How Botox went middle-class

NZ Herald

03-08-2025

Dubrow, who is married to the Real Housewives of Orange County star Heather Dubrow, still remembers a time when talking about Botox was 'verboten': 'Nobody would admit to [using] it.' But that moment has disappeared like a stubborn facial line under a good injector's needle. 'Botox is so ubiquitous,' Dubrow said. 'It's almost like, if you look older, if you don't do Botox, what does that say about you?'
'It's not even about vanity anymore,' he added. 'It's like having agency over ageing in a weird way.'
Botox has gone from a niche beauty treatment to a blockbuster phenomenon. With medical spas and Botox bars proliferating from city to city, a procedure that was once performed only on the doyennes of the 1%, in the secrecy of a plastic surgeon's office, is now accessible to anyone with a few hundred dollars and a dream of line-free skin.
'It's just become something that people do, just like they get a manicure,' said sociologist Dana Berkowitz, who is the author of Botox Nation: Changing the Face of America.
'Obviously it's a little more intrusive or invasive, but it's become so normalised and just so casual ... it's just a routine.'
The stats bear this out. A 2024 report from the American Society of Plastic Surgeons shows that US injectors performed more than 9.8 million procedures using neuromodulators (Botox, Dysport, Xeomin, Jeuveau and Daxxify) that year, up 4% over 2023, which the organisation had dubbed 'the year of Botox'. Compare that with the pre-covid 2019 report, which shows roughly 5 million neuromodulator injections in the US – in five years, demand has almost doubled.
'It's now so normal in American culture that patients mention it as casually as running an errand to the store or post office,' the 2023 report noted, confirming that Botox has become a catch-all word for an entire category of products, like Kleenex or Xerox.
It wasn't always like this. Berkowitz attributes this current moment to 'the rise of medical spas, the very aggressive marketing from Allergan [Botox's Big Pharma manufacturer], this circulating discourse that Botox is preventative and that seduces younger and younger users.' Now, more and more women – and yes, the 2024 ASPS report states that 94% of patients are women, even still – see Botox as a regular part of their overall aesthetic maintenance, like bikini waxes or balayage.
'It's really changed the way we think about how we quote, unquote, treat the appearance of ageing on the face,' Berkowitz said.
Like practically any beauty trend of the 21st century, you can't talk about Botox without bringing up celebrities. Celebrities are what sculptures probably were to the ancient Greeks: uncannily, gorgeously smooth. Glossy. Lineless. Until recently, an A-lister would never admit to meddling with her looks, maintaining the illusion of her natural aesthetic superiority.
But somehow, Botox has crept into the cultural lexicon enough that even the most venerated among us are copping to it. In an interview with Allure magazine in 2022, Kim Kardashian – who, with her sisters, is often credited-slash-blamed for the rise of plastic-surgery-coded 'Instagram face' – nevertheless insisted that the only invasive treatment she had on her face was 'a little bit of Botox'.
It's the same with Lindsay Lohan, who has been the subject of a rolling tide of plastic surgery rumours since she stepped out looking remarkably youthful for the Our Little Secret movie press tour in late 2024. This past May, Lohan did an interview with Elle magazine in which she attributed her flawless complexion to skin care, juicing and pickled beets.
Oh, and Botox. 'Everyone does Botox,' said Lohan, who turned 39 this month.
Lindsay Lohan attends a special screening for Our Little Secret. Photo / Getty Images
There was a time, not too long ago, when accusing a celebrity of using Botox was like calling them out for something sinister. In 2011, a then-25-year-old Megan Fox uploaded a carousel of selfies to her Facebook page in which she grimaced and furrowed, showing off her forehead lines for the camera. It was a response to rumours that the actress had succumbed to the lure of the needle. Fox called the gallery 'Things you can't do with your face when you have Botox'.
Flash-forward to March 2024, when Fox sat across from Call Her Daddy host Alex Cooper and broke down her list of cosmetic enhancements, which include multiple breast augmentations, a rhinoplasty, Botox and filler.
What happened in between?
Most actors and influencers aren't as forthcoming as Fox – even with a sudden spate of honesty from the Kardashian-Jenners, the Lohan model of deflection still reigns. But Dana Omari says that the reason these women are 'fessing up to Botox is because, 'Now, celebrities can't rely on our total ignorance and so they have to give a little bit of something.' She's referring to wider awareness of the menu of cosmetic treatments, which is thanks in part to social media content like hers.
Omari, who has more than 250,000 followers on Instagram, started her account in early 2019 and posts side-by-side photos of celebrities, breaking down the work she thinks they've had done, often wielding the word 'allegedly' to comedic effect. The dietitian and former consultation manager at a medical spa said that notable women – among them the Today show's Jill Martin, dancer Allison Holker and actress Allison Williams – have picked up on the fact that sharing details from their dermatological diaries isn't a liability anymore.
'I think that they are kind of realising that this makes them more relatable,' Omari explained. 'And Botox is a really safe one [to admit to] because it's not permanent, it's just a little quick injectable, you know?'
Reality television has paved the way for this era, from a burgers-and-Botox-themed open house on a 2020 episode of Selling Sunset to the cast of The Secret Lives of Mormon Wives getting Botox (and, controversially, laughing gas) together in the first season, which aired in 2024. 'It's no longer taboo,' Omari said definitively. 'Botox is no longer the thing that people are afraid to talk about. It's more ubiquitous.'
The stars of reality shows, from Heidi Montag to Bre Tiesi, have also adjusted our collective eyeballs to the vision of an unmoving face. A 2006 episode of The Real Housewives of Orange County, in which a then-43-year-old Vicki Gunvalson gets Botox for the first time – in her kitchen, while yelling, 'I don't like this' – might as well be a historical newsreel, for how distant that world seems.
Case in point: Omari said that in the six years her page has been up and running, she has posted multiple photos suggesting that Taylor Swift may have had subtle work done, including Botox. The first time, her followers were enraged. 'My page was in shambles, it was being reported, it was a miserable day,' she said. Nobody wanted to believe that Swift, 'the girl next door,' would answer the siren call of the syringe, Omari explained: 'The girl next door does not get Botox.'
But now that the procedure is so much more mainstream, the response is different.
'I posted her more recently, and while I did get some negative comments, a lot were like, 'Yeah, she's 34, 35,'' Omari said.
Botox, which is a purified form of the deadly bacteria Clostridium botulinum, was first approved by the Food and Drug Administration for cosmetic use in 2002. For all of the ways we've acclimatised to widespread Botox use, it's easy to forget that it carries risks, including iatrogenic botulism, which is when the toxin spreads beyond the injection site – a rare but potentially life-threatening complication. Like so many paradigm-shifting drugs, Botox was developed to address health concerns; in this case, excessive blinking and strabismus, or crossed eyes. It was approved by the FDA for these ophthalmologic conditions in 1989.
Its ability to all but erase wrinkles was a happy discovery, and by the 1990s upscale dermatologists and plastic surgeons were offering off-label Botox services.
'I started my private practice in 1998, and that's pretty much when I started [providing] Botox,' said Doris Day, a dermatologist on New York's Upper East Side with a 270,000-strong Instagram following. 'And in the beginning – we still laugh about it with my patients – I would be so nervous [injecting it]. … I wasn't worried about hurting anyone in terms of their health, but I didn't want to cause a brow droop or other side effects.'
Day describes neuromodulators as 'tools to help people age in a youthful, healthy way'. Nonetheless, she disagrees with some of the marketing and the wider discourse surrounding the drug. 'These [pharmaceutical] companies … they train people to start hating their lines,' she said.
This causes customers to seek out bargain Botox or, worse, engage in dangerous TikTok trends like 'Backyard Botox'.
'I think it has become so commoditised,' Day continued. 'Every corner salon and med spa and even hair salons are offering it … and then it becomes a race to the bottom in terms of pricing.'
And when you go to inexperienced injectors, you get what you pay for, Day warned: 'It's like going to fast-food takeout. You're not going to get the quality.'
Carolyn Treasure, who co-founded the New York City-based Botox bar Peachy in 2019, wants to democratise neuromodulators – without compromising on results.
'Botox, or neuromodulators, are getting taken out of the cosmetic bucket and getting integrated into the skin care bucket,' Treasure said. To make the drug more accessible, Peachy – which also has locations in Austin, Chicago and DC – offers a flat-rate price of US$425 ($720) for unlimited units of Xeomin or Jeuveau (brand-name Botox costs US$150 more).
'I really wanted to eliminate any perceived trust gap,' Treasure said of the decision to charge customers this way. 'Meaning what Peachy … is recommending to you is absolutely in your best interest based off of your goals, your anatomy, etc.'
Treasure credits the 'Zoom boom' for the company's success, as well as Gen Z's openness to – as well as about – aesthetic intervention. 'I feel like Gen Z's take on it is: 'It's your body, do what you want, but just be honest about it. Don't be disingenuous,'' she said.
But according to Berkowitz, no amount of honesty or even expanded accessibility can change the fact that the heyday of cosmetic Botox speaks to the underlying, and stubbornly persistent problem, of social inequality.
'If you look at it through that lens, then the story is not a happy one,' said Berkowitz, the 'Botox Nation' author. When wrinkles have become increasingly optional for customers who have the means to eradicate them, 'You wear your social class on your face.'
Like the vast majority of beauty standards, it's affluent women who feel most compelled to conform, versus the relative freedom of their male counterparts. 'The irony is that it's privileged women who feel the weight of their ageing bodies most,' Berkowitz said of the pressure to look younger.
Berkowitz doesn't judge anyone who avails themselves of Botox, even when studies show that neuromodulators can dampen emotional responses in users, and that expressive faces are actually more likeable.
'Women are supposed to look like effortless perfection,' Berkowitz said of the cultural messaging that has led us here. 'I don't want to blame an individual woman for doing what she's been told to do since birth, basically.'