Learning to live with wrinkle lines: Breaking down Botox

… While Botox and fillers have yet to reach drugstore cosmetics counters, … Raphael, a popular chain of skin-care salons, concurs. “Twenty … its use as a cosmetic treatment. 
Though I’ve … Beauty Wellness Clinic in Jerusalem, offers a gentler, nonsurgical face …

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With the lines on my face growing deeper by the day, I’ve started to think about “having work done.” “Work” can mean a full surgical facelift, but what is on my mind are injectable chemical compounds shot into the skin to roll back the hands of time.

Not so long ago these treatments were only for the uber-rich, the uber-famous, or the uber vain, who sometimes overused them to horrific effect. But that has changed. While Botox and fillers have yet to reach drugstore cosmetics counters, they are well on their way to being adopted by the masses – even here. 

“More and more people are doing it,” says Dr. David Friedman, a US-certified dermatologist with over 30 years of experience, who practices in Jerusalem and Ramat Aviv.

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Judy Raphael of Ronit Raphael, a popular chain of skin-care salons, concurs. “Twenty years ago, women were afraid, Now I see women from every population group, Jewish, Arab, haredi, national-religious, secular, and also men, and it’s growing.”

COULD YOU learn to accept and even love your wrinkles?  (credit: Caroline Veronez/Unsplash) COULD YOU learn to accept and even love your wrinkles? (credit: Caroline Veronez/Unsplash)

“Many people came because using Zoom made them more conscious of their wrinkles.”

Dr. Yoav Gronovich

Dr. Yoav Gronovich of Shaare Zedek Medical Center’s Harmonia aesthetic medicine clinic agrees. Gronovich, reports a 350% rise since the clinic opened its doors a decade ago including an increase during the pandemic. 

“Many people came because using Zoom made them more conscious of their wrinkles,” he says.

Though some men inject, having work remains a women’s thing. 

“I’d estimate that it’s 80/20,” says Gronovich.

Who is doing it?

Even today many people are reluctant to speak about their work and that seems to be part of the mystique. Here’s a quote from Friedman’s website. “Subtle enhancements are achieved so that no one will know that you had anything done, just that you look great.”

BUT IF nobody is being upfront, how do you find an aesthetic physician? That’s tough. A first step is to learn the basics – what injectables are, and what they can and can’t do.

Botox remains the best-known injectable. A 2020 study conducted by the American Society of Plastic Surgeons found that Botox injections were the most popular non-invasive cosmetic procedure, with 4.4 million procedures performed that year. That’s a lot of Botox. There are no statistics for Israel. 

Made from a highly purified strain of the botulinum toxin – the same microbe that causes botulism, a form of food poisoning – Botox is actually a miracle drug with many uses. It can stop excessive sweating, help with urinary incontinence and it can heal cross eyes and eyelid twitches. Interestingly, it was eyelid twitch patients who first noticed its wrinkle-erasing effects, prompting its manufacturer, the eye-care giant Allergan, to seek FDA approval for its use as a cosmetic treatment. 

Though I’ve never experienced it, I am told that Botox isn’t painful. Users say that it feels like a prick or a mosquito bite. It works by paralyzing the injected muscles and causing them to lay flat and smooth. Botox is quick; doctors say that the process can take under 10 minutes and it’s mostly safe. But some say it can cause headaches, double vision and bruising. Ugh.

Unless you are one of the unlucky ones, recovery is generally quick. Other than foregoing one’s siesta – napping immediately after injection can cause the Botox to fail to settle – patients can get back to life right away and the magical youthful effect can last for up to six months.

Botox works best on dynamic wrinkles. That means wrinkles that move around like crow’s feet, brow lines, frown lines, or the elevens between the eyes. If one’s aging presents in the form of sagging jowls, hollowed cheeks, or droopy jaw lines, filler gel-like products can help restore the dewiness of youth.

EVEN THOUGH the mass use of fillers is new, they have been around for more than a century. In the late 19th century, plastic surgeons injected their patients with liquid paraffin or Vaseline to heal facial deformities. Sometimes that worked, but sometimes the substances seeped into nearby blood vessels with predictably disastrous results.

 In the 1980s, aesthetic physicians started using collagen-based fillers made of substances extracted from cows, but the results were overly bold and unnatural. These days, fillers are made from hyaluronic acid, a naturally occurring substance that attracts water, causing the face to plump. Fillers continue to get better, as do the techniques for injecting them, which can include flooding the skin with tiny pinpricks to achieve natural results. 

“As we get older, we lose volume and our muscles play more of a role. As a result, people’s facial expressions make them look angry or unhappy. Fillers can knock off between 10 or 20 years and still look natural,” says Friedman.

And if you don’t like the results, you aren’t stuck. “Fillers can be dissolved by a special solution, in case of an adverse event, such as if the person dislikes the appearance,” writes Dr. Kristina Liu in a Harvard Medical School article.

Fillers are costlier and more complicated than Botox. They take longer to inject, and appointments can last an hour or more and are more painful. The fillers themselves contain lidocaine, a numbing agent, which some doctors top up with a numbing cream. While Botox can show results within 48 hours, it may take up to a week for fillers to settle on the face. 

SO WHAT is one to do? Are these substances the contemporary equivalent of the fountain of youth? 


In their waiting rooms, aesthetic medicine clinics often display striking before-and-after images. Are they for real? 

Maybe and maybe not.

“Before-and-after pictures may be photoshopped. Look at them with a jaundiced eye,” warns Dr. Y, a family physician who has been practicing aesthetic medicine for more than a decade. Dr. Y didn’t want to go on record putting down his colleagues, so he spoke on the condition of anonymity. On the whole, he is a fan of these procedures, which can give a refreshed appearance, but he says that sometimes they can go dangerously wrong.

“There can be failures – hematoma, obstruction in blood flow, even emboli,” he says. 

What is key is finding the right physician to do the work but how does one make the choice?

According to Gronovich, the type of doctor is key. Not surprisingly he insists the doctor of choice for aesthetic procedures is a plastic surgeon. “That’s because our toolbox is large. Plastic surgery is the only field that can offer that whole spectrum of treatments, from surgery to injectables, to laser, to Morpheus treatments which tighten the skin using radio waves administered under local anesthetic,” he says. 

At Shaare Zedek Medical Center’s Harmonia clinic, all work is done by plastic surgeons but that isn’t the norm or the Health Ministry’s requirement. 

In Israel, and in many other countries including the US, any licensed physician or dentist can undergo training to perform aesthetic procedures. In some parts of the US, nurses can also inject. The training is brief.

“For most doctors, this means a few courses, a basic four-to-six week course, once a week for five hours. Some courses are better and some worse,” says Dr. Y.

Afterward, a physician can follow up with more advanced courses; some are organized by equipment manufacturers or drug companies. Dr. Y believes that these continuing education options provide valuable training. “I took many courses, many of them with leading doctors who came from out of the country,” he says.

Shaare Zedek’s Gronovich isn’t a fan. “Many aesthetic doctors lack a good understanding of anatomy. They are only familiar with a limited range of needles injections and materials. There may be an incentive to buy cheap materials or push the treatments the doctor knows,” he warns.

Gronovich says that he has seen the fallout from these treatments. “Every week we see complications from procedures done at cosmetician’s clinics, including necrosis of the skin, which means cessation of blood flow, to inability to open the eye caused by improperly administered Botox.”

While Dr. Y agrees that plastic surgeons are generally well trained, he points out that their surgery backgrounds might bias them to recommend unneeded operations. 

“Other kinds of physicians and dentists can be just as good or even better than plastic surgeons at administering injectables,” he says.

 “You need to be careful,” he warns. “But there are good people in each field. What matters is real-life experience and what kind of person you are – do you care about your patients?”

Along with good character, Dr. Y stresses the importance of finding a doctor with a refined aesthetic sense. “Doctors who don’t have it will do work that isn’t attractive,” he says. Another tip-off is the pricing. “If it’s too low, that may indicate that the doctor is using inferior materials.”

Another red light is a doctor who restricts him or herself to injectables from one company. “That means that the doctor is getting a deep discount. You don’t want to be treated by someone who has a conflict of interest,” he says.

“A doctor must be familiar with the entire range of injectables,” he says. As in all things, medical experience is the key. “Go to someone who does this a lot.”

If needles make your skin crawl, you might be better off with a less invasive strategy 

“Injectables are like a Catholic marriage,” says paramedical cosmetician Itael Katsch-Cohen. “Once you start, there’s no stopping and some people are panicky about feeding themselves Botox, which is made out of a poison.” 

Katsch-Cohen, the owner of the Pi Health and Beauty Wellness Clinic in Jerusalem, offers a gentler, nonsurgical face-lift for clients who have lost muscle tone. Rather than chemicals, she applies electric pulses to tense the skin muscles. “It sounds scary, but it’s painless.” She also offers “no-needle Botox” or oxygen therapy, which uses pressurized oxygen to push anti-aging peptides and serums into the skin. Katsch-Cohen points to research that indicates that this increases the skin’s collagen and elastin production.

ALL OF THIS is very interesting, but what am I to do right now?

For the moment, I have no plans to inject or even go the nonsurgical route – my pockets aren’t deep enough. These treatments also create an illusion of youth. If they could eliminate the clicks and ticks and aches and pains, then maybe…

So what will I do? Make peace with my wrinkles. 

Jewish tradition sees them as a gift. According to the midrash, Abraham prayed to look old so that he could distinguish himself from his son Isaac. Wrinkles remind us that our time is limited and we’d better make the best of it. 

Perhaps that’s a message that is better left unerased. 

The author leads a weekly memoir workshop on Zoom. [email protected]

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