Botox has become increasingly popular with people in their 20s seeking to stave off wrinkles.
Clinics market what is known as "baby Botox," lower dose treatments administered less frequently than those for midlife adults — perhaps only once or twice a year.
Patients share the process in online videos filmed from injectors' offices, asking for a touch up to blur away any hint of crows feet or 11 lines between the brows.
It may seem absurd that anyone so young would be worried about aging. But like putting on sunscreen, patients say their use of Botox is preventive.
Botox is a brand name for botulinum toxin type A, an injectable neurotoxin derived from the bacterium that causes botulism. Other brand names include Dysport, Xeomin and Jeuveau. When administered in small amounts, the treatments block the nerve signals to the muscle causing it to relax, thereby temporarily reducing the appearance of wrinkles.
Attorney Stephanie Moore started getting Dysport when she was 27 to slow the formation of wrinkles around her eyes, which she attributes to her expressive face.
She pays about $460 per visit, and says these thrice-yearly injections are one of her favorite ways to treat herself: "I feel a lot more confident."
With Baby Botox, is age just a number?
There aren't comprehensive stats on what age groups are getting Botox, but data from the American Society of Plastic Surgeons shows that between 2019 and 2022, the use of injectable neurotoxins grew by more than 70% across all age groups under 70, including Gen Z adults.
It is not approved for use in minors, so the youngest someone can get Botox is 18.
Demand for other types of aesthetic procedures and surgeries, including cheek implants and fillers, has also jumped since the COVID-19 pandemic.
This timing is no coincidence says sociologist Dana Berkowitz, author of the book Botox Nation: Changing The Face of America.
During the pandemic, people's lives migrated to virtual spaces. That included younger people who had this experience at a formative age. They attended high school or college on Zoom during the day, and then logged onto TikTok and Instagram for socialization in the evenings.
Berkowitz says by looking at curated images of others far more frequently, inevitably, people were comparing those faces to their own.
At the same time, Berkowitz says some celebrities, along with social media influencers, now openly earn income through endorsements of various cosmetic procedures, further normalizing it.
While the 20s seem young for Botox, Dr. Kristy Hamilton, a board-certified plastic surgeon in Houston, says young adults can start to show signs of aging — a lot of it comes down to genetics and sunscreen.
"Sometimes we see people in their mid-20s that have a lot of wrinkles, and that's just life," she says.
But what's wrong with having wrinkles?
Ageless beauty is seen as a "status symbol" in today's society, says Berkowitz. Young women she researched told her these treatments show they were able to invest in themselves at a very early age: "It was like they were part of this elite kind of social club."
As Berkowitz explores in her book, falling short of society's definition of feminine beauty can incur a professional tax. "Our ideal femininity is a youthful one," she says.
Research shows that people who are perceived as beautiful get better treatment, says David B. Sarwer, who studies the psychological aspects of appearance and cosmetic procedures at Temple University's College of Public Health.
Sarwer points to a robust body of literature on how attractiveness can positively influence one's academic performance, professional advancement and legal outcomes. One study even found that newborns who are seen as more attractive by hospital nursing staff get picked up more frequently.
"It may make some, dare I say, strategic sense for people to say, 'I want to find a way to improve the way that I look,'" he says.
Are there any risks to starting young?
Botox was first approved by the Food and Drug Administration for cosmetic use in 2002. Physicians interviewed for this story note that since then millions have gotten it safely.
Reports of dangerous side effects are extremely rare, and typically linked to counterfeit or mishandled Botox.
There are still some risks. For one, it can stop working because your body forms a resistance to it.
This can be frustrating for patients, says Dr. Paul Durand, a Miami-based board-certified plastic surgeon. He hasn't seen any research explaining why this happens, but theorizes that younger people might be at higher risk because of their more robust immune systems.
Another concern is that too much Botox at too high a dose over time can cause excessive atrophy, or shrinking of the muscles. Since we lose volume in our faces as we age anyway, a person's face can start to look hollow instead of youthful.
Durand says well-trained clinicians can avoid that result by not overdoing it, i.e. not injecting too deep or using too much of the drug. But assessing a clinician's skill level may be difficult for patients.
Any medical doctor, regardless of specialty, can legally administer cosmetic injections without any special training or certification. That includes dentists.
Durand and Hamilton both recommend going to a plastic surgeon or dermatologist's office. Though Berkowitz says there are skilled injectors outside these specialties. She recommends that a Botox-curious patient ask friends or family for a referral.
Most people who get cosmetic procedures say they're happy with the outcome. Sarwer says the patients who are most satisfied are seeking to address discontent with a specific feature — like Moore's desire to soften the lines around her eyes.
But the evidence on how these procedures improve self esteem and quality of life are inconclusive, Sarwer says.
When cosmetic patients chase an unattainable ideal of beauty due to a mental health condition like body dysmorphic disorder or severe depression, Sarwer says Botox and other procedures don't improve their symptoms.
He explains these patients are, "better treated by a mental health professional than they would be treated by a plastic surgeon."
A life-long habit ... and expense
Durand turns away patients who want so much Botox that it would essentially freeze their face, blocking their ability to form expressions. "That looks terrible," he says.
But in his experience, a determined enough person will eventually find a clinician to say "yes," given that administering Botox can be a lucrative revenue stream with relatively few overhead costs.
Not only do clinician training and skill levels vary, so do prices. Discount treatments are unlikely to yield desired results, as Berkowitz warns. Amateur Botox can result in an obviously treated face.
And there's another problem: Once patients start with Botox or a similar injectable, they're unlikely to stop, says Berkowitz: "You get people in their 20s, you have a lifelong consumer."
Berkowitz herself is one of those lifelong consumers: She started getting Botox at 32 and now at 47, needs higher doses, paying about $800 per appointment.
For someone who starts young, that money — which could add up to tens of thousands of dollars in your 20s and 30s — could be spent paying off student loans, investing for their future, or traveling the world.
If you stop getting the injections, the effects wear off and wrinkles reappear.
In this way, Botox is addictive, argues Berkowitz, who admits that getting it feels in conflict with her feminist ethics, which aim to decenter appearance.
But Hamilton, the Houston plastic surgeon, says for many of her young patients, Botox is simply part of their overall investment in their health and appearance.
"Gen Z have this very different view on these things," she says. "This is part of their self-care. It's part of their wellness."
Stephanie Moore in Pittsburgh, says shaping her appearance with Botox makes her happy. She notes that her husband has tattoos, which she thinks are unnecessary and expensive.
"But that's his body and his choice," she says. "And this is my body and my choice."
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