JAMA Dermatology Addresses Prejuvenation


Is it ever too early for botulinum toxin type A? A new article about the preventive use of cosmetic procedures to freeze the aging process may raise a few eyebrows—at least for those who haven’t had too many botulinum toxin type A shots.

The commentary, published online on JAMA Dermatology, states that it is “rarely too early” to start the “conservative and thoughtful use of neuromodulators, fillers and noninvasive energy-based treatments.” Critics of the concept, on the other hand, point to the potentially exorbitant cost of starting such procedures in early adulthood.

“It’s been clearly shown for a long time that frown lines, forehead furrows and crows’ feet are due to repetitive folding of skin from normal expressions,” says Kenneth Arndt, MD, a Boston-area dermatologist and co-author of the piece.

Arndt says many people in their 40s, 50s and 60s attempt to fix these wrinkles and folds once they’ve developed. But by injecting earlier, people can keep them from ever happening.

“If you slow down the use of these muscles beginning early in adult life, the lines never develop,” he says. “Rather than going backward and fixing something that’s there, you can inhibit it from starting in the first place.”

Arndt, a dermatologist and an adjunct professor of surgery at Dartmouth Medical School, points to a handful of studies to back this up, particularly a 2006 study involving identical twin sisters, one of whom used botulinum toxin type A regularly for 13 years and the other who did not.

“The study shows pictures of them 10 to 15 years later and one has a smooth and attractive forehead and the other has the expression lines you’d expect with someone with normal aging,” he says.

Could other extenuating circumstances be responsible for the disparity in the women’s appearance?

“A charmed life doesn’t lead to a smooth face,” he says.

Arndt admits nipping things in the bud does have its limits.

“We’re not advocating treating infants, children and people in their teens,” he says. “What I would suggest is at whatever point [people] begin to notice and are bothered by some of these things like frown lines or forehead lines … it’s reasonable to consider starting treatment with botulinum toxin type A. It’s easier and more effective to inhibit progression than come in 10 years later and take them away. We’ve termed it ‘prejuvenation.’”

Devin Harper, a 22-year-old laser hair removal sales representative from Dallas, says she started getting botulinum toxin type A injections at 19 specifically to stop wrinkles in their tracks.

“I started to prevent wrinkles and avoid having to receive fillers later in life,” she says. “I’ve seen women as they get older and their skin wrinkles and deteriorates. A big part of it is because I’m in sales in the cosmetic industry. But honestly, it’s also a fear of aging.”

Harper says she’s had five procedures so far (one dermal filler, the rest botulinum toxin type A) and plans to continue on with the botulinum toxin type A.

“I’ve got one wrinkle and as soon as I got it, I went in and got a filler, but it was painful and made me have a headache,” she says. “I’m not going to do the filler again.”

But not everyone is hip to hip-checking wrinkles before they start.

Harper says her parents are unhappy with her early cosmetic treatments and she’s even lost a relationship over it.

“Some people just don’t agree with you altering your body,” she says. “They feel God made you how you’re supposed to be made. But I feel God also made plastic surgeons.”

And not all plastic surgeons are comfortable with the concept of “prejuvenation.”

“For the average person to start using botulinum toxin type A in their twenties is overkill,” says Arthur Perry, MD, a board certified plastic surgeon with offices in New York and New Jersey. “There’s a variability in the wrinkles and thinning of the skin, so to do it before the late thirties is probably unnecessary in the vast majority of people.”

Plus the procedures are pricey, he adds. Botulinum toxin type A shots in three areas—the forehead, the area between the eyebrows and the crows’ feet—would average between $500 and $1,500 per treatment, says Perry.


“That’s an average of $1,000 and the recommended interval is every four months,” he says. “So you’re talking about $3,000 a year just for botulinum toxin type A, just the upper part of the face. You could buy a car with that money if you do it for, like, a decade.”

Harper, who got a discount for her procedures, says she’s seen “cheapie places where you can get it for like $10,” but the idea of patronizing one of those spots scares her.

“If I’m going to pay someone to put a needle in my skin that has a toxin, I’d rather pay more and know I’ll be okay after,” she says.


As for “prejuvenation,” Perry does agree that there’s evidence cosmetic intervention can prevent wrinkles from developing but says the million dollar question is when do you start.

“I think we can all get a little carried away with this and start way too early,” he says.

This content was originally posted on www.today.com and written by Diane Mapes (2013).

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