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  A Peril of the Veil of Botox


By:
RICHARD A. FRIEDMAN, M.D.
NY Times, August 6, 2002

 

The woman fantasized about having a face-lift for years, but had an insurmountable fear of the knife. So when Botox was approved in April for cosmetic use by the Food and Drug Administration, she jumped at the opportunity.

Recently divorced and a recovering alcoholic, she had just turned 48 before the first Botox injection. And like the 1.6 million Americans who used Botox last year, she hoped to recapture her youthful appearance. At about $600 a pop every four to six months, she considered this an endlessly renewable face-lift.

Except for a quick sting, she barely felt the injection of Botox into her forehead and went back to work later that day. By the end of the week, she noticed the effect. Standing in front of her bathroom mirror, she was stunned to see that the deep wrinkles that scored her forehead had been erased, and that her skin was smoother. Though she was pleased by her new look, she felt ill at ease without knowing why. It was obvious later — her physical and psychological self-images were suddenly incongruent.

The sense of strangeness subsided over several weeks, and she was clearly satisfied with the results. Then something odd happened. First her close friend casually mentioned that the woman seemed unusually calm. "Too tranquil; it's not you," she recalled. Her boyfriend accused her of being unsympathetic, and her mother asked whether she was feeling down.

She was certainly not depressed and had lost no affection for her boyfriend. And she was definitely not feeling calm. She found their reactions unexplainable.

Frustrated and on the verge of tears in my office, she suddenly made me understand. For while she claimed to be puzzled, she did not look at all distressed or baffled. In short, her facial expression did not fully reflect her emotional state. And she was completely unaware of it.

Unlike a face-lift, where the skin is stretched taut like a drum but facial expression is unaffected, Botox paralyzes the underlying muscles that control facial movement and produce wrinkles. Botox, or botulinum toxin, is the neurotoxin derived from the bacteria Clostridia botulinum, the cause of botulism.

Botulinum toxin is the most poisonous substance known and is a potentially potent bioweapon. A single gram of the purified toxin, widely dispersed and inhaled, could kill a million people.

Ingested systemically, botulinum toxin kills by paralyzing the diaphragm, the muscle used in breathing. The toxin prevents neurons from releasing acetylcholine, the neurotransmitter that causes muscle contraction. But injected locally, it paralyzes just a small area of skeletal muscle. The effect is temporary, lasting three to four months.

Little is known about the long-term cosmetic effects of Botox. But there is evidence that prolonged use can cause some people to produce neutralizing antibodies against Botox, which diminish or block its effect over time.

Botox had wiped the wrinkles from the woman's brow but had also robbed her face of some human expressiveness. It made her appear not so much youthful as lifelike — a frozen imitation of youth.

Unlike this woman, many Botox users receive extensive injections above the nose, around the eyes and across the forehead, which deeply alter their expressions.

It made me wonder: Should we become a Botox nation? What are the implications for human relationships? I'm not too worried about the adults; they can figure out that their friends and loved ones are poker faced not because of lovelessness but thanks to Botox. But what about infants and children?

Infants are exquisitely sensitive to facial expression long before they communicate with language. It is not hard to imagine that a Botoxed parent with diminished facial expression might elicit a different response from her infant and that this could have an effect on mother-infant bonding. Given the extremes to which some parents go to provide their babies with enriched environments, the possibility of an expressively dulled parent would be ironic, to say the least.

At the end of Choderlos de Laclos's "Liaisons Dangereuses," the scheming countess gets her comeuppance: she is stricken and disfigured with smallpox, her beautiful face now an object of revulsion — a just punishment, de Laclos writes, because God has now made her ugly soul visible for all to see.

The peril of Botox is just the opposite. Some Botox enthusiasts may discover that their paralyzed faces cannot respond to their emotions; they could not bare their souls if they wanted to. Who knows? They might grow wistful for a wrinkle or a frown.


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