The Myth of Preventative Botox
Was the concept of “preventative Botox” perhaps dreamed up by the wordsmiths behind “clean beauty” and “anti-aging”? Because the idea of using neuromodulators to avoid rather than correct wrinkles is similarly ambiguous and every bit as polarizing. Preventative Botox is “not a real thing with a set definition,” says Ranella Hirsch, MD, a board-certified dermatologist in Boston. It’s marketing. Clickbait. A hashtag with more than 60 million views.
That kind of critique raised a few eyebrows (or not, as the case may be…) in the Allure offices. After hearing about and reporting on preventative Botox for years now, we’ve come to accept it as another skin-care maintenance tool. You slather on retinoids, you wear sunscreen, you get Botox … you get fewer wrinkles, right? There are some studies, albeit a small number, pointing to the benefits of preventative Botox. But there are also patients taking to social media who believe their muscles have atrophied because they started getting Botox too young. And there are doctors who either flat-out draw the line at injecting 20-somethings with neuromodulators or will agree to treat only specific areas of the face prophylactically.
In fact, nearly every expert I interviewed for this story released an audible sigh when asked about preventative Botox. Here’s why.
Meet the experts:
Ranella Hirsch, MD, is a board-certified dermatologist in Boston.
Papri Sarkar, MD, is a board-certified dermatologist in Newton, Massachusetts.
Ellen Gendler, MD, is a board-certified dermatologist in New York City.
Amelia Hausauer, MD, is a board-certified dermatologist in Campbell, California.
Jason Bloom, MD, is a board-certified facial plastic surgeon in Bryn Mawr, Pennsylvania.
Shannon Humphrey, MD, is a board-certified dermatologist in Vancouver.
In this story:
Botox patients are getting younger
The term preventative Botox tends to conjure eager injectors rotely paralyzing the smooth, dewy faces of an entire generation. And while this syringe-happy scenario may play out in some medspas or Botox bars, recent statistics paint a more accurate picture: Twentysomethings accounted for only 1% of neuromodulator injections performed in 2022, according to the American Society of Plastic Surgeons (ASPS). Gen X, those born between 1965 and 1980, claimed the biggest slice of botulinum pie, comprising 57% of the 8.7 million shots administered that year—a tally that represents a 73% spike in total neurotomodulator use since 2019.
But just because Botox hasn’t cornered the youth market (yet) doesn’t mean it's not attracting patients at earlier ages. In a survey of 516 women and men (all ages and income brackets, scattered across the United States), the average age of first Botox injection was 30, with 63% of respondents stating the shots are intended “for both the prevention and treatment of wrinkles.”
The data also suggests that neuromodulators may be gaining momentum with younger folks: “When examining trends among age groups, it appears that with every subsequent 10-year span, the average age of first injection gets younger by an average of 8.8 years,” note the authors of the study, which was published in the journal Face in 2021. For example, 19- to 25-year-old Botox users in the study reported getting their first shot around age 20 (on average) while those a decade older (31 to 35) started neurotoxin injections at an average age of 28.8. It’s unclear whether this trend stems from a greater acceptance of and access to these drugs today versus years ago, or is simply due to our modern intolerance for wrinkles, but younger patients do seem to be experimenting with Botox earlier in life than their predecessors.
“Now we have patients in their 20s asking about Botox—and most of them just don’t need it.”
Doctors are seeing a similar phenomenon in practice. “People used to consider Botox in their late 30s or 40s even,” says Papri Sarkar, MD, a board-certified dermatologist in Newton, Massachusetts. “Now we have patients in their 20s asking about it—and most of them just don’t need it.”
How is preventative Botox different from regular Botox?
The short answer is that it’s a lower dose of Botox in a younger patient—“that’s really the only difference,” says Ellen Gendler, MD, a board-certified dermatologist in New York City. (When we say “Botox” here and throughout the story, we’re referring to neuromodulators in general. Since Botox was the first to market, the brand name is often used as a generic catch-all for the entire category, which now includes Botox, Dysport, Xeomin, Jeuveau, and Daxxify.)
If you really think about it, all neuromodulators are prophylactic in nature, whether injected into a 26-year-old or a 62-year-old. By preventing muscle activity, they prevent the skin from creasing, thereby preventing expression lines from forming or deepening. They prevent powerful muscles, like the masseters (in the jaw) and the trapezius muscles (in the upper back), from getting overly bulky from chronic use. They prevent migraines, muscle spasms, gummy smiles, perspiration, and more. Thus, one could argue that all Botox is preventative.
In the modern lexicon, though, “preventative Botox” implies something more specific: injecting highly mobile areas of the face “to soften muscle contractions, but not completely obliterate them,” says Amelia Hausauer, MD, a board-certified dermatologist in Campbell, California. The goal, in many cases, is to keep dynamic lines (that appear with expression) from hanging around when the face relaxes. (Temporarily, at least: Neuromodulators work for about two to six months, their power gradually waning as impaired nerve endings regenerate and cellular signaling whirs back to life.)
But if you expect Botox to stop the aging process, you will be disappointed. Getting Botox in your 20s will not—we repeat, will not—halt aging, says Dr. Hirsch. “When I see someone who’s 23 saying, ‘Oh, I never want to get wrinkles,’ well, I have to be honest, my office doesn't schedule them, because it’s just pointless,” she tells Allure. “I’m never going to make someone happy whose goal is to not wrinkle, ever. That’s an achievement I cannot guarantee. In fact, I can only guarantee that I can’t do it.”
Neurotoxins aren’t designed to stave off every crease, and I’ve got the nasolabial lines to prove it. What’s more, the expression lines they do target are only one manifestation of aging. The drug does nothing for the other inevitable (and often more prominent) signs, like hyperpigmentation, deflation, and sagging. Which is why preventative Botox is almost never done in isolation, Dr. Hirsch points out, but rather in conjunction with lasers (which zap redness and brown spots) and other cosmetic treatments, like brightening chemical peels and volumizing fillers. All of which are fairly worthless if you’re not protecting your skin from the sun.
Wrinkles aside, there’s another aspect of prevention to consider with Botox: treatments that “lead to our feeling more comfortable and confident,” says Dr. Sarkar. Using toxin to thwart painful teeth clenching and TMJ, to neutralize “perma-frowns” and scowls that miscommunicate how we feel, to loosen tight muscles that promote poor posture, to quell anxiety-induced sweating under the breasts or along the hairline—these versions of preventative Botox, she says, are “100% worth it.”
What’s the right time to start Botox?
Here’s where things get a little divisive. There are two main schools of thought on the ideal age to begin preventative Botox. While some doctors insist on administering it before expression lines form, others like to wait until there’s a hint of an actual line at rest (when the face is relaxed). The difference: The first group aims to delay the initial onset of fine lines; the second strives to stop the earliest, faintest lines from worsening.
Physicians in the former camp (those injecting unlined faces) will look to see where muscle activity is impacting the skin in an obvious or disproportionate way by observing patients in casual conversation and also by having them frown, smile big, pout, and raise their brows on command. They’ll then lightly Botox any dynamic expression lines, which could imprint into the skin over time, becoming static wrinkles if left unchecked.
“It took me a long time to decide that I was okay with doing toxin in the 20s—and I still say ‘No’ to probably 50% of those who come in for it.”
Since we all wrinkle differently—based on our genetic skin quality, history of sun exposure, and other factors—there isn’t really one “best” age at which to intervene. You just need to “start before the skin gets creased,” according to Jason Bloom, MD, a board-certified facial plastic surgeon in Bryn Mawr, Pennsylvania. In his opinion, “once you have etched-in lines, it’s kind of a little bit too late” for preventative toxin. Which isn’t to say those furrows are forever: If used consistently, Botox can reverse a crease that’s not super-deep, he says. More entrenched or established wrinkles don’t usually disappear with Botox alone; smoothing them often requires filler injections and/or microneedling or energy treatments in addition to toxin.
Taking a more conservative approach (on Team Wait-For-Lines-At-Rest), Dr. Hirsch will “almost never” Botox a wrinkle-free face, believing there’s no ethical reason to do so. Likewise, Dr. Gendler prefers to have a visible target to Botox and “will not inject anyone who doesn’t have some lines at rest.” She goes on to say, “It took me a long time to decide that I was okay with doing toxin in the 20s—and I still say ‘No’ to probably 50% of those who come in for it.” To her, “it just seems wrong to start doing lots of cosmetic procedures in the early 20s—that’s when you look your best.”
Best areas to treat (and avoid) using preventative Botox
“The only place I’ll do it is between the eyebrows,” says Dr. Gendler, and that’s only after she’s carefully analyzed a patient’s face. There, she can treat the corrugator muscles (which pull the brows down and in) to keep 11 lines from digging in. Routinely placing a tiny bit of neuromodulator into the corrugators early on can also help keep the brows in a youthful position, she explains, and perhaps delay the heaviness and sagging that eventually lead some people to surgery (blepharoplasty, a brow lift, or both).
Relaxing the mighty corrugators may also postpone the arrival of horizontal forehead lines. “The corrugator muscles pull our brows down so forcefully that the forehead muscles have to compensate by contracting and lifting the brows,” Dr. Gendler explains. In some people, deep forehead furrows form as a result. With preventative toxin, “the idea is to make the muscles between the eyebrows work less forcefully, so they don’t pull so much.”
It’s best to start countering forehead lines in youth, should you be so inclined. In fact, doctors often hesitate to Botox the forehead later in life, since knocking out those lifting muscles when there’s skin laxity in play can cause the brow to drop, crowding the upper eyelids and sometimes even obscuring vision.
(Quick cautionary tale: One of the dermatologists I interviewed for this story told me about an older patient who was bothered by heavy forehead creases. Given the patient’s brow position and the severity of her skin laxity, the doctor refused to Botox her forehead, fearing she’d exacerbate the droop. The patient left her office upset and got her forehead injected elsewhere. Weeks later, she called her original doctor to apologize for not heeding her advice. She was driving when she called—using one hand to physically hold up her fallen brow so she could clearly see the road ahead.)
The crow’s feet are an iffy area to treat preventatively. “I think you can really distort someone's smile if you overtreat the crow's feet,” Dr. Hausauer says. Even if you lightly Botox the eye area when it’s still relatively smooth, “you're just not going to move—and it's gonna look funny.” I can attest to this: The one time I tried toxin in my crow’s feet—at 45, mind you—it gave me the oddest, dead-eyed look, because my smile abruptly stopped at my cheeks.
Dr. Sarkar feels the same: “I hate preventative Botox for crow’s feet,” she says. Her reason is a bit more complex. Mounting research shows that neuromodulators can improve well being; they’re actually being investigated as a treatment for depression. The proposed mechanism: By reducing our ability to frown, neuromodulators can interfere with the facial feedback loop that ordinarily triggers the release of mood-altering chemicals associated with upset expressions, thereby staving off feelings of sadness. By the same token, freezing the crow’s feet and hindering a genuine smile (one that extends to the eyes) may diminish the joyful feelings that come with it. (In a 2018 study, crow’s-feet Botox was correlated with increased depression scores.) In simpler terms, “when you smile and get crow’s feet, your brain starts making happy neurotransmitters,” says Dr. Sarkar. “And I don’t want to interrupt those happy hormones.”
The case for preventative Botox
Neuromodulators are well studied, and there's ample evidence supporting their long-term use, but “we’re kind of in new territory” with preventative Botox, says Dr. Hausauer. “We don’t have data specific to somebody starting the treatment at 21 and doing it twice a year, every year.”
The closest thing to it is a 19-year case report of identical twins initiated in the early ‘90s. One twin, living in Los Angeles, got Botox injections every four to six months for 19 years. Her sister, in Munich, received only four treatments total during the study. The more frequently Botoxed twin, unsurprisingly, fared better in terms of skin smoothness, developing no static lines in the treatment areas. Her sister formed creases across her forehead and around her eyes. Neither woman used retinoids or had other cosmetic treatments throughout the trial. While the study didn’t control for much else (geography, lifestyle, UV exposure), it served to strengthen the case for preventative Botox.
Proponents of preventative Botox often point to the work of Shannon Humphrey, MD, a board-certified dermatologist in Vancouver. She published literature reviews (in June 2017 and December 2017) on the cumulative effects of Botox—the changes born from repeat treatments. In her experience, “patients who come in at regular intervals to receive cosmetic Botox, quite frankly, just look better,” she says. “They appear to be aging better than their counterparts who aren't getting Botox regularly or aren't getting it at all.” Much of what registers as “better,” she notes, relates to improvements in skin quality, not just wrinkles. “Even when injecting Botox into muscles, there’s a measurable impact on the skin,” Dr. Humphrey adds.
There’s science backing her observations. “In vitro models show fibroblasts make collagen when incubated with neuromodulator,” she tells Allure. “And collagen-digesting enzymes are less expressed in the presence of Botox.” Translation: botulinum toxin can increase collagen production while minimizing its breakdown—at least in the lab (where researchers measured the activity of collagen-making cells that were doused with botulinum toxin in a test tube).
“By intervening early—the late 20s or early 30s—we can impact the trajectory of aging."
In other studies, in which skin biopsies were taken from subjects before and three months after Botox injections, researchers saw that “collagen actually reorganizes when neuromodulators are injected, taking on a younger, smoother shape, even with a single treatment,” Dr. Humphrey says. In the real world, “when there's a line etched into the skin, you might need more than one round of Botox [to accomplish this], but with regular treatments, etched lines seem to get better.”
Ultimately, Dr. Humphrey believes, “by intervening early—the late 20s or early 30s—we can impact the trajectory of aging. We can use more conservative treatments to help patients age well, rather than more dramatic treatments at a later stage.”
The risks of preventative Botox
So, what’s the catch? Well, besides the toll on your bank account—at current pricing, if you got Botox twice a year, starting at 25, you’ll have spent $26,400 by age 50—there are a couple of issues early adopters should consider.
Muscle atrophy
“Atrophy” has become a dirty word in the context of neuromodulators (preventative treatments, in particular). All over TikTok, there are patients claiming to have muscle atrophy (a flattening or sagging effect) from Botox and doctors reacting to the allegations. Here’s the deal: Some degree of muscle atrophy, or wasting, is an expected consequence of repeatedly disabling a muscle. Think about how withered an arm looks after being immobilized in a cast for months.
In some cases, doctors use atrophy to our advantage. They inject generous doses of Botox into our masseters (chewing muscles) to relieve TMJ and contour the lower face. They “traptox” the shoulders to ease tension while creating a more streamlined look. Even after a single dose, treated muscles can thin out, but abstaining from the shot (for about a year) typically allows them to build back up.
The latest social chatter focuses on the forehead, however, which is not a target for intentional atrophy. The forehead muscle is already very thin, doctors explain, and it’s the only lifting muscle in the upper face. So when treating it, they usually avoid freezing it. They aim to preserve its form and function by lessening lines with as few units as possible.
“If you use really high doses in the forehead, for continuous periods of time, you can definitely cause atrophy,” notes Dr. Hausauer, but this isn’t commonly seen. Sometimes, what’s perceived as forehead atrophy, especially in those 40-plus, is actually something more. As we age, the ligaments in the brow start to get lax, causing the brow to drop, Dr. Bloom explains. The skin goes slack. And our tissues naturally thin out with age: “You get a ton of fat and bone atrophy in the forehead,” Dr. Sarkar stresses. This happens to everyone, regardless of neuromodulator use. And all of these factors can contribute to a flat or fallen brow.
The best way to avoid unwanted atrophy is to use light doses of neuromodulator that allow you to move your face, and to limit treatments to three or four times a year. “I really try to keep people on schedule, especially if they’re doing preventative Botox,” says Dr. Hausauer. “I want the muscle to return to full activity before we retreat, so we're not depleting it over and over again.”
Botox resistance
Allowing neuromodulators to wear off completely between appointments can also help skirt another risk associated with long-term toxin use: Botox resistance, which occurs when the body forms antibodies to the drug, dampening its effect. “One of the biggest things that cause those neutralizing antibodies is repeat exposure,” says Dr. Bloom. While resistance is incredibly rare—this 2023 meta-analysis cites an incidence of 0.5%—some physicians worry that if we start Botox too early in life, it could eventually stop working for us, and possibly right when we need it most (not that anyone needs Botox, but you know what I’m saying).
Getting Botox too frequently is a recipe for developing Botox resistance.
The good news? Presently, “there’s no data to suggest that a cosmetic patient who comes at regular intervals, for years or decades, has a higher risk of developing antibodies than a patient who comes once a year or gets a lower dose,” Dr. Humphrey notes. Key words: “regular intervals.” Putting at least three months between neuromodulator sessions may help reduce the risk of antibody formation, adds Dr. Hausauer.
Getting Botox too frequently or in a staged fashion—tackling your 11s one week, getting a lip flip the next, traptox two weeks later (as medspa membership programs sometimes encourage)—is a recipe for resistance. Again, this approach repeatedly exposes the immune system to the Botox proteins, each jab increasing your chances of forming antibodies that can make the drug stop working. While the body doesn’t normally read Botox as a threat, it’s still a foreign substance that could potentially raise a red flag, especially if your immune system is already revved up from stress or illness, Dr. Sarkar explains. “If you're getting treated really frequently, your body is much more likely to make a mistake,” she says. “You're giving the body more chances to get confused.”
The bottom line on preventative Botox
“Done in a safe way, done properly, done judiciously, Botox is a great procedure that makes a lot of people very happy,” says Dr. Hirsch. “But there is some element of the unknown here and anything too extreme is never going to be great.”
Before boarding the preventative Botox bandwagon, research the pros and cons as well as alternatives. Think critically about your goals and expectations. Choose a doctor whose aesthetic and ethos aligns with your own. And if they someday say “No,” listen and be grateful.
To read more about injectables like Botox:
Injectables Trends From Around the World
Every Injectable in Allure Editors’ Faces Right Now
What Happens When You’ve Gotten Filler for Years — and Then Stop?
Now watch Kendall Jenner try nine things she's never done before:
Originally Appeared on Allure
