Brave New Botox

Since it first hit the scene in 1989, Botox has gone through more reinventions than Madonna. Back then it was an ophthalmologic treatment for spastic eyelids, but it wasn't long before doctors noticed the smoothing side effects and started using it "off label" (for purposes other than the official FDA nod) in Canada. In 2002, the 'tox finally received FDA approval for treating wrinkles, kicking off the stateside face-freezing frenzy. Now it's the country's most popular cosmetic procedure and its second most recognized prescription name (after Viagra), pulling in an estimated $1.28 billion worldwide last year for its maker, Allergan. Yeah, the stuff is still ubiquitous as an antiager and medical fix-it, treating everything from migraines to "BlackBerry thumb." But with its bold new applications, Botox is making sure that even if the economy slumps, your face doesn't have to.

WIDE EYES

Most of us rely on eyeshadow and liner tricks to get that innocent, doe-eyed look, but some women are turning to dermatologists for a more intense fix. Many docs are injecting a minuscule amount of Botox into the center of the lower lashline's orbicularis oculi muscle to create "a widening of the eye and more of an almond shape," says Boston derm Dr. Ranella Hirsch, who performs the procedure. "It's especially popular with Asian women, but it's magnificent and very subtle on anyone." ($300 - $500)

SKI-SLOPE NOSE

Changing your nose used to mean thousands of dollars in plastic-surgery bills and a pair of shiners. Though Botox can't do anything for the bridge, some doctors use it to give patients a perfect swoop - with no recovery time. Dr. Nodar Janas of MesoBoutique in Great Neck, NY, injects it into the bottom of the septum to lift the tip of the nose, a procedure he does for more than a dozen patients per month. You get "plastic-surgery results," he says, especially when combined with a filler like Juvéderm or Restylane. Other doctors, like NYC dermatologist Dr. Patricia Wexler, use Botox to make an upturned nose slope downward by injecting the nostrils. "The change is pretty dramatic in making a straighter nose," she says. "You can raise or lower the tip by about three millimeters." ($150 - $250)

PERFECT SMILE

A few inches south comes the horse-teeth gummy smile - not the result of big gums or small teeth but rather facial muscles that are too strong. Some doctors treat it by injecting a small amount of Botox into five places around the upper lip, or into the band above the chin, so the top lip doesn't lift as high during smiles. But Wexler, who performs the procedure, warns that shots to this area require prudence. "Botox around the mouth can flatten the lip or cause asymmetry, giving people trouble pronouncing their P's or V's," she says. Dr. Macrene Alexiades-Armenakas, an assistant clinical professor at Yale University School of Medicine, recommends patients stick to a dermatologist or facial plastic surgeon with at least 10 years of experience, as opposed to a gynecologist trying to make some cash on the side. "Any doctor can legally administer Botox, but whether that's wise is a totally different thing," she warns. ($200 - $400)

SMOOTH SKIN

An even more controversial but potentially promising new use for Botox is to reduce acne by shrinking the appearance of pores, a treatment that's been practiced for several years in Asia. Dr. Kamran Jafri, a New York City facial plastic surgeon, injects a much smaller amount less deeply than he would for wrinkle-smoothing to paralyze the oil-producing sebaceous glands without affecting the muscles. After the shots, mostly in the T-zone, "you see a 50 to 75 percent reduction in pore size," he says. Alexiades cites an encouraging study in which Botox decreased oil production in 17 out of 20 patients, but she bristles at the idea of using Botox on patients younger than, say, 30, since the research goes back only three decades. "Does it have any ill effects 40 years later? We don't know. We don't have adequate follow-up to assure we're not doing these young people harm," she says. ($500 - $600)

PERKY BREASTS

The boldest frontier in body Botox is the chest. Regardless of size, some docs are getting surgical breast-lift-like results with Botox. Injected into several points from just below the sternum to underneath each breast, it counteracts the upper back's rhomboid muscle, which usually pulls the breasts down. Though Wexler was initially enthusiastic about performing the procedure, she hasn't done one in months since the results were "unpredictable - it could work beautifully or it could not work at all," and patients pay $1750 either way. Some doctors, like Alexiades, believe you shouldn't use Botox in the chest, given the area's susceptibility to breast cancer: "This is an area with a very high risk for a deadly cancer, so you have to apply more stringent rules about off-label use." Though Botox hasn't been linked to breast cancer, "it is a neurotoxin, so that's my conservative recommendation."

REFINED CLEAVAGE

Another way Botox gets breasts bikini-ready is by fighting cleavage crinkle. The deep V in the chest is caused by the weight of the breasts (usually leaving vertical lines) and sun damage (lines that crosshatch). To treat both at once, Wexler uses laser procedures combined with Botox to relax the muscles, which works on cleavage grooves the same way it does on crow's-feet or frown lines. If you do get chest injections, Alexiades warns that "breast tissue extends from the nipple all the way up to the shoulder, a fact that a lot of physicians aren't necessarily aware of," so stick to a derm or plastic surgeon with breast experience. ($1500 and up)

MEET THE COMPETITORS

With the hotly anticipated approval this year of Reloxin and PurTox, two drugs made from the same neurotoxin as Botox, expect lower prices all around:

BOTOX

Made by: Allergan

Time to kick in: Three to five days

Lasts for: Three months

RELOXIN

Made by: Medicis Pharmaceutical Corp.

Time to kick in: One to two days

Lasts for: Five months

PURTOX

Made by: Mentor Corp.

Time to kick in: Three to five days

Lasts for: Three months

NO MORE NEEDLES

Topical Botox sounds too good to be true, but it may be a reality by 2010, says Dr. Ranella Hirsch. Made by Revance Therapeutics, a gel version is currently in stage two of clinical trials. But before you worry about accidentally turning yourself into a Real Housewives look-alike, know the treatment can be applied only by a doctor.