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A growing number of Americans are choosing to leave a few faint lines on their foreheads rather than smoothing them out entirely with Botox. The reasoning: skin that is too perfectly taut can signal desperation to hide one's age. Among those seeking a natural yet polished look, Botox is shifting from a treatment people get in abundance to one they use in careful moderation, the Wall Street Journal reported Monday.

Stephanie Avent, 45, had been getting Botox for years to erase her forehead lines — until she found herself wishing the wrinkles would come back. "The smooth, shiny skin I had wanted so badly seemed to give the impression that I was trying to hide my age," she said. "In your 40s, a forehead that's too smooth feels like it's advertising, 'I've had Botox.'"

She still gets Botox and filler, but now deliberately leaves some fine lines on her forehead — a choice she says gives her a refined look without going too far.

Botox first received approval in the United States for cosmetic wrinkle treatment in 2002. Since then, neurotoxin injections that relax facial muscles have become widely accessible and mainstream, and the once-coveted look of a perfectly smooth face has begun to lose its appeal. Consumers in their 30s and older are increasingly asking their providers to preserve some natural, expressive movement in their faces.

Anthony Rossi, a professor of dermatology at Weill Cornell Medicine in New York, calls the phenomenon "strategic wrinkles." "A moderate amount of wrinkling adds character and personality to a person," he said. Rossi added that more patients are also asking him to leave some crow's feet around the eyes intact.

These patients still use Botox and filler, but in far smaller quantities than before. They often pair them with other procedures to achieve a more natural effect. New York dermatologist Aneta Leszko highlighted two popular options: Skinvive, a hyaluronic acid micro-injection treatment, and radiofrequency microneedling. Fractional laser treatments that stimulate collagen production and fat-transfer procedures that move fat from other parts of the body to the face are also gaining traction.

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Botox itself has not fallen out of favor. According to the American Society of Plastic Surgeons, neurotoxin injections — including Botox, Dysport, Xeomin, Jeuveau and Daxxify — remain the most commonly performed nonsurgical cosmetic procedure in the country. The number of treatments last year rose 4 percent from the previous year to about 9.88 million.

What has changed is how people use it. Lacey Harris, 40, of Texas still gets Botox across her face — her forehead, around her mouth and elsewhere — but recently asked her provider to reduce the dosage. "I want my face to move naturally," she said.

Some have stopped getting Botox altogether. The treatment works by temporarily blocking nerve signals to facial muscles, but too much — or an injection placed incorrectly — can cause unwanted sagging.

New York dermatologist Doris Day recommends facial muscle exercises as an alternative to frequent Botox. She said an "Ear Lift" exercise that tightens the jaw muscles near the ears can help break the habit of furrowing the brow.

Rossi, who coined the term "strategic wrinkles," used to get Botox on his forehead himself but has since stopped. He said a forehead that moves naturally conveys greater trustworthiness and reflects his years of experience as a physician. He still undergoes some cosmetic treatments, but leaves his crow's feet untouched.


mokiya@heraldcorp.com