Once upon a time, when patients came to Dr. Michael Olding looking for a procedure to make them look younger and eliminate wrinkle lines in between their brows, the best he could offer them was a forehead lift.
The procedure is as elaborate as it sounds, with the surgeon literally cutting out sections of muscle to make way for a fresher-looking, smoother forehead canvas, explained Olding, the George Washington University Hospital’s chief of plastic surgery.
Then, in 2002, everything changed.
The Food and Drug Administration approved Botox cosmetic, an injectable, non-surgical anti-wrinkle treatment. A competitor with the same basic properties, Dysport, was allowed onto the market in the United States seven years later.
In the time since, the drugs have exploded, with more and better competitors expected to join the cosmetic craze over the coming years (also see “Cosmetic Capital: D.C. Enhances Its Beauty — Albeit Quietly” in the February 2009 issue of The Washington Diplomat).
“When I’m not in the OR [operating room], I’m injecting,” Olding notes. “Every single day I’m in the office, patients are coming in for this.”
Based on Olding’s personal figures, he’s seen a recent doubling of the amount of injectables he uses on patients. This also includes fillers, peels and microdermabrasions, although Botox and Dysport are the clear leaders.
Nationwide, non-surgical procedures like Botox have increased 99 percent since 2000, even with the recession prompting Americans to put a pin in their splurges, according to Olding, who also is a spokesman for the American Society of Plastic Surgeons.
According to the group’s statistics, an astonishing 4.8 million people last year received Botox injections, known in the medical community as botulinum toxins. That’s more than the top five cosmetic surgeries performed in 2009 — breast augmentation, nose jobs, eyelid surgeries, liposuction and tummy tucks — put together.
The pricing is also less prohibitive than cosmetic surgery, which can run several thousand dollars, whereas Botox generally costs a few hundred, usually around $300 to $600.
“It’s become a lot more acceptable,” confirmed Dr. Paul G. Ruff IV, a double board-certified surgeon in D.C. “It used to be just done by plastic surgeons, but now doctors of varying specialties are doing it…. It’s so commonplace it’s like going in and getting a manicure.”
Non-Surgical ‘Salon Day’
In the Washington region, Botox is performed in every Maryland and Virginia suburb, not to mention throughout the nation’s capital, particularly in the plentiful supply of hospitals and doctor’s offices in Georgetown and nearby areas of Northwest D.C.
While the business is steady year-round to primp and pretty up lawyers, politicians, socialites and everyone in between, practitioners say big events, like last year’s presidential inauguration, attract a flurry of new clients anywhere from two weeks to a month before the big occasion.
Weddings, too, have become much more synonymous with Botox injections, as brides and their bridal parties try to achieve “their best look for the big day,” according to Dr. Alex Mesbahi, a plastic surgeon with offices in suburban Maryland and Virginia.
Olding says he gets a reliable client base from within the diplomatic community, particularly before they head out for major international summer trips.
And he speaks fondly of a group of middle-age female friends from southern Maryland who drive two to three hours each way to get to his office and have their injections done as a group. As part of their road trip, they like to stop at Kinkead’s, an upscale Foggy Bottom restaurant, “for an imbibed lunch and then make a whole day of it,” Olding said.
In that way, non-surgical injections — which have to be repeated every few months — allow plastic surgeons a rare opportunity to connect with clients and build up a sort of family of patients who keep coming back.
“Plastic surgeons, we tend to see patients, operate on them and then not see them for 10 years,” Olding explained. “We don’t get to know them the way primary care physicians do. One of the great things is that [with Botox] patients come back on a regular basis and we become very familiar with them.”
Botox and Dysport also can be a gateway of sorts to other cosmetic work, as Ruff has seen in his nine years practicing in D.C. “It’s often their first foray into rejuvenation,” he said. “They’ll then go on to fillers, chemical peels and beyond.”
More Snap, Less Plastic
So what do Botox and Dysport accomplish exactly?
Olding likes to tell his patients that when they’re young, their skin is like polyester, able to snap back in a hurry. By middle age it more closely resembles cotton. In advanced age, the skin is most like linen — “you touch it and a wrinkle shows up.”
Botox and Dysport are medicines that are shot directly into the muscles, usually between the eyebrows. The toxin then blocks nerve impulses to the muscles, which reduces moderate to severe lines between the brows.
Wrinkles are, at least temporarily, warded off with few side effects and little to no recovery time needed.
The biggest difference between Botox and Dysport is timing. While it takes about a week to realize the full effects of Botox injections, Olding says Dysport kicks in within a few days and usually doesn’t require touch-ups as frequently.
“I’ve switched over most patients to Dysport because they like that earlier onset,” he said. “A lot of people who travel internationally, they forget about having the service done until right before their trip. They’ll get Botox and it takes until they’re nearly at home to see the full results.”
Although the procedures have changed little over the past decade, attitudes certainly have, according to the experts. Ruff says that in addition to the expected crop of 40- to 50-year-old women, a full quarter of his Botox business is men. He also injects a sizeable number of women in their 30s and younger hoping to use Botox as a preventative tool against unflattering aging.
“There are definitely 20-somethings who have looked at older relatives and said, ‘I don’t want to get that feature that’s in my family,'” he explained. “I have clients like this who at this point have been getting injections for almost a decade and feel that they have aged better than their counterparts and peers.”
Another big shift has been to a more natural end goal. The criticism of Botox and Dysport has tended to be that users come away with emotionless faces, stuck in one spot and unable to elicit expressions.
“We now try to avoid that frozen look,” notes Mesbahi. “Every once in a while you have a patient who comes in and wants that stiff effect. Generally though, the goal is to look natural and refreshed … the key to that is proper technique and not diluting the injection.”
A patient of Olding’s told him once that she was advised in the past to avoid facial animation after Botox treatments and that a sure-fire way to uncover who had gotten work done was to see who refused to bend over to do something as simple as adjust their footwear.
“Now the attitude is less is more, not looking plastic,” Olding said. “As the procedure has gotten more mainstream people know how to spot an overdone facelift or injection. So the mindset has changed, and I see it as a welcome change.”
About the Author
Dena Levitz is a contributing writer for The Washington Diplomat.