Botox can eradicate a pre-existing line, which stays improved as long as treatment continues. It therefore makes sense that treating before the line appears should give the same result. Having said that, I don’t believe it’s necessary to start before lines appear to get good results – it’s fine to wait until you can see a faint line.
We may never get high-quality evidence for this, because that would require a study with young people over about 10 years, with half treated with Botox and the other half treated with saline. This would be challenging! Imagine being in the saline group and having injections for years with no benefit. I think you would get a very high dropout rate.
It’s important to remember that Botox isn’t a magic anti-ageing potion. There are features of ageing it can’t prevent, like volume loss, sagging and sun damage. It relaxes muscles, and so reduces wrinkles caused by muscle action, but it won’t magically prevent ageing. You must still wear your sunscreen!
At what point would you recommend someone with no wrinkles start getting Botox (if minimal wrinkles is the ultimate goal)?
I think starting Botox injections before you see a line isn’t necessary. I think it’s a waste of money, as Botox is very effective on visible lines. It’s perfectly fine to wait until you can see a faint line at rest, and I’m confident Botox would eradicate it. If you have lots of sun damage or have inherited strong frowning muscles, then you might start early, say in your later 20s. I don’t think it’s necessary to start in your early 20s, or god forbid, your teens. If you’re worried about skin ageing, it is much more important to wear sunscreen at that age!
When is it too late to bother? At what age/stage has the horse already bolted?
Once a line is very etched into the skin, it is harder to treat with Botox, as it can remain visible even when the muscle has been relaxed. However, studies show that you get cumulative improvement with the first six Botox treatments, so don’t despair if one treatment doesn’t take the line away. It might still work with persistence.
We can add other treatments like filler or laser resurfacing to reduce a static line, as these combine well with Botox. Cheek filler is great to support crow’s feet. However, I am cautious about treating frown lines with filler, as it’s close to the arteries that go to the back of the eye, so it’s a higher risk area for filler-associated blindness. I don’t jump in immediately with filler in that location.
When it comes to excess skin, like droopy upper eyelids, bags under your eyes or jowls along your jawline, then you might find a surgical procedure addresses these more effectively. Although it’s more effective if you start before 45-50 years old, Botox can still help in older people. My oldest patient is 86 years old. Botox in her frown line didn’t eradicate it, but it had a lovely softening effect that made her happy. If your expectations are realistic, there’s no age limit to a Botox treatment.
Can you have Botox to tighten the under-eye area?
I advise against it as weakening the muscle under the eye isn’t useful. The muscle under the eye holds the fat bags in and weakening it can make your lower eyelid droopy or increase eye bags. It doesn’t look good!
What is the difference between Botox and Dysport?
They are very similar, as both are botulinum toxin type A, just different brands. Botox is American and Dysport is English. In my experience, Dysport spreads a little further than Botox but they are both good, safe products.
What studies have been done on the safety of long-term Botox users?
Any medication has risks, but the safety record for Botox is excellent. It was first injected in 1977 and has been used for wrinkles since the early 1990s. Now, 30 years later, tens of millions of patients have been treated with Botox giving a lot of data and many studies. Cosmetic Botox requires much smaller doses than “therapeutic” use and studies on long-term cosmetic use have revealed minimal problems. These include a study with identical twins over 13 years, and a study by Professor Greg Goodman on 194 patients over a maximum of 16 years.
Antibodies to botulinum toxin can form after years of use, but we very rarely see this with the tiny cosmetic doses. In therapeutic Botox use, where the doses are many times higher than in cosmetic use, it is seen more but is still rare. If you have antibodies to botulinum toxin, you become immune to Botox treatment.
Does having Botox alter the shape of your face in the long run (by using different muscles to compensate)?
Our facial muscles can get smaller when we treat them repeatedly with Botox, just like any muscle can when you don’t use it. Shrinkage of large facial muscles can be noticeable. For example, when we relax the bulky chewing muscle for teeth grinding (an off-label treatment), the lower face can become slimmer because of the muscle shrinkage.
Most people like this effect. Another muscle called procerus that sits between the eyebrows can shrink when we treat the frown, although it’s less noticeable because it’s a small muscle. The higher the dose and the longer the muscle doesn’t move, the more shrinkage. If you want to avoid shrinkage, have the smallest effective dose and let your muscles return to movement between treatments.
Muscle compensation can also happen. This is because when you treat part of a muscle with Botox, the remainder can get more active to compensate. We use this to our advantage for brow lifting, but sometimes it is unwanted.
The most common unwanted compensations are bunny lines and Spock brows. Bunny lines occur when treating the frown or crow’s feet, which can activate the nose-scrunching muscle. Spock brows happen when the brow-lifting muscle works too hard over the brow peak. Both can be fixed with an extra drop of Botox in exactly the right place. The important thing is to watch for it! That’s where a well-trained practitioner is worth their weight in gold, tweaking if needed at your follow-up appointment.
Once you start getting Botox, can you keep getting it for the rest of your life, or does a cumulative amount do you damage?
No, it doesn’t cause cumulative damage, as it always wears off. Botox works by snipping a tiny protein receptor, stopping the nerve releasing a chemical called acetylcholine that makes muscles move. Botox is said to “wear off” once the body makes new receptors and the muscle starts moving again.
I’ve personally been having Botox for about 25 years and have many patients I’ve treated for 20 years. I’ve noticed Botox lasts longer after a few years of regular treatments, so you can use less, or space your treatments further apart. It’s important to adjust your injection pattern as you age, just like adjusting hair and makeup as the years go by. Changes in facial skin, fat and bone with ageing can cause droopy upper eyelids for example, so your injection pattern should be tweaked to account for this.
Can Botox be used to lift areas of the face that might be sagging — like a non-invasive facelift? Or is it not strong enough to achieve that effect?
Yes, in the right person, you can create a slight lift by relaxing muscles that pull downwards on the face. It only works if the muscle that pulls down is strong (so it makes a difference to weaken it) and the opposing muscle that pulls up is active (so it does the lifting work). For example, the muscle that causes crow’s feet also pulls the end of the brows down. When we relax it with Botox, the muscle in the forehead that pulls the brows up is “unopposed” and can lift the end of the brows more easily, so they sit higher. That’s a Botox brow lift. You can do the same thing using Botox off-label in the jawline with a Nefertiti Lift. It works better in some than others, depending on their muscle movement patterns.
What age approximately should one start — what is too young, too old?
The usual starting age is between 30 and 40 years old. When you start to see a faint line at rest, while not actively frowning or smiling, then the muscle movement has affected the skin enough to justify Botox.
Dr Sarah Hart graduated as a doctor from Otago University in 1994 and has practiced cosmetic medicine in 2001. In 2006 she became a member of the New Zealand Society of Cosmetic Medicine (NZSCM). This is the only body recognised by the Medical Council of NZ to train and regulate cosmetic doctors. Dr Hart now serves as Censor on the Executive Board of NZSCM, as a valued member of the NZSCM Education Faculty, and on the Botox, Juvederm and Belkyra Advisory Boards. Her passion for raising standards has led her to develop an international career lecturing about cosmetic injectables. She presents at top conferences around the world and trains practitioners across Australasia and China.