It was a thorough treat to read Starshine Roshell’s column “Botox, Don’t Take My Coercive Creases” in the January 17 issue of the Independent. As someone whose professional practice has prominently featured Botox treatments for the past 13 years, I can relate to the sentiments that she expressed with such candor. More importantly, my patients can relate – especially to the concept of “natural beauty.” Starshine is totally right – “natural beauty” is an ideal that is difficult to describe, but we know it when we see it. After absorbing her article, the humanist-populist in me felt not only empathy from hearing her echo my own thoughts, but also admiration of her ability to communicate them with humor and sardonic wit. While I didn’t LOL, I did GTM (grin to myself) several times.

The scientist-perfectionist-educator in me also awoke, and I feel compelled to take this opportunity to expand the context of her commentary a little further, simply because I have seen so many patients face similar concerns and still successfully find an “aesthetic balance” with their successful Botox program. A few years ago at a national professional meeting, I recall being presented with market research that 97% of people who are candidates for Botox have never tried it. Why so many?

Over the past decade, I have observed 3 main reasons why people who would benefit from Botox haven’t tried it:

(1) Fear,

(2) Cost, and

(3) Prejudice (okay, let’s call it incomplete understanding).

I believe a little education would be very beneficial here, to address each of these concerns. (It is an appropriate time for me to give the standard disclosures: I have no proprietary interest in Botox, Dysport, or Xeomin, and I am not a paid consultant for any of the three companies that produce these muscle relaxing agents. As mentioned earlier, my professional practice does include a large volume of these treatments.)


I’ve had husbands accompany wives during their aesthetic consultation and insist that “you can do anything to her except inject poison.” As Starshine said, she had no fear of “shooting poison into my face.” Is Botox really poison? Absolutely not! The Botox produced by Allergan is a fragile biological agent that must be kept refrigerated or else it loses effectiveness. It is shipped in dry ice and arrives in a sterile bottle which looks empty. A trained medical technician does a “reconstitution,” which involves injecting a small but exact amount of sterile saline into the bottle. The saline carries the microscopic amount of Botox into the skin via an injection. It is the saline that causes that little raised area when you get the injection; people who have had the treatment know that those areas disappear within minutes.

No case of systemic toxicity from commercially available Botox has been reported, short term or long term. I am aware of a single reported case of a non-MD who acquired botulinum (not Botox) from a different source and attempted to make his own formulation. He treated himself and three others. His calculations were incorrect, and he caused overdoses. But this would not have been possible had he used the commercially available Botox (or either of its two FDA-approved competitors, Dysport and Xeomin). To restate clearly, it is not medically possible to get botulism from a Botox treatment!


I have a lifelong obsession with my hair. It grows super fast, about an inch every two weeks. It’s a blessing and a curse. Mychael, a meticulous and talented hairdresser, tames this jungle on top of my head once a week. That’s $40 x 52 = $2,080 a year. Perhaps you say most people don’t go once a week? Last week I asked Mychael how much a typical client spends on a hair-color treatment, and how often she does it: $150-200 per treatment, every six to eight weeks, which comes to an annual budget of $975-$1733.

How much does Botox cost? A standard treatment of 25-40 units, maintained every 3-4 months, at $10 per unit, comes to an annual budget of $750-$1600. Turns out it’s cheaper to maintain your face than your hair.


The heart of Starshine’s article was her need to maintain her facial expressions. As a father of three (soon to be four), I understand the reality of being in a phase in life where playing the role of an authority figure is of paramount importance. I treat myself with Botox, and as my children point out, I have complete facial expression with which to terrify them. I treat professional actors, politicians, news anchors, and other community leaders whose careers require them to maintain a “normal” appearance with a full range of expression. The camera is merciless. Despite stereotypes, and despite the images we are bombarded with on so-called “reality TV,” the vast majority of patients achieve results that I believe most people would agree meet the desired and desirable look of “natural beauty.”

Some people say, “I just don’t want to do Botox,” or “I will never try Botox.” They have simply made up their minds. There’s nothing at all wrong with that; everyone has the right to make their own choices, and they do not have to give any reason if they don’t want to. It’s a free country, right? I choose not to snowboard, and I certainly can give a lot of good reasons why I think skiing is a better sport, but ultimately it’s just my choice never to buckle both my feet onto a single plank on a snowy mountain. Some people say they don’t want to do Botox because it wears off and they have to go back to repeat it several times a year. And other people choose not to cut their hair, because it’s just gonna grow out again. It’s a personal choice – it’s a free country, God bless America!


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