I Tried Botox. It Didn't Work. That's Not the Point.
It’s July 2020. I’m on my twelfth video call of the day. Maybe thirteenth. I stopped counting around June.
The pandemic turned my home office into a place where I stared at my own face for more than ten hours a day. I had never spent this much time looking at myself. Nobody had. Before, you saw yourself in the bathroom mirror or checked your hair in the elevator, then moved on. Now my face stayed in the corner of my laptop screen from eight in the morning until the last call.
By the tenth call, my brain stopped pretending to look interested. I stopped watching the other people and started watching myself.
That’s when I noticed the frown lines.
Two deep lines between my eyes. The kind that makes you look angry even when you are not. In German, they are called Zornesfalte, or ‘wrath folds.’ The name fits. They deepened as the day went on. By afternoon, they looked permanent. I trained in facial surgery. I know the muscle responsible: corrugator supercilii [1]. I have seen this anatomy in cadavers, textbooks, and patients.
Knowing the Latin name did not make it less annoying.
I did what a responsible and sensible person with too much screen time would do. I booked an appointment with a plastic surgeon. I did not tell anyone. It felt a bit ridiculous. A doctor seeing another doctor for something cosmetic. Not urgent. Not medical. Maybe just vanity. I did not have a better word.
He did the injections. Standard Botox, but a higher dose for my build. Thirty units across my forehead and between my brows. It was quick and clinical. I drove home and waited for the lines to fade.
The lines stayed.
I went back after a week. “No effect at all,” I told him. He did seem surprised. He injected more. Maximum dose. “This is as high as I can go.”
Still nothing.
Apparently, I am in the under-one-percent group. I do not respond to botulinum toxin. My neuromuscular junction ignores it [2]. Some people win the lottery. I got the version where nothing happens, and there is no fix. I still had to pay.
The frown lines are still there. I see them every morning. I have made peace with it.
What stayed with me was not the injections. The hardest part was driving to the appointment. That was when I admitted I cared enough about my appearance to do something about it.
The Quiet Tax
Men don’t talk about this. Researchers at Promundo studied the pressure and gave it a name: “The Man Box” [3]. The expectation to project toughness, self-reliance, and a general indifference to anything that might be coded as caring about your appearance. The American Psychological Association flagged it in their 2018 guidelines on men’s health: boys learn early to manage their problems on their own [4]. A 2023 study in Cultural Sociology found that men actively buy skincare and grooming products but deliberately hide the fact [5]. They maintain themselves in secret. Like a fight club, but with moisturizer.
Women face a different version of the same trap. There’s an unspoken expectation to look put-together at all times, but God forbid anyone catches you investing real effort in it. Too much time on appearance? Not serious. Spent money on a procedure? Vain. The double bind is brutal: maintain yourself, but make it look like it happens naturally. Like you woke up like this. Nobody woke up like this.
Both versions end the same way. Quiet, private shame about caring.
In 2024, more than 20.5 million non-surgical cosmetic procedures were performed worldwide [6]. The industry trend called “Brotox” saw a 403% increase in male procedures between 2000 and 2018 [7]. Women still make up 85.5% of patients [6], but the gap is closing. Minimal downtime. Nobody at the office needs to know. Most people make sure nobody does.
Sixty Newsletters About the Inside
I have written about sleep. Nutrition. Hormones. Recovery. Mitochondria. VO2 max. Grip strength. Fiber. More than sixty editions, all focused on what happens inside your body.
I never wrote about the outside. The part you see when you brush your teeth in the morning.
The research shows this is a blind spot that needs attention.
In 1920, psychologist Edward Thorndike studied evaluations of military officers and found something odd. Officers who looked physically impressive received higher ratings on traits unrelated to appearance: intelligence, dependability, and leadership [8]. The correlation was 0.28-0.39 [8], so appearance alone accounted for about 9% of how someone was rated on leadership. Not everything. But not noise either. Across thousands of evaluations, hiring decisions, and promotions, it adds up. He called it the halo effect. A hundred years of research shows it never went away.
Economist Daniel Hamermesh put a dollar figure on it. Men seen as attractive earn, on average, 4% more than those seen as less attractive [9]. Over a career, that gap added up to about $230,000 [9]. Attractive candidates get more interview callbacks, better performance evaluations, and advance faster [10].
Self-perception works the same way. Research on workplace attire found that people who felt well-presented rated themselves as more competent, authoritative, and trustworthy [11]. Your nervous system does not separate how you look from how you feel about yourself. The outside affects the inside.
In the Upward ARC framework, this is part of Capacity. What you see in your reflection before a meeting either gives you energy or takes it away. This happens every day.
The Honest Part
The simple story is to fix the problem, feel better, and move on. The research is not that simple.
A systematic review and meta-analysis in Plastic and Reconstructive Surgery found that body-specific satisfaction after cosmetic procedures is high. At six months, 87.2% of patients report satisfaction with the specific area they changed. At twenty-four months, 93.8% [12]. People are generally pleased with what they fixed.
But when researchers looked at broader measures like overall happiness, mental health, and social functioning, the evidence was described as limited and inconclusive [13]. A 2025 systematic review confirmed this gap: short-term improvements in body-area satisfaction and self-esteem. The link to lasting psychological well-being is still unclear [13].
So what is actually happening?
I got Invisalign in my mid-30s. Crooked teeth I’d lived with since I was a teenager. I have a dental degree. I literally studied orthodontics. And I still waited years before doing anything about my own teeth.
The treatment lasted about a year. People noticed the aligners. Clear plastic trays on your teeth are not invisible, no matter what the marketing says. I had decided to fix it, and the fact that wired braces were no longer needed made the decision easier. A small, modern fix for something that had bothered me for two decades.
When the aligners came off, I did not feel a rush of happiness. My life stayed the same. What changed was simple. I stopped thinking about my teeth. I stopped angling my smile in photos. I stopped running my tongue over the spot that bothered me. The background noise was gone.
That is what matters. It is not about transformation, but removal. You take away a small, constant drain on your attention. Something you worked around for years without realizing how much space it took.
The research supports fixing a specific issue. It does not show that fixing your nose will change your life. The value is smaller and more honest: one less thing to work around.
What the Evidence Actually Supports
Most things do not work. Most products have weak evidence. Here is what actually works.
Sunscreen. A randomized controlled trial in the Annals of Internal Medicine followed 903 adults over 4.5 years. Daily broad-spectrum SPF 30 or higher reduced skin aging by 24% compared to the control group [14]. Ten seconds in the morning. Costs almost nothing. Highest-return intervention for your face.
Retinoids. Tretinoin is the most studied topical for reversing fine lines and improving skin texture [15]. It increases collagen and speeds up cell turnover. It is prescription-only in most countries. Expensive serums at the store do not compare. Your dermatologist can prescribe what works for much less.
Teeth. Align Technology has treated over 20 million patients with Invisalign [16], and other clear aligner providers serve millions more. Adults are the largest segment of the clear aligner market, holding about 59% of global share [17]. Treatment takes six to eighteen months. Teeth whitening has one of the highest satisfaction rates of any simple cosmetic procedure. If you have been working around a smile you do not like, the fix is faster, easier, and cheaper than most expect.
Hair. In androgenetic alopecia, a 5-year clinical trial found that 86% of men on finasteride maintained or increased their hair count compared with baseline [18]. A large observational study of 5% minoxidil showed results in about two out of three users, with about 16% seeing no benefit [19]. Hair transplantation works but is expensive and needs realistic expectations. Supplements and devices have little to no evidence supporting their use. Do not waste your money.
Posture and body composition. No procedure can replace resistance training and daily movement. Forward head, rounded shoulders, the office body from years of sitting. Two resistance training sessions a week change how you carry yourself more than losing five kilos [20].
Injectables. Botulinum toxin works for most people, but not for me. It reduces dynamic wrinkles for three to six months and is safe when given by qualified doctors [21]. Hyaluronic acid fillers can restore lost volume and are reversible [6]. Both require a skilled provider. In aesthetics, who does the injection matters more than the brand.
Try This Today
The Sunscreen Default. Use SPF 30 or higher on your face every morning. The trial data are clear [14]. If you do one thing, do this. Your future self will thank you.
The Maintenance Calendar. You schedule oil changes for your car. Do the same for yourself. Teeth cleaning every six months. Skin check once a year. Bloodwork, depending on your needs. Posture check if you sit more than six hours a day. Put it on your calendar. Treat it like any other regular investment.
The Honest Look. Not at the mirror, but at yourself. Is there something you have been working around for years? Something small that takes up more space in your mind than you admit? You have two options: fix it or make peace with it. I tried Botox, and it did not work. I made peace with the frown lines. I got Invisalign, and it worked. I fixed my teeth. Both choices were right. The only mistake would have been pretending not to notice.
The Screen
I still have those frown lines. They show up on every video call, every morning in the bathroom.
The Botox did not work. The lines stayed. Somewhere along the way, I stopped caring about them. Not because I think frown lines are beautiful. They are not. But because I stopped following a rule I did not know I had: that caring about how you look is for other people. For weaker people. For vain people. For people without real problems.
That rule feels comfortable. It is also not true.
You maintain your career. Your finances. Your children’s health. Your team. Your car. Your house.
The body you live in gets whatever time is left. Most weeks, that is nothing.
In the Upward ARC framework, Capacity is not just cognitive reserve and physical fitness. It is also how you feel when you look at yourself. That feeling either gives you a bit of energy every morning or takes some away. Over the years, that adds up.
The change does not need to be dramatic. Most of the time, it is sunscreen, a retinoid, and fixing the thing you have put off since your twenties.
Start with one thing. The one you already know about.
Stay healthy.
Andre
References
[1] Carruthers, J., & Carruthers, A. (2003). Aesthetic botulinum A toxin in the mid and lower face and neck. Dermatologic Surgery, 29(5), 468-476.
[2] Dressler, D. (2004). Clinical presentation and management of antibody-induced failure of botulinum toxin therapy. Movement Disorders, 19(S8), S92-S100.
[3] Heilman, B., Barker, G., & Harrison, A. (2017). The Man Box: A study on being a young man in the US, UK, and Mexico. Promundo-US and Unilever.
[4] American Psychological Association. (2018). APA guidelines for psychological practice with boys and men.
[5] Byrne, A., & Milestone, K. (2023). ‘He wouldn’t be seen using it.’ Men’s use of male grooming products as a form of invisible consumption. Cultural Sociology, 17(1), 89-108.
[6] International Society of Aesthetic Plastic Surgery. (2024). ISAPS International Survey on Aesthetic/Cosmetic Procedures Performed in 2024.
[7] American Society of Plastic Surgeons. (2024). 2024 Plastic Surgery Statistics Report.
[8] Thorndike, E. L. (1920). A constant error in psychological ratings. Journal of Applied Psychology, 4(1), 25-29.
[9] Hamermesh, D. S. (2011). Beauty pays: Why attractive people are more successful. Princeton University Press.
[10] Hosoda, M., Stone-Romero, E. F., & Coats, G. (2003). The effects of physical attractiveness on job-related outcomes: A meta-analysis of experimental studies. Personnel Psychology, 56(2), 431-462.
[11] Peluchette, J. V., & Karl, K. (2007). The impact of workplace attire on employee self-perceptions. Human Resource Development Quarterly, 18(3), 345-360.
[12] Dreher, R., Blaya, C., Tenorio, J. L., & Saltz, R. (2016). Quality of life and aesthetic plastic surgery: A systematic review and meta-analysis. Plastic and Reconstructive Surgery - Global Open, 4(9), e862.
[13] Hart, T., et al. (2025). The psychosocial outcomes following cosmetic surgery are largely unknown: A systematic review. Journal of Plastic, Reconstructive & Aesthetic Surgery.
[14] Hughes, M. C. B., Williams, G. M., Baker, P., & Green, A. C. (2013). Sunscreen and prevention of skin aging: A randomized trial. Annals of Internal Medicine, 158(11), 781-790.
[15] Mukherjee, S., Date, A., Patravale, V., Korting, H. C., Roeder, A., & Weindl, G. (2006). Retinoids in the treatment of skin aging: An overview of clinical efficacy and safety. Clinical Interventions in Aging, 1(4), 327-348.
[16] Align Technology. (2025). First quarter 2025 financial results. Investor Relations.
[17] Grand View Research. (2025). Clear aligners market size & share: Industry report, 2025-2033.
[18] Kaufman, K. D., Olsen, E. A., Whiting, D., Savin, R., DeVillez, R., Bergfeld, W., Price, V. H., Van Neste, D., Roberts, J. L., Hordinsky, M., Shapiro, J., Binkowitz, B., & Gormley, G. J. (1998). Finasteride in the treatment of men with androgenetic alopecia. Journal of the American Academy of Dermatology, 39(4), 578-589.
[19] Olsen, E. A., Dunlap, F. E., Funicella, T., Koperski, J. A., Swinehart, J. M., Tschen, E. H., & Trancik, R. J. (2002). A randomized clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men. Journal of the American Academy of Dermatology, 47(3), 377-385.
[20] Westcott, W. L. (2012). Resistance training is medicine: Effects of strength training on health. Current Sports Medicine Reports, 11(4), 209-216.
[21] Carruthers, A., & Carruthers, J. (2017). Botulinum toxin products overview. Dermatologic Surgery, 43(S2), S67-S73.
A note for new readers:
I’m a trained reconstructive facial surgeon, medical doctor, and dentist. Before launching this newsletter, I had a varied career: competitive freestyle wrestler, management consultant (McKinsey), entrepreneur (Zocdoc, Thermondo, and docdre ventures), and corporate executive (Sandoz). Today, I’m a Managing Director and Partner at BCG.
Husband of one. Father of three. Split between Berlin’s urban pulse and our Baltic Sea retreat. I’d rather be moving than sitting. Not just hobbies. Research. My body is my primary laboratory; I’ve been conducting experiments for decades.
If this is your first time here, welcome. I’m excited to share what I’ve learned and will continue to learn with you.
DISCLAIMER:
Let’s get one thing straight: None of this, whether text, graphics, images, or anything else, is medical or health advice. This newsletter is here to inform, educate, and (hopefully) entertain you, not to diagnose or treat you.
Yes, I’m a trained medical doctor and dentist. No, I’m not your doctor. The content here isn’t a replacement for professional medical advice, diagnosis, or treatment.
If you have questions about your health, talk to your physician or a qualified health professional. Don’t ignore their advice or delay getting care because of something you read in The Upward ARC. Be smart. Do your research. And, as always, take care of yourself.