I'm a 47-yer.old Man with Strong Forehead Muscles. I Did Botox Twice, but See Very Little Improvement.. Any Suggestions?

The first time Botox didn't work at all, the second time horizontal wrinkles got softer, but still there, the same as between the eyes. Doctor is using an Allergen Botox Cosmetic. Each time he gave me 100 units. He is saying that my muscles are too strong and I need more injections then 2 sessions. Is this true? or I just have resistance to Botox?

Doctor Answers 8

Injection technique and/or resistance

A recent review that I published (see link) documents how men require higher botulinum toxin doses and a unique injection technique given the male facial musculature.  While 100 units of Botox is high dose for the upper face (even in men), the problem may be the injection pattern.  The other concern is resistance to the proteins complexed with Botox.  I recommend trying Xeomin which lacks complexing proteins and visiting a dermatologist who has experience treating men.  - Dr. Keaney

Washington DC Dermatologic Surgeon
5.0 out of 5 stars 3 reviews

Botox treatment or the forehead

Men usually have stronger muscles that require higher doses than women, however 100 units seems pretty high. You may want to consider getting a second opinion and seeing if they target different areas of your forehead, as this may be the problem. Best of luck.

Jerome Edelstein, MD
Toronto Plastic Surgeon
5.0 out of 5 stars 176 reviews

Performance of Botox for forehead

Resistance to Botox occurs in 1-3% of patients.  This can happen if your body’s immune system is producing antibodies in reaction to Botox’s protein structure. So to reduce the potential for this resistance, the label actually recommends that patients be given the lowest possible dose with longer amounts of time in between treatment sessions.

Also you may want to consider Dysport as an alternative to Botox. Dysport is also a botulinum toxin. The protein structure of this compound has fewer surrounding proteins, which lowers the chances of immune resistance. Some patients have better experiences with Dysport (see attached video).

If Botox fails to produce desired results, Dysport can be considered. And likewise, if Dysport fails to give desired results, Botox can be considered. If both fail, consider dermal fillers or discuss with your physician possible surgery as a remedy

Sanusi Umar, MD
Redondo Beach Dermatologic Surgeon
4.6 out of 5 stars 32 reviews

Botox and strong forehead muscles

When Botox doesn't "work" we must evaluate the anatomy and determine if the muscles are moving. If the muscles are relaxed and not contracting during active attempt at raising the forehead, then the Botox is working. If the lines however remain, despite the muscles not moving, then more units or more frequent treatment will not help. 100 units is a large amount for a forehead.  If the deep lines persist without muscle movement, those lines will start to look better sometimes, after many months of skin / muscle inactivity. It might need several treatments of Botox ensuring that it doesn't wear off in between treatments so that the muscle inactivity is preserved and the skin doesn't start creasing again.  When the muscle is large and the skin thick, some of those deep creases take many months to improve, and sometimes they are so engraved in the skin that they won't improve.

If your muscles are still moving despite 100 units of Botox per session, then I think you should consider not attempting more treatment as it may lower your whole forehead if you have more units and you might notice that your upper eyelids hang low to cover your eyes like window shades. Furthermore, that would be a significant amount of units to have in one cosmetic area.

Ronald Shelton, MD
Manhattan Dermatologic Surgeon
4.9 out of 5 stars 37 reviews

Botox injections and resistance

In most cases, 100 units of Botox, will improve horizontal forehead wrinkles even if you are a male with a strong frontalis muscle.  It is possible that if the Botox was not newly reconstituted or improperly stored, that it may have lost some of its potency.  It is also possible that you may have some resistance to Botox.  If this is the case you could try a higher dosage or try switching to Dysport. Also, check with your physician to determine that the issue is truly a problem of a hyperactive frontalis muscle, and not an issue of brow sagging (ptosis) which would not be resolved with Botox alone.  If this is the case, you may want to consider a browlift surgery.

Vincent D. Lepore, MD
San Jose Plastic Surgeon
4.8 out of 5 stars 56 reviews

Forehead and botox in men

Men usually have stronger muscles than women, but Botox is usualy quite effective.  You can always try Dysport or see another injector.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

Forehead Wrinkles Resistant To Botox

It is extremely rare to be resistant to Botox, especially if this was your first or second time trying the product. In this situation, I would make sure the product was not compromised in some way. If the botox was stored incorrectly, for example, it can lose it's effectiveness. It is also hard to advise you without seeing a photo, however, if you have significant laxity of the skin on you forehead, you might see better results with a brow lift than Botox. 

Adam J. Mamelak, MD
Austin Dermatologic Surgeon
5.0 out of 5 stars 4 reviews

Resistance to Botox is very rare

If you really got 100 units, then you may be resistant. 100 units to the forehead and glabella (frown lines between the eyes) should have weakened the muscles considerably. If you were able to frown or wrinkle your forehead 10 days after the injections, then you need more. If the muscles were weak, and you could not frown or raise your eyebrows, the effect was strong enough but the wrinkles may be permanently "ironed" into the skin. The "ironed in" wrinkles can soften if you keep the muscles that are causing them weak with continuous (every 3 months ) Botox injections over a couple of years. Fillers can also help in the glabella in some patients.

Jeffrey Schiller, MD
Edison Oculoplastic Surgeon
5.0 out of 5 stars 11 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.