Horizontal glabellar creases + rolling acne scars, what can I do if Botox didn't work? (photos)

Question

I have 2 horizontal glabellar creases that run across my nose between my eyes. I’m pretty sure they’re genetic because my dad has them, and are a result of a very expressive face and personality. I’m only 24 and have had two treatments of Botox in the past. It’s been 2 months since my last treatment and this time time around it doesn’t seem like the Botox accomplished anything. I also have an abundance of acne scars. Since I’ve stopped birth control my skin has improved a lot!

Nelson Lee Novick, MD · Answer

In general, when properly injected, in the apprropriate locations, and in adequate concentrations, Botox typically works well for both glabellar frown (scowl, angry, "eleven") lines and for the horizontal lines shown in the photos, which are often referred to as "bunny" lines. Although true resistance to Botox is felt to be very uncommon, I have found, in the course of the 27 years I have personally been injecting Botox for aesthetic reasons, that some individuals may tend to develop a relative resistance to the product, especially if they are injected too frequently or when "touch up" treatments are performed only a week or two after actual treatment, rather than a preferable four or more weeks afterwards, which is my routine recommendation. Alternatively, you may be switched to either Dysport or Xeomin, the two existing competitive neuromodulator products currently available. Regarding the acne scars, it appears that there are several rolling and boxcar scars and many ice pick scars. For the latter TCA CROSS is an excellent, simple, quick and relatively inexpensive tried and true treatment approach. Subcision, another time-tested, quick and relatively inexpensive acne scar treatment, may be used for  the boxcar/rolling scar varieties. It is important to note that successful background treatment with Botox can actually improve the results of the actual treatments by diminishing movement in the region and allowing new collagen and elastic fibers to be lain down without interference or disruption by the excessive mechanical motion of the background musculature.   Be cautious about recommendations for this or that laser or energy-based therapie that may be pitched to you, as these are backed far more by device manufacturer supported marketing hype than hard science. Due your "due diligence."  For more information on any of the above, check out the archives of RealSelf.com, and be certain to consult with a board certified aesthetic physician with experience and expertise in  Botox injections and acne scar treatments. Best of luck.

Harold J. Kaplan, MD · Answer

Hi SF.  For the lines you are targeting at the bridge of the nose, the muscle that controls them (the lower procerus) needs to be injected.  Perhaps your previous injector only dosed the upper portion of the procerus?  Also, the "bunny lines" at the sides of the nose contribute to this concern as well and so we would inject those lines at the same visit.  
For the acne scars, they appear very moderate.  If anything, we would suggest a glycolic acid or Retin A product to expedite the exfoliation process, which will resolve those red scars as quickly as possible.  Best of luck.

Michael A. Zadeh, MD, FACS · Answer

Sorry to hear about your Botox experience. Looking at your pictures, you appear to be a good candidate for Botox to the area to help weaken your strong muscles. It may be that you didn't get enough Botox or the placement was incorrect. I would consider another try with an experienced physician injector. If for some reason you are Botox resistant then a treatment like ThermiRase can disable the nerves in the area long term, providing a Botox like effect. As for your acne scars, a combination of treatments can provide improvement. Make sure you see an experienced provider. Best wishes.

Jason Emer, MD · Answer

Botox can be used to improve horizontal lines. Deeper wrinkles need a combination approach with Botox and lasers, microneedling/prp and fillers. I recommend getting a formal evaluation with a cosmetic dermatologist. Best, Dr. Emer

Ron Shelton, MD · Answer

One of your photographs shows with contraction of muscles that the procerus muscle and some of the corrugator muscles are still working despite the Botox. It is possible that either not enough units of Botox were used for your strong muscles or the placement of the Botox was not exactly where it needs to be for your anatomy.
It might be worth seeing another board-certified specialist such as a dermatologist or plastic surgeon for one more try of Botox.
The information provided in Dr. Shelton's answer is for educational purposes only and is not intended to constitute medical advice.  The information provided should not be relied upon as a substitute for consultations with a qualified health professional who may be familiar with your individual medical needs

Monika Soni, MD · Answer

Thank you for your question! It may be that you need more product to help with the lines that bother you.  Botox typically works well in that area.  For acne scars you can consider microneedling (Skin Pen).  It does a very nice job in improving skin tone and texture, including improving the appearance of acne scarring. Best of luck!

Camille Cash, MD · Answer

It may be that you need more product to help with the lines that bother you.  Botox typically works well in that area.  For acne scars you can consider microneedling (Skin Pen).  It does a very nice job in improving skin tone and texture, including improving the appearance of acne scarring.

Nicholas Gentry, MD · Answer

You should be able to greatly reduce those lines with Botox (tell them to inject your bunny lines and glabella). If you are the rare person who is more resistant to Botox, then I recommend Disport or Xeomin, which are different enough structurally to help avoid this. For Acne scars, I would start with a Vampire Facial which is a combination of micro needing and platelet rich plasma +/- Profractional laser treatments. I usually have patients do a Vampire Facial then 6 weeks later a Profractional Laser treatment with PRP and then for the 3rd treatment pick whichever they prefer or whichever we think they responded to better. VampireFacial.com can help you find a certified provider in your area

Anne V. Hale, MD · Answer

Hi. One could add additional strategically placed Botox and skin tightening with other modalities. This would likely at least minimize your concerns.

Jean M. Casello, MD · Answer

Botox is a very good option for horizontal glabella lines.  It may be that the dosing and/or placement of the botox needs to be adjusted.  You should discuss this with your provider especially if you have had a good result previously.
  There are many types of acne scars. The treatment for scars depends on the type of scar and the patient's skin type.  Options for treating scars include laser resurfacing,microneedling/PRP , subscision and dermal fillers. Often times we combine treatments to get the best outcome. You should consult with an experienced provider who can best advise you.

Horizontal glabellar creases + rolling acne scars, what can I do if Botox didn't work? (photos)

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