Why is my Botox Only Lasting 4 Weeks (50 Units on 33 Year Old)?

I have twice had Botox on my frown lines and on each occasion It's lasted only 4 weeks. I've been very happy with the results but not sure why it wears off so quickly. I'm 32 and have had 50 units each time. I'm a runner, could it be exercise related?

Doctor Answers 22

50 Units High Dose by Villar

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You most likely have developed Antibodies to the Botox which is rare but occurs. In our experience, 10 units will treat the glabellar lines in 90% of patients when properly injected.  The maximum recommended dose is 20 units for the glabellar area in the Botox insert.  "Distant spread of toxin effect" is being reported.

Try another product such as Dysport.  Increasing the dosage may not be prudent.

BOTOX® molecules attach to a nerve ending membrane.  They are then internalized into the cytoplasm of the nerve terminal. One molecule of Botox® then cuts one molecule of SNAP-25.  SNAP-25 is one of three molecules than must attach (docking) in order for acetylcholine to be released across the cell membrane to a muscle receptor for it to contract.

Imagine you have 10 SNAP-25 molecules in a glass.  You add ten Botox® molecules in the glass and all the SNAP-25 molecules will be cut.  Now imagine you put 100 Botox molecules in the glass of 10 SNAP-25 molecules.  You have now wasted 90 molecules of Botox®.  Some theorize that a single Botox molecule can continue to cleave more than one SNAP-25 molecule, which would be more wasteful.

At higher concentrations, cell-to-cell transfer of active Botox® has been demonstrated, which raises questions about the toxin affecting cellular targets that are distant from the injection site.

The objective is to use the least amount of Botox® that will cleave the SNAP-25 molecules in the treatment area and not overload the treatment area with wasted Botox.  Botox that may migrate to affect distant targets.

While Acetylcholine is blocked by Botox®, new nerve buds are forming.  If Botox® permanently blocked the treated nerve endings, new ones would simply grow and replace the non-functional ones.  Therefore claims, that one product is longer lasting than the others, or higher concentrations prolong the blockage, are highly suspect.  The objective is to use the least amount to do the job. 

In the early 90’s we experimented by trial and error.  We diluted a 100 unit bottle of Botox® with 10 cc of normal saline, yielding 10 units per cc which we injected using a 1cc syringe and a 30 gauge needle.  We videotaped our patients before and after for muscle function.  We decided to inject the muscle though and across muscle bellies, and across lines of innervation rather than poke them directly from above, to lessen the pain and bruising.   We observed that in over 90% of patients, 10 units of Botox® would paralyze the frown lines for over three months.  10 units of Botox® across the forehead would weaken the muscle to soften the wrinkles but avoid the “bowling ball” effect of complete loss of facial expression and forehead droop.  5 units on each side of the crow’s feet avoiding the lower lid would improve the area without lid ptosis.  We then adjusted for patients with greater or lesser degrees of muscle mass.  In five days we could evaluate the effects and adjust accordingly.  We were pioneering in those days and had to figure this out for ourselves when treatment for wrinkles was off-label.   It now seems we evolved our technique on one of the Galapagos Islands.

Botox® Cosmetic recommends reconstituting a 100 unit bottle with 2.5cc of 0.09% sterile non-preserved sodium chloride which would yield 40 units of Botox® per 1cc syringe.  

In our twenty-one year experience, this is four fold the effective dose.  It may also explain reports of effects and complications beyond the site of injection.  Advances in immunostaining techniques reveal active Botulinum A can migrate cell to cell in high concentration. (jneurosci.org/content/31/44/15650.full.pdf).   We have just scratched the surface of understanding Botox®.

Perhaps our technique improves the effectiveness of our dosages, but we had similar results with the more common stabbing technique, which we also tried.  We encourage intellectually curious colleagues to experiment and find the lowest possible dosage that saturates the nerve endings and accomplishes the mission without wasting molecules of Botox® that are yet to be fully understood and may migrate to sites beyond local injection as noted in the warning label.

West Palm Beach Plastic Surgeon
4.4 out of 5 stars 11 reviews

Botox in forehead

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I have found very active athletes chew up filler and botox faster than average atheletes.  You may want to try dysport.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Botox wears off too quickly

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Thank you for your question and concern. I train a lot of injectors in the proper technique for Botox injections. Here are some of the common reasons that Botox wears off too quickly:
1) Inadequate dose - higher doses usually corrects the problem
2) Cookie cutter approach to injecting Botox. The same technique is used for every patient and it works for most, but not all patients. The cookie cutter approach fails to appreciate the differences in anatomy of the facial muscles that can vary by the individual.
3) Rarely, there are patients who truly have shorter durations with Botox and may want to consider the different neuromodulators available to see if there is a difference.

I would recommend that you go an experienced board certified plastic surgeon or dermatologist who does a high volume of injectables to discuss your experience in more detail.

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When botox lasts only a month, then there's a problem...

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sorry to hear about your short duration of botox activity...the usual culprits include not getting 50 units but much less, improperly stored botox that was left at room temperature for too long, counterfeit product that really wasn't the botox or some resistance your body has to the product...remember botox doesn't work on everyone...botox works at a specific site...if you have an abnormality of the gene encoding the area where botox works, then you may be resistant to the product...the idea that your body makes antibodies that cancels the effects is old, outdated and not of clinical significance...the running may be an issue but will not totally explain the situation...finally do you have before and after pictures...often you may still have an effect that you're unaware of without the advantage of side to side pictures...maybe next time try a different doctor and see if the results are the same

Ken Landow, MD
Las Vegas Dermatologist

Possible Injector Inexperience

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It is most likely the amount used for the specific area that makes the botox appear as it is “worn off.” The peak effect of botulinum toxin is 2 weeks, and from there new nerve endings start to sprout to regain normal activity, but wrinkles from movement take about 3 months to be seen again (if the right amount is used to begin with) and full movement typically comes back shortly thereafter.  Antibodies can occur, although usually in those who have had large doses used for other indications (ie: cervical dystonia, muscle spasms, etc) for a long period of time.  I would consider seeing a board-certified Dermatologist or Plastic Surgeon for a second consultation and treatment.

Sabrina Fabi, MD
San Diego Dermatologic Surgeon
5.0 out of 5 stars 91 reviews

Why is my Botox only lasting 4 weeks?

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The amount of time Botox lasts will not be related to exercise. In general, the Botox lasts for 3 months on average. If you do not feel that the Botox is lasting long enough, you may want to ask your provider about Dysport. It has a faster onset than Botox and lasts slightly longer. I hope this helps, and best of luck to you.

Paul S. Nassif, MD
Beverly Hills Facial Plastic Surgeon
4.7 out of 5 stars 49 reviews

Botox and longevity

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Depending on placement and technique, this has been know to happen for some people, a shorter efficacy than what's expected for cosmetic Botox. Sometimes we recommend trying a different neuromodulator - or waiting a little longer between treatments to avoid potentially building up a tolerance to the product.

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

Duration of Botox

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Make sure you are seeing an experienced injector preferably a board certified doctor in plastic surgery or dermatology. It has been my experience that some people do develop a tolerance to Botox or the other neuromodulators and it is more common in more athletic active patient's possible due to a higher metabolic state in there body were they break the substance faster. There is a theory about possibility of antibody's to Botox but not sure if it has been proven.

Good luck


Botox Resistance

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Botox "wears off" gradually; it's not working one day and gone the next. Usually at four weeks post treatment this process loss of treatment effect has not begun. That said, I have had a couple male body builders who were quite resistant to Botox. They required more and did not last long. The usual explanation is anti-Botox antibodies. I've wondered if something about this activity, bodybuilding, has an effect on all muscles including the facial muscles even though they are not the ones being intentionally exercised.

Alexander Lewis, MD
Walnut Creek Dermatologic Surgeon

Duration of Botox in a runner

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People who exercise more, especially if it involves facial straining (e.g. weight lifting), tend to have a shorter duration of Botox effect. That said, make sure you have an expert injector such as a dermatologist to ensure you're receiving the correct dosage, injected into the correct anatomic muscles, and at the right depth. Another option is to consider a different botulinum toxin such as Dysport or Xeomin which may give you a longer effect. Dr. Benjamin Barankin, Toronto Dermatology Centre.

Benjamin Barankin, MD, FRCPC
Toronto 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.