Botox: The Ultimate Guide

Botox works by temporarily blocking nerve signals to the muscles and reducing the intensity of muscle contractions. 

Because the injected muscle can no longer fully move, dynamic wrinkles caused by the movement smooth out and become less visible. It may prevent existing wrinkles from worsening over time—and prevent new wrinkles from forming.

Baby Botox refers to using very small doses to achieve a more subtle, gentle result. According to Dr. Klein, microdosing can be a good option for: 

• anyone who’s new to the treatment and doesn’t have severe lines or wrinkles
• patients who don’t tolerate normal doses well (such as patients who develop brow drop when their forehead is treated)
• young adults who want to prevent future wrinkles 

Each treatment is relatively inexpensive because your injector uses fewer units, but “the longevity of baby Botox is typically less because you are receiving less than the recommended dose for a specific area. To keep up your results, treatments can be done every two months.

Dr. Douglas K. Henstrom, a facial plastic surgeon in Draper, Utah, also cautions that this approach “can be less effective on someone with more moderate to severe wrinkles. If the wrinkles are highly visible, the microdose may not be effective enough for the muscle, especially if it is a stronger muscle."

RealSelf Tip: A growing number of providers are using various techniques to stamp or microneedle the neurotoxin into the superficial layers of skin. Learn the benefits of this new treatment trend, often called a Botox facial.

Micro Botox (also called MesoBotox) refers to the technique of injecting Botox superficially, into the skin rather than into muscle. This is primarily done to tighten pores, reducing oil and making the skin appear smoother, though it may also improve the appearance of redness and flushing from rosacea. However, many doctors on RealSelf recommend other treatments, such as lasers and microneedling, instead of Micro Botox—or in addition to it—for best results. 

The dilution and the number of units is the same as for traditional Botox injections, but the Botox is dispersed over a larger area. “Micro Botox is usually injected in the T-zone area and through the entire face: in the forehead, cheeks, nose, and chin area,” says Dr. Usha Rajagopal, a San Francisco plastic surgeon.

Micro Botox doesn’t last as long as traditional Botox, with follow-up treatments needed within two to four months for continued effects.

The lip flip, a growing lip augmentation trend, uses a microdose of Botox (about 1-2 units on either side) to relax the muscles in the upper lip. Dr. Scott K. Thompson, a facial plastic surgeon based in Layton, Utah, says that this “flips the upper lip up just enough to make it appear slightly fuller and more youthful.” 

Natural-looking results appear within ten days and “typically last 8-10 weeks, not as long as other treated areas, due to the fact that doses in this area must remain low in order to maintain normal lip movement,” explains Dr. Lorrie Klein, a board-certified dermatologic surgeon in Laguna Niguel, California. 

A lip flip won’t create the same kind of volume as injectable lip fillers or the dramatic, long-lasting results of a surgical lip lift, but it’s a popular option for people seeking a subtle improvement.

Pros

• Botox (and similar injectable neuromodulators such as Jeuveau, Dysport, Xeomin and Daxxify) relax dynamic lines and wrinkles caused by muscle movement, while preventing new wrinkles.
• Patient satisfaction is high: Botox has a 97% Worth It Rating from RealSelf members.  
• This injectable treatment is quick and relatively painless. In some cases, it takes just a few minutes. 
• Downtime is almost nonexistent, although bruising can occasionally occur.
• As Dr. Klein explains, “as long as your injector is experienced, doesn’t overdo the dosage, and injects in the appropriate areas for your face (certain areas such as the forehead need to be customized for each individual), your face should still look natural, not frozen, expressionless or having an unnatural look, such as ‘Spock Brows.’”
• Botox has been studied for over 20 years, and many providers have well over a decade of experience in using it to treat patients.

Cons

• Botox results aren’t permanent. To keep them up, you'll need to return to your injector every three to four months. 
• As with other nonsurgical treatments, its anti-aging results can’t replicate what you’d get with a plastic surgery procedure, like a facelift.
• The most common Botox side effect is mild bruising at the injection site.
• Muscle weakness is an intended effect, but some patients find it unsettling when certain muscles don’t function normally, particularly those around the mouth. Especially in the first few weeks after a lip flip procedure, you may not be able to do everyday things, like purse your lips, swish mouthwash, suck through a straw, or fully close your lips as you chew food. (You can still drink through a straw on the side of your mouth.)
• Botox is not recommended if you’re pregnant or breastfeeding, , as it hasn’t been tested in these conditions.

RealSelf Tip: Seeing an injector who isn’t experienced or licensed, or is using a knock-off botulinum toxin that hasn’t been purified or approved for human use, could mean risking a medical emergency. Make sure you find a qualified injector who will give you the real thing.

• Average Cost:
• $555

• Range:
• $168 - $1,850

You should expect to pay between $10 and $25 per unit of Botox. 

The number of units you’ll need will depend on how deep your wrinkles are (an indication of your muscle strength) and the size of the treated area. People commonly get 10–20 units of Botox for the forehead and another 20–30 (sometimes more) for the glabellar lines between the eyebrows, but your injector will assess your situation and recommend more or less. 

Cosmetic treatments like this one aren’t covered by insurance, but many providers offer payment plans or accept third-party financing options like CareCredit.

See our complete guide to Botox costs

As you're picking your injector, look for Botox pictures of patients of a similar age and wrinkle depth as your own, who have been treated in the same area you’re concerned about. The results should look smoother and more youthful, while still showing some natural range of expression. 

The Botox before and after photos in our gallery have been shared by the provider, with the patient's consent.

Before you get Botox, you can minimize your chance of bruising by stopping any blood thinners (that aren’t medically necessary) a week before your appointment, specifically nonsteroidal anti-inflammatories (NSAIDs), like naproxen and ibuprofen, or Omega-3s.

Botox is approved for patients over 18. Some doctors recommend starting it in your mid-20s to early 30s for "prejuvenation," but Dr. Klein says that’s only necessary “if and when you start to see lines forming. There is no need to start Botox treatments prior to that time.”

A good candidate is a healthy adult who is not pregnant or nursing. Botox is contraindicated in pregnancy, mostly due to the fact that its safety has not been thoroughly studied.

While it's generally well-tolerated, you should also avoid it if:

• you’re hypersensitive or have had previous reactions to any botulinum toxin product
• you have an infection at the injection site
• you have a neuromuscular disease (like myasthenia gravis). 

Clinical trials have shown that Botox is safe, with minimal risks and side effects. 

Aside from mild bruising at the injection site, the most common side effects include mild bruising at the injection site or droopy brows, if the forehead is treated.

There's also a risk that it can unintentionally spread into other areas, causing drooping eyelids, a lopsided smile, or crooked eyebrows. The best way to prevent this is to avoid touching the treated area for 4 hours after your treatment.  

The neurotoxin can also leave you with a frozen look, if you’re over-injected. Results are never permanent and will gradually disappear over three to four months, but that's yet another reason to find an experienced, artful injector.

Related: 7 Signs of Bad Botox and How to Avoid or Fix Botched Injections

Some patients also experience these temporary side effects. 

• dry mouth
• tiredness 
• discomfort at the injection site 
• headache 
• neck pain 
• vision problems, including blurred vision and dry eyes

This treatment is derived from a toxin—botulinum toxin type A, produced by a type of bacteria called bacterium Clostridium botulinum—that temporarily interrupts the nerve signaling between muscles to induce short-term muscle weakness. However, it can't actually give you botulism (a type of food poisoning).

Rare but serious side effects of botulinum toxin injections include:

• Trouble swallowing, breathing, or speaking may occur after very high doses, when injected into the neck muscles. 
• Allergic reactions can also happen. Seek emergency healthcare if you develop hives and itching, wheezing, feeling faint, or swelling in your face, tongue, or throat.

If you have any concerns about these risks, talk to your injector prior to your treatment.  

To help reduce your chances of a complication, find a qualified injector with a solid track record of experience and happy patients. The rules about who can perform injections vary from state to state in the U.S. In some places, only a doctor is allowed to administer any botulinum toxin product, but most states permit other medical professionals, such as a nurse or physician assistant, to work under a doctor’s supervision. 

RealSelf Tip: While some news stories have cautioned against getting Botox after having a COVID booster shot, dermatologists say that there’s no data showing that it’s necessary to separate toxin injections from vaccines. Find out more.

Botox cannot cause cancer. In fact, it may be beneficial for cancer patients. 

A 2020 review of the scientific literature concludes that there’s some evidence that botulinum neurotoxin injections eases the pain of cancer and radiation—and possibly even “slows/halts the growth of certain cancer cells.” The “positive effect of [botulinum neurotoxins] on different cancer cell lines and their direct effects upon certain cancerous tumors is encouraging,” but the authors say “further studies are needed to verify these results.”

Botox injections are a lunchtime procedure that usually takes 5-15 minutes. Here’s what you can expect.

• You’ll start with a consultation, where you and your injector will discuss your concerns, goals, and medical history to ensure that the injectable is safe for you.
• They may take photos so you’re able to see the changes from your treatment.
• Then your face is cleansed, and the physician injects the areas of concern. 
• Once your treatment is done, you’ll be able to drive yourself straight home or back to the office. 
• If you have any residual redness or bruising, it can be easily covered with makeup.

Most patients experience only a brief twinge of mild discomfort during Botox treatment. The needle used for these injections is very thin, but if you're concerned, you can request a topical numbing cream before the procedure.

“I personally don’t use a numbing cream beforehand, because it’s a really quick and pretty painless procedure, if done the correct way,” says Charlotte, North Carolina facial plastic surgeon Dr. Jonathan Kulbersh.

Related: 9 Ways to Get Over Your Fear of Needles

Recovery is relatively simple. “When people are done, they may look as though they’ve been bitten by mosquitoes,” Dr. Kulbersh says. “They’ll have some little bumps on their face that last about 15 to 20 minutes.” 

As we’ve mentioned, you may also have some mild bruising around the injection sites.

Related: Injectable Bruises? Been There. Here’s How to Handle Them Without Hiding Out

The most important thing you need to know is how to reduce the chance that the Botox could spread and paralyze a nearby muscle.

Just remember one simple rule: Don’t rub the treated areas for at least four hours, or do anything else that could apply pressure. This includes applying an ice pack, wearing a tight hat, or scrubbing your face.

Learn more about what not to do after Botox.

“Botox results start kicking in as early as day two or three,” Dr. Kulbersh says, but the maximum effects of Botox can take up to two weeks to appear. It has to bind itself to receptors on nerve cells before it starts to relax the muscles, which takes time.

“[Fine lines] continue to improve as the muscles are relaxed and not moving over a three- to four-month time period, and they continue to improve the longer you do Botox,” continues Dr. Kulbersh. 

Botox lasts three to four months, on average. The effects on the forehead usually wear off first, followed by crow’s feet, and lastly glabella. 

It’s not necessary to get it again as soon as the effects start to wear off, but if you want to get the maximum benefits, you may want to plan on having maintenance treatments about every four months.

That said, every person is different. “Since your body makes new receptors and neurotransmitters all the time, each patient will have different lengths of effective [Botox] paralysis,” says Dr. Richard H. Tholen, a plastic surgeon in Minneapolis, Minnesota. The average may be three or four months, but Dr. Tholen puts the range at two to six months.

“Remember, while Botox is working, you are getting ‘wrinkle-free time,’” says Dr. Jennifer Reichel, a dermatologist in Seattle. “So if it works for six months and you do it only once a year, you’re still going to have fewer wrinkles.”