NEW YORK?Last month, Charice Pempengco, the petite Filipino teenager whose knockout voice has wowed Oprah and millions worldwide, caused a stir of another kind.

To prepare for her appearance on the Fox show ?Glee? this fall, Pempengco, who is 18, got Botox injections and a skin-tightening treatment called Thermage. ?I want to look fresh when I appear before the camera,? she said on Philippine television during the visit at which her doctor, Vicki Belo, injected her jaw.

Outrage ensued. Doctors, child-rearing experts and others?including New York magazine and Psychology Today?chimed in to lament the regrettable message sent to young fans of ?Glee,? a show with a theme of self-acceptance.

Even the celebrity blogger Perez Hilton was apoplectic, pronouncing what Pempengco had done, ?SICK!!!?

But like it or not, Pempengco has plenty of company.

According to the American Society of Plastic Surgeons, botulinum toxin?which is sold under the brand names Botox and Dysport?was injected into Americans ages 13 to 19 last year nearly 12,000 times, including some teenagers who got multiple doses. The number represented a 2-percent increase from 2008.

Needless to say, teenagers do not have wrinkles, which is the usual cosmetic reason adults seek out Botox. Before the US Food and Drug Administration (FDA) approved Botox, a muscle-relaxing toxin, for cosmetic use in 2002, it was used as a medical treatment for neuromuscular and eye disorders.

Aesthetic reasons

Today, nobody knows how many teenagers who get injections of Botox or Dysport are using them for medical rather than aesthetic purposes.

The lines can be blurry, since the drug can help with physical problems?like pain in the temporomandibular joint of the jaw?and improving the patient?s looks can be a side effect.

On the medical side, Botox is approved by the FDA to be used therapeutically in children as young as 12 with abnormal twitching of the eyelid or crossed eyes. It can also help patients 16 and older with involuntary contraction of neck muscles, and by people 18 and up to combat excessive sweating.

The controversy stems from the off-label uses of Botox by children and young adults. Doctors are injecting teenagers for a variety of perceived imperfections, from a too-gummy smile to a too-square jaw.

In February, Phu Pham, who is 19 and lives in San Antonio, Texas, got Botox injections to narrow what he considered to be his ?bodybuilder?-big jaw muscle, which he felt didn?t fit his otherwise slim face.

Pham?s doctor, Samuel M. Lam, is a facial plastic surgeon who said he had seen more than 100 patients for jaw reduction via Botox. About 90 percent of them sought treatment for cosmetic reasons, he said, but even the 10 percent who had medical problems wanted it for aesthetic purposes, too.

Lam said he had injected many people in their late teens and 20s, but no minors. But he said he was not opposed to treating children this way, depending on their maturity and motivation.

Lam said he has performed cosmetic surgery on teenagers, including nose jobs and an operation to create creases in the eyelids of minors of Asian descent.

Disagreement

Among Pempengco?s representatives, there is disagreement over why she underwent Botox treatment. Belo said she injected her patient to narrow her face and target enlarged jaw muscles that made her look mataba, or fat. In other words, she used Botox to reshape Pempengco?s face.

But a representative for Pempengco said she did not use Botox for cosmetic reasons, and declined a request for an interview.

The fact that many teenagers would use a toxin to improve his/her looks surprises and upsets many adults. On her website, Michele Borba, the author of many parenting books, didn?t disguise her scorn.

?If your daughter is begging for Botox, believe me, an injection is not the cure,? Borba wrote. ?There?s a much deeper issue at stake and I?m betting it?s self-esteem ... Address her feelings of ?inadequacy? and not her need to cover up a so-called wrinkle.?

Some doctors question why a temporary injection of botulinum toxin should cause any more of a stir than a permanent surgery. Dr. Lisa M. Donofrio, a dermatologist, said, ?nose jobs are very accepted,? yet fillers and liposuction are not.

Donofrio has performed liposuction on the jaw lines of normal-weight minors with a family history of double chins. She has also injected Botox in a few teenagers who were self-conscious about their gums.

?Smile is important?

She injects Botox in the muscles that elevate the upper lip to relax them, so that the lip stays lower when a teenager smiles, for up to four months. Her reasoning? ?A smile is so important,? she said, adding that the treatment is about $100.

Donofrio isn?t surprised by the outrage over Pempengco. There is a ?very extreme distaste about doing anything cosmetic on minors,? said Donofrio, who has been a paid consultant for the makers of Botox and Dysport.

Dr. Rod J. Rohrich, the chair of plastic surgery at the University of Texas Southwestern Medical Center, said that in his practice he selectively does ?lots of Botox? for wrinkles on patients starting in their late 20s.

When it comes to teenagers, Rohrich injects them with Botox infrequently?and usually only for migraine relief. ?That works well,? he said. ?I do it a lot around final exams.?

Some teenagers mistakenly think Botox can prevent wrinkles.

In March, after a British teenager who got Botox injections at 15 told the tabloid The Sun, ?I wanted to have Botox for two reasons?it prevents wrinkles and everyone at my school was talking about having ?B,? ? the Physicians Coalition for Injectable Safety issued a statement decrying ?Teen Toxing? in the United Kingdom and reminding people that Botox does not prevent natural aging.

?Botox apocalypse?

At the heart of Pempengco?s ?Botox apocalypse,? as one headline dubbed it, is ?a collision of cultural norms,? said Dr. Richard G. Glogau, a clinical professor of dermatology at the University of California at San Francisco.

Reshaping the lower face with Botox is ?not an uncommon goal if you happen to live in Southeast Asia or China,? Glogau said.

Yet, this kind of facial reshaping with Botox is not that common in the United States, which may be why a baby-faced star like Pempengco wanting to alter her jaw line still puzzles?or offends?many Americans.

?A 16-year-old in New York getting a rhinoplasty, it?s a birthday present,? said Glogau, a paid researcher for the makers of Botox and Dysport. ?If you told teenagers in Southeast Asia that, they?d probably be aghast. It would never occur to them.? New York Times News Service