A Fountain of Youth in a Vial of Poison

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 L.A.’s 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,” Dr. Andrew Frankel instructs his patient.

In one gloved hand, 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 the surface of her forehead. Frankel swabs them with gauze.

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

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. Frankel has just injected 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% chance of dying. Frankel administered a third of a vial to Kelly 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 dermatologists, plastic surgeons, cosmetic surgeons, 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% increase. According to the group’s statistics, that makes Botox the sixth-most-common cosmetic medical procedure today.

The company benefiting from this boom is Allergan, an Irvine-based pharmaceutical firm. Sales of Botox climbed from $25.3 million in 1993 to $125 million last year. Allergan officials--who are forbidden to promote the off-label uses of their product--say less than 30% of that figure is attributable to cosmetic uses. Matarasso begs to differ.

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

Poison your face? If you don’t do it, you think it’s appalling--another act of lunacy by those yoga-chanting, Zone-dieting Westsiders. If you do partake, it ranks on the continuum of cosmetic procedures somewhere in the territory of acrylic fingernails. It’s not surgery. It’s grooming.

“It’s just like a quick fix,” says Allison Mayer, a 34-year-old Palos Verdes Estates stay-at-home mother who Botoxes away her frown lines. She took along two friends the last time she had it done at her doctor’s office. “We went to Crustacean for lunch and then we walked up to the doctor’s office and had our Botox done--one, two, three.”

On Some Faces, Marks of Character

Wrinkles in a face historically have denoted character--especially in the faces we worshiped. Barbara Stanwyck became the picture of a steely woman because of her seasoned face. You can’t imagine Paul Newman in his prime--and a bit beyond--without wisps of crow’s feet garnishing his eyes and making him bemused. Humphrey Bogart wouldn’t have been the tough guy with a wounded soul without his Sharpei-like face. A Botoxed Georgia O’Keeffe? People would laugh. She’d look like Joan Rivers.

But these days Hollywood and Madison Avenue--those twin pillars of superficiality--have decreed perfection to be a face as smooth as a Creamsicle. Fashion magazine editors tout a baby-faced 16-year-old as the model of the moment and swathe her in $10,000 outfits (clothes that, ironically, only wrinkled women, who have worked long and hard, can afford to buy). When people talk about an interesting flaw, they mean Cindy Crawford’s mole.

You don’t have to live in the worlds of fashion and entertainment to be affected by their dictates. You just have to be living--and conscious that you’re aging, a phenomenon sometimes far more terrifying and toxic than a little bacterium.

Into this nexus of anxiety and cosmetic science has rolled the Botox vial. On an ever-expanding menu of methods for scraping and polishing away the years--dermabrasion, microdermabrasion, laser peels, chemical peels, collagen injections--Botox stands out as the emblem of the new minimalism in cosmetic work. It’s fast, relatively painless, knife-free, and won’t reverse-engineer your face into some eerily young version of yourself.

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. Botox is also lucrative. Doctors pay $370 a vial which, for most practitioners, yields roughly $900 worth of treatment. Average time to treat one patient who’s already familiar with Botox and not in need of being reassured that it won’t kill him: 10 minutes.

Once the province of older women, cosmetic procedures are now done on younger and younger women and men--as if continual weeding of your face throughout your life will ensure youthfulness. Not only is Botox routinely administered to those in their 20s and 30s, but it works best on them. “The ideal person is someone who’s 29 or 30 years old who has just the beginning of a line,” says Dr. Frankel. “If you go in and treat them, it will go away and they’ll never get the line to begin with.”

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. It’s the cosmetic equivalent of a Faustian bargain: Paralyze parts of your face for the beauty of youth.

For actress Annie Potts, who has worked in films and a succession of TV shows--most notably as Mary Jo on the sitcom “Designing Women”--the trade-off was not worth making.

“I hated it,” Potts says during a lunch break on the set of her current series, “Any Day Now,” for the Lifetime cable network. At 46, she has lovely peaches-and-cream skin, but a light dusting of lines has settled on her forehead.

“I was working with an actress and she came flying in one day and she said, ‘This is the most incredible stuff. I was so lined up here, and they’re gone!’ I thought, ‘I love that, I want to do that too.’ So, of course, I went right in to get it done. And here’s what happened to me.” She fixes a glazed smile on her face. “This is me happy. This is me sad.” She never changes her expression.

“I had to do a photo session not long after that and the guy said, ‘Could you lift your eyebrow up a little bit?’ And I said, ‘Yeah, sure.’ He went, ‘OK, go ahead.’ And I was like, ‘Didn’t I? Is it not lifted?’ ”

She let the Botox wear off.

“There are those people who say, ‘Well, you didn’t get it done right. You did too much at once, you just need to go back in every couple of weeks and get a little.’ Maybe that’s true. I’d just as soon have my face working.” She shrugs. “So I look a little older.”

Discovery From a Deadly Ham

The story of this elixir of beauty begins with raw, salted ham. In 1895, a group of Belgian musicians fell desperately ill after eating the meat. Three died. What felled them was identified as Clostridium botulinum, a bacterium that thrives in rotting meat or oxygenless places--like your stomach--and produces a neurotoxin that paralyzes muscles. When the diaphragm and respiratory muscles fail, it is fatal.

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.

It was a husband-wife team of Canadian doctors who first realized the cosmetic implications of the toxin. In 1987, Vancouver ophthalmologist Jean Carruthers was using Botox to treat eye spasms when a patient raved about how relaxed her brow looked after treatment. Carruthers went home and told her husband, Alastair, a dermatologist: “Maybe we should use my poison on your wrinkle patients.”

Early patients were initially skeptical. “They said, ‘You want to put what in our brows?’ ” Jean Carruthers says. Side effects were substantial as the Carrutherses taught themselves how to find the correct muscles to dose. That first year, 20% to 30% of their patients got a droopy eyelid.

The Carrutherses have since turned Botox instruction into a cottage industry, holding monthly seminars for doctors throughout North America and other areas.

The popularity of Botox for cosmetic reasons leaves Allergan officials demurring like Shakespearean actors who suddenly find fame in action films. Although barred from promoting the off-label prowess of Botox, they are delighted to discuss the versatility of their drug. “Botox is the jewel in the crown of Allergan,” says Drake Barborka, the company’s vice president of sales and marketing for Botox. Last year, sales of the drug represented a little less than 10% of the company’s $1.3 billion in sales.

Allergan officials may emphasize that Botox is a medicine, but they don’t handle it like an innocuous drug. The toxin is housed and initially processed in a California plant that the company keeps secret from the public and under security. The U.S. government, also, treats Botox like a potentially dangerous substance.

The Commerce Department accused Allergan of shipping Botox to various foreign countries from July 1992 through October 1993 without the special export licenses required for a drug made from materials that might be used in biological warfare. Allergan officials contended that the rules didn’t apply to a finished pharmaceutical product.

Last year, the company (which has long since obtained the licenses) agreed to pay a civil fine of $824,000 without admitting wrongdoing. According to a Commerce Department spokesman, the penalty is the largest assessed by the agency in a case of alleged violations of biotoxin export requirements.

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 dermatologists and surgeons standardize cosmetic treatments.

“It’s kind of like the telephone game,” 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.

Although a few doctors are venturing to the nasolabial fold, the arc of skin between the nose and lips, generally they have stayed away from treating wrinkles around the mouth. Muscle paralysis there can leave you looking like a stroke victim unable to smile--not an inviting trade-off, no matter how vain you are.

On average, doctors have two to five complications per 1,000 treatments--and they’re generally related to a miscalculation in dosage or needle position.

In the years since Botox became available, there appear to have been no negative cumulative effects. A 1990 National Institutes of Health study concluded that Botox was effective for the treatment of several medical conditions but that long-term effects remained unknown. Although it may take 10 to 20 more 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. “No one has even reported anyone getting systemically ill.”

Buying a Few Years in the Business

Botox is about buying time. We exercise to keep our bodies lean and hearts purring. We down herbs in the hopes of repelling senility. Botox is just the latest weapon in the arsenal against aging.

One 40-year-old actress, who uses Botox on her forehead lines and crow’s feet, estimates that she has staved off “maybe four years, five years.”

After nearly two decades in the business, the actress (who spoke on the condition that she not be named) is watching her career, mostly as a soap opera siren, begin to trickle away as casting directors crave younger actresses. She has prepared for the inevitable by cultivating a writing career. But while she’s still acting, she’ll Botox.

Cabaret singer Juliet Annerino wants a record deal. Now on her third round of Botox, she doesn’t worry that erasing her frown lines restricts her expression when she’s singing. But she does worry that just a hint of the ravages of time might impede her campaign for a recording contract.

Even if you acknowledge that your face is your passport through a rich life--the more well-traveled, the more interesting--it can be a painfully difficult notion to accept. The tattered cover begs to be renewed.

“You know who I think is really sexy?” says Kelly Cutrone, standing outside by her car, her Botox bumps already beginning to recede. “Beatrice Wood,” she says, invoking the flamboyant potter who lived to 105.

“She had a lot of wrinkles. She was wearing saris, and she was a lover of Duchamp, and she had a 25-year-younger boyfriend. She was really cool. And I’m all for that,” Cutrone muses. “But now is just not the time that I want my face to say, ‘Yeah, you partied in New York and London at the age of 21.’ ”

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Paralyzed Lines

Physicians can erase or reduce forehead wrinkles, frown lines and crow’s feet with Botox, a purified form of the paralyzing botulinum toxin that is injected into facial muscles.

Among 24 cosmetic procedures, the biggest increases from 1997 to 1998 were in:

Botox treatments: 142%

Breast augmentation: 25%

Liposuction: 23%

Cosmetic eyelid surgery: 15%

Facial expressions occur when the brain sends a signal to muscle tissue. Nerve endings release acetylcholine, a neurochemical that stimulates movement. Botox blocks the release of acetylcholine. A few days after treatment, the paralyzed muscles lose their tone, and wrinkles begin to flatten out.

Source: American Society for Aesthetic Plastic Surgery