Botox Resistant in Crows Feet is a Misnomer
I am so happy to see this question. I spent many years getting frustrated with a few patients where I could not get the crows feet to respond, no matter how many units I put in.
Finally, one day I was watching a physician's webinar when she mentioned the same problem and stated that 'IT IS CAUSED BY THIN SKIN AROND THAT AREA WITH YEARS OF LOSS OF COLLAGEN. WHEN ONE SMILES THE CHEEK IS PUSHED UPWARDS AND YOU SEE WRINKIES CAUSED BY PRESSING THIN SKIN BETWEEN CHEEK TISSUES AND THE RELATIVELY IMMOBILE TEMPLE SKIN. IT HAS NOTHING TO DO WITH BOTOX RESISTANT ETC.'
So, what is the solution? Building up the volume by using a volumizing agent such as Sculptra. I have had great success with it.
Please mention this to your physician and hopefully it will take care of your problem.
There are some patients that have Botox resistance. Fortunately other forms of Botulinum toxin are now available that work a bit differently. Dysport is one new form that is Botulinum A and should be effective if you are resistant to Botox.
I don't think it's possible to be Botox resistant. However, are you really getting 20 units? I use new Botox each time and 25 units per side. My patients are paralyzed for up to 5 months. Also, is the injector getting it deep enough? If he/she is only putting it under the skin it won't do much. It must get into the muscle. This is evident by the "crunch" that is felt during injection.
I would try a new physician, not nurse or spa or traveling salesman, a physician who knows how to inject Botox.
I have never seen Botox resistance.
In New York, we have done thousands of Botox injections, and we have never seen resistance. Try another doctor, and maybe you need 30 or 40 units, but I believe you can expect a good result for 4 months. Technique is very important.
I need to know a few things
You did not state your age or sex. While 20 units is fine for a female in her 20's and maybe 30's, it is totally inadequate for someone older because of skin laxity, and it is not enough for men because their muscle mass is bigger. That is why we recommend patients start Botox (and now Dysport) younger in order to prevent those deeply etched lines that Botox alone can't handle efficiently. The major sign of inadequate dosing is short duration of effect. You certainly might want to try Dysport, the new toxin. It might work better in you, but in the end, it is the total dosage based on the line severity that gives best results, no matter the product.
Before you declare yourself BOTOX resistant, ask yourself a few questions: Have you been getting treatment by the same injector? Does the office do before and after pictures and show these images to you so you understand what the treatment is doing for you. In Los Angeles, some offices sell BOTOX at a price per unit that is less than the cost of the service. Generally these offices have a generous "top off policy." I think the reality is that many of these offices are not giving a full unit of BOTOX. This leads people to believe that BOTOX effects wear off quickly or that they are resistant. The best way to explore this is to find a new injector with a good reputation.
Don't look for the bottom dollar because it is human nature to cut corners. Find an office that does not cut corners and expect to pay more for your treatment. Another aspect is that some issues actually benefit from surgery. If you actually are resistant to BOTOX you will also likely rapidly develop resistance to the dysport. Myobloc duration is so short that it has not proven to be a very satisfactory agent for cosmetic purposes.
Botox resistance: consider Dysport
If you are Botox resistant, you may want to consider using Dysport as an alternative.
This recently became available and may be a good option to test if you are resistant to Botox or the basic product : Botulinum toxin A.
True Botox resistance with total absence of response to injections is rare. Partial resistance is more common. You might need to have a higher dose to achieve the same response. You might consider trying a different doctor for treatment to see if slightly different technique might give you better results.
If these don't work,different medications, such as Dysport (same Botulinum Toxin A) or Myoblock (different toxin - Botulinum Toxin B), might give you the results you are looking for. New medications, including topical preparations are coming on the market, so you should do find something that will work for you in the long run.
Antibodies; Add superficial filler
If your physician is injecting the same amount of Botox and you are getting less and less of an effect, you may be developing blocking antibodies to the Botox. Usually, Botox will last somewhat longer between injections in someone who has received multiple Botox visits as the body has difficulty re-establishing new nerve-muscle connections. However, if you are finding that Botox is working less and less, and you are receiving the same or increaed dosages, you may be developing antibodies.
A recommendation for the crow's feet area, would be to have filler injections. The should be injected superficially by an experienced injector. Too superficial and there may be "beading". The collagen fillers are a little more likely to cause this beading,. However, if you develop beads, you will not be disfugured by the bluish hue of a hyaluronic acid filler. Incidentally, very little filler is needed in this area. I usually try to top off injections elsewhere by using fillers in the crow's feet area.
Dysport often works in Botox Resistant Patient.
The short answer is try Dysport. Dysport may work in a Botox resistant patient. Occasionally when Botox doesn't seem to work as well after years of injection, switching to Dysport seems to help in many patients. Also be aware that the expertise of the injector and the number of units injected are also variables that may account for decreased response.
Dysport and Botox are both preparations of botulinum toxin A, a derived protein that works at the nerve-muscle interface to relax targeted muscles. The Dysport protein is slighlty smaller and seems to work slightly faster. Dysport has been around in Europe more recently introduced in the USA. At this point it as slightly cheaper even with the more units required to inject, that is the dosage is not the same between the two drugs though both work well in my experience. Dysport is made by Medicis (owned by Valeant) the makers of Restylane and Perlane. The end result is the similar from the patient' standpoint.