The injection of botulinum toxin (commercially known as Botox) is one of the most commonly performed non-surgical cosmetic procedures in the world. It is particularly effective for facial lines and wrinkles that can result from chronological ageing or simply from exaggerated facial movements. Over the years, there has been a steady increase in young adults in their 20s starting botulinum toxin treatments, which may be partly influenced by the contemporary celebrity culture, but also because botulinum toxin is remarkably effective, has no long term side effects, works within days (with no down time) and lasts for several months, in my experience.

Eighteen is the age of consent for cosmetic procedures in Australia; therefore, young adults in their 20s can decide for themselves whether botulinum toxin is for them. Botulinum toxin is not merely cosmetic, it has additional well defined medical indications, including headaches, teeth grinding and excessive sweating. However, those who condone medical botulinum toxin may frown upon its cosmetic use in young adults, even when there is evidence that botulinum toxin may not only make you look better, it may also make you feel better, through negative biofeedback from down-regulation of facial expressions such as frowning and scowling.

The pursuit of beauty is something very important for many people in our society, and there is evidence that human appreciation of beauty is deeply ingrained in our DNA. Beauty is linked to human sexual attraction, mating and procreation. Sexual selection precedes natural selection and is, therefore, a significant driver of species survival. According to evolutionary psychologists and anthropological studies, we have an innate appreciation of universal attractiveness that is independent of race and culture. The hallmark of facial beauty is clear skin with symmetrical features – traits that represent a genotypic and phenotypic quality from the absence of the assaults of mutations, pathogens and toxins. Thus, beauty has great social currency.

There is no evidence that in Australia the state of the dermatological profession is suffering because of cosmetic work. Further, if trained professionals don’t perform cosmetic procedures, there is the risk that young women and men may go elsewhere for lower quality procedures.

We must do our best for our young patients, and appreciate that they are traversing life’s lessons and that for many “beauty is only the promise of happiness”. Dermatologists have a central role in facilitating this realisation by offering our understanding and mentorship for patients in our care, even if amidst the distraction of botulinum toxin.

Dr Adrian Lim is in private practice and is a staff specialist at the Department of Dermatology at the Royal North Shore Hospital in Sydney. He currently serves on the Boards of the Australasian College of Dermatologists (ACD), Skin Hospital and the Australasian College of Phlebology (ACP). Dr Lim also chairs the National Education Committee of the ACD and the Board of Training of the ACP.



According to the author of 10 things girls need most, Steve Biddulph, problems begin in primary school, with comparisons of schoolwork, appearance, behaviour and sport results, and as they enter their teens, comparisons may lead to attempts to control the shape of their bodies through diet and unhealthy levels of exercise.

When you look at a classroom full of 15-year-old girls, almost half will be unhappy with their body shape and will be dieting to try and change it. It is sad that, when these comparisons are made, girls may develop an external locus of control and think happiness depends on the approval of others.

Girls today see more images of how they’re supposed to look in a week than their grandparents saw in a lifetime. There is pressure from all media to be cool and amazing and successful.

Cosmetic work is now more acceptable than ever. It is promoted that is easier to fix the outside than the inside. Yet, it doesn’t always make them happier or get rid of their insecurities, in my experience.

In a woman’s 20s, her skin is very elastic and will not permanently crease. So, using botulinum toxin is a waste of money.

Retraining your frowning muscles with a biofeedback technique is a far better idea than botulinum toxin in your 20s. This will stop the creases before they appear and will save hundreds of dollars.

Botulinum toxin used in the wrong place may actually make the face look old, both temporarily and long term.

Starting botulinum toxin treatments earlier will increase the risk of developing antibodies that may render the neurotoxin ineffective in the future.

There’s also a perception that “preventive work” will ward off ageing – it won’t. You don’t need to start these treatments until your 30s or 40s, and only then if you’re seriously concerned about ageing.

If a 20-something girl is really worried about ageing, she should spend her money on good sun protection and eating healthily. And if she’s a smoker, she should stop.

Because happy people aren’t worried about competing on looks, it is best to avoid comparisons between yourself and others. See a psychologist or a life coach and learn how to foster better self-esteem.

Use health and wellbeing apps to help you cultivate a positive self-image and encourage true beauty with inspirational quotes, media articles, videos and tools.

Use biofeedback to train those wayward corrugators.

Have time out from social media. Make your Instagram private. Smile. Use cosmetics and good skincare products.

In your normal 20s, botulinum toxin is a waste of money, may make it more difficult to have relationships, may actually make the face look old, risks the ability to use neurotoxin in the future if it is really needed, and offers no long term benefit against ageing.

Dr Michael Freeman is the principal dermatologist at the Skin Centre, specialising in cosmetic and laser dermatology. He is the director of dermatology at the Gold Coast Hospital, a visiting dermatologist at the Princess Alexandra Hospital in Brisbane, and is an associate professor of dermatology at Bond University. He is also a member of the Skin and Cancer Foundation of Queensland and an international member of the American Academy of Dermatology.


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Should 20-year-olds be using botulinum toxin?
  • I would advise them not to, but it's up to them (35%, 22 Votes)
  • No (35%, 22 Votes)
  • Only if they've been informed of all pros and cons and still want it (29%, 18 Votes)
  • If that's what they want, then yes (0%, 0 Votes)

Total Voters: 62

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4 thoughts on “Should a 20-year-old woman use botulinum toxin?

  1. Anonymous says:

    Saul you better change your mater profile as it lists Botox treatment in it pretty prominently.

  2. Anonymous says:

    The MJA should have given the background story of this article.
    These were both spoken arguments as part of a ‘Great Debate’ during the recent Australasian College of Dermatologists ASM in Sydney.

  3. Dr Saul Geffen FAFRM says:

    Please correct your article. The proprietary name Botox should no appear in the article or advert. ( Unless the publication is getting a kickback from Allergan)
    The claim that botulinum toxin has no side effects is wrong and Dr Lim should read the product information and / or retrain in its use. Besides the risk of the procedure, antibody formation is documented, dysphagia and ptosis are also recognised complications.

  4. Anonymous says:

    Completely agree with Dr. Freeman. He is obviously putting the patients interest first.

    Dr. Lim view on botulinum for 20 years olds is seems to be driven by greed and commercial interest.

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