Does everyone eventually develop resistance to Botox?

Question

Does everyone eventually develop resistance to Botox? I’ve been getting Botox in my masseter muscles and understand that they require higher units. Over an extended period of time, such as 10–20 years, does it stop working eventually? Is this a common occurrence? I know the Botox clinical trials report that true resistance occurs in only about 1.5%, but I wonder if that data may be biased since it comes from the company itself.

Rosy Sandhu, MD · Answer

That's a good question, which I get asked often by my patients as well. Botox or neuromodulator resistance is actually quite rare. In over 12 years of injecting, I’ve only seen it happen twice, and in both cases it was more a case of the patients being "non-responders" Fromm the beginning rather than it stopped working over time. I have not seen it become an issue even in higher-dose areas like the masseters. When people feel their Botox “isn’t working as well,” it’s usually due to small changes in technique, dilution, or muscle atrophy over time, and not true antibody resistance.I recommend waiting for muscle movement to come back over 3-4 months, rather than getting it too soon and staying on a regular schedule, and as such botox should continue to work reliably for many years. Hope that helps. Best, Dr Rosy Sandhu

Anna Chacon, MD, FAAD · Answer

That’s a really thoughtful question. True resistance to Botox is actually quite rare, with studies showing that only a very small percentage of people develop neutralizing antibodies that make the treatment less effective. The figure you mentioned, around 1.5% is consistent with what’s seen clinically, and while it is company data, it has generally held up in broader use as well.

What most people notice over years of treatment isn’t usually “resistance,” but rather changes in their own anatomy, muscle bulk, or even technique adjustments by the injector. For example, the masseter muscles are larger and often need higher doses, so it may feel like more is required over time. But that doesn’t necessarily mean your body has stopped responding, it can simply reflect the natural changes in your facial structure or your treatment goals evolving.

In very long-term use (10–20 years), Botox still works for the vast majority of patients. The key is careful dosing and sometimes switching between different formulations (like Dysport, Xeomin, or Jeuveau) if there’s ever a concern about diminished response.

So, to answer directly, no, not everyone eventually develops resistance. It’s uncommon, and most patients continue to benefit from Botox safely and effectively for decades.

Leonard Grossman, MD · Answer

Not all individuals develop Botox resistance. Botox resistance would imply that your immunologic response is such that the neuromodulator simply no longer works on you. That happens in a very small group of patients. The good news is that even in the group of patients who no longer respond to Botox there is Myobloc, which is an excellent replacement and works in practically everyone. I hope this helps and good luck from Leonard Grossman, M.D., organic Plastic Surgery, New York City.

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