We may live in an age of candour around cosmetic interventions, with celebrities publicly praising their facelift surgeons and influencers documenting procedures online. Yet disclosure and discretion coexist in aesthetics culture, and when it comes to wrinkle‑relaxing injectables, many of us are happy to admit we’ve had them – so long as they read as invisible. “That’s the word I hear now,” says cosmetic dermatologist Dr Sam Bunting of today’s changing face on Harley Street. “The focus is on preservation at just the right time so that a very minimalist approach can be adopted.”
It’s a sentiment I’m hearing increasingly from doctors at the higher end of the market. Their use of neuromodulators – like Botox – has become hyper-strategic: not only to soften static lines, but to enhance facial expression, rather than erase it. “When I started practising, our training was to do very high, standardised doses resulting in relatively little movement,” says aesthetic doctor Dr David Jack. Over time, his philosophy – anchored by an anatomy degree and plastic surgery studies – has shifted to “anatomical restoration” rather than wrinkle reduction. “Expression is fundamental to how we recognise one another and I think patients increasingly understand that a face can be technically very smooth and still look older, tired or unlike oneself.” As a Botox virgin who’s always feared the frozen look and opposed the homogenisation of beauty by way of tweakments, this approach intrigues me.
Still, I sense an irony in suddenly paying to strategically retain wrinkles. “I’ve always done that for my onscreen patients,” Dr Bunting shares, “where the goal is to reduce the force of the movement, so the face still moves naturally, rather than to eradicate it”. It’s also about playing the long game, she points out: this way, “the lines are much less inclined to get etched in”. For Dr Bunting, removing “excessive negativity or distraction” in the face is always the driver with Botox, which in turn means her patient’s features and skin can take centre stage.
In a sense, some doctors are training a face by modifying its movement, reducing it here, preserving it there. The toxin doesn’t permanently teach a muscle to behave differently, Dr Jack notes – without it, eventually neuromuscular activity returns. Rather, over repeated treatments, practitioners can “interrupt habitual patterns of excessive recruitment and alter the relative balance between opposing muscles”. The result? Patients become less inclined to make certain movements so forcefully because they have effectively spent long periods without relying on them. Through neuroplasticity – as Dr Bunting puts it – certain facial movements can become habits, and Botox helps us unlearn them. It creates new muscle memory, if you like. “I tell my patients that even if they stop having Botox, there’s a good chance that they’ll frown less in the future.”
Of course, neuromodulators aren’t always used in isolation when restoring vibrancy to a face. In Dr Jack’s assessments for toxin, he looks at the direction of dynamic changes related to gravity, where deeper volume has been lost, and which muscles have therefore become dominant or compensatory. “All of these factors together give you a completely different treatment plan compared to looking for lines,” he says. Sometimes restoring deeper support first – with dermal filler – changes how the overlying tissues sit and consequently dictates what you can do with Botox. While restoring volume is key to some, optimising skin quality is a priority for others. For Dr Bunting, that likely means combining Botox with in-office microneedling and at-home retinoids, to “maximise collagen” and encourage thicker skin.
Additional treatments aside, this hyper-specific strategy to Botox placement wouldn’t necessarily cost more via increased appointments; in fact, one could argue that a minimal approach costs less. Dr Ash Soni, a plastic surgeon and aesthetic injector who has been beating the natural Botox drum since day one, tells me his goal is to see his patients as little as possible. “Whether you do less or more, the maintenance is the same if you want a consistent result,” he says. What will cost more is visiting a medic – which is likely the only way you’ll achieve “anatomical restoration”. Most injectors can do light-handed ‘baby Botox’, or micro-dose in a traditional pattern. But making dynamic anatomical assessments is only really possible with the nuanced knowledge that comes with a medical degree.
As Dr Jack says, the most sophisticated results don’t necessarily involve using more toxin or eliminating more movement. “They come from understanding the anatomy well enough to know which movement to reduce or preserve – and which wrinkle is better left as is.” It’s the kind of restraint to make me consider a very strategic start.