Botox

As a plastic surgeon in northern California, Dr. Steven Williams performs a lot of operations.

Steven WILLIAMS: We tackle the full spectrum, from head to toe: facelifts, blepharoplasties, liposuction, tummy tucks, and breast augmentations.

But one of his most in-demand treatments happens outside of the operating room. Every month, around 150 patients each pay hundreds of dollars to get one of the most toxic substances on Earth injected into their faces.

WILLIAMS: Markets go up and down, the economy is good or bad, but Botox is one of those things that people will really, really try not to cut back on. Twenty years ago, people were very quiet about it — like, “I don’t want anyone to know.” But now it’s part of what people see as self-care.

Botox is often touted as a cosmetic miracle drug. A few injections can temporarily reduce wrinkles and stave off signs of aging. Last year, there were more than 9 million procedures involving Botox or competing injectable brands in the U.S. alone. You can get Botox treatments from a credentialed doctor like Steven Williams — who happens to be the president of the American Society of Plastic Surgeons — but you can also get them at medical spas and even dentist’s offices. And people are seeking them out much earlier in life than they used to.

Jean CARRUTHERS: I think we’re seeing a generational shift in the patients. Boomers treat things once they’ve happened. Millennials are into prevention. And they’ve taken a look at their boomer parents and thought, “I don’t want to go there quite as fast.” And so they’ve done — it’s actually got a slang word: Baby Botox.

For the Freakonomics Radio Network, this is The Economics of Everyday Things. I’m Zachary Crockett. Today: Botox.

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Before Botox was a lucrative business, it was a deadly toxin found in sausages.

WILLIAMS: Like all crazy things, the story starts back in the 1700s.

Again, that’s Dr. Steven Williams.

WILLIAMS: In Germany there was this phenomena called sausage poisoning. People would consume uncured meats, and every once in a while people would die. As time went on, people began to study it a little bit, and the first thing they did is they classified the symptoms, and they noticed that people kind of had flat faces in effect and sometimes would have a little bit less ability to move.

Researchers eventually isolated the toxin in these meats and gave it a name — botulinum — derived from the Latin word for sausage. It was deemed to be around 100 billion times more toxic than cyanide. So deadly, in fact, that it was considered for use as a bioweapon.

WILLIAMS: In a pure form, botulinum toxin is incredibly, incredibly deadly. And so, of course, the military said, “This is great — we have this thing that’s really potentially deadly.” And, you know, there’s all this really nefarious stuff that was planned to do with it. There were even plans to maybe assassinate Castro by putting it in his cigar.

None of those plans ever panned out. But in the decades following World War II, researchers started to wonder if botulinum toxin might have medical uses. And in the late 1970s, an eye surgeon named Alan Scott thought it might be useful to treat a disorder called Strabismus, which causes the patient’s eyeballs to misalign.

WILLIAMS: That was the first entry into it being used clinically to make people better.

Scott found that injecting extremely small, purified, non-lethal amounts of a certain type of botulinum toxin — around the eye — could temporarily paralyze and weaken the orbital muscles and fix the problem. He named this drug Oculinum. It was a therapeutic breakthrough — one that Dr. Jean Carruthers witnessed firsthand, and she found it emotional.

CARRUTHERS: I remember one patient, who came in, led by his wife by the hand — he couldn’t open his eyes. And three days later, he sent me a picture of himself driving — oh, sorry — driving his red convertible. Yeah, sorry!

Carruthers is a clinical professor of ophthalmology at the University of British Columbia in Vancouver. She worked closely with Dr. Scott in the early 1980s before starting her own practice with her husband, a dermatologist. She used botulinum to treat optical problems — but one day she discovered it had other benefits.

CARRUTHERS: One of my patients got angry at me. She said, “You didn’t treat me here!” — pointing at her medial brows. And I apologized to her and said, “I’m so sorry. Didn’t think you were spasming there.” And she said, “I know. I know I’m not spasming there. But every time you treat me there, I get this beautiful untroubled expression.” And the penny dropped, because my husband had told me how difficult it was to treat these frown lines.

Carruthers began studying the cosmetic use of botulinum toxin. The first test subject was the receptionist in her office.

CARRUTHERS: She had really impressive frown lines. By 3:00, they were pretty severe. We treated her, and you could see this amazing difference.

In 1991, Dr. Scott sold Oculinum to the pharmaceutical company Allergan. The following year, the treatment was renamed Botox. It took Allergan another decade to secure FDA approval for cosmetic use — and even then, sales weren’t so hot. It was hard enough to sell the public on the merits of a watered-down neurotoxin that once killed sausage enthusiasts. But Botox had another problem, too.

Dana BERKOWITZ: Early on there was a stigma that Botox froze your face.

That’s Dana Berkowitz. She’s a sociologist, and the author of the book Botox Nation: Changing the Face of America.

BERKOWITZ: They really wanted to get around that stigma and show that, “Well, if you just use a little bit of Botox, you can still express yourself.” It was couched in this post-feminist narrative of, you know, “Doing it for you.”

Allergan embarked on an advertising campaign to convince millions of people — mostly women — that Botox could be a form of aesthetic liberation.

Botox 2008 commercial: Talk to your doctor about the one, the only Botox cosmetic. Freedom of expression! That’s what it’s all about.

This kind of messaging worked. Between 2000 and 2015, Botox sales jumped tenfold. In 2020, Allergan was bought out by another pharmaceutical firm, AbbVie, and today, global sales of therapeutic and cosmetic Botox clock in at $5.7 billion dollars annually. There are now multiple competing drugs on the market — like Dysport, Xeomin,and Jeuveau. But Botox is still the undisputed king of the industry, accounting for around 70 percent of the market share in its category. That’s largely thanks to ongoing ads that target the everyday woman.

Botox 2024 commercial: Hi, my name is Tonya and I’m 42 years young. I am a mom of nine. And this is, like, the first thing I’ve done for me in a really, really long time. My life is still crazy, it’s just as full as it was before — just with less lines!

Getting regular injections to treat wrinkles has become much more culturally acceptable — even for men. And, you don’t have to look hard to find a place to get treated.

BERKOWITZ: There’s medical spas in every suburban small town now across the country who promote Botox injections. It’s really everywhere.

That’s coming up.

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There are two main ways that our faces age. One is through the natural loss of the protein collagen. This causes our skin to sag over time. The other way is through repetitive facial movement. By smiling and frowning in the same ways, year after year, we etch wrinkles into our skin. Botox works on the second kind of wrinkles — It binds to nerve receptors that temporarily paralyze a targeted muscle. But it doesn’t work on the first kind.

WILLIAMS: When people have nasolabial folds — those are kind of the folds along your cheek — or what we call marionette lines, which are sometimes those wrinkles that are on the corners of your mouth down to your chin, Botox is terrible for those, because they’re not caused by a lot of muscle activation. 

Again, that’s Dr. Steven Williams, who runs a plastic surgery practice in California. For those wrinkles caused by collagen loss, surgeons usually recommend dermal fillers. These are injections of synthetic or natural polymers that plump up the skin.

WILLIAMS: But when we think about wrinkles on your forehead, when you kind of raise your eyes in surprise because someone says something really weird, those wrinkles are caused by the muscles in your forehead contracting and creating these lines in your skin. Or the wrinkles between your eyebrows when you are confused. Temporarily paralyzing those muscles decreases the wrinkles. 

Medical practitioners typically buy Botox wholesale from a medical distributor. A single vial of cosmetic Botox might cost them between $350 and $700. That one vial contains 100 “units” — which might be enough for a dozen treatments, or for one big one.

WILLIAMS: For a brow lift, where you inject a little bit on the side of the eye, you know, those doses are relatively small, you know, 6-8 units. For people who are trying to get reduction in their platysma, so those neck muscles that give people some of the banding on the neck, dosages can be 50-100 units at one setting. The treatment cost itself is usually about double what the cost of Botox is to us. That’s typically the markup at most reputable dermatology or plastic surgery offices. 

There aren’t any federal regulations around who can administer Botox. In some states, you can find treatments offered not just by plastic surgeons and dermatologists, but by aestheticians and even dentists. Across the country, thousands of medical spas have popped up offering Botox treatments for lower prices than most plastic surgeons charge. And they’re lucrative enough that private equity firms have started buying them up and consolidating the industry.

WILLIAMS: There has been a little bit of a race to the bottom. You know, a lot of these med spas, as they proliferate, it’s a pricing thing and they’ll say, “Well, you know, we’ll do $4 a unit or $5 a unit.”

As Botox has become more accessible, so too has counterfeit Botox, that can be readily found on the internet. These fakes can be hard to tell apart from the real thing. They might contain no botulinum toxin at all — or they might contain far more than the proper dosage. Federal agencies have identified more than 2,000 instances of counterfeit Botox being sold by medical professionals in the last decade.

WILLIAMS: These products are manufactured under different regulatory scrutiny in other countries. And because there’s less regulation around it, a lot of times it’s less expensive. They’re trying to make money and they don’t necessarily care about people. The problem is that the treatment itself is a medical procedure and has risks. And then the medication — even when sourced appropriately — if you don’t know how to use it, has risks. 

While plastic surgeons charge a premium for trustworthy service, a single visit for Botox is still a lot less lucrative than surgery. A frown line treatment might cost $500 or so, compared to $10,000 or more for a face lift. But for most people, the effects of Botox wear off in 3 to 4 months. So, you have to keep going back to maintain your desired look. That means that offering Botox provides doctors like Williams with a form of recurring revenue.

WILLIAMS: If we’re just doing surgeries, we might see our patients for some liposuction or breast augmentation in their 20s — and then potentially after they’ve had children, maybe a tummy tuck, and then maybe as they get older, maybe a blepharoplasty or facelift. Botox allows a continual relationship with patients over time. We have patients using Botox for almost 20 years now.

People are getting started with Botox at younger ages than they used to. Botox was originally marketed to women in their 50s and 60s. Today, many new patients are women in their 30s, 20s, or even late teens — they’re getting Botox before wrinkles even form. Dana Berkowitz, the sociologist, says this has a lot to do with social media.

BERKOWITZ: I interviewed women between the ages of 20 and 30, who had used Botox. Every single one of them said that social media was the culprit. We have targeted ads. You have young influencers who are getting free procedures from clinics and medical spas, so that they document the procedure on their feed. There was this idea that you used to get beautiful in private and now you get beautiful in public for the world to see.

Some of the women that Berkowitz interviewed also expressed an economic justification for getting Botox.

BERKOWITZ: I interviewed three broadcast journalists. All of them spoke about the importance of using Botox to preserve their appearance. Some people also talked about writing it into their contract — that they would be able to get Botox for their career preservation. A lot of people said, “You know, my face is my business card. I need it to preserve my appearance.”

Dana Berkowitz has gotten Botox injections herself — but she also has some reservations about it. Because all of those Botox’d faces we see on Instagram, TikTok, and local news stations have introduced new insecurities around the natural process of aging.

BERKOWITZ: Does Botox work? Yes. Does Botox make people look and feel better, a lot of the time? Yes. Is this still problematic? Absolutely. Every single time I use Botox, I feel like I am individually failing at feminist ethics. It transforms our perception of what is normal, of what is beautiful, of what an aging face should and does look like.

Dr. Steven Williams has mulled over that conundrum many times.

WILLIAMS: Unfortunately, there’s bias to pay, there’s bias to access to resources, there’s bias to finding a mate or a life partner. I think that it’s important to recognize that society puts an enormous pressure on people to look a certain way. Some people choose to respond to that, saying, “I’m going to age gracefully, and not fight it.” But the flip side is: that is what society is. People really like the things that Botox is able to do for them.

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For The Economics of Everyday Things, I’m Zachary Crockett. This episode was produced by me and Sarah Lilley, and mixed by Jeremy Johnston. We had help from Daniel Moritz-Rabson.

CARRUTHERS: I want to tell you right now: I haven’t frowned since 1987.