The Botox Boom

Someday the world of science may recognize the contribution of Cathy Bickerton Swann, perhaps the only person to make medical history as a receptionist in a dermatologist's office. It was back in 1987 when Dr. Alastair Carruthers, of Vancouver, B.C., noticed the frown lines on the otherwise uncreased forehead of his pretty, 30-year-old assistant--an inverted V whose tips just touched her eyebrows, and that deepened hour by hour, until by midafternoon she "actually looked pretty hostile." When Carruthers suggested to her that he might be able to do something about what are technically known as glabellar lines, Bickerton Swann didn't respond, Gee, you know, I kind of think they give my facecharacter. And when he approached her with a syringe containing an extremely dilute solution of botulinum toxin type A, which in a more concentrated form is one of the deadliest poisons known, she didn't say, Well, you know, maybe I should just think about bangs. The injection was no more than a "prick," she recalls, and within a few days she had the silken forehead of a 12-year-old--in fact, a different 12-year-old, because she had been afflicted, if that's the right word, with frown lines since childhood. Someday maybe they'll put up a plaque to Bickerton Swann, perhaps in a dermatologist's office on Park Avenue or in Beverly Hills. In recognition of her achievement, the plaque will be blank.

And from that little pinprick has grown a huge and lucrative market for the cosmetic use of botulinum toxin--occasionally mentioned in the press as a possible bioterror weapon--in the form of a product now called Botox. It has been a boon to the demographic now known officially as Aging Baby Boomers--helping to make trophy wives out of ordinary ones, turning character actresses back into ingenues and erasing the stigma of failure from the brows of laid-off technology executives. And it even works on regular people. "I never looked like a Shar-Pei, but I really didn't like what I saw," says Diana Garno, 51, a sales rep for a Cleveland radio station, who calls Botox "the miracle drug for boomers."

Botox has come to the aid of comedians and talk-show hosts in their search for the next Viagra. And it has been a fabulous enhancement to the practices of the nation's dermatologists and plastic surgeons, because behind an $80 dose of Botox stands a doctor with a syringe who may charge anywhere from $300 to $1,000 for the brief procedure of injecting the drug just under the skin. More than 1.6 million cosmetic Botox procedures were performed last year on roughly 850,000 patients, according to figures from medical associations. Its simplicity and safety has led to the phenomenon of in-home "Botox parties," modeled on the ones that sell Tupperware: a doctor, a dozen or so prospective patients and a cheese platter. As each sale is made, the procedure is performed right in the next room. Who would have imagined that at the beginning of the 21st century some doctors would still be making house calls--and that they'd be dermatologists and plastic surgeons?

But as big as Botox is, it is about to get much, much bigger, after the Food and Drug Administration's announcement last month that the drug was now approved for use "to temporarily improve the appearance of moderate to severe frown lines between the eyebrows." The FDA's action does not actually affect the legal status of Botox. The substance has been approved since 1989 to treat a variety of medical conditions involving muscular spasms or twitches, especially a disabling eye disorder called blepharospasm. And for about a decade, doctors have also been quietly using botulinum to erase wrinkles--a so-called off-label use that is perfectly legal, as long as the drug in question has been approved for something. Starting right now, though, the drug's manufacturer, Irvine, Calif.-based Allergan, can market and advertise Botox as a wrinkle cure--specifically just for those vertical glabellar creases, although doctors can continue to use it on any part of the body between the soles and the hairline. Allergan sales of Botox for all uses were $310 million last year, a figure the company expects to grow by 25 to 35 percent this year, and which some analysts think could reach $1 billion in a few years. (Viagra's sales in 2001 were $1.5 billion.) Cosmetic uses accounted for about a third of the total, or $100 million, last year, but Allergan is committing $50 million to its consumer-ad campaign--which gives a pretty good idea of which kind of growth they expect to see.

The ads themselves, which began running last week in 24 magazines including People, The New Yorker, Vogue and InStyle, show where they expect that growth to occur. Not in the already botulinum-saturated market that stretches from Palm Springs to Palm Beach, skipping most of the country in between, but among the roughly 29 million women age 30 to 64 with household incomes of $50,000 and up--especially a group, believed to number about 7 million, that the company describes as "quite aesthetically oriented and concerned about the lines between their brows." Men, who by most reckonings account for only about 12 percent of Botox sales, are being left to fend off time by themselves until the next campaign, in 2003. Some aren't willing to wait that long, like Ian Crawford, an aspiring singer in New York who at 28 has already had five injections of Botox, acknowledging that his forehead is as important to his career as his voice. "The industry has changed," he says. "If Bob Dylan came out today, he wouldn't be Bob Dylan."

And Botox is about to become even more culturally ineluctable. An estimated 90 percent of the target audience, the company boasts, will see the print and television ads at least 10 times in the next year. The first run of magazine ads appear to rank about midway between perfume and laxatives on the glamour scale: the model wears an ordinary-looking sweater and a wedding band you could see from the far end of a supermarket aisle. But that's almost certainly intentional. "The market," says Allergan marketing strategist Tom Albright, "could be much bigger than a lot of people have ever thought... because right now it's concentrated in very-high-innovation areas like New York City, southern California and Florida." And unlike, say, Savannah, Ga., where Tracy Mayes, 36, got a Botox treatment recently while her husband, Michael, was out of town. "I wanted to look like me, but a softer me," she says. "I'm sitting across the table from my husband and he said, 'You just look so good!' It was nice he noticed." Until fairly recently, Botox was associated with women who were accustomed to being noticed. Take Madonna, who has been photographed carrying a keepsake bag from Miami dermatologist Dr. Fredric Brandt, who according to Allergan uses more Botox than any other doctor in the world.

It is, of course, poison. Botulinum is the toxic byproduct of a naturally occurring bacterium, Clostridium botulinum, that can contaminate improperly processed canned food. It can be fatal, especially if a large dose of the toxin is consumed along with live bacilli. But for therapeutic use, the toxin is rigorously purified and enormously diluted. A typical cosmetic injection contains 20 units; Allergan vice president Dr. Mitchell Brin, a former professor of neurology at Mount Sinai Medical Center in New York, says the amount needed to kill a human being is in the "hundreds of thousands" of units. Botulinum is a paralytic; it interferes with the action of acetylcholine, which transmits nerve impulses to the muscles, which is why it is such a lifesaver for people with crippling muscle spasms, especially around the eyes. (It also finds use in treating excessive sweating under the armpits, and is being considered for FDA approval against migraines and back spasms.) It was while working with eye patients that ophthalmologist Jean Carruthers, Alastair's wife, noticed a curious side effect: the wrinkles around their eyes tended to fade after an injection. She mentioned it to her husband, who tried it on Bickerton Swann and pronounced it a success.

Around the same time Brin and his colleague Andrew Blitzer at the Neurological Institute of New York noticed the same thing, but when they brought it up at a conference "everyone said, 'This is neurology, don't talk about it!' " For years, word about Botox traveled slowly; a doctor would hear about it at a conference and try it on a patient, and the patient would tell her friends. It had to overcome the natural reluctance of doctors to use a neurotoxin on what was essentially a self-esteem problem. "If you would have told me in 1990 that I'd be injecting a poison to get rid of somebody's wrinkles, I would have said you were nuts," says dermatologist Kirsten Trotter, of South Euclid, Ohio. Allergan, a conservative company specializing in the opthalmology field, was willing to sell the product but did nothing to promote its cosmetic use and didn't even seek FDA approval until a management change in 1998. But demand kept building anyway, for the simple reason that for certain conditions, it really, really works. "In the right hands, Botox is so very simple, and so very easy, and gives such great results that it's amazing," says Dr. James Zins, chairman of the department of plastic surgery at the Cleveland Clinic. And it really doesn't hurt, either. "I'd rather do this than have my teeth cleaned any day," says Julie Tapley, 44, of Swainsboro, Ga., who goes for her Botox shots together with her mother, Shelba Youmans, 64.

The conditions it works best for are in the upper third of the face--frown lines between the eyebrows, horizontal bands of wrinkles across the forehead and crow's-feet at the corners of the eye. Allergan is preparing to ask for FDA approval to market Botox for the latter two conditions, although doctors are already using it that way. That's because wrinkles in those places tend to be "dynamic," the result of muscle contraction that wrinkles the overlying skin like an accordion. Those movements are an integral part of communication in some cultures, including ours, says Dr. Richard Glogau, a clinical professor of dermatology at the University of California, San Francisco. (Japanese, by contrast, make less use of facial expression in conversation, Glogau says, and therefore get fewer wrinkles around their eyes.) Over time, he says, the contraction becomes chronic, even during sleep, and "the skin never really has a chance to completely unfold."

That's where Botox comes into it: injected into the muscles controlling brow furrows, over the course of several days it temporarily paralyzes them into relaxation, smoothing out the skin above. And that explains why it tends to be less useful elsewhere on the face, especially around the mouth, where "static" wrinkles--the result not of muscle contraction but of aging, sagging skin--predominate. Those are more successfully treated by injecting something under the skin to plump it up, either collagen or the patient's own fat, previously harvested from a place in the body that can spare it--there's usually plenty to go around. (The hot topic in Hollywood these days is about an injectable substance called Perlane--available only outside the United States--which lasts longer than collagen and, because it is manufactured from a product found naturally in the body, minimizes the problem of allergies to collagen, which is derived from cows.)

The other reason some doctors are reluctant to use Botox around the mouth is that the unintended consequences can be a lot more serious. Even when used for its FDA-approved purpose, Botox results in the occasional wayward eyebrow or drooping eyelid. But there are many more things that can go wrong around the mouth than on the forehead. "You can't be aggressive around the mouth," says William Coleman, a professor of dermatology at Tulane University. "You need the muscles there to chew and to kiss and to talk." Fortunately, the one notable downside to Botox--it wears off after three to four months and the injection has to be repeated--also provides a measure of safety: any screw-ups eventually disappear, as well.

Of course, even when everything goes exactly as planned, a Botox injection takes away the ability to frown--that's the point. That was the problem confronting soap-opera star Susan Walters, who plays Diane Jenkins on "The Young and the Restless." Walters laughs about sitting in makeup and being told to raise her eyebrows. "I'd say, 'I am, I am'," she says, "but my brow would just be sitting there." Even worse was the dramatic scene in which she flung open a door to confront Michelle Stafford (Phyllis Summers on the show) and they both burst into laughter as Walters attempted, unsuccessfully, to force her features into an angry glare. "It's tough to emote when your forehead is frozen," says Walters, who says she has sworn off Botox forever, except possibly just before this month's Daytime Emmy Awards, when she will be a presenter, looking out with 38-year-old eyes at a sea of "flawless faces."

Some doctors, though, specialize in tailoring their use of Botox to their patients' emotive needs. "It is very common for actresses to tell me, 'Doctor, I have to do such and such a scene'," says Ezra Kest, a Beverly Hills dermatologist. "If you do the injections the proper way, you can give them a natural expression without the little lines. They love that. They want to look expressive, but not that intense."

For an entertainer, of course, a flawless brow is part of the job description. But you'd be surprised at how many people in more humdrum occupations see themselves just the same way. To listen to Botox patients you might almost convince yourself that the sin of vanity has been vanquished in America--supplanted by a tough-minded approach to personal grooming that emphasizes bottom-line results. "I'm not at all a vain person," says Debbie Jefkin, 45, a Chicago woman who leads exotic foreign tours. "This is just a little help. When it comes to seeing myself get older, I think I should use every means available to combat that." Pat Wexler, a New York dermatologist, treated a nursery-school teacher who was afraid her frown was offputting to her students. Even Janet Rubin Fields, 45, a professional mediator from Hidden Hills, Calif., justifies her Botox treatment partly in terms of the need to have a good professional appearance--although one might think that the ability to frown would occasionally come in handy to a mediator. But also, she admits: "I like what I see in the mirror."

Ever since there have been mirrors, people have wanted to look good in them, says Nancy Etcoff, a Harvard psychologist and author of "Survival of the Prettiest: The Science of Beauty." But the industrialization of beauty has vastly amplified that natural desire. "In the past," she says, "if someone came in and wanted plastic surgery, they might be seen as vain or depressed or narcissistic. Today it's seen as a normal desire for social or economic advantage." Gloria Steinem, the 68-year-old social critic, even takes a stand in favor of wrinkles. "Think about [artist] Georgia O'Keeffe's face," she urges. "What made it beautiful was the lines." She hastens to add that she doesn't fault individual women (or men) who seek Botox, but "the social pressure that brings you to the point of injecting poison into your muscles." She might, then, be heartened to learn about Cathy Bickerton Swann, the young woman who started it all back in 1987. After a half dozen or so injections by Carruthers, she moved away and allowed her forehead to return to its natural configuration. "Lifestyles change," she says. "I'm 45 now, and married. I'm a little chubby, and I have gray hair. And I have the line."