Quitting Toxin

The booming toxin business may not really be booming anymore in the US, but it is still the first request from consumers learning of a new practice or Medspa. The promise of toxins is still powerful, especially in the older consumer segment. After all, 60 is the new 40 they say… After that age though, even the most vital woman begins to wonder how long she can carry on with that strategy. Retirement looms, grandkids are growing, post-menopause is the new normal, and every once in a while, thoughts turn to “What would I look like at 70, 75 with a baby-smooth forehead but weathered hands, reconfigured body and age-wisened eyes? Great or ridiculous?”  Is it about the finally earned right to match one’s internal state to one’s external appearance? How does one match “older” hair, hands, neck and gaze to a toxin-treated face? How does one quit toxins? Does one need to???

I asked these questions to my good friend Dr. Sophie Shotter, owner of the Illuminate Skin Clinic on Harley Street in London and in Kent. Dr. Shotter is a renowned Aesthetic Physician specialized in Dermatology who accompanies her patients on their skin journey in the UK, US and in the Middle East.

LD: Dr. Shotter, what is your approach to treating the 60+ face? 

SS: I treat so many people in their 60s and even beyond (my oldest patient was 94!) My approach, and of course the results we can achieve, are different than they would be for someone in their 40s. Toxins can still absolutely have their place, but I will usually start with structure, not surface. If you start by trying to eradicate movement related lines whilst not addressing changes in the skin canvas or the facial structure, then you can look un-harmonised. A smooth, wrinkle free forehead when you’ve not had treatment elsewhere doesn’t look natural. At 60-plus we have loss in deep fat pads, bone resorption of the skull, and attenuation of the SMAS ligaments. I find that by addressing these structural changes first, we can also create change in the skin envelope. This can be done with fillers and/or biostimulators, depending on the individual. I will then focus on skin quality using energy-based devices or injectables like polynucleotides and skin boosters. Then I will move on to low dose toxin and refine skin tone with laser or IPL. The toxin will often be much lighter. I may not treat the forehead muscle at all and instead focus on opening up the eye area to give freshness. For me toxin is far more about helping address emotional signals than it is about fine line eradication.

LD: I love that last line because it sums up the insight perfectly: there is a time

when it becomes about helping the patient NOT looking sad, tired, worn out, or

even angry instead of focusing on skin relief.

LD: What is the role of toxins in helping the very mature face? 

Often by our 60s, wrinkles are no longer just dynamic (movement related) but are there at rest as well. So toxin will have a more limited effect on these etched in lines. SS: However we can still use toxin in gentle doses to soften movement, while not eradicating. It’s important to note that very often in older faces, the brows have dropped and there is eyelid skin laxity, which can be exacerbated by treatment/overtreatment of the forehead (frontalis) muscle. I will often focus on achieving maximal lift and not try to eradicate lines and wrinkles. We will often use toxin in other ways as well, for example to treat a strong neck muscle which can help improve the appearance of the neck and jawline. Toxin is still a great treatment as we get older, but how we use it needs to be adjusted so that we can continue to age harmoniously.

LD: It is clear that in the aging face, toxins are no longer about wrinkles but about lift and freshness. More about aging gracefully, it is about aging harmoniously.

LD: How are the patients verbalizing their expectations in that regard?                                                                                                                                                                         SS: In clinic, I so commonly hear comments like “I want to look fresher, not tighter; “Please don’t make me look like I’m 30—I just don’t want to look tired.” “Keep some smiles lines; they’re part of me.”

Several of my new over-60 consults now arrive already talking about “transitioning into graceful ageing,” i.e. keeping features of the aging process whilst focusing on overall facial messaging. It’s rare nowadays that I get someone come in asking to look 10 years younger. There’s an understanding that looking young isn’t what they should be or want to be striving for, but still ageing well and looking fresh and rested is most desired. 

LD: What proportion of your patient are thinking about that transition?                                   

SS: I’d estimate maybe around 50-75%

LD: This transition is clearly now on the Boomer generation’s mind and practitioners need to adapt their injection strategy.

LD: Fillers and biorejuvenators play an important role for volume in the older face, and no clinical endpoint can really be taken in isolation anymore, but what does the older patient worry the most about? Do you see them worry less about wrinkles and more about volume? Pigmentation? Do they ask you (as I have asked my injector)  to “leave some slight wrinkles in”?                                             

SS: Absolutely. Patients at this stage of life seem to generally worry far less about specific wrinkles, and instead tell me they feel they look angry or tired or sad. Or possibly that they look in the mirror and don’t feel they look how they feel anymore. Their specific concerns are far more wide ranging, and tend to include the health and appearance of the skin (from pigmentation to having a healthy skin barrier to maintaining hydration), and concerns about structure or areas of the face where they perceive they’ve lost volume. And yes, I am often asked to keep lines! I like that, because our lines tell a story.

LD: Data shows that when people look at faces, what influences perceived age is not wrinkles but uneven pigmentation. In other words, it is the way light is reflected from the face that drives age perception. 

LD: You once mentioned to me that the overall effect should be a “fresh look” for that age group or any patient thinking about transitioning into a graceful match with their internal state. How do you execute this and how do you verbalize this to your patient?                                                                                                                                                                      

SS: I often incorporate an analogy to help patients understand what is happening in their face. Imagine a three-layer cake. First we reinforce the base (bone and deep fat) so the cake doesn’t collapse. Next we improve the sponge texture—think superficial fat, collagen and elastin. Finally, we ice the top with light resurfacing, micro toxin and pigment correction. A key to keeping everything looking fresh and natural is to stage this over time rather than trying to do everything at once. I talk about treatments which address the skin overall, rather than focusing on a specific line or wrinkle, and focusing on the emotional messages they see in their face. A crucial thing I think here is empathy - understanding that these changes aren’t always easy from an emotional standpoint can help our patients to navigate this more easily. My patients still want to recognize themself, but they invest in their health in every way and want to see that reflected to them in the mirror. 

LD: A great analogy to reflect a better, more holistic perspective on skincare as a healthcare measure. 

LD: The UK has a different perspective from the US or the Middle East on injectables, can you elaborate on this?                                                                                                                                                                           

SS: In the UK, aesthetic patients typically seek subtle, “nobody-must-know” tweaks, favoring staged micro-doses, regenerative skin work and a natural skin texture. By contrast, my perception of the US market is that it prizes high-definition contouring and instant, camera-ready impact—clients are comfortable financing larger treatment packages in a single sitting, and state-by-state rules still allow a wide range of practitioners to inject. In the Gulf/Middle East, cultural norms lean toward even bolder correction: higher-volume fillers, sculpted cheeks and full-face makeovers timed to key events. The result is a spectrum: UK minimalism, U.S. statement aesthetics, and Middle-Eastern maximalism, each shaped by local beauty ideals, spending habits and regulatory climates.

LD: Dr. Shotter’s insightful answers perfectly capture that delicate relationship between the practitioner and the mature patient at a time when traditional toxin use not only seem futile but also no longer fit lifestyle, emotional state or that palpable comfort “women of a certain age” can reach with a more realistic viewpoint of their Beauty Capital. Short of the ability to clone her for myself so my face can transition in the way she describes, I appreciate her and her subtle, holistic approach to aesthetics from afar. Thank you Dr. Shotter!

Find Dr. Shotter at https://drsophieshotter.com/    and   https://www.linkedin.com/in/sophie-shotter-779239a0/