Botox Did Not Work

Question

I got my first injections of Botox done one month ago, which didnt actually work. I went back in after waiting 2 weeks and got more put in, while hoping that it would be enough. Although the 2nd lot of injections stopped me from being able to frown, I still have my 2 very deep lines on each side of my eyebrow. I'm 29, and I was assured that the lines would lessen. Yet, they haven't at all. Can someone help by letting me know what could have gone wrong?

Harold J. Kaplan, MD · Answer

Hi Jane,
There are several explanations for why your Botox may not be working well for you:

Even though you were injected twice it may be that too little Botox was injected.  Normally in the area between the eyes, we inject between 15-25 units.
It is possible that the lines you have are too deep for Botox alone.  In cases like these we add dermal fillers such as Restylane to eliminate the lines completely.
It is possible that your injector missed the mark.  This is lesslikely as you noted that you are not able to frown.

Jerome Edelstein, MD · Answer

Either the Botox was not aggressive enough or you may need fillers to smooth away those wrinkles rather than Botox.  Talk to your injector about this.

Otto Joseph Placik, MD · Answer

Not all wrinkles will disappear with Botox. Let me give you an oversimplified antalogy to explain.
Movement lines and their associated wrinkles are generally caused by the repeated action of the underlying muscles. Weakening the muscles will soften the creasing of the skin and make the wrinkles appear less severe. 
This is not  dissimilar from the wrinkles which are formed from wearing a pair of pants all day long. When you put them on the hanger at night, most of the wrinkles will soften by the next morning. However, some of the more severe creases will persist. Your face is quite similar. 
Botox will put the skin at rest. However it will take several weeks and up to two months to see the full effect on the wrinkles. Most will soften and some will remain.
You may have obtained the maximal benefit and you may want to consider some filling agents to improve any remaining creases once the muscles have fully relaxed.

Kenneth D. Steinsapir, MD · Answer

Dear Jane Smith
First and foremost, it pays to deal with a reputable core physician.  This should be some one who is well respected and belongs to one of the core aesthetic specialities: Dermatology, ophthalmology, otolaryngology (facial plastic surgery), and general plastic surgery.  Obviously other physicians can and do provide BOTOX.  However these specialist have the largest experience with working with this agent.  So did you see a core physician?  Did you see a physician?  Did you pay commodity prices.  BOTOX cost the physician in the United States about $5 per unit for just the medication so anyone who sells the product for about $5 USD is essentially giving away the product.  Since few businesses can sustain themselves this way, if you are paying a price that seem too good, it probably is too good.  It is only the reputation of the physician that ensures that a unit of BOTOX is a unit of BOTOX.  I suspect that some providers are injecting their patients with saline.  Obviously injecting saline is highly profitable but not very effective.  So ask yourself if you went to a factory that is perhaps not on the up and up.  This might account for why your BOTOX was not too effective.
If you went to a reputable physician injector, then the suggestion that the BOTOX did not work because it is too old is not valid.  Ethical offices do not inject patients with old BOTOX.  Once mixed, BOTOX is probably good for two weeks.  In my office, it is rare for a vial of BOTOX to last more than a few hours because of the volume of service we do.  
I also disagree with the doctor who states that it might take a year to erase a line with BOTOX.  If you have a creased skin, then the BOTOX is never getting rid of that line.  If that is the case, an ethical core physician will be honest with you before you are even injected to help set your expectations.
My recommendation is do your homework and find an ethical office where you are getting treatment by a core physician.  You might look on the liquidfacelift.com website for the name of someone in your area with a large BOTOX practice.

David Shafer, MD, FACS · Answer

Botox works on dynamic wrinkles by paralyzing the underlying muscles and inhibiting the formation of wrinkles in the overlying skin. If you have static wrinkles (wrinkles at rest) then no matter how much Botox you use, the wrinkles are still going to be there. Over time, with constant use of Botox, the dermal atrophy which occurred causing the static wrinkles make improve. In the mean time, you may require a dermal filler to help push out the wrinkles. In general it takes up to two weeks for Botox to reach its maximum effect. Finally, 1 out of 10,000 people do develop a resistance to Botox. However, this usually requires a previous exposure to Botox. The chance that you have this is very low. I would suggest that you look at your pre-injection pictures and you will be surprised at how well the Botox is working. Good luck.

Ron Shelton, MD · Answer

For those people with very deep vertical lines between the eyebrows, it is not unusual that it takes more time to see improvement than when the lines are fine. The lines are there from having contracted the muscles underneath the skin for many years. Botox is not a filler so it does not plump up the line. It treats the cause of your problem which is the muscle movement. If you can not bring the inner eyebrows closer together, then your muscles were correctly treated. Maintain the Botox every four months or so such that the muscle does not “wake up” and allow the overlying skin to continue to relax and not crease. After several months to a year the lines can improve nicely. If you want a quicker fix, continue the Botox ,but the doctor can inject a filler underneath the crease so that it looks better while you’re waiting for the skin crease to fade. If however, your muscles are still moving between the eyebrows then you may need Botox placed in slightly different locations than the sites in which it had been previously placed, or you may just need a larger number of units of Botox.

Camille Cash, MD · Answer

There are several potential reasons for your result.  One may be that not enough Botox was used.  It may have been placement of the product.   It could be that the lines you had are too deep to be fully resolved from treatment.  Botox works to soften lines that form from muscle activity.  If you had the lines even when you weren't animating, Botox may soften that look but may not be enough to smooth them completely.  I encourage you to visit with your injector to discuss your results and concerns.

Sapna A. Patel, MD · Answer

I echo what many of the others have said. Botox works best on dynamic lines, ie. those that are not etched into the skin. If they are static or already etched into the skin, botox cannot make them go away. Those wrinkles have formed due to repetitive muscle contraction for 10, 20, 30 yrs etc. I have seen a few instances when botox does not take as well- sometimes, it may be a less potent batch. However, at our office, we always offer complimentary touch ups as we stand by what we do and want to achieve our #1 goal of satisfying the patient. The other potential scenario is if not enough was injected or if it was injected into the wrong plane- if the former occurred, you should have seen some improvement. The latter should not happen if you go to a licensed provider. Lastly- I have had a few patients build up a tolerance to botox in that it does not last as long or it takes more to achieve the same result. This is not super common but can happen. Same reason why if you have been taking an allergy pill ie. Claritin for some time,- it stops being as effective, then you switch to a different brand ie. Zyrtec or allegra and it works. There are other brands of botox, ie. xeomin and dysport which you can consider trying should this be the case.

Steven Wallach, MD · Answer

Botox does not always smooth out all lines especially if the lines are very deep or what I call "etched." They may eventually soften some more with repeated treatment. Sometimes a small amount of filler may help too.

Christopher L. Hess, MD · Answer

First, don't go back to where you got Botox.  If done correctly Botox should paralyze the muscle within 3-5 days.  It can continue this paralysis for several months.  For instance I use 25 units in the glabellar region.  I just saw a patient back today after 5 months and she's still paralyzed.  So anyone who injects Botox and it "doesn't work" after two weeks didn't do you any favors.
The next issue is skin memory.  If you've frowned for a long time then when you get Botox the wrinkles will not go away right away.  The skin has memory and will try to hold the wrinkle for some time.  It may take several sessions of Botox to resolve the issue.  If it doesn't resolve in a year consider injection of a dermal filler.
But overall time is your friend and let the Botox work.  But see a Board Certified Plastic Surgeon next time.

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