I Think my Botox Injections Didn't Work, Is This Possible?

Question

On Friday, I got 38 units injected into my forehead, crows feet, and area between my eyebrows. It's been over 72 hours and I see no effects. I've had Botox 2 times before. The 1st time I got 45 units and the 2nd time I got 30 units... which I felt was more natural. This time I went to a different doctor (I moved) and she gave me 40 units. I called her and she said to come in on Friday and she'll reinject me, as much as needed. But I'm scared! Why didn't it work?? Can I get 80 units and be OK??

Theda C. Kontis, MD · Answer

I would not recommend getting more Botox until you have waited a full 2 weeks. After 2 weeks, return to your doctor for re-evaluation. Very occasionally, we have people complain that it "didn't work"--sometimes we notice it was from the same lot number. Usually when I see patients who complain that it "didn't work," it has worked; either they just need a touch-up, or they weren't looking at the right area on their face. It is safe to get 80 units, but you may not need that much.

Jerome Edelstein, MD · Answer

It can take up to 2 weeks for results to appear. If by two weeks you still aren't satisfied with your results, please return to your injector.

Ron Shelton, MD · Answer

Botox can take up to two weeks, and even more to have the peak onset of effectiveness. If you get more Botox injected before the peak effect occurs, then you may have more of a relaxation effect than you wish. A reasonable wait is between one and two weeks, and unless a patient is very asymmetric, and needs an urgent readjustment, I prefer to have patients wait two weeks. Of course some patients need more units than others. Other variables are if the Botox was diluted a while ago and lost some potency, or if another product is used or if it is injected into different anatomic sites. Botox uses a physician's scientific and aritistic sense. Hopefully you'll see more improvement as you wait for a few more days.

Kelly Gallego, MD, FACS · Answer

Botox is an extremely common treatment in the United States with roughly 5,300,000 procedures performed in 2010 according to the ASPS. Every injector probably administers the medication a little differently. For moderate to severe frown lines, I typically start with 20 units total and make five separate injections each with 4 units. I prefer to use 16 units for forehead lines, and another 16 units for the crow's feet. It usually takes a day for the medication to start working and one week for it to have its final effect. I always try to take photos prior to the treatment, and I see patients back at two weeks to make sure the results are desirable. If it gets to be a week, are you are still not happy, you should certainly discuss your concerns with your plastic surgeon.

Alex Eshaghian, MD, PhD · Answer

Thank you for your question Kato Potato. I understand your concern. Botox is a purified protein used to address wrinkles associated with facial expression. When injected into the skin Botox will relax the muscles and smoothen out the overlying wrinkles. The most common areas of treatment are in the upper face. These include the horizontal lines seen on the upper forehead when one raises the brows, the vertical lines seen between the brows when one frowns (frown lines), and the crow's feet seen around the eyes when one smiles.It is difficult to make an assessment in the absence of consistent photographs before and after in the same lighting and angles for comparison. However, I hope the information provided here is useful.The appearance of frown lines is variable from person to person. Usually they are in a vertical orientation but sometimes they can be oblique and sometimes a horizontal line is seen across the upper portion of the nasal bridge. The most common variation is to have two parallel lines, hence the common term "11's" to describe them. But some people have one, three, or more lines. Some people also will see a bulge in the area when contracting the muscle. This bulge is smoothened out after a Botox treatment.The pivotal studies used 20 units of Botox in the glabella area between the brow to address the frown lines, 24 units of Botox (12 units per side) to address the crow’s feet, and 20 units of Botox in the forehead area above the brows to address the horizontal lines seen when one raises the brows. These studies demonstrated that the peak results are seen 14 days after the treatment and most people enjoy their results for 3-4 months. At that point, a maintenance treatment is recommended. While some people start to see results as early as the next day, it can take two weeks for full results so patience is important. We have our patients return two weeks after their treatment to assess their results via photographs. At that time additional units may be added if necessary.If I had a patient with the concern described here I would recommend being patient and waiting a full two weeks for full results.With any injection, there are risks such as pain, bleeding, bruising, redness, swelling, tenderness, and infection. We take special precautions to minimize these risks such as using a painless technique. We also treat bruises with a laser as early as the next day. Bruises usually resolve within two weeks if untreated. After a laser treatment bruises usually resolve in 1-3 days, but may still take two weeks for full resolution. In addition to these risks, with Botox there is also a risk that the product spreads or diffuses to nearby structures. Spread to nearby muscles can lead to side effects such as the temporary appearance of droopy eyelids or a temporary asymmetric smile.
  
After a Botox treatment, I recommend that my patients avoid heat exposure, alcohol consumption, and strenuous exercise for 24 hours and not lie down flat for four hours. This is because all of these activities may possibly lead to the movement of the product and consequent side effects such as droopy eyelids. Although there have been no definitive studies shown that these actually occur and some physicians do not provide such aftercare instructions, in the absence of data I err on the side of caution and recommend that my patients avoid such activities.
  
Please consult with a doctor for specific recommendations. Good luck!

Kris M. Reddy, MD, FACS · Answer

It will take another week to ten days to determine the maximum benefit of the treatment. The efficacy of botox can be impacted by the technique, storage, and dilution of the product. Therefore, 40 units in experienced and expert hands will go further than 40 units in inexperienced hands. If you wait for the two weeks, it would be safe to get additional units when you return.

Esta Kronberg, MD · Answer

Botox can take 2 to 10 days to work. I would not get any more injections without waiting 10 to 14 days. I usually use 20 units in the frown crease, 20 units for the forehead and 24 units for the crows feet.. So you definitely did not get a lot of units if you had all 3 areas injected. Another thing to ask is do they save their Botox? If so ...how old was the bottle? Botox is it's most potent if mixed the day you receive the injetions.

Sheri G. Feldman, MD · Answer

Please wait at least two weeks before assessing whether or not your Botox treatment has worked. 38 units to cover the three areas you described is not a lot of material. It is possible that you will need more, but please wait the two weeks before making that decision.

I Think my Botox Injections Didn't Work, Is This Possible?

Answers (8)

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