Alex Eshaghian, MD, PhD

Thank you for your question and for sharing your photographs brii411. I understand your concern. Botox is a purified protein used to address wrinkles associated with facial expression. When injected into the skin Botox will relax the muscles and smoothen out the overlying wrinkles. The most common areas of treatment are in the upper face. These include the horizontal lines seen on the upper forehead when one raises the brows, the vertical lines seen between the brows when one frowns (frown lines), and the crow's feet seen around the eyes when one smiles.

It is difficult to make an assessment without a formal exam in the office where I can view the skin in multiple angles and observe wrinkles formed with facial expression. However, I hope the information provided here is useful.

The appearance of frown lines is variable from person to person. Usually they are in a vertical orientation but sometimes they can be oblique and sometimes a horizontal line is seen across the upper portion of the nasal bridge. The most common variation is to have two parallel lines, hence the common term "11's" to describe them. But some people have one, three, or more lines. Some people also will see a bulge in the area when contracting the muscle. This bulge is smoothened out after a Botox treatment.

The pivotal studies used 20 units of Botox in the glabella area between the brow to address the frown lines and 20 units of Botox in the forehead area above the brows to address the horizontal lines seen when one raises the brows. These studies demonstrated that the peak results are seen 14 days after the treatment and most people enjoy their results for 3-4 months. At that point, a maintenance treatment is recommended. While some people start to see results as early as the next day, it can take two weeks for full results so patience is important. We have our patients return two weeks after their treatment to assess their results via photographs. At that time additional units may be added if necessary. 

The pivotal studies for the horizontal lines on the upper forehead were published many years after doctors had been using Botox. In these studies, 20 units of Botox were used to treat this area. However, in my experience I find that anywhere from 10 to 20 units works well in this area. For patients with narrow foreheads a lower dose may be used and those with a broad forehead generally require higher doses. I have also found that the full results in this area are seen by two weeks. Therefore, we have our patients return two weeks after their treatment to assess the results via photographs. At that point additional units may be used if further enhancement is desired.

When patients present with concerns about specific wrinkles in the upper face such as the frown lines, I always assess and usually treat the other wrinkles in the upper face including the horizontal forehead wrinkles and crow’s feet. The reason is to maintain a harmonious and natural balance to the appearance of the upper face. The muscles in the glabella which are responsible for the formation of the frown lines serve to pull down on the inner brows when a person frowns. Similarly, the muscles around the eyes which are responsible for the formation of the crow’s feet seen when smiling (orbicularis oculi) are also responsible for pulling down on the brows, but in this case the outer brows. On the other hand, the muscle in the upper forehead which is responsible for the formation of the horizontal forehead wrinkles when a person raises the brows (frontalis) serves to pull the brows upward. If one of these muscles is relaxed with Botox and the others are not, the other muscles will still be active. This will lead to an unbalanced and unnatural appearance of the upper face where the brow can be elevated, depressed, or uneven in shape or position. Therefore, I recommend that my patients take a global approach to the upper face when receiving Botox treatments and treat all three of these areas. Sometimes bunny lines on the bridge of the nose are also treated.

Despite having a natural appearance when performed correctly, many people are afraid of the results of their Botox treatment, in particular before their first treatment, which is natural. In these cases, a lower dose can be used. For example, sometimes I use 10 units in the glabella region instead of the recommended 20 units. In these cases, I advise my patients that the full results will be seen approximately two weeks after the treatment and have them return at that time to take after photographs. At this point, more Botox can be added if further enhancement is desired. I find that when lower doses are used, patients do not enjoy their results for as long; six to eight weeks as compared to three to four months. Therefore maintenance treatments must be performed more frequently.

A common misconception is that Botox is only for those who are in their 60's or 70's. On the contrary, I have a lot of patients in their 20's who receive Botox. This is either for prevention or for those who have expressive faces. I find that the younger one is when one starts receiving Botox treatments the more signs of aging will be delayed. In other words, Botox can be used to prevent wrinkles from either appearing in the first place or from getting deeper over time.

Botox is a prescription strength medication that is injected into the skin or other areas. Therefore, it is important that the treatment is performed by a trained medical professional. This can be a physician, physician’s assistant, nurse practitioner, or nurse. Laws vary from jurisdiction to jurisdiction on who is allowed to provide the treatment. In California, for example, any of these aforementioned medical professional is permitted to provide a treatment. With the recent explosion of cosmetic medicine, there are more and more people offering such services. This includes core physicians such as plastic surgeons and dermatologists as well as other physicians who are trained in cosmetic treatments such as general physicians, gynecologists, or other specialists. It is important to understand that just because a doctor is a plastic surgeon or dermatologist does not necessarily make them an expert on Botox. General doctors who routinely perform Botox treatments multiple times per day likely have more experience and expertise than a plastic surgeon who spends most of his time performing surgeries and performs perhaps only a single Botox treatment per month. Similarly, there are many outstanding nurse injectors who spend their entire days performing cosmetic treatments, as they are often delegated to nurses. Their experience can at times be great than that of many doctors. This understandably makes it difficult to find a good provider. I recommend looking for experience (specifically in Botox and other minimally invasive cosmetic treatments such as fillers and lasers), before and after photographs, and testimonials. Looking for an office who offers the most competitive price is often a recipe for disaster. We have had many patients come to our office to correct various issues they have had when they selected an injector based on price alone.

If I had a patient who looked like the person in these photographs I would say that a dose of anywhere between 16 and 30 units would be appropriate for the horizontal wrinkles on the forehead and the frown lines. I would also recommend taking a global approach as described above and treating the crow's feet with 6-12 units per side.

With any injection, there are risks such as pain, bleeding, bruising, redness, swelling, tenderness, and infection. We take special precautions to minimize these risks such as using a painless technique. We also treat bruises with a laser as early as the next day. Bruises usually resolve within two weeks if untreated. After a laser treatment bruises usually resolve in 1-3 days, but may still take two weeks for full resolution. In addition to these risks, with Botox there is also a risk that the product spreads or diffuses to nearby structures. Spread to nearby muscles can lead to side effects such as the temporary appearance of droopy eyelids or a temporary asymmetric smile.

After a Botox treatment, I recommend that my patients avoid heat exposure, alcohol consumption, and strenuous exercise for 24 hours and not lie down flat for four hours. This is because all of these activities may possibly lead to the movement of the product and consequent side effects such as droopy eyelids. Although there have been no definitive studies shown that these actually occur and some physicians do not provide such aftercare instructions, in the absence of data I err on the side of caution and recommend that my patients avoid such activities.

Please consult with a doctor for specific recommendations. Good luck!

Thank you for your question jen26368. I understand your concern. Botox is a purified protein used to address wrinkles associated with facial expression. When injected into the skin Botox will relax the muscles and smoothen out the overlying wrinkles. The most common areas of treatment are in the upper face. These include the horizontal lines seen on the upper forehead when one raises the brows, the vertical lines seen between the brows when one frowns (frown lines), and the crow's feet seen around the eyes when one smiles.

It is difficult to make an assessment without a formal exam where the entire medical history is reviewed. However, I hope the information provided here is useful.

The safety record of Botox is well established. The product has been used for over 20 years for a variety of treatments with minimal side effects. Botox is amongst the safest treatments for treating facial wrinkles.

While Botox is one of the safest treatments offered, there are some situations where it is not appropriate. These include anyone who has an allergy to any of the inactive ingredients or who has had an allergic reaction to any botulinum product including Botox, Dysport, Xeomin, or Myobloc. The safety and efficacy of Botox has not been established in women who are pregnant, trying to become pregnant, or breast feeding. Therefore, women in these categories are advised to wait until breast feeding is completed prior to having a Botox treatment. Botox should not be placed in the skin on the site of an infection. Those who are taking an aminoglycoside antibiotic, an anesthetic, D-penicillamine, antimalarials, or immunosuppressants should not be treated, nor should those who have undergone chemotherapy within the previous six months. It is important to avoid blood thinners before and after a treatment. These include both prescription and non-prescription medications such as warfarin (coumadin), aspirin, ibuprofen, alcohol, fish oil, vitamin E, and ginko biloba. Those with conditions that affect muscles and nerves such as amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease), myasthenia gravis, or Lambert-Eaton syndrome should not undergo Botox treatments.


Having a tetanus shot two weeks prior is not a contraindication to receiving a Botox treatment. If I had a patient with the concern described here I would say that it is safe to have a Botox treatment two weeks after a tetanus shot assuming there are no contraindications.

With any injection, there are risks such as pain, bleeding, bruising, redness, swelling, tenderness, and infection. We take special precautions to minimize these risks such as using a painless technique. We also treat bruises with a laser as early as the next day. Bruises usually resolve within two weeks if untreated. After a laser treatment bruises usually resolve in 1-3 days, but may still take two weeks for full resolution. In addition to these risks, with Botox there is also a risk that the product spreads or diffuses to nearby structures. Spread to nearby muscles can lead to side effects such as the temporary appearance of droopy eyelids or a temporary asymmetric smile.

After a Botox treatment, I recommend that my patients avoid heat exposure, alcohol consumption, and strenuous exercise for 24 hours and not lie down flat for four hours. This is because all of these activities may possibly lead to the movement of the product and consequent side effects such as droopy eyelids. Although there have been no definitive studies shown that these actually occur and some physicians do not provide such aftercare instructions, in the absence of data I err on the side of caution and recommend that my patients avoid such activities.

Please consult with a doctor for specific recommendations. Good luck!

Thank you for your question and for sharing your photographs Bkbaby. I understand your concern. Botox is a purified protein used to address wrinkles associated with facial expression. When injected into the skin Botox will relax the muscles and smoothen out the overlying wrinkles. The most common areas of treatment are in the upper face. These include the horizontal lines seen on the upper forehead when one raises the brows, the vertical lines seen between the brows when one frowns (frown lines), and the crow's feet seen around the eyes when one smiles.

It is difficult to make an assessment without a formal exam in the office where I can view the skin in multiple angles and observe wrinkles formed with facial expression. However, I hope the information provided here is useful.

Although Botox is most commonly used in the upper face, it can also be used in various areas in the lower face. Botox can be placed in the mentalis muscle on the chin to address a cobblestone appearance or dimpling on the chin. In this area 2-8 units of Botox are used.

If I had a patient with the concern described here I would say she is a good candidate for the treatment described above using 2-8 units.

With any injection, there are risks such as pain, bleeding, bruising, redness, swelling, tenderness, and infection. We take special precautions to minimize these risks such as using a painless technique. We also treat bruises with a laser as early as the next day. Bruises usually resolve within two weeks if untreated. After a laser treatment bruises usually resolve in 1-3 days, but may still take two weeks for full resolution. In addition to these risks, with Botox there is also a risk that the product spreads or diffuses to nearby structures. Spread to nearby muscles can lead to side effects such as the temporary appearance of droopy eyelids or a temporary asymmetric smile.

After a Botox treatment, I recommend that my patients avoid heat exposure, alcohol consumption, and strenuous exercise for 24 hours and not lie down flat for four hours. This is because all of these activities may possibly lead to the movement of the product and consequent side effects such as droopy eyelids. Although there have been no definitive studies shown that these actually occur and some physicians do not provide such aftercare instructions, in the absence of data I err on the side of caution and recommend that my patients avoid such activities.

Please consult with a doctor for specific recommendations. Good luck!

Thank you for your question and for sharing your photographs melaniewell. I understand your concern. Botox is a purified protein used to address wrinkles associated with facial expression. When injected into the skin Botox will relax the muscles and smoothen out the overlying wrinkles. The most common areas of treatment are in the upper face. These include the horizontal lines seen on the upper forehead when one raises the brows, the vertical lines seen between the brows when one frowns (frown lines), and the crow's feet seen around the eyes when one smiles.

It is difficult to make an assessment without a formal exam where the entire medical history is reviewed. However, I hope the information provided here is useful.

Although Botox is most commonly used in the upper face, it can also be used in various areas in the lower face. Botox can be placed in the mentalis muscle on the chin to address a cobblestone appearance or dimpling on the chin. In this area 2-8 units of Botox are used.

A phenomenon seen with Botox is called muscle recruitment and compensation. When a muscle has been relaxed with Botox, sometimes other muscles or a different part of the same muscle are recruited and contract when one attempts to make the facial expression. This serves to compensate for the inability of the primary muscle to contract. Sometimes a bulge can appear in a muscle that was untreated or a part of a muscle that was not treated. A common example is the bunny lines (caused by contraction of the nasalis muscle) that are seen on the sides of the upper nose after treatment with Botox in the glabella or for the crow's feet. Since the muscles in the treated area are relaxed, the nasalis muscle contracts in an attempt to compensate for this loss when one frowns or smiles. In such a situation, the bunny lines can be treated with a small amount of Botox (2-4 units per side). In the upper face, sometimes a portion of the frontalis muscle in the upper forehead which was previously not active becomes active once the muscle is relaxed with Botox. In these case, new wrinkles may be seen, often near the hairline. This can be treated with a small dose of Botox in that area. This can also be seen in the lower face when not enough product has been used in an area such as the chin. Sometimes another part of the muscle begins to contract in order to compensate for the relaxation of the muscle from Botox. This can also be treated with a small dose of Botox in that area. Compensatory recruitment can also occur when the platysma muscle in the neck contracts after muscles in the lower face have been relaxed with Botox. Similarly, this muscle can be relaxed with Botox as well. For my patients, I usually use approximately 10 units per band. If placed properly it does not affect other muscles. Relaxing the platysma muscle may also lead to an improvement of jowls and jawline definition. When such recruitment occurs, I recommend prophylactic (preventive) treatment of the recruited muscles at the next treatment.

If I had a patient with the concern described here I would say that there is likely some compensatory recruitment involved here and that additional units in the bulge will provide correction.

With any injection, there are risks such as pain, bleeding, bruising, redness, swelling, tenderness, and infection. We take special precautions to minimize these risks such as using a painless technique. We also treat bruises with a laser as early as the next day. Bruises usually resolve within two weeks if untreated. After a laser treatment bruises usually resolve in 1-3 days, but may still take two weeks for full resolution. In addition to these risks, with Botox there is also a risk that the product spreads or diffuses to nearby structures. Spread to nearby muscles can lead to side effects such as the temporary appearance of droopy eyelids or a temporary asymmetric smile.

After a Botox treatment, I recommend that my patients avoid heat exposure, alcohol consumption, and strenuous exercise for 24 hours and not lie down flat for four hours. This is because all of these activities may possibly lead to the movement of the product and consequent side effects such as droopy eyelids. Although there have been no definitive studies shown that these actually occur and some physicians do not provide such aftercare instructions, in the absence of data I err on the side of caution and recommend that my patients avoid such activities.

Please consult with a doctor for specific recommendations. Good luck!

Thank you for your question and for sharing your photographs CJ2017. I understand your concern. Botox is a purified protein used to address wrinkles associated with facial expression. When injected into the skin Botox will relax the muscles and smoothen out the overlying wrinkles. The most common areas of treatment are in the upper face. These include the horizontal lines seen on the upper forehead when one raises the brows, the vertical lines seen between the brows when one frowns (frown lines), and the crow's feet seen around the eyes when one smiles.

It is difficult to make an assessment without a formal exam in the office where I can view the skin in multiple angles and observe wrinkles formed with facial expression. However, I hope the information provided here is useful.

The pivotal studies used 20 units of Botox in the forehead area above the brows to address the horizontal lines seen when one raises the brows. These studies demonstrated that the peak results are seen 14 days after the treatment and most people enjoy their results for 3-4 months. At that point, a maintenance treatment is recommended. While some people start to see results as early as the next day, it can take two weeks for full results so patience is important. We have our patients return two weeks after their treatment to assess their results via photographs. At that time additional units may be added if necessary. 

When patients present with concerns about specific wrinkles in the upper face such as the frown lines, I always assess and usually treat the other wrinkles in the upper face including the horizontal forehead wrinkles and crow’s feet. The reason is to maintain a harmonious and natural balance to the appearance of the upper face. The muscles in the glabella which are responsible for the formation of the frown lines serve to pull down on the inner brows when a person frowns. Similarly, the muscles around the eyes which are responsible for the formation of the crow’s feet seen when smiling (orbicularis oculi) are also responsible for pulling down on the brows, but in this case the outer brows. On the other hand, the muscle in the upper forehead which is responsible for the formation of the horizontal forehead wrinkles when a person raises the brows (frontalis) serves to pull the brows upward. If one of these muscles is relaxed with Botox and the others are not, the other muscles will still be active. This will lead to an unbalanced and unnatural appearance of the upper face where the brow can be elevated, depressed, or uneven in shape or position. Therefore, I recommend that my patients take a global approach to the upper face when receiving Botox treatments and treat all three of these areas. Sometimes bunny lines on the bridge of the nose are also treated.

Sometimes after a Botox treatment a peaked appearance of the eyebrow is seen. This is sometimes called the Spock or Mephisto look, which makes a person appear surprised or sinister. It is also called the Jack Nicholson look, after the appearance of his eyebrows. This can occur if the muscles that pull the eyebrow down are relaxed with Botox. It can also occur if the upper forehead only is treated. In this case the inner portions of the muscles are relaxed preferentially over the outer portions of the muscle. This allows the outer portions of the muscle to pull up on the tail of the eyebrow. While some people desire this appearance, others do not. This effect can be corrected by placing a small amount (1-2 units) of Botox in the upper forehead approximately midway between the eyebrow and the hair line at the peak of the brow. This relaxes the muscle that pulls up on the tail of the eyebrow, thereby restoring a natural appearance.

If I had a patient with the concern described here I would suspect that an appropriately conservative amount of product was used for correction the first time and that another similarly conservative dose can be used for further correction.

With any injection, there are risks such as pain, bleeding, bruising, redness, swelling, tenderness, and infection. We take special precautions to minimize these risks such as using a painless technique. We also treat bruises with a laser as early as the next day. Bruises usually resolve within two weeks if untreated. After a laser treatment bruises usually resolve in 1-3 days, but may still take two weeks for full resolution. In addition to these risks, with Botox there is also a risk that the product spreads or diffuses to nearby structures. Spread to nearby muscles can lead to side effects such as the temporary appearance of droopy eyelids or a temporary asymmetric smile.

After a Botox treatment, I recommend that my patients avoid heat exposure, alcohol consumption, and strenuous exercise for 24 hours and not lie down flat for four hours. This is because all of these activities may possibly lead to the movement of the product and consequent side effects such as droopy eyelids. Although there have been no definitive studies shown that these actually occur and some physicians do not provide such aftercare instructions, in the absence of data I err on the side of caution and recommend that my patients avoid such activities.

Please consult with a doctor for specific recommendations. Good luck!