USA TODAY (04-Jun-99)

Dr. Ourian is quoted as one of the experts in a comprehensive article about the uses of Botox.

Beauty in Botulism?

Deadly toxin part of the hottest cosmetic surgical procedure
By Carla Hall

LOS ANGELES – She has a husband, a public relations business, scrupulous eating habits, and — as she puts it — “a really good body for 33″. In what has so far been a full and chaotic life, she has survived a broken marriage and made a happy new one; she has conquered a drug habit that bedeviled her in her 20s and sworn off alcohol.

But nothing continues to betray her like the vertical lines that have etched their way between her brows and into her psyche. She can live with not looking like a model. Her olive skin and almond-shaped eyes give her a slightly exotic-white-girl look, a distinction in Los Angeles’ sea of prettified faces. What she can’t live with are these frown lines.

As she looks up from the chair in her doctor’s examining room, you can see the creases that torment her — but just barely.

“Frown”, Andrew Frankel instructs his patient.

In one gloved hand, Dr. Frankel, a plastic surgeon, holds a 30-gauge needle, slender as a strand of hair. He studies the lines that form when Kelly Cutrone scrunches up her face. Like a pastry chef dabbing at the sugar flowers on a cake, he pricks the musculature that makes his patient frown. Tiny dots of blood bead up on her forehead. Dr. Frankel swabs them with gauze.

In 10 minutes, Dr. Frankel is done, dismissing his patient with the admonition not to exercise that day or lie down for four hours.

Ms. Cutrone walks out into the afternoon sunlight, a little pink welt between her brows. “I have to tell you, it’s so great,” she says. Delight gushes from her voice as the deadliest toxin on the planet creeps through a tiny segment of her forehead. Dr. Frankel has just injected Ms. Cutrone with Botox.

Frown lines, forehead wrinkles and crow’s feet are caused by the constant use of muscles — the ones that purse your forehead, raise your eyebrows and crinkle your eyes when you smile. Derived from the bacterium that causes botulism, Botox temporarily paralyzes the muscles into which it’s injected. The paralysis wears off in about four months.

The difference between Botox, the therapeutic treatment, and botulism, the scourge of home preserving, is about 35 vials of the toxin. That’s how many Botox vials it would take to give you a 50 percent chance of dying. Dr. Frankel administered one-third of a vial to Ms. Cutrone.

In the garden of the face, where we have long pruned and plucked away what we don’t want, now we have poison; Botox has become the easiest and most popular cosmetic weedkiller around. What started as a treatment for the muscular problems that cause strabismus (crossed eyes) and blepharospasm (eye spasms) — and remains approved by the Food and Drug Administration only for those two conditions — has become the potion of choice for plastic surgeons, cosmetic dermatologists, and patients in search of wrinkle-free faces.

“It’s the fastest-growing cosmetic procedure,” says San Francisco dermatologist Seth Matarasso, who lectures on Botox and is compiling statistics on its use.

According to the American Society for Aesthetic Plastic Surgery, there were 65,157 Botox treatments for cosmetic purposes in 1997. That figure rose to 157,439 in 1998 — a 142 percent increase. According to the group’s statistics, that makes Botox the sixth most common cosmetic medical procedure today.

Dr. Matarasso begs to differ.

“Bull,” he says. “I have (San Francisco) 49ers. I have politicians. I have priests, doctors, lawyers. I have women, men, Asians, African Americans. It crosses every potential boundary.”

The standard today is to look refreshed, not 17. Botox devotees say people tell them they look more relaxed, less angry.

“We call it the poor man’s face lift,” says Dr. Simon Ourian, a Beverly Hills cosmetic surgeon who uses Botox on his patients and himself.

Well, maybe not a poor man’s face lift — more like an indulgence of the comfortably middle class. At prices ranging from $200 to $1,000 (depending on how many muscle sites are treated), Botox is far less expensive than plastic surgery. It’s also less permanent.

For doctors, Botox is the perfect pet — easy to control, people-pleasing, willing to go away when its presence is no longer desired. Potential side effects are less dangerous than creepy — a droopy eyelid is the most common — and dissipate in a few weeks.

Some drawbacks

Despite the rewards of a smooth brow and the minor invasiveness of the needle, Botox exacts a toll not levied by far more violent forms of cosmetic work: your facial vocabulary. Botox users lose their wrinkles, but they also lose their ability to raise their brows in surprise, to have a smile spread up to their eyes, to frown.

Botulinum is the deadliest toxin on Earth because it takes so little to be lethal. It’s 100,000 times more toxic than sarin nerve gas. American scientists studied botulinum in the 1940s and decided it was too inefficient to use as a weapon of mass warfare; the toxin might degrade in the air, and it doesn’t pass through the skin. However, that combination of potency and immobility has made it perfect for therapeutic use, especially for hyperfunctional muscles.

In 1989, Allergan acquired the only medical-grade batch of botulinum toxin Type A in the United States and dubbed it Botox. That same year, the FDA approved the use of Botox for the eye disorders strabismus and blepharospasm. Today, Allergan sells Botox to doctors who use it for at least a dozen “off-label” problems, ranging from migraines and profusely sweaty palms to the muscular complications of cerebral palsy and strokes.

The learning curve

Roger Aoki, the scientist who heads Allergan’s research on neurotoxins, did not go into pharmacology to save humanity from wrinkles. Still, he is eager for the FDA to approve Botox for cosmetic use if only so he can help cosmetic dermatologists and surgeons standardize cosmetic treatments.

“It’s kind of like the telephone game,” Dr. Aoki says of how doctors learn to use Botox cosmetically. “One physician teaches another, and they teach another, and things become different at the end.”

The muscles of the face are connected. Paralyzing one muscle without taking into account an adjacent muscle can leave your face looking strange. “You don’t want to end up with a quizzical brow,” says Beverly Hills dermatologist Arnold Klein, describing what happens when you Botox the middle portion of the forehead but not the sides. “The eyebrows will look like Mr. Spock.”

Some doctors have moved on to treating necks — though one occasional side effect is that the neck muscles get so weak you have to lift your head manually from a reclining position. Some are treating the upper lip (the downside here: you can’t whistle), the chin, the area beneath the eye.

In the two decades that Botox has been available, there appear to be no negative cumulative effects. A 1990 study by the National Institutes of Health concluded that Botox was effective for the treatment of several medical conditions but that long-term effects remain unknown. Although it may take another 10 to 20 years to know for certain about long-term effects, “there’s enough data, enough experience to make me feel the risk of systemic side effects is very remote,” says Dr. Robert Goldberg, chief of orbital and ophthalmic plastic surgery at UCLA’s Jules Stein Eye Institute.