Botox Resistance - Why Doesn't Botox Work for Me?

It is possible to develop a resistance to Botox, but this is extremely uncommon. Other reasons for failure of treatment can be related to injection technique or inadequate number of units. The dilution technique is not relevant, but the total number of units injected is the key.
Another reason for "failure" may be when the corrugator/procerus muscles are immobilized there is recruitment of orbicularis oculi muscles. What this means is that the eyelid squeezing muscles can create some movement between the eyebrows, but any resultant lines should be significantly less severe than those present before Botox treatment.
If it is determined that there is patient resistance, one option is to try a different variety of botulinum toxin such as type B (Myoblock). This is off-label for cosmetic use. Another alternative is radiofrequency ablation of the corrugator nerves. This is a procedure marketed by Bioform (Relaxed Expressions) that is FDA approved for peripheral motor nerve ablation and can produce a Botox-like effect for a longer period of time than Botox.

We're wondering whether you are resistant to Botox or if Botox is not the right tool for the problem. Every once in a while, we see a patient with ONE vertical line in the area between the eyes that is so deep that Botox will not fix the problem. In these cases, it is possible to use Botox and/or a dermal filler such as Restylane to solve the problem. While this injection technique is not that common, it can be very effective when used by an experienced injector.

Julianna,

Resistance to Botox is very rare (1:10,000) and the cause is not completely known. What is known is that your body forms an antibody response to the Botox. If you do have resistance, there are other forms of Botulinum toxin that can be used. That said, it is unlikely that you are resistant. From your description, it seems more likely that you need a dermal filler in addition to the Botox. Botox works on dynamic wrinkles - that is, wrinkles that appear when the muscle contracts. Wrinkles that are there at rest are called static wrinkles. These wrinkles are not completely treatable by Botox. The wrinkles are due to years of trauma to the dermis (skin) from continual movement. (These could have been prevented had you started Botox before they appeared) Now that the wrinkles are there and not treatable by Botox, you need a filling agent such as collagen, fat or any of the off the shelf fillers to push the wrinkle out from below.

I hope this is helpful.

"Why doesn't Botox work FOR ME?" and "What is wrong WITH ME?" are the most commonly heard self-directed complaints we hear from patients coming to us from other offices or spas thinking that somehow they are to blame for inferior or non-existent Botox results.
Let's cover the causes of "Botox work for me"RAREST cause - your body has formed a resistance to Botox by forming antibodies to it. It is known as TACHYPHYLAXIS (take notes - this would sound great at a cocktail party...). I have done thousands of Botox treatments and have never seen it. Can it happen? theoretically, yes with large doses of Botox given frequently.
Common cause - you have a wrinkle which is present at rest. If the wrinkle deepens when you smile or frown BUT is present when you do not. Botox, despite of how potent of expertly it is given you, will not smooth the wrinkle by itself. A filler needs to be put it.
COMMONEST CAUSE - you were given an insufficient amount of active Botox. The Botox in your syringe was either too old and inactive, overly diluted and watered down (too few active units), fake Botox or all of the above. A touch up with more (active) Botox is in order.
REMEMBER - Unless you are Superman, properly administered Botox WILL work on you.

It is unusual for a patient to be immune to Botox. However, there are some patients that develop resisitance and newer products not yet available may be helpful( Reloxin). Reloxin is derived from a different strian of botulinum toxin than Botox.

If the muscle are paralyzed and theline is still there, then it is most likely a dermal deficiency crease which may benefit from undermining surgically or a filler or the combination of the two to soften its appearance.

There are rare but documented cases of Botox resistance.

If the Botox was stored properly, freshly opened and mixed properly, you may need additional units to obtain optimal results. You just need to ensure that you are not receiving too many units in order to avoid possible side effects.

If a photo was taken prior to treatment, you may want to see if any improvement occured. If you did receive some improvement, you may need to repeat the treatment after a few months.

The muscle is generally easier to treat after a couple of treatments.

Sometimes the muscles between the brows (the corrugators) are bigger and more hyperactive in some people. For this reason, one patient may require a little more of the product than another patient to gain the same amount of paralysis of the muscles.
The muscle also spans from the top, or root, of the nose all the way over to the lower forehead just above the inner third of the bony orbit of the eye, so the expanse of the muscle belly needs to be injected in order for it to be completely immobilized.
Also, different doctors use different dilutions of the product to deliver a certain amount of units of Botox into the muscle. Perhaps you could ask your doctor what dilution he or she is using.
Best,
Dr Walden

There are occasional cases of true Botox resistance. If you are indeed resistant to Botox (botulinum toxin type A), which is very rare, you might be more susceptible to botulinum toxin type B, which will be coming on the market soon. In these cases, treatment with Restylane can provide enough volume support to improve your appearance significantly. Often it is helpful for patients who respond well to Botox, but have really deep creases, and need additional correction. Sometimes, the solution is even easier, and just additional touch up Botox injections are all that is needed to correct a seemingly resistant case.

I would agree with Dr. Sinclair's bulleted list completely; however, I do not agree with his assessment that all failures are due to the injector and not the Botox. There are case reports of failure of Botox, even in the cosmetic realm after its reformulation.

The most recent of these reports of failure of Botox Cosmetic was provided in the facial plastic surgery clinics of North America in 2007. Several other case reports of Botox Cosmetic have been published as well as several case reports from use of Botox in other areas for medical purposes. It seems that the onset is variable and some reports show no response to injection even on the first injection, though most nonresponders occur after several injuections (the 2007 article I referenced showed no response on his 15th injection).

I would suggest returning to the physician and discussing your problem and if this does not work, obtaining a second opinion.

The incidence of Botox resistance is very small.  More likely an inadequate dosage of Botox units was used and more is required. Sometimes a dermal filler is needed for deep grooves instead of more Botox.