Botox Stopped Working: Resistance?

Question

I've had Botox for frown lines, crows feet, and forehead wrinkles about 6 - 8 times since 2004. I travel a lot so have been to several different doctors and always had wonderful and almost immediate results. In January this year, I went to a new doctor and was disappointed with the results - I felt the treatment was too conservative - did not get as dramatic or long lasting result.  In October, I went to someone else, absolutely no results; 2 weeks later they did more Botox  - still no results.  Then about a week ago, after consulting with the Botox rep, they tried to inject other facial muscles - still no results. I have been reading about Botox resistance, and it seems patients with resistance experience this from the very first injections. But mine is years after the fact. What does this mean?  What can I do short of surgery?

Richard Baxter, MD · Answer

Resistance to Botox is not as well understood as we would like, but it is most likely to be related to formation of antibodies (an immune system response). This does not typically occur early on, but after several injection sessions. There is some evidence that having injections too frequently, less than 3 months apart, may make it worse! There are some more invasive options such as the "no-tox" procedure or browlift. Your best bet might be to wait at least 6 months and try it again.

Larry S. Nichter, MD, MS, FACS · Answer

It is possible to develop resistance to Botox,usually through your body making antibodies to the Botox. Also be aware that the expertise of the injector and the number of units injected are also variables that may account for decreased response. However, if you have developed a resistance, then Dysport or Xeomin  may still work.  Dysport, Xeomin and Botox are all preparations of botulinum toxin A which is a derived protein that works at the nerve-muscle interface to relax targeted muscles. Dysport and Xeomin have been around in Europe for a long time and more recently introduced in the USA. Note the dosage is not the same between the drugs though each works well in my experience.

Harold J. Kaplan, MD · Answer

It is possible to become Botox resistant. In fact for the two patients we have had in our practice over the past 5 years that have experienced this phenomenon, it has happened after they have been using Botox for a period of years. 
There is no easy explanation for why this happens, but the product simply does not have the same effect after it does. With both cases, our experience was the same as Dr. Baxter's that the patients were getting injected more frequently than recommended (and not just at our office!).

David C. Pearson, MD · Answer

It's certainly possible that antibody formation has occurred, in which case Botox will be unlikely to paralyze or weaken the muscles of facial expression. (And don't get your hopes up for Reloxin, since it's also botulinum toxin type A and should be antigenically the same).
Myobloc--botulinum toxin type B--may be worth a test, but it's generally reserved for non-cosmetic use for disorders of muscle spasticity.
Bioform's technology for electrically frying the nerve branches to these muscles is not available in the U.S., and Bioform has suspended clinical trials of the device for the time being.
Is it possible, though, that the wrinkles you're trying to minimize are really requiring a filler to smooth them out (something like Restylane, Juvederm, etc.) or are you saying that the muscles themselves were still moving well despite the Botox?

Steven Wallach, MD · Answer

Botox resistance has been reported, and it sounds like you are maybe one of these individuals. Botox is botulinum A toxin, a product available in Europe and soon to be available in the US is Reloxin which is Botulinum toxin B. This should work for you.

Botox Stopped Working: Resistance?

Answers (8)