Radha Mikkilineni, MD

Botox is very effective when used for dynamic wrinkles.  When it fails to work, it is usually because not enough was used or the botox was expired or stored incorrectly.  Very rarely there are patients who develop resistance to botox if they have been using it for a very long time.  In this case it is best to use an alternative such as Dysport.

If you have wrinkles present at rest and these lines are due to muscle movement (typically between the brows or horizontal forehead lines), these can be improved significantly by botox.  They may not disappear completely if they are present at rest.  In addition to botox, a small amount of filler can be used to minimize, even further, the presence of lines at rest.  I have found many of my patients to be very satisified with botox alone since they still have a great result and appear more relaxed. 

There is no age limit to botox use.  I don't treat patients who have a history of neuromuscular disorders such as myasthenia gravis or other neurologic conditions or allergies to any components of botox.  Clinical history is always important to obtain, particularly a history of prior procedures (face lift for instance) since the musculature that is injected may be in different positions.  In addition, older patients may have wrinkles due to skin laxity, rather than muscle movement and these wrinkles are less likely to be improved by botox.  Finally, lower doses may be used in older patients due to weaker muscles and there are nuances to injection sites in older patients, so that I typically do not inject extensively in the forehead as there is a higher chance of a brow ptosis (inability to raise eyebrows).

Botox does wonders for crows feet as well as for undereye wrinkles that are caused by excessive movement of the muscles.  That being said, if someone has a lot of loose skin under the eyes and crepiness (loss of elasticity, etc), then I typically never treat infra-orbitally and very conservatively (low units) will treat the lateral lines.  Sagging of the lower lids is an issue whenever there is skin laxity and needs to be addressed as a potential problem prior to injecting this area.  I will often perform a clinical test to determine if there is a lot of lid lag (and therefore too much loss of elasticity) before injecting this area.

Botox is very effective for wrinkles on the upper part of the face, forehead, frown lines (between the brows) and crow's feet.  These lines are due to repeated muscular movement and are known as dynamic wrinkles.  The lower face wrinkles, such as the marionnette lines (lines radiating from the lateral corners of the mouth towards the chin) are better treated with fillers to replace volume.  Occasionally, a tiny amount of botox can be used in the depressor angularis oris (DOA muscle), a lip depressor, to relax marionnette lines and create an uplifting effect on the mouth corners.  This is better done in combination with a filler.