What happens when the physician who helped introduce Botox to the world reflects on how far aesthetics has come? Dr. Jean Carruthers shares the unexpected moment that changed everything, and why it still shapes how she thinks about facial rejuvenation today.
She talks through the early days of skepticism, how botulinum toxin A evolved from treating frown lines to influencing everything from jawline slimming to scar healing, and why precision and restraint matter more now than ever. What started as a simple observation became a global shift in how we approach aging.
Looking ahead, Dr. Carruthers explains what excites her most about the future of aesthetics, from skin quality treatments to scar prevention, and why customization, safety, and long-term patient trust will always outlast trends.
About Jean Carruthers, MD, FRCSC, FRC
Dr. Jean Carruthers is a globally recognized pioneer in cosmetic surgery and non-invasive aesthetic procedures, with unparalleled expertise in both research and clinical practice. Together with her husband, Dr. Alastair Carruthers, she revolutionized the cosmetic industry by pioneering the use of botulinum A exotoxin (Botox), a treatment that has since become the most widely performed cosmetic procedure worldwide.
Learn more about cosmetic surgery pioneer Dr. Jean Carruthers
Follow Dr. Carruthers on Instagram @carrutherscosmetic
About Dr. Lawrence Bass
Innovator. Industry veteran. In-demand Park Avenue board certified plastic surgeon, Dr. Lawrence Bass is a true master of his craft, not only in the OR but as an industry pioneer in the development and evaluation of new aesthetic technologies. With locations in both Manhattan (on Park Avenue between 62nd and 63rd Streets) and in Great Neck, Long Island, Dr. Bass has earned his reputation as the plastic surgeon for the most discerning patients in NYC and beyond.
To learn more, visit the Bass Plastic Surgery website or follow the team on Instagram @drbassnyc
Subscribe to the Park Avenue Plastic Surgery Class newsletter to be notified of new episodes & receive exclusive invitations, offers, and information from Dr. Bass.
Transcript
Summer Hardy (00:01):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Summer Hardy, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. This is the start of a new series, Aesthetic Titans. What is the idea behind this series, Dr. Bass?
Dr. Lawrence Bass (00:28):
There are certain individuals who've made game-changing contributions to plastic surgery and aesthetic medicine. Beyond that, they've continued to actively research, lecture, and teach over a span of decades really changing the way these fields are practiced. This gives these individuals an unparalleled breadth and depth of experience and perspective about plastic surgery. Listening to the accumulated wisdom of these individuals is a very worthwhile undertaking because their accomplishments make them proven thought leaders. Mostly these are physicians, but there are some business people and engineers in this group as well, along with some people in journalism and media.
Summer Hardy (01:24):
That all sounds very exciting and worthwhile. I can't wait to get started. Who are we talking to today, Dr. Bass?
Dr. Lawrence Bass (01:32):
I'd like to introduce Dr. Dr. Jean Carruthers. Dr. Carruthers is an oculoplastic surgeon who practices in Vancouver, British Columbia. She pioneered the development of treatments using Botox for aesthetic purposes. Since then, she's lectured thousands of times worldwide and written hundreds of scientific publications on these techniques and many others in aesthetics. She's a clinical professor of ophthalmology at the University of British Columbia in Vancouver. I'm delighted that she has agreed to join us for an episode of the podcast to discuss the history of Botox as well as cutting edge advances and her vision of future trends.
Summer Hardy (02:23):
Welcome Dr. Carruthers. How did you get involved with aesthetics? Was it Botox or did it precede your work with Botox?
Dr. Jean Carruthers (02:33):
I knew about aesthetics because my husband is a dermatologist, but I didn't realize that I would ever get involved with aesthetics, and it was really the fact that I had done a fellowship with Dr. Allen Scott in San Francisco at the Smith-Kettlewell Institute of Visual Sciences on the use of botulinum toxin A to treat misaligned eyes, and also to treat blepharospasm where the eyelids really spasm shut a person can't safely cross the street for drive a car. So when it was one of those patients who got angry at me, she said, you didn't treat me here. And I apologized to her and said, I'm so sorry, but I didn't think you had been spasming there. And she said, oh, I know I'm not spasming there, but every time you treat me there I get this beautiful untroubled expression. And that was when the penny dropped because my husband had explained to me that it was very difficult to get a natural result with the face at rest and the face moving with the currently available treatments for glabellar frown lines, collagen, fiber, fat. So that was when the penny dropped that we should maybe do a study. So that's how I got involved. I was definitely a therapeutic doctor before that.
Summer Hardy (04:09):
Okay. Thank you for sharing. You touched on it a little bit, but could you tell us about the early days with Botox and when you really realized that the aesthetic potential was there?
Dr. Jean Carruthers (04:20):
It was a long time to get that realization because wow, we started the study and it took us several years to get enough patients to publish. It took us until 1992 to get 18 patients from 1987. So that's a lot of patients would say, well, I don't know. It's poison, isn't it? I don't think I want to be in your study. And so we realized what we had to do was to walk a walk. So I got Alastair to inject my glabella, and then they would say the poison thing, and then I would say, well, what do you think? And I'd pull out my picture of my big frown lines, which I had lovely ones before. And what do you think and moved my bangs back and show that there's not a single frown line. And they'd say, oh, do it. That would be great. And so that's the story is you have to walk the walk if you want and show that you believe in it if you want other people to follow you. And now I say probably I haven't frowned since 1987.
Summer Hardy (05:38):
That's really interesting. Where has Botox gone from this focus start then?
Dr. Jean Carruthers (05:43):
It's really gone so far. It is now the commonist cosmetic procedure performed worldwide. It is accepted by early generations, perhaps more by the millennials than any other generation. It has gone from the glabella where we started it all over the face now the neck and into our other neck muscles, the bladder, the back, shrinking the taf, treating scars, preventing scars, treating other things that people had never thought of before, such as emotional states such as depression and social anxiety, and also doing self-esteem. It improves self-esteem as well. So it's a huge thing that it's gone from being a more obvious treatment, treating cosmetic things that you can actually photograph to now you need to use a different measuring device such as a scale of how somebody is feeling. There are a lot of validated scales for the emotional states. So it's really just galloping on into a whole new arena from the aesthetic world. But it also has kept its place in the aesthetic world because as surgeons, we all like to give our patients the very best result. And it works perfectly with surgery to enhance. It's like the icing on the cake.
Dr. Lawrence Bass (07:26):
And I think sticking again with the aesthetic applications for a moment. That's a good point that you started with that really Botox has turned out to be something that's part of the beauty plan along with all kinds of other modalities, but part of the beauty plan for almost everyone at every stage of aging. So it really plays a central role across the board. And that can't be said for many other things in aesthetic medicine. There are some things that are right at the right time and do a tremendous job, but there are very few things that are as broadly applied as Botox, and that's part of what's made it the most popular treatment amongst all the aesthetic treatments. But one of the other things I think we've learned and that you've been very central, Dr. Carruthers in teaching people is amongst modalities or even amongst medications, pharmaceutical agents, there are a few that have the precision that Botox does, the selectivity that Botox does, and for people who really understand the anatomy and the dynamics of how facial muscles were, that rewards you with tremendous benefits and tremendous precision in treatment.
Dr. Jean Carruthers (08:58):
Yeah, I totally agree. In the days when I was doing endoscopic brow lifts, six months later I would sometimes see a regrowth of the corrugated muscles and you would see these strange movements here, and rather than have to go in again surgically, the little Botox would solve the problem. I think that it's been, I totally agree with you that it's the young people who start with the Botox, but as the aging process comes along, they add in the surgical procedures because Botox wonderful as it is, can't do everything.
Summer Hardy (09:40):
So changing gears a bit, this has been a really interesting discussion, but I'm curious, what is the mix of surfaces in your practices today?
Dr. Jean Carruthers (09:48):
I used to do a lot of surgery, blepharoplasty, facelifts, liposuction, but now I have confined myself to neuromodulators, fillers and energy-based devices such as intense pulsed light and the various devices that are used to resurface such as microneedling and also ultrasound devices that tighten skin. There are a lot of combinations that I do of those things. And so we also have added in devices that electrically stimulate muscles, so that one treatment of the abdominal muscles will be the equivalent of inches and also will change your shape and improve your waist line. So the other thing that we're doing now is treating more people who have a lot of laxity in their skin because they've finally lost all that weight they wanted to lose using one of the GLP drugs such as ozempic. And I think that that has made liposuction perhaps less important, but skin tightening way more important, skin lifting way more important.
Dr. Lawrence Bass (11:08):
That's really interesting and it's a perfect illustration of how the aesthetic marketplace never stands still because laser liposuction was a big thing five or 10 years ago, 10 years before that, there were big surgical treatments for post-bariatric surgery patients who had a loss of a hundred pounds or 200 pounds in some cases. But the advent of the GLP one medications like Ozempic has created yet another pivot in the body contouring marketplace that really creates a lot of opportunity for patients that didn't exist before, that were having a lot of frustration with body contouring, but now have a good option. But there are still related issues that the aesthetic medicine physician needs to jump in on to help those patients as well. So you answered about your practice in particular that at this point you're essentially non-surgical, but I'm curious to hear your perspective on the role of let's say in facial rejuvenation surgery versus non-surgical treatment.
Dr. Jean Carruthers (12:36):
I think that there's a change in where the transition is between surgery and non-surgery. So supposing you have a person who's 45 say, then her brows have come down, probably you're going to start treating that person these days with Botox in her brow depressor muscles in order to lift her brows. And that may obviate the need for a blepharoplasty an upper bleph, for some time, she may buy two or three years, but eventually the dermatochalasis, the saing will require a little work with surgery. And I think in the lower face is a great place to, you can lift the jawline nicely using Botox in the platysma muscle because the platysma now goes, we know goes from the collarbone up and in the lower third of the facial muscles. So it's really a facial muscle as well, but you can, it's one of these bi-directional muscles when it contracts, it can pull the lower face down, but if you actually weaken its action along the jawline, the upper facial muscles, pull the upper face up and you can actually also improve can for orbital hollows.
(14:02):
So that's the thing I think is so exciting about doing the face these days. And you mentioned Larry, the anatomy being so uber important that what we can do now is to change the, we can shape the face using neuromodulators, not just treat wrinkles. So we can lift the brows, we can actually make the lower face more heart shaped. We can lift the jawline all using neuromodulators. Things that we could only do before this sort of change in a way of thinking about neuromodulators of and binding. That thinking into the real anatomy has allowed us this whole new play.
Dr. Lawrence Bass (14:45):
And that surgery that used to be done to try to contour the jawline, that was big surgery with big recovery, taking off the angle of the mandible to get a narrower shape that now is so easily done in a non-invasive way. And that's really a big change as a big trend right now in the facial surgery side of neck lift is a lot of very aggressive treatment of glands as well as muscles deep in the neck. And some of us are not as sanguine about proceeding with those kinds of procedures, and I'd much rather be treating with botulinum toxin to try to shrink the glands than risk, the bleeding, the nerve injury or just the recovery time associated with going deep in the neck.
Dr. Jean Carruthers (15:46):
I think that you couldn't say it better because it is safe, it's effective, okay, it's not permanent, but then complications can be permanent, whereas just having a few injections again in four to six months, that's really up. Most people would much rather do that.
Dr. Lawrence Bass (16:05):
Yeah, I mean it's never a happy thought that you have maintenance, but I think it's a universal thought that life is maintenance. I tell my patients, how many teeth would you have? It doesn't matter how good a cleaning you got, how many teeth would you have left if you didn't do some daily maintenance on your teeth? Maintenance is just part of life and if the maintenance steps are quick and you to be very reliable, then we can be pretty happy about that.
Dr. Jean Carruthers (16:39):
Yeah, definitely.
Summer Hardy (16:40):
So then just to move on to the future, I'm wondering where are neuromodulators and botulinum toxins going in terms of role capabilities and types of new products that we might see?
Dr. Jean Carruthers (16:53):
I think that's a great question because it's a question that is, the answer is going to change because the growth is so phenomenal on an annual basis. But right at the moment, what we've seen now is recently in the last couple of years, a profusion of new neuromodulators that are very similar to Botox, but we've also seen some new derivatives like botulinum toxin E, which is very short acting or come on right away and last for as long as two weeks. So it could be used as a rehearsal or it could be used because you forgot to get your Botox treatment and your daughter's getting married in three days. It's a rescue. And there are other things that could be used for as well, such as you had surgery with a knee replacement and of taking those nasty drugs, the opiates, you could have your pain released by botulinum toxin E so that you can painlessly do the physiotherapy that's required.
(18:03):
I think also we've seen long acting where initially we felt that this was a longer acting product with Daxxify botulinum toxin and some of the more recent studies have shown, maybe it's not lasting as quite as long as initially thought, but I think that what we're seeing is a profusion of neuromodulators, that there's enormous competition out there in the marketplace. But I think we're seeing some changes in what's in the bottle as well between products that have only the 150 kDa like Xeomin for Revance that have the 150 kDa with a small peptide chain rather than the big overcoats, if you will, of complexing proteins. So there's an interesting too, what's happening is that it's not just plastic surgeons and dermatologists, oculoplastic surgeons and ENT people that are using botulinum toxin now. It's a whole lot of people. And so when we see our patients, we must be sure that we know what else is going on in their treatments from other physicians. For example, somebody gets 400 units into their neck for cervical dystonia and 500 units into their bladder, and now they come in and want to have cosmetic treatments on their face, another 50 or 60 units. We know that immunogenicity is much more common in higher doses. So it's very important if you know that people are getting these big doses elsewhere to adjust your timing so that you don't do treatments too quickly, that you're not immunizing somebody.
Dr. Lawrence Bass (19:59):
Yeah, these are really important points and it points up why, and this is something we talk about a lot on the podcast, why it's important to have a relationship with a physician who's treating you, who understands your entire aesthetic plan, not just that you're getting 20 units of Botox today in your elevens, that's coordinating what happens to you watching how things change as you age. And separate from that, I think in addition to the new products, we're seeing a lot of tinkering by the physicians, which we can term customization with how much dilution is being used, what kind of injection patterns, and that customization is letting us again, target the results we're aiming for more precisely, more effectively and perhaps more durably because there's some argument about whether it's concentration effect in the injection or other things that's contributing to some of the durability seen in some of the recent studies. So physician input as well as medical marketplace pharmaceutical input is going to probably continue to evolve what we're doing with the neuromodulators.
Dr. Jean Carruthers (21:40):
I totally agree. The high dose studies that you are referring to were really remarkable in how it increased the length of time that people had a response. So I think that's something that a lot of people are interested in, and I think too that you need to be really aware of which neuromodulator using and get really familiar with one or maybe two rather than having a real panorama of neuromodulators and also having them indifferent syringes so that you can tell what's what.
Dr. Lawrence Bass (22:22):
Yeah, I mean, that's interesting because you travel the world and you talk to everyone. And I talked to some of my European colleagues and they have dozens of products between injectable fillers and neuromodulators, dozens in their office, and I think we're not quite as overwhelmed with product spread the way Europeans are and probably some of our Asian colleagues in North America. We have a lot of products, but much more confined number that's much more thoroughly studied. And again, from a safety point of view and a consistency in terms of producing results for patients, I think that helps us in a lot of ways.
Dr. Jean Carruthers (23:16):
I agree with you.
Summer Hardy (23:18):
This has been a really interesting discussion to listen to. I'm curious in the broader sense now what your vision for the future of aesthetic medicine and surgery is.
Dr. Jean Carruthers (23:28):
I think it's not going away. I think it's going to carry on very exponentially. When you look at the millennials, boomers are initially very hesitant because they were the product of a generation four that went through World Wars, very frugal, and then boomers were rebels, and they actually decided that this would be a good thing. And luckily as boomers became luckily for the products, as boomers became the predominant members of the population, it became very happy for them to have treatments that were symbol and to apply because they're looking after their aging parents and after their children. Well, along come generation X and then the millennials a little bit different because millennials actually are quite into prevention when they've seen how the boomers look and they would like to look better than their parents, and they're quite willing to do that. And it's interesting that even though they don't have nearly as much money as their parents already, they're spending twice as much on self-care as their parents.
(24:52):
Plus they are sharing the inflammation about their treatments on the internet, which most boomers don't want to do. And then generation Z come along. It's always been there. There's always been, it's like Kleenex, Botox, it's always been there, and there's no stigma whatsoever. So people are sharing even before they've left the office and what they've just done. So I think that the power of that change of attitude in the millennials in particular, plus the power of magnification given by the internet are just going to and the lack of stigma is just going to make sure that new developments carry on. People are going to be excited to try them, share the results. So I think that's one big thing for the aesthetic part, but I think that the emotional part is going to really grow as well, because if you could have a treatment which is just treating for the frown lines for your depression in nine out of 10 patients in one study and 52% in another study, and there's many other studies, get these lovely results of no depression lasting for four to six months without the side effects of the SSRI group where people gain weight and lose libido.
(26:18):
I mean, it makes so much sense. So I think look good, feel good, and do even better.
Dr. Lawrence Bass (26:27):
Absolutely. I'm curious to hear your thoughts about microneedling with Botox and effects of Botox on sebum production.
Dr. Jean Carruthers (26:38):
Yeah, I think it works really nicely. Most of work on the sebum I think has been by injection and people trying to get as intradermal as possible. So I think the microneedling is a good idea. As long as you get the neuromodulator on there quickly, it's just very difficult to get that huge molecule through the stratum cornium and into the lower dermis. So maybe the microneedling with instant botulinum toxin is the better. I haven't seen a comparison study, but certainly if you look at complexion, that's one of the side effects of I think probably people looking at rosacea as well as acne. Terrific. Dr Woffles Wu, who's a plastic surgeon of renowned in Singapore, has really explored this area. And I think that it's really worthwhile reading his work because he has done amazing work in improving the complexion of all his patients, but he's also done amazing work with scars.
(27:53):
And for those of us who are surgeons, well, we'll wait until six weeks and then we'll see if we treat your scar. No. Now you get in there with your Botox at say, two weeks, and you inject the Botox into the skin next to the scar, and it works on TGF beta and some other cytokines. And so then you just stop from fibroblasts from making too much collagen so you can really treat not only the anatomy of the scar and stop it becoming a hypertrophic scar about there's a hundred million new scars a year, and about 10% of those become hypertrophy. So I think it's a great treatment for that. Plus when a scar is going to become hypertrophy, it often is quite itchy and uncomfortable, so that gets rid of that as well. So I think it's a whole new world and scar treatment.
Dr. Lawrence Bass (28:55):
Wow. Yes. So that's really a fascinating look back at the history and forward at future trends using botulinum toxins and Dr. Carruthers, tremendous for you to join us today and share your deep insight into these trends in aesthetic medicine.
Dr. Jean Carruthers (29:17):
Thank you so much for franking on me and your brilliant podcast. I really appreciated it, and it's an honor to work with you.
Summer Hardy (29:26):
Thank you for joining us, Dr. Carruthers. It was a pleasure to meet you and hear your fascinating perspectives.
Dr. Jean Carruthers (29:32):
Thank you so much. Thank you Summer.
Summer Hardy (29:34):
Thank you for listening to the Park Avenue Plastic Surgery Class Podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that is coming your way. If you want to contact us with comments or questions, we'd love to hear from you, send us an email at [email protected] or DM us on Instagram @drbassnyc.
