The Efficacy, Safety, and Side Effects of Botox and Facelifts

Antiaging medicine is one of the fastest growing medical specialties and often targeted at women who are urged to restore their youthful appearance by “any and all available means.” This includes surgery. Ninety-two percent of cosmetic procedures are performed on women, most commonly Botox, fillers, and laser or chemical peel skin resurfacing. But millions in the U.S. undergo cosmetic surgery every year, including hundreds of thousands of facelifts.

There is no consensus on a best facelift technique. None have been shown to be definitively better than others. A systematic review found that most of the studies on the newest techniques were mere case series, one of the lowest levels on the hierarchy of evidence, basically composed of a string of glorified anecdotes.

According to one of the largest and most up-to-date analyses, facelifts are considered relatively safe when performed by a board-certified plastic surgeon, with surgical complications only happening in about 1 in 20 cases, most often hematomas, where blood collects under the skin flaps, or minor infections. Serious infections, like facial necrotizing fasciitis caused by flesh-eating bacteria are rare, as is pyoderma gangrenosum, a disfiguring skin ulcerating autoimmune disease that can be triggered by facelift surgery. Other uncommon consequences include scarring, hair loss, and injuries too gruesome to show. Nerve injuries occur in at most a few percent of cases, but only about 1 in 1,000 procedures may result in permanent facial nerve injury.

About two-thirds of facelifts are performed under general anesthesia, which is associated with a greater risk of complications. The most important way to mediate risk is to refrain from smoking. Smoking can increase the risk of skin flap necrosis, or tissue death, up to twenty-fold. Patients should refrain from smoking at least a month before and a month after surgery. Tempering expectations is also important. Approximately one in three women experience a period of postoperative depression, but this may just be in reaction to the temporary distortion and discoloration of swelling and bruising after surgery.

The most profitable cosmetic procedure is Botox, in the billions, as well as the most common, performed more than four million times a year in the U.S. alone. It all started when a group of surgeons noticed that patients with Bell’s palsy—facial paralysis—didn’t have as many wrinkles. So, what about injecting minute amounts of the nerve-blocking toxin that causes botulism to paralyze a few facial muscles on purpose, and a multibillion-dollar industry was born. The effect is temporary, typically lasting three to four months until the body can grow back new nerve terminals.

In response to cases of respiratory failure and death occurring hours or even weeks after injection, in 2009, the FDA mandated a black box warning regarding the potential spread of the toxin resulting in death from swallowing and breathing difficulties occurring hours, days, or weeks after injection. However, most of these complications were tied not to cosmetic uses but to treating muscle spasms (for example, in cerebral palsy). For wrinkles, only 30 to 60 units of the toxin may be used, compared to an average of about 180 units for severe muscle spasms, though still a far cry from the estimated lethal dose of perhaps 3,000 units. (The dose is given in MU, “mouse units,” with one MU being the amount capable of poisoning half of a group of albino mice to death.)

In studies, less than 1 in 2,000 Botox procedures resulted in complications, which can include droopy eyelids, double vision, an asymmetrical smile, or “the Spock,” a devilish curvature of the outer portion of the brow.

Unfortunately, not all such procedures are performed under such controlled conditions. In many states, there is surprisingly little or no regulation as to who can deliver Botox, leading to a rapid increase in injections by nonmedical personnel. In one fiveish-year period, about 30,000 complications allegedly tied to Botox were reported to the FDA, most commonly pain, swelling, and eyelid or eyebrow drooping, but most adverse effects are transient and self-limited.