“When should I start using Botox?” This is a common question I get from my younger patients and other wrinkle-conscious folks. That question is usually followed with this one: “Can Botox prevent wrinkles?” These are both great questions, with varying answers depending on who you ask.
First, to clarify, Botox is a trademarked name for a brand of neuromodulator. Neuromodulator is the term used to classify drugs like Botox, which affect the transmission of signals from nerves to muscles. Other brands of neuromodulators that are made from the same neurotoxin as Botox are Dysport and Xeomin. Neuromodulator treatment is the most common, minimally invasive cosmetic treatment performed in the US, with 6.7 million neuromodulator procedures in 2015 alone according to the American Society of Plastic Surgeons.
A Highly Debated Subject
When looking for a clear answer among medical experts about what age to start Botox treatment, you will not find only one. The million-dollar question is whether to initiate neuromodulator treatment before or after wrinkles show up.
There are many providers that stand behind the concept of “prejuvenation,” a term coined by Dr. Kenneth Arndt, a Boston-area dermatologist and co-author of, “When Is “Too Early” Too Early to Start Cosmetic Procedures?” With “prejuvenation,” we use neuromodulators to treat common areas that develop wrinkles before the wrinkles appear.
Conversely, other aesthetic providers caution against “prejuvenation” on the grounds that neuromodulator treatment can become a costly waste of money. But, before we look into each opposing view, let’s discuss first how wrinkles develop.
The Mechanism of Wrinkles
Wrinkles can be classified into 2 major categories: dynamic and static. Dynamic wrinkles are only visible when your face is in motion, for example, when you crack a smile. Wrinkles start out as dynamic but over time can become static. A static wrinkle is present not only when your face is in motion, but also at rest without making any facial expression. In other words a static wrinkle is like a “Stage 5 Clinger.” That wrinkle is sticking around at all times for all the world to see.
Dynamic wrinkles can evolve into more permanent static wrinkles because of 2 major contributing factors. As skin ages, the dermis atrophies or becomes thinner with reduced collagen production and sun exposure. This thinned skin then becomes less resilient to repetitive motions, or facial expressions, causing wrinkles to become etched into skin over time.
Argument for prevention or “prejuventation”
So if repetitive muscle movements contribute to the formation of wrinkles, keeping those muscles from exerting any force on the skin should prevent wrinkles from forming, right? That’s the exact logical argument made by those who advocate neuromodulators for the prevention of wrinkles.
This argument is supported by an identical twin study from 2006. In the study, one twin was regularly treated with botulinum toxin type A, or Botox, in the glabella and forehead areas for 13 years beginning at age 25, which equated to about 2-3 treatments per year. Whereas her twin sister was only treated twice, in the same anatomical areas, with the toxin over the entire course of the study.
Results revealed static, or etched in forehead and glabellar lines were not seen in the regularly treated twin but were seen in the twin treated only twice. Facial areas that were untreated, like nasolabial folds, showed similar aging in both twins. Also of importance is that neither twin experienced any adverse effects (Binder, 2006).
It is also known that muscles treated over a long period of time with neuromodulators become weakened and atrophy over time. These atrophied muscles therefore will have reduced strength causing less force/tension on skin, thus reducing the severity of wrinkles that could develop.
Argument for waiting until lines appear
Proponents for waiting until lines appear ague that youthful skin is meant to be expressive and is able to bounce back from repeated facial motions. The dermis layer of skin is much thicker in your twenties due to increased collagen production. At ages 30-40 the dermis begins to thin as a result of reduced collagen production and sun exposure; this is when lines begin to show. However, even though lines begin to become visible the skin is still able to achieve full correction with neuromodulator treatment. Remember, lines start out as dynamic and evolve to become static, a.k.a. “Stage 5 Clingers.”
Therefore since full correction of wrinkles is generally possible if waiting until your thirties, to start neuromodulator treatment in your twenties runs the risk wasting thousands of dollars. Doing the math, at an average of $500 to $1500 per treatment for 3 treatment areas, this could total to an approximate average of $3,000 per year of unnecessary neuromodulator treatments. Imagine the things you could buy with an extra $3,000 in your pocket each year!
Not to mention, it’s so terrible to see a youthful expressionless face, which can sometimes have the opposite effect of making a patient look older than are.
Already have wrinkles…
If you have wrinkles, don’t despair. You can check yourself to see how effective neuromodulator treatment can be at temporarily erasing yours. The test is called the “Stretch Test” and simply requires you to spread the target wrinkle using 2 fingers. If the wrinkle disappears then you can expect full correction with neuromodulator treatment. If the line remains visible you can expect some improvement with neuromodulators, but not full correction of the wrinkle. In this case, dermal fillers would also be required for better correction.
Even with deepening dynamic wrinkles, or if you’re in your forties or fifties and have never had neuromodulator treatment before, it is not too late to start! There is still time to prevent the worsening of your wrinkles so that they do not become permanently etched into your skin.
Neuromodulators have the ability to prevent worsening of wrinkles through the inhibition of certain muscle groups used during normal facial expressions. It also has shown its capability of preventing the development of wrinkles as evidenced by the previously mentioned twin study.
It seems that most professionals agree to start utilizing neuromodulator treatment once the lines begin to appear. Wrinkle conscious 20-something’s who have no lines do have other anti-aging options and can still be proactive. An excellent option for the young and wrinkle free are topical retinoid creams, which increase cellular turn over and collagen production, helping to maintain a nice thick and youthful dermis.
Also for those in their later twenties there is the option to receive half the usual neuromodulator doses. Reduced doses will weaken muscles and decrease tension placed on the skin, but still allow full facial expressions.
So wrinkles be afraid, be very afraid…