Why Didn't Botox Work?

I was treated with the maximun allowed amount of Botox. It was injected into my forehead, between the eye frown lines and the crows feet. There was NO improvement at all, I looked exactly the same. My Doctor said "It doesn't always work"....$600 later, and he tells me...."sorry, it didn't work for you, lets try Juvederm". I told him absolutely not and left his office extremely frustrated.

Doctor Answers 10

Why didn't Botox work

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Botox has to do with the number of units, the concentration of those units, and the technique of your injector. All of those play a role in how Botox works. However, Botox really only works well on dynamic muscles - the muscles that make you move your eyebrows, create wrinkles in your forehead, and pull your eyebrows together to furrow them. If you have static wrinkles - lines that are still there in the mirror even when you're not moving your face muscles - Botox doesn't work as well on those. This is often what people don't understand. I have a feeling that if you had a full treatment, you can't move your dynamic muscles anymore, but you still have static wrinkles, which is what is frustrating you. Some people do require both Botox (to stop the muscles from moving and creating the lines) and a filler (to fill in the lines that are still there regardless of muscle movement). However, based on your frustrations, I would suggest you visit another physician or two for an in-person evaluation and assessment.

Botox for the deep glabellar lines

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It is extremely rare that Botox, at the right dose, and right placement, won't inhibit the contraction of the frown muscles. Once the muscles are seen to be relaxed and can't contract with the attempt, the finer creases in the skin overlying those muscles often improve quicker than the deeper lines or folds.  It might have taken years for the creases to develop after many contractions of the muscles pulling the skin into pleats. It could then take a long time for those lines to improve after the skin isn't being pulled back and forth.

In some patients, the off-label use of sparingly applied hyaluronic acid fillers can help lift the lines while waiting for Botox to produce its long term result. The patient may not need ongoing filler, but the Botox does have to repeated as it wears off usually between three to four months. There are some risks with any cosmetic injection so discuss them with your doctor.


Ronald Shelton, MD
Manhattan Dermatologic Surgeon
4.9 out of 5 stars 39 reviews

No response to Botox

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Is this your first time with Botox? Were you told how many units were used? There is no such thing as a maximal amount of Botox.  It should be described as an optimal amount.  There are several reasons Botox 'does not work'. One is that the solution was too dilute.  The bottle could have diluted too long ago or stored inappropriately and therefore no longer active.  If the doses of Botox were not placed directly into the desired muscle it could diffuse out into fat or serum before it had a chance to block the muscle and create the desired relaxation.  There are very rare cases of long term Botox patients who develop antibodies to Botox and effectively neurtralize an injection before it has a chance to work.  Botox is not the same as any filler or collagen stimulator, so there is substitution of one for the other. Be careful with fillers in the forhead!

Steven Swengel, MD
Los Gatos Dermatologic Surgeon
5.0 out of 5 stars 13 reviews

When Botox doesn't work...

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There are a number of answers to your problem.  First of all, a careful analysis of your pre and post injection photographs will help determine how much the Botox affected the treated areas.  If you have reduced movement of the muscles now compared to before your injections, then the Botox is working to some extent.  In this case I would recommend a thorough discussion with your injector in order to clarify the expected results in the treated area.


If indeed you do have full movement 2 weeks after injection, then there are several possibilities:


1.  Poor injection technique will lead to poor results (improper placement of the medication)

2.  Botox which was left at room temperature too long or was used too long after reconstitution has reduced efficacy.  If your injector does not use Botox on a regular basis (as a side business) this might be more likely.

3.  Very, very rarely, patients can develop antibodies to the Botox so that the body inactivates it before it can take effect.  This is occurs in patients who have received Botox at least once before.  This can be evaluated with a lab test...but again it is EXTREMELY unlikely.


I would consider evaluation and treatment with another experienced injector in the future, but be sure to discuss your previous experience and your expectations with your new doctor.

Michael Bowman, MD
Roanoke Facial Plastic Surgeon

Botox Did Not Work vs. Managing Patient Expectations

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Before and after photos are helpful in these situations to assess the results. It is rare that the type A botulinum neurotoxins (BoNT-A) do not produce any muscle paralysis at all. However, I have had about three patients over the years that seem to have a more blunted response. They have returned to the office stating that the product did not work at all. I have compared their post-treatment muscle movement to the pre-treatment photos and this has demonstrated that some muscle relaxation has occurred, but not to the extent I would expect for the typical patient. I have then re-treated them with some subtle improvements; but the overall result is still blunted and less than what I would consider even an average response. The use of these pre-treatment photos has helped the patients understand that there have been changes even though the muscle relaxation has not been significant.

I don’t know if your situation fits with the above scenario or if you were expecting deep lines/wrinkles in these areas to be eliminated by Botox. I suspect that since your physician recommended Juvéderm, it was the (deep) lines and wrinkles you were focusing on and expecting to be improved. The Botox may have worked well to relax the muscles -- but you may have not recognized that since the lines still remain, or you had a misunderstanding of what Botox would achieve.

It is important to establish expectations for these treatments ahead of time so patients understand what type of result they will experience and how long that result will last. For those individuals with deeper lines, a BoNT-A may not be the only answer, and the use of a soft tissue filler may be needed to (greatly) enhance the results. Patients are accepting of this if a detailed explanation is provided to explain how each product works individually, and how the results are enhanced by combination treatment. Your frustration has been increased by the response you received from your physician. An experienced injector should be able to evaluate a patient and communicate an idea of the anticipated result so that patient’s expectations are appropriate. In situations where a BoNT-A may not correct the line(s) completely, the patient then understands that a filler may be necessary.

In all but the most severe lines, when I think patients will need both neurotoxin and filler to achieve the best result, I usually stage the treatments. I will inject the BoNT-A first. Two weeks later I will assess the results and decide if I have maximized that treatment; if not I will touch it up as needed. If the lines are too prominent I will add a hyaluronic acid filler. This combination treatment provides significantly better results than either treatment could alone; the filler softens and smoothes the deep lines and the muscle relaxation minimizes continued skin wrinkling and creasing, and prolongs the life of the filler.

Best wishes, Ken Dembny

Kenneth Dembny, II, MD
Milwaukee Plastic Surgeon
4.9 out of 5 stars 36 reviews

Dysfunctional Botox...

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It is very difficult to determine what the problem is based on your history.  I have never had a "bad batch" of Botox, but it could happen.  If it wasn't refrigerated and was allowed to deteriorate, it won't work.  More often I usually discover when patients complain to me that it didn't work, that it actually did work, but that it didn't do exactly what the patient wanted.  For example some patients have the 11s treated successfully but then recruit other muscle groups on the forehead.  Also, the results may not be as good as you would like if you are just starting with Botox and have very large-beefy muscles.  Maybe if you could post some pictures, describe what areas have been treated and then provide us with resting and frowning photographs we could help you further.  Good luck!

Curt Samlaska, MD
Las Vegas Dermatologist

Botox didn't work

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I'm not certain as to what is meant by "Botox didn't work". Botox is a neuromodulator and it is intended to weaken the muscle being injected so that over time, the extent of wrinkles caused by the contraction of that muscle is reduced. One Botox injection is not going to correct your wrinkles, especially if they are static wrinkles which are easily visible fur roes or lines at rest. I expect that you have significant decrease in muscle activity in the targeted area if you were injected with adequate dose and in proper plane. It will take repeated, regular treatments to see improvement in advanced rhytids.

Edwin Ishoo, MD
Cambridge Facial Plastic Surgeon

Botox and Efficacy

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It is very unusual for someone not to respond to Botox, and very difficult to answer your question without seeing you in person and assessing your specific situation. Juvederm and Botox are two completely different products that aren't used interchangably.

Sam Naficy, MD, FACS
Seattle Facial Plastic Surgeon
4.7 out of 5 stars 231 reviews

Botox with no results

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There are a few factors that may have occurred causing you to receive “no results” following your Botox treatment. First is, there may have been a “bad batch” of Botox product and all the patients treated from that vial, would not have results. Check with the provider to see if that may have happen.  Second, less than two percent of the population treated with Botox can build up a tolerance to the botulinum  A toxin. If either of those were not the situation, you may want to revisit what your expectations were prior to having the treatment preformed. Botox is used to immobilize the muscle and not “fill” lines. The two treatments work well together, it can be pricey, but the results are more often than not worth the cost.

Steve Laverson, MD
San Diego Plastic Surgeon
4.9 out of 5 stars 50 reviews

Botox disappointment

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It is very difficult to tell why you did not improve with your treatment.  Usually a patient is evaluated to see whether relaxing muscular movement alone with solve their problem, but sometimes combined treatment with fillers is needed.  If this was not made clear to you up front you should discuss it with your current physician or consult another experienced physician before you undergo further treatments.  

Margo Weishar, MD
Philadelphia Dermatologic Surgeon

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.