JUST A LITTLE PRICK
Injectables have long been associated with a cookie-cutter aesthetic. Now, cosmetic doctors are using Botox and fillers to add expressiveness to facial features. WH asks if this new form of treatment can help you reclaim your face… and your confidence
Injectables have had a rebrand. But can they really boost your confidence?
Just full of self-loathing,’ says Anne*, describing her mindset in the run-up to her fortieth birthday. The emotions that contributed to her state of mind in that moment were far from straightforward, but it was a mindset that led Anne, now 43, to Dr Sophie Shotter, aesthetic doctor and founder of Illuminate Skin Clinic – and the decision to have Botox and fillers injected into the upper part of her face. In the months following the treatment, her confidence grew; she became more outgoing and less insecure, and made new friends for the first time in years. Her personality, she says, was transformed
– a change she credits entirely to the cosmetic treatments she received.
That women have Botox and fillers in order to feel good about themselves is unlikely to be news to you, and we suspect your views on the subject are pretty well established. But here’s where Anne’s story is different. She wasn’t seeking injectables to freeze her expression or eradicate frown lines, but to deliver an expressiveness that she’d longed for all her life, via a procedure known as myomodulation – an umbrella term for the strategic placement of fillers and Botox to alter the resting facial expression. First coined by Brazilian plastic surgeon Dr Maurício de Maio in a 2018 paper, myomodulation has been gaining ground among cosmetic doctors ever since. It’s a shift that begs the question: more than two decades after injectables first became a talking point, is your stance due a rethink?
SHIFT THE NEEDLE
If the very word ‘injectables’ calls to mind a Kardashian, you’d be forgiven – though their origin story is rather more pedestrian. It begins with a 19th century sausage, when a Belgian scientist traced
‘For the first time in my life, I could actually use my facial expressions in the way that I wanted to’
a food poisoning outbreak back to botulinum toxin (which is how the Botox drug got its name) within meat. By the 1940s, it was being used to treat patients with strabismus (crossed eyes). The discovery of its other merit, decades later, was a happy accident. In 1987, Dr Jean Carruthers, a Canadian eye specialist, was using Botox to treat a female patient’s blepharospasm – or eye twitching – when the woman reported that the formula was having a wrinkle-reducing effect. Dr Carruthers shared the news with her husband, a dermatologist, and together they spent five years investigating their cosmetic breakthrough. They published their first study in 1992 and, a decade later, Botox was approved for cosmetic use in the UK.
It was around the same time that cosmetic fillers were approved and, in the years that followed,
‘filler or Botox’ became water cooler chat among the celebrity-watching public. Then along came social media and – somewhere between the #spon posts and the birth of face-tweaking apps that enable you to try before you buy – using injectables became as ordinary to some as getting your roots done. Since 2011, the number of people receiving fillers or Botox has risen by a staggering 41%, fuelling an industry that’s now worth £2.75billion in the UK. So telltale are the signs (think: a suspiciously smooth forehead and pillowy plump cheeks) that the look has even earned its own moniker: Instagram face. It’s exactly this one-size-fits-all approach that cosmetic doctors are now attempting to counter.
To understand how fillers can add expressiveness, here’s a quick refresher on the facial muscles, courtesy of Dr Shotter. ‘In a nutshell, they can be divided into those that have a lifting action (known as elevators) and those that have a depressing one (depressors) – and they work in opposition to each other.’ This changes as you age, she explains; when you’re younger, the elevators are stronger than the depressors, but as you get older, your depressors become disproportionately strong. ‘This results in a kind of downturned expression, which can cause someone to look angry or sad when they don’t actually feel that way,’ she adds. In some women, this imbalance is present from a younger age, too. ‘My face has always portrayed someone who looked aggressive and miserable,’ Anne recalls. This feeling of being misunderstood affected her deeply – and over many years. ‘I’d be accused of being aggressive while doing normal activities, like queuing in the supermarket. It affected me so much that I never went on dates, I didn’t see friends. My confidence became so low that I’d avoid my son’s parents’ evenings and even ended up leaving my marketing and PR job because I couldn’t face going to events where people would judge me.’ Anne didn’t opt for therapy, but she’d always wondered whether injectables could help her. After her son went to university, and she found herself with more disposable income, she decided to visit Dr Shotter, whose knowledge of myomodulation meant she could use injectables to alter Anne’s resting expression.
This is where myomodulation comes into its own, says Dr Steven Harris, a leading aesthetic doctor and founder of The Harris Clinic. ‘If you have a face where your mouth is downturned, myomodulation would involve placing a filler under the elevator muscle of the cheek. This increases the activity of these muscles to lift the corner of the mouth. At the same time, this weakens its counterpart depressor muscle, which would normally have the opposite effect of pulling down the corner.’ The fillers, he explains, act as modulators for the muscles – causing a shift in the resting expression. On the results, Anne is effusive. ‘The treatment softened my permanent frown; my mouth no longer looked downturned. My face isn’t crease-free, and nor would I want it to be, but for the first time in my life, I could actually use my facial expressions in the way that I wanted to.’
SMILE LIKE YOU MEAN IT
You’d be forgiven for feeling cynical about the idea that you can boost your confidence – that much-studied, can’tput-your-finger-on-it feeling – by simply turning that frown upside down. But it’s an argument substantiated by research from the University of South Australia. The 2020 study aimed to evaluate the impact of forced smiling on your mood (timely, in a year when no one was doing much of the authentic kind). Participants in one group held a pen between their teeth, forcing their facial muscles into a smile, while a second group held nothing between their teeth. When both groups
were shown a range of facial expressions and a series of body movements, the pen group interpreted them more positively than the no-pen group, leading researchers to conclude that smiling delivers a tangible impact on mood. This theory isn’t new; first conceived by Charles Darwin, the so-called facial feedback hypothesis is based on the idea that positive facial expressions have the power to influence your mood, and a wealth of studies since have added significant weight to the theory. In the penbetween-the-teeth study, when participants forced a smile, it stimulated the amygdala – the almondshaped region of your brain tasked with managing your emotions – which, in turn, triggered the release of neurotransmitters that encourage an emotionally positive state.
So powerful is this effect thought to be that the mechanism of manipulating mood via muscle movement is even being floated as one explanation for lower levels of depression among Botox recipients. A study published in the journal Scientific Reports last July added weight to existing research on the connection; researchers found that depression was reported between 40% and 88% less often by those who’d received botulinum toxin for cosmetic reasons, as well as for conditions like migraines and neck pain, than by those who’d received a different treatment for the same condition. ‘For years, clinicians have observed that Botox injected for cosmetic reasons seems to ease depression for their patients,’ said Dr Ruben Abagyan, professor of pharmacy at the University of California, San Diego, who worked on the study. ‘It’s been thought that easing severe frown lines in the forehead region disrupts a feedback loop that reinforces negative emotions. But we’ve found that the mechanism may be more complex, because it doesn’t really matter where the Botox is injected.’ The team’s now working on clinical trials to test Botox as a treatment for depression.
FACE VALUE
It makes for fascinating research, but as an argument for injecting confidence, not everyone is convinced – not least because of the unintended consequences of getting injectables, regardless of your motivation for doing so. Concerns over her ability to connect with people in a largely video-based time led Sarah*, a 35-year-old PR director, to give up her Botox habit earlier this year. ‘Botox helped me look fresh-faced after sleepless nights raising two babies, and I always felt more confident after having it done,’ she explains. It wasn’t until Sarah started working from home last March that she realised how unexpressive her face had become. ‘I’d be on video calls and the animation I thought I was conveying just wasn’t there – I was shocked to see how expressionless I looked.’ This loss of expressiveness has been studied; research published in 2011 found that those who had Botox were physically unable to mimic the emotions of others, a process known as ‘embodied cognition’.
For Sarah, the tipping point came when she heard that some of the 20-somethings from her office were getting injectables, too. ‘I felt incredibly sad that these women felt like they needed to have these types of treatments before they’d even hit 25. I wanted to prove that I don’t need them and made a point of telling them why I was stopping.’
That women are seeking them out at a young age makes the framing of injectables as a tool for selfempowerment all the more concerning, says Renee Engeln, professor of psychology at Northwestern University in the US and author of Beauty Sick. ‘If doctors want to sell more cosmetic procedures as “treatments”, then they need to decide what disease these procedures are treating,’ she says. ‘Suggesting they treat “low confidence” sounds superficially more empowering than admitting that Botox and fillers are designed to disguise the perfectly normal process of ageing.’ She argues that this shift is capitalising on female insecurity, and adding fuel to the fire of an appearance-centric culture – a culture that research has linked with the development of self-esteem-related issues; studies have found an association between appearance-based exchanges and poor body image and disordered eating, for example. Her advice? Opt out, to the extent that you reasonably can. ‘Real confidence cannot be purchased in a dermatology office. You only experience real confidence by knowing what your deeply held values are, and by living your life in accordance with those values.’ See page 106 for more actionable advice on building confidence from the ground up.
The experts WH spoke to for this piece agreed that understanding your motivation for seeking injectables prior to committing isn’t just valuable, but essential to ensure you’re prioritising your self-esteem. This begins, says Dr Mark Leary – esteemed researcher on the subject – with understanding the impact low confidence is having on you. ‘We all have struggles and pockets of dissatisfaction that are just ordinary aspects of being human,’ he argues. ‘The question is whether those challenges are undermining your quality of life so frequently and extensively that they interfere with daily life. When in doubt, it’s almost always useful to seek out a professional mental health expert for a
The framing of injectables as a tool for self-empowerment is concerning
reality check and possible help if needed.’ It’s a sentiment echoed by consultant dermatologist and WH columnist Dr Anjali Mahto, who adds that practitioners have a responsibility to ensure they’re treating patients for the right reasons. ‘A good cosmetic doctor should be able to identify issues such as body dysmorphic disorder or other self-esteem concerns,’ though she notes that since aesthetics isn’t formally recognised as a medical speciality, this isn’t always the case – meaning it’s vital to ensure you seek out a practitioner with good qualifications. Anne didn’t discuss her feelings with a therapist, but she did choose a qualified practitioner; following her treatment, she found that she was perceived as being warmer, and happier, which, in turn, helped her confidence to snowball. As for Sarah, rejecting Botox in favour of ‘skin health’ – an acid-based regime and facials every few months – has helped her make peace with the image reflected back at her on Zoom. What’s right for someone else won’t necessarily be right for you – but like the bronzer you sweep over your cheekbones and the mascara you apply to your lashes, if you do opt for injectables, they should be the icing on the cake – not the cake itself.