So, you finally made the decision to take the leap and get Botox injections for the first time. Or you’re an old hand who’s had successful Botox treatments for several years. You make an appointment with your trusted cosmetic practitioner and have the procedure done. After waiting to see results, to your surprise, Botox doesn’t work. What’s going on?
To answer this question, it’s helpful to know what happens when Botox does what it should.
HOW DOES BOTOX WORK?
Made with purified botulinum toxin, Botox is an injectable used as an anti-aging treatment. Botox is the most popular of all cosmetic procedures and for good reason. It’s a quick treatment that has proven to have very good results. You don’t need anesthesia, and there’s virtually no downtime.
You probably don’t think about the hundreds of times a day you make facial expressions. Whether it’s laughing, crying, frowning, or showing surprise, when you move the muscles in your face, those muscles contract. Those contractions make what doctors call dynamic wrinkles or movement lines. In your youth, when you stop making a facial expression, the lines disappear. With the passage of time, those lines start to linger.
The botulinum toxin in Botox has the capacity to interrupt the chemical message that tells facial muscles to contract. As these muscles relax, it leads to a softening of wrinkles and lines. Aestheticians use Botox both to treat existing dynamic wrinkles. In younger patients, they use it to prevent the formation of new ones. They do this by treating the facial furrows that show where dynamic wrinkles will one day form.
Frowning, squinting your eyes, and raising your eyebrows are some of the most common facial movements. Logically then, aestheticians administer Botox most frequently in the forehead and the areas around the eyes and between the eyebrows.
The loss of Botox’s effect is gradual. Depending on the metabolism of each patient, the results last from 3 to 6 months. When the effect of the paralysis wears off, the muscles regain their mobility, so lines and wrinkles reappear.
COMMON EXPLANATIONS OF WHY BOTOX IS NOT WORKING
You Need More Time
If you fail to see results after receiving Botox injections, it’s important to differentiate between “my Botox treatment isn’t working” and “my Botox treatment isn’t working yet.” You won’t be able to see the outcome immediately after having the procedure done. The onset of the effect begins gently, after two or three days; it gradually increases until it stabilizes around seven to ten days later. It may be a full two weeks before you’ll be able to see the maximum results. So, before you call and give the doctor an earful or start shopping around for another practitioner, make sure to wait at least ten days and see what happens.
In the early years of Botox treatments, the goal was often a “total ironing” of the face. Patients receiving injections had their facial muscles downright paralyzed. The result was a very smooth but frozen and artificial appearance. Fortunately, that’s a thing of the past. Aestheticians today seek natural results where, yes, there will be facial movement. There will just be less of it than without the injections. It’s thus important to discuss your expectations with your provider ahead of time. You don’t want to consider Botox a failure because you can still frown. It could be your doctor intended to leave you with some ability to do that so you’d look natural.
But let’s say enough time has gone by and yours is a clear-cut case of Botox not working. What could be causing this?
The first impulse is often to attribute the problem to the product. It goes without saying, though, that cosmetic procedures are not where you want to skimp. The risks simply aren’t worth the few dollars you might save. So, if you are receiving your treatments from a trustworthy provider, you shouldn’t have any doubts about the authenticity of the Botox you receive. Reputable doctors and aestheticians wouldn’t dream of jeopardizing their practices by using watered-down versions of injectables.
The Injector Lacks Experience Treating You
You go to a provider that is trustworthy, experienced, even Board certified. Of course, you expect that they know what they’re doing. But just because someone is a skilled injector doesn’t mean she knows the contours of your face by heart. In order for Botox to work, it must be precisely placed. A doctor can’t use the same injection pattern on everyone though. He must study each patient’s individual anatomy, adjust the injection sites, and then see how the muscles react. A touch-up after two weeks have gone by, one with small adjustments made with a minimal dose, can be the solution to Botox not working.
Likewise, the dosage for every patient will be different. Receiving too few units of Botox is one of the main reasons that a patient may not see the expected outcome. As doctors like to start with the lowest dose possible, adjustments to dosage are often necessary. It would be great if when an aesthetician sees wrinkles that look twice as deep, he could assume he’ll need to use twice the Botox. Unfortunately, it doesn’t work that way. There’s no mathematical formula that practitioners can apply to figure this out. It’s mostly a combination of clinical judgment and observation.
Finally, another reason that Botox may not work is because of something known as Botox resistance. Rare, Botox resistance is estimated to happen in only 1%—3% of cases. For these patients, the results after injection are not the same as the previous ones. They decrease or sometimes don’t appear at all. What happens is that the Botox injection activates a mechanism similar to that of vaccines. The immune system reacts against the botulinum toxin by developing antibodies to neutralize it. Some have suggested that it’s like what people who handle snakes sometimes experience. After being bitten several times, they start becoming resistant to the venom.
Botox resistance can develop over the years after a dozen applications. It can also happen after the first treatment, as some people are simply immune to the effects of botulinum toxin. It’s not a product failure but rather a reaction on the part of an individual’s body. Unfortunately, there aren’t any methods that allow practitioners to predict resistance to Botox before its application.
Too High a Dose Applied Too Often May Trigger Antibodies
Some studies have suggested that antibodies to Botox are more likely to be a problem if doctors apply higher doses or inject too frequently. So, to be on the safe side, it’s wise to follow the recommendation of using the lowest effective dose and waiting at least four months between appointments. Some plastic surgeons recommend not applying Botox for a year if resistance to the product is suspected. After this period, they’ll inject again and check the results.
You May Need to Try a Different Product
One solution to Botox resistance is to switch to another product. Although people often use the words Botox and botulinum toxin interchangeably, Botox is actually a brand name. Allergan manufactures Botox. Glabellar lines treatment Dysport, made by Ipsen Biopharm, is a similar product with a slightly different botulinum toxin composition. The chances of developing antibodies to a second formulation are quite slim. Xeomin, from Merz Pharma, is botulinum toxin without added complex proteins. This gives it a higher degree of purity than either Botox or Dysport. Some injectors see this lack of additives in Xeomin’s formula as a big advantage. They feel it lowers the odds that the body will have an immune response and create antibodies.
Just as no two individuals are exactly the same, there are no two reactions to products that will be identical. For people for whom Botox isn’t working as they had hoped, the solution will have to be found on a case-by-case basis. At least take heart in the fact that Botox resistance is very rare, and have confidence that you and your provider will work together to fine-tune your treatment plan until you’re happy with the outcome.