Social media, selfies and reality TV celebrities are among the influences driving millennials to the cosmetic surgeon’s office for neurotoxin injections and more, according to 2015 stats released earlier this year by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).
But the experts we interviewed say treating younger patients with Botox (onabotulinumtoxinA, Allergan), Dysport (abobotulinumtoxinA, Ipsen) or Xeomin (incobotulinumtoxinA, Merz Aesthetics) isn’t necessarily the same as treating middle-aged and older patients.
Manolis G. Manolakakis, M.D., an oral/maxillofacial surgeon and fellowship trained facial cosmetic surgeon in Shrewsbury N.J., says he has noticed the upswing in demand for botulinum toxin treatments among patients 30 and younger. The surgeon says he has been treating younger patients with “subclinical” Botox, to give them a smooth — not frozen — look.
“By relaxing the resting state of the muscle, the skin will have smoother appearance,” he says. “Preventative Botox is something that has been sort of a controversy. My belief is that if done properly (conservatively) on younger patients, Botox can be utilized as an antiaging modality to prevent dynamic rhytids to turn into static rhytids, without creating a disuse atrophy.”
Washington, D.C.-based facial plastic surgeon Houtan Chaboki, M.D., says he commonly starts Botox for women and some men in their 20s.
“Generally, I will recommend starting with the basics: sun block/protection, hydration, gentle cleansing, no smoking, avoid excess salt. Next, some patients will start tretinoin topical ointment. Lastly, Botox for those who still want to maximize their appearance. Even young skin can benefit from Botox (or similar wrinkle relaxers such as Dysport),” he says.
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How To Inject 30s-and-Under
First, and notably, there are safety precautions to consider when treating especially younger female patients with botulinum toxins.
“Important safety precautions include asking about potential pregnancy or insuring the patient is not breastfeeding,” says James Marotta, M.D., who practices in Smithtown, N.Y. “Indications for treating young patients are wrinkling at rest, muscle hypertrophy or hyperactivity or a family history of early rhytids.”
Dr. Manolakakis says that similar to his evaluation of older botulinum toxin patients, he wants to make sure the young patients are physically and mentally healthy before doing the injections.
“Dynamic rhytids are expected in younger patients. I evaluate the strength of their facial muscles [for] all of their expressions, (frowns, smiles, lifting of brows, etc). I also evaluate their brow shape and position, and their smile line,” Dr. Manolakakis says. “If a smile is more ‘gummy’ than what I feel is appropriate, I will inject the ala que nasi on either side of the nose. This will reduce the amount of upwards pull of the upper lip and reduce the amount of gummy show. The lateral brow lift with crow’s feet injection is a nice way to lift the brow without making the lateral orbicularis muscle look frozen.”
Over-injecting younger patients can actually make them look older, according to Dr. Manolakakis.
“A little bit goes a long way [in the 30-and-younger crowd],” Dr. Manolakakis says.
Mathew A. Plant, M.D., a plastic surgeon in Toronto, Ontario, Canada, says he also uses lower neurotoxin doses on young people, than older patients.
“I personally use only six units in the forehead diluted to smooth the frontalis but not paralyze it,” Dr. Plant says.
Hollywood, Fla., dermatologist Todd Minars, M.D., says younger people requesting Botox are often seeking prevention of lines, rather than treatment of lines. But not every young person is a good candidate for treatment.
“There are times where I have discouraged younger patients from beginning the procedure and encourage them to reassess in six months to a year,” Dr. Minars says. “The biggest ‘novice injector’ mistake I see involves the forehead. A difficult patient to treat is the young person who has no frown lines but does have prominent forehead lines. The temptation is to just treat the forehead, but that often leads to a heavy brow, which does not look good and does not feel good either. The patient often feels like weights are hanging from their brow.”
The solution, according to Dr. Minars, is to balance the brow by also injecting the glabella — even if the patient’s frown lines do not need to be treated.
“We explain to them that glabella is necessary for balance. While the forehead injections lower the brow, the frown line injections raise the brow,” Dr. Minars says. “Our experience has proven that even 10 units in the glabella will help balance out a forehead.”
San Diego, Calif.-based plastic surgeon Robert Kearney, M.D., says he injects under-30 patients only when they have an animation deformity that he believes will lead to permanent wrinkles.
“If they do not have strong muscles that are creating creases when they animate then they are probably not yet candidates,” Dr. Kearney says.
The most common sites for botulinum toxin injections in patients younger than 30 are the forehead and glabella, Dr. Kearney says.
“Once injected, if they like the results they should continue the process at regular intervals to keep the muscle from moving,” he says. “If they like the results, they should get regular injections (on average that would be every three months) … for 12 to 18 months. At that point you may be able to go every six months as the muscle gets weaker.”
Dr. Kearney adds that any patient who already has creases from muscle action should get the neurotoxin, first, and, at a second visit, get a filler to fill in the hollows.
Managing Millennial Expectations
Cosmetic physicians should not oversell expectations or outcomes, regardless of a patient’s age, according to Dr. Manolakakis.
“Because the driving force for these patients to come in for injections is typically someone famous or [a] reality star, I have to remind them that these people usually have a whole team of people who work on their image…,” Dr. Manolakakis says. “Although Botox works, I really try to convey to my patients that what you see in the media is not completely real.”
Young patients won’t see the more dramatic effects that older patients do, simply because young people tend not to have wrinkles, according to Dr. Plant.
“It’s best to manage their expectations, as they probably won’t see a huge difference …. I always ensure to suggest a small Botox brow lift to open the eyes, so they do see some sort of change,” Dr. Plant says.
Not everyone believes in botulinum toxin’s ability to preserve a youthful appearance. And if that’s the case, doctors need to share that information with patients, according to one dermatologist.
“I only treat static rhytids in the pre-30s crowd,” says dermatologist Valerie Goldburt, M.D., Ph.D., who practices in New York City. “Also, I tell them that it won’t actually stop aging. It’s so important to set expectations, because they may erroneously think it will somehow preserve their face at that age.”
Dr. Manolakakis says that while younger patients tend to tell him what they want done, older patients are more likely to ask him what he thinks they need.
“What the younger patients need to understand is that less is more. Even though they know what they want, it’s still my aesthetic [experience] that I need to stay true to,” he says.
His policy? Dr. Manolakakis says it’s complete honesty with his patients. He’s honest, for example, about whether he thinks patients should get the injections.
New Treatment Opportunities
Botulinum toxin’s popularity in the younger set goes beyond cosmetic facial concerns, according to New York City plastic surgeon Leonard Grossman, M.D. In the much younger patients, neurotoxins are used mostly for treatment of hyperhidrosis, he says.
“Next are the patients with familial or genetic and habitual frowning. Most of them are after 18 years of age and they simply don't like looking ‘perplexed’ all the time,” Dr. Grossman says. “Then you have patients with very developed masseter muscles…, which create a wide and disproportioned face. Lastly, there is a group of young models who wish to have thinner lower legs (calves in particular). Treating them with Botox makes the legs appear longer and leaner.”
San Francisco-based plastic surgeon Jonathan Kaplan M.D., MPH, Pacific Heights Plastic Surgery, says that patients younger than 30 who come in for injectables present an interesting opportunity.
“They aren't as worried about the ‘taboo’ of cosmetic surgery, and they're well-versed in social media. So these millennials are a great way to promote your practice,” Dr. Kaplan says. “I had a neon sign made that offers a saying with a double-meaning: ‘I GOT STUCK AT PHPS’ along with a smiley face that has the 11's (wrinkles) in between the eyebrows! After treatment, patients take a photo in front of the sign and post it on their social media.”