New York:
Last month, Charice Pempengco, the petite Filipino teenager whose knockout voice has wowed Oprah and millions worldwide, caused a stir of another kind.
To prepare for her appearance on the Fox show "Glee" this fall, Ms. Pempengco, who is 18, got Botox injections and a skin-tightening treatment called Thermage. "I want to look fresh when I appear before the camera," she said on Philippine television during the visit at which her doctor, Vicki Belo, injected her jaw.
Outrage ensued. Doctors, child-rearing experts and others -- including New York magazine and Psychology Today -- chimed in to lament the regrettable message sent to young fans of "Glee," a show with a theme of self-acceptance. Even the celebrity blogger Perez Hilton was apoplectic, pronouncing what Ms. Pempengco had done, "SICK!!!"
But like it or not, Ms. Pempengco has plenty of company. According to the American Society of Plastic Surgeons, last year, botulinum toxin, which is sold here under the brand names Botox and Dysport, was injected into Americans ages 13 to 19 nearly 12,000 times, including some teenagers who got multiple doses. The number represented a 2 percent increase from 2008, the society said.
Needless to say, teenagers do not have wrinkles, which is the usual cosmetic reason adults seek out Botox. Before the Food and Drug Administration approved Botox, a muscle-relaxing toxin, for cosmetic use in 2002, it was used as a medical treatment for neuromuscular and eye disorders.
Today, nobody knows how many teenagers who get injections of Botox or Dysport are using them for medical rather than aesthetic purposes. The lines can be blurry, since the drug can help with physical problems -- like pain in the temporomandibular joint of the jaw -- and improving the patient's looks can be a side effect.
On the medical side, Botox is approved by the F.D.A. to be used therapeutically in children as young as 12 with abnormal twitching of the eyelid or crossed eyes. It can also help patients 16 and older with involuntary contraction of neck muscles, and by people 18 and up to combat excessive sweating.
The controversy, though, stems from the off-label uses of Botox by children and young adults. Doctors are injecting teenagers for a variety of perceived imperfections, from a too-gummy smile to a too-square jaw.
In February, Phu Pham, who is 19 and lives in San Antonio, got Botox injections to narrow what he considered to be his "bodybuilder"-big jaw muscle, which he felt didn't fit his otherwise slim face.
"I was nitpicking myself a little bit," said Mr. Pham, a student and X-ray technician for the Air Force. Before his $800 Botox procedure, his left jaw muscle bulged a bit more than the right one, he said, and now, "neither side really bulges out as much."
After the treatment, Mr. Pham said, his parents asked whether he'd lost weight. He had not. "I told them I didn't go under the knife," he said. "I didn't do anything drastic. I just got Botox injected into my chewing muscles," or masseter muscles. After their initial surprise, Mr. Pham said, his parents did not object.
His doctor, Samuel M. Lam, is a facial plastic surgeon in Dallas who said he has seen more than 100 patients for jaw reduction via Botox. About 90 percent of them sought treatment for cosmetic reasons, he said, but even the 10 percent who had medical problems wanted it for aesthetic purposes, too.
"It's cause and effect," Dr. Lam said. The initial problem may be pain in the temporomandibular joint (TMJ), "but the effect is an enlarged lower face," he said.
Dr. Lam said he had injected many people in their late teens and 20s, but no minors. But he said he is not opposed to treating children this way, depending on their maturity and motivation. "A lot of teenagers tease each other about things that as adults we may not consider as important," Dr. Lam said, adding that he has performed cosmetic surgery on teenagers, including nose jobs and an operation to create creases in the eyelids of minors of Asian descent.
Among Ms. Pempengco's representatives, there is disagreement over why she underwent Botox treatment. In an interview on Philippine television, Dr. Belo said that she injected her patient to narrow her face and target enlarged jaw muscles that made her look "mataba," or fat. In other words, she used Botox to reshape Ms. Pempengco's face.
But a representative for Ms. Pempengco said that she did not use Botox for cosmetic reasons, and declined a request for an interview with her.
The fact that any teenagers would use a toxin to improve their looks surprises and upsets many adults. On her Web site, Michele Borba, the author of many parenting books, didn't disguise her scorn.
"If your daughter is begging for Botox, believe me, an injection is not the cure," Ms. Borba wrote. "There's a much deeper issue at stake and I'm betting it's self-esteem. Say no to that injection. Address her feelings of 'inadequacy' and not her need to cover up a so-called wrinkle."
But in a culture in which teenagers have long been given nose jobs as Sweet 16 presents, some doctors question why a temporary injection of botulinum toxin should cause any more of a stir than a permanent surgery. Dr. Lisa M. Donofrio, a dermatologist with four offices, including one in Manhattan, said, "nose jobs are very accepted," yet fillers and liposuction are not.
Dr. Donofrio has performed liposuction on the jaw lines of normal-weight minors with a family history of double chins. She has also injected Botox in a few teenagers who were self-conscious about their gums. The patients -- most older than 16 and female -- were "not just showing a little bit of gum and teeth, but showing a lot of gums," she said. "They feel like they have a horsey smile."
Dr. Donofrio, who gets patient referrals from dentists or orthodontists, injects Botox in the muscles that elevate the upper lip to relax them, so that the lip stays lower when a teenager smiles, for up to four months. Her reasoning? "A smile is so important," she said, adding that the treatment is about $100.
Interestingly, her gummy-smile patients all "outgrow" their desire to get Botox, she said. "They get busy, and it's just not as important," Dr. Donofrio said.
She isn't surprised by the outrage over Ms. Pempengco. There is a "very extreme distaste about doing anything cosmetic on minors," said Dr. Donofrio, who has been a paid consultant for the makers of Botox and Dysport.
Dr. Rod J. Rohrich, the chairman of plastic surgery at the University of Texas Southwestern Medical Center, said that in his practice he selectively does "lots of Botox" for wrinkles on patients starting in their late 20s. (Models sometimes start in their early 20s.)
When it comes to teenagers, Dr. Rohrich, who is editor of the Journal of Plastic and Reconstructive Surgery, says he injects them with Botox infrequently -- and usually only for migraine relief. "That works well," he said. "I do it a lot around final exams."
Some teenagers mistakenly think that Botox can prevent wrinkles. In March, after a British teenager who got Botox injections at 15 told the tabloid The Sun, "I wanted to have Botox for two reasons -- it prevents wrinkles and everyone at my school was talking about having 'B,' " the Physicians Coalition for Injectable Safety issued a statement decrying "Teen Toxing" in the United Kingdom and reminding people that Botox does not prevent natural aging.
As for jaw-line shaping with Botox, Dr. Rohrich has done it in adults, but cautions that this off-label technique requires a highly skilled dermatologist or plastic surgeon who's "very attuned to injecting Botox in these areas." Problems like facial nerve paralysis and weakened chewing can occur. (Dr. Donofrio said that complications of using Botox to treat a "gummy" smile could include an asymmetrical smile or speech impairment.) Using Botox to soften a strong, square jaw is not uncommon in Asia, particularly Korea. In the United States, a handful of doctors told me they had injected some women, mostly Asian, to change their square-jawed look.
At the heart of Ms. Pempengco's "Botox apocalypse," as one headline from the Philippines dubbed it, is "a collision of cultural norms," said Dr. Richard G. Glogau, a clinical professor of dermatology at the University of California at San Francisco. Reshaping the lower face with Botox is "not an uncommon goal if you happen to live in Southeast Asia or China," he said.
Yet, this kind of facial reshaping with Botox is not that common in the United States, which may be why a baby-faced star like Ms. Pempengco wanting to alter her jaw line still puzzles -- or offends -- many Americans.
"A 16-year-old in New York getting a rhinoplasty, it's a birthday present," said Dr. Glogau, a paid researcher for the makers of Botox and Dysport. "If you told teenagers in Southeast Asia that, they'd probably be aghast. It would never occur to them."
To prepare for her appearance on the Fox show "Glee" this fall, Ms. Pempengco, who is 18, got Botox injections and a skin-tightening treatment called Thermage. "I want to look fresh when I appear before the camera," she said on Philippine television during the visit at which her doctor, Vicki Belo, injected her jaw.
Outrage ensued. Doctors, child-rearing experts and others -- including New York magazine and Psychology Today -- chimed in to lament the regrettable message sent to young fans of "Glee," a show with a theme of self-acceptance. Even the celebrity blogger Perez Hilton was apoplectic, pronouncing what Ms. Pempengco had done, "SICK!!!"
But like it or not, Ms. Pempengco has plenty of company. According to the American Society of Plastic Surgeons, last year, botulinum toxin, which is sold here under the brand names Botox and Dysport, was injected into Americans ages 13 to 19 nearly 12,000 times, including some teenagers who got multiple doses. The number represented a 2 percent increase from 2008, the society said.
Needless to say, teenagers do not have wrinkles, which is the usual cosmetic reason adults seek out Botox. Before the Food and Drug Administration approved Botox, a muscle-relaxing toxin, for cosmetic use in 2002, it was used as a medical treatment for neuromuscular and eye disorders.
Today, nobody knows how many teenagers who get injections of Botox or Dysport are using them for medical rather than aesthetic purposes. The lines can be blurry, since the drug can help with physical problems -- like pain in the temporomandibular joint of the jaw -- and improving the patient's looks can be a side effect.
On the medical side, Botox is approved by the F.D.A. to be used therapeutically in children as young as 12 with abnormal twitching of the eyelid or crossed eyes. It can also help patients 16 and older with involuntary contraction of neck muscles, and by people 18 and up to combat excessive sweating.
The controversy, though, stems from the off-label uses of Botox by children and young adults. Doctors are injecting teenagers for a variety of perceived imperfections, from a too-gummy smile to a too-square jaw.
In February, Phu Pham, who is 19 and lives in San Antonio, got Botox injections to narrow what he considered to be his "bodybuilder"-big jaw muscle, which he felt didn't fit his otherwise slim face.
"I was nitpicking myself a little bit," said Mr. Pham, a student and X-ray technician for the Air Force. Before his $800 Botox procedure, his left jaw muscle bulged a bit more than the right one, he said, and now, "neither side really bulges out as much."
After the treatment, Mr. Pham said, his parents asked whether he'd lost weight. He had not. "I told them I didn't go under the knife," he said. "I didn't do anything drastic. I just got Botox injected into my chewing muscles," or masseter muscles. After their initial surprise, Mr. Pham said, his parents did not object.
His doctor, Samuel M. Lam, is a facial plastic surgeon in Dallas who said he has seen more than 100 patients for jaw reduction via Botox. About 90 percent of them sought treatment for cosmetic reasons, he said, but even the 10 percent who had medical problems wanted it for aesthetic purposes, too.
"It's cause and effect," Dr. Lam said. The initial problem may be pain in the temporomandibular joint (TMJ), "but the effect is an enlarged lower face," he said.
Dr. Lam said he had injected many people in their late teens and 20s, but no minors. But he said he is not opposed to treating children this way, depending on their maturity and motivation. "A lot of teenagers tease each other about things that as adults we may not consider as important," Dr. Lam said, adding that he has performed cosmetic surgery on teenagers, including nose jobs and an operation to create creases in the eyelids of minors of Asian descent.
Among Ms. Pempengco's representatives, there is disagreement over why she underwent Botox treatment. In an interview on Philippine television, Dr. Belo said that she injected her patient to narrow her face and target enlarged jaw muscles that made her look "mataba," or fat. In other words, she used Botox to reshape Ms. Pempengco's face.
But a representative for Ms. Pempengco said that she did not use Botox for cosmetic reasons, and declined a request for an interview with her.
The fact that any teenagers would use a toxin to improve their looks surprises and upsets many adults. On her Web site, Michele Borba, the author of many parenting books, didn't disguise her scorn.
"If your daughter is begging for Botox, believe me, an injection is not the cure," Ms. Borba wrote. "There's a much deeper issue at stake and I'm betting it's self-esteem. Say no to that injection. Address her feelings of 'inadequacy' and not her need to cover up a so-called wrinkle."
But in a culture in which teenagers have long been given nose jobs as Sweet 16 presents, some doctors question why a temporary injection of botulinum toxin should cause any more of a stir than a permanent surgery. Dr. Lisa M. Donofrio, a dermatologist with four offices, including one in Manhattan, said, "nose jobs are very accepted," yet fillers and liposuction are not.
Dr. Donofrio has performed liposuction on the jaw lines of normal-weight minors with a family history of double chins. She has also injected Botox in a few teenagers who were self-conscious about their gums. The patients -- most older than 16 and female -- were "not just showing a little bit of gum and teeth, but showing a lot of gums," she said. "They feel like they have a horsey smile."
Dr. Donofrio, who gets patient referrals from dentists or orthodontists, injects Botox in the muscles that elevate the upper lip to relax them, so that the lip stays lower when a teenager smiles, for up to four months. Her reasoning? "A smile is so important," she said, adding that the treatment is about $100.
Interestingly, her gummy-smile patients all "outgrow" their desire to get Botox, she said. "They get busy, and it's just not as important," Dr. Donofrio said.
She isn't surprised by the outrage over Ms. Pempengco. There is a "very extreme distaste about doing anything cosmetic on minors," said Dr. Donofrio, who has been a paid consultant for the makers of Botox and Dysport.
Dr. Rod J. Rohrich, the chairman of plastic surgery at the University of Texas Southwestern Medical Center, said that in his practice he selectively does "lots of Botox" for wrinkles on patients starting in their late 20s. (Models sometimes start in their early 20s.)
When it comes to teenagers, Dr. Rohrich, who is editor of the Journal of Plastic and Reconstructive Surgery, says he injects them with Botox infrequently -- and usually only for migraine relief. "That works well," he said. "I do it a lot around final exams."
Some teenagers mistakenly think that Botox can prevent wrinkles. In March, after a British teenager who got Botox injections at 15 told the tabloid The Sun, "I wanted to have Botox for two reasons -- it prevents wrinkles and everyone at my school was talking about having 'B,' " the Physicians Coalition for Injectable Safety issued a statement decrying "Teen Toxing" in the United Kingdom and reminding people that Botox does not prevent natural aging.
As for jaw-line shaping with Botox, Dr. Rohrich has done it in adults, but cautions that this off-label technique requires a highly skilled dermatologist or plastic surgeon who's "very attuned to injecting Botox in these areas." Problems like facial nerve paralysis and weakened chewing can occur. (Dr. Donofrio said that complications of using Botox to treat a "gummy" smile could include an asymmetrical smile or speech impairment.) Using Botox to soften a strong, square jaw is not uncommon in Asia, particularly Korea. In the United States, a handful of doctors told me they had injected some women, mostly Asian, to change their square-jawed look.
At the heart of Ms. Pempengco's "Botox apocalypse," as one headline from the Philippines dubbed it, is "a collision of cultural norms," said Dr. Richard G. Glogau, a clinical professor of dermatology at the University of California at San Francisco. Reshaping the lower face with Botox is "not an uncommon goal if you happen to live in Southeast Asia or China," he said.
Yet, this kind of facial reshaping with Botox is not that common in the United States, which may be why a baby-faced star like Ms. Pempengco wanting to alter her jaw line still puzzles -- or offends -- many Americans.
"A 16-year-old in New York getting a rhinoplasty, it's a birthday present," said Dr. Glogau, a paid researcher for the makers of Botox and Dysport. "If you told teenagers in Southeast Asia that, they'd probably be aghast. It would never occur to them."
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