Why Isn't my Botox Working As It Has in the Past?

There is no real way to answer this question other than there may be some variance in technique between injectors and/or storage, dilution, and technique between injectors.  generally speaking, 40 units of Botox should be sufficient to treat the glabella and horizontal forehead lines. I encourage you to discuss your concerns with your Surgeon.  If you aren't satisfied, you might want to consider returning to your previous injector.

Before too much time goes by, it is worthwhile to see the treating physician if your Botox treatment hasn't worked. Try not to let more than one month pass before seeing them. It is best to try to see the doctor between two and four weeks. Less than a week is not enough time to allow the Botox to take peak effect and close to three months is the time that is wearing off in most patients.  Your doctor can examine you and determine why their treatment wasn't successful. It can take one or two treatments for a doctor to get to learn your unique anatomy and give you an ideal treatment. Most doctors would want you to be happy with your result and would want to see if you if are displeased.

It is very difficult to know, especially in the case of switching from one doctor to another, what precisely may be contributing to non-responsiveness to Botox in someone who has previously responded well to such treatments. If differences in injection technique and placement, and variations in dilutions can be excluded, it is theoretically plausible that antibodies may have formed to some of the proteins that are typically bound to Botox in the manufacturing process. 

I was one of the first physicians in the United States to use Botox for aesthetic purposes back in 1991. On a number of occasions in the course of these past more than two decades I have encountered individuals who in the past responded beautifully to Botox but who subsequently lost their excellent responsivity to the product despite the lack of any changes in technique, dosage or dilution--a phenomenon suspected, though not proven, to be due to the development of antibodies against the Botox

In the past little could be done for such individuals. Today, I simply switch these people to the one of the two other currently FDA-approved forms of neuromodulators: Dysport and Xeomin. Xeomin has the advantage of being manufactured free of the proteins commonly attached to the Botox molecule. Since it is these proteins, rather than the active neuromodulator itself, that is believed responsible for promoting antibody formation, Xeomin offers the theoretic advantage of being least likely to engender antibody resistance. To date, I have found that switching such individuals does result in a return to the former degree of responsiveness. So, if the development of antibody-based resistance seems a possibility, a switch to Xeomin would be worth a try.

Presumably you have gone to a new injector than you have in the past.  Two different injectors can use identical treatment dosages and have two very different treatments.  Further complicating this is that one does not always get what one pays for and treatment response is inherently subjective.  What are your recourses?  I would speak to the injector.  If there is any funny business, these types of office are often happy to provide additional "free treatment."  I personal feel this is a red flag.  An experienced injector using an appropriate amount of agent knows what type of treatment results they get.  In my office, treatment results are so consistent that we simply charge more money if you want more treatment effect.  I have never had a patient for whom the before and after photos did not show a difference.  40 units is a significant number of units of BOTOX or Xeomin for the gabellar area.  Beyond that it is very difficult to "prove" the doctor is not giving you what you paid for.  See if the office will provide more treatment and consider finding a new office for service in the future.  Board certification is not a guarantee of results.

Please return to your surgeon to express your concern.  I'm certain he would want to know  and would try his best to give you a good result.  He can reinject you since it is possible the Botox you had was inactive (it can rarely happen) or you may need to be switched to another neuromodulator if Botox is no longer working for you.  Give him a chance and if you are still unhappy, see another specialist.