Why my Frown Lines Are Still There After One Week of my Botox Injection?

Question

I'm 29 years old and I've had my first botox injection a week ago. I can't frown anymore but my frown lines are still there! should I repeat botox with higher amount?

Babak Azizzadeh, MD, FACS · Answer

Botox relaxes the muscles, but does not erase existing wrinkles. Try to do your next treatment soon to when it wears off. Start working on your skin care (retinols, exfoliation, hyrolonic acid, etc.) If lines persist, a filler may be ideal.

Young R. Cho, MD, PhD · Answer

Thank you for your question. The frown lines between the brows can be address two different ways:1) Botox or Dysport can be used to soften the deepening of the frown lines when making a frown expression. The treatment may even soften the lines that are present at rest. The effects typically last 3-4 months depending on the dose.  I generally use between 15-40 units of Botox (30-120 units of Dysport) in the frown area depending on the strength of the muscle and the degree of frown reduction we are trying to achieve.  2) Restylane or Juvederm can be used to soften the frown lines that are present even when you don't make an expression. This can last for a year or more when used in conjuction with Botox.For someone who has concerns with both the static lines (without expression) and the dynamic lines (with expression), then using both products would work well together. I often find that patients who return after a Botox or Dysport treatment in the frown areas complaining it didn't work, is due to the confusion between the static and dynamic frown lines. They continue to see the static lines even though the dynamic lines have softened considerably.

Luis Villar, MD, FACS · Answer

Whatever etched wrinkles you have when your muscles are relaxed, will determine the result after Botox has taken effect 3 to 5 days after injection. 

	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.

Sam Naficy, MD, FACS · Answer

Even though you've had treatment with Botox and it's working, those static lines took time to form, and will take time to soften. Regular treatments with Botox (every 3-4 months) will gradually help soften those static lines.

Ken Landow, MD · Answer

the full effect of botox may not be apparent for 2-3 weeks...so before deciding what to do...you need to wait awhile...while it's possible your creases are permanent and in need of a filler, that's less likely since you're only 29...and remember not all lines go away...some very fine, very superficial lines may remain...these may disappear with repeated treatments but that's not a guarantee...over three decades you're entitled to a line or two...but rest assured botox will do it's job repeatedly and with certainty

Judith M. Gurley, MD, FACS · Answer

If the muscles aren't moving (sometimes this can take up to two weeks after Botox) then the lines may be permanent. The skin has memory. Chances are since you are young repeated Botox every 3-4 months should completely or nearly completely result in resolution of lines.

Martie Gidon, MD, FRCPC, FAAD · Answer

If you are still unhappy with your treatment in another week, please return to your injector for assessment. You may require a filler into the lines. Please have treatment with an experienced dermatologist or plastic surgeon to avoid complications in this area.

Steven Wallach, MD · Answer

The lines themselves may need completely efface but over time using repeated treatment they may. Often there is dermal deficiency and fat atophy below the lines. These can sometimes be softened with fillers.

Steven F. Weiner, MD · Answer

If you stretch the skin in the frown area and still see lines, they will still be there after Botox. These are called "etched in" lines and can be considered almost like scar tissue. They will gradually improve over time with additional treatments of Botox, but probably won't go completely away. Belotero can be used there, but my preference is to just have routine Botox injections. You got a good treatment because you say you can't move the area at this point.

Peter J. Jenkin, MD, FAAD · Answer

You have to remember that botox doesn't fix the creases. Botox fixes the cause of the crease. Once you eliminate the cause, the skin will heal and crease will gradually soften and disappear. This could take a few weeks or a couple of months depending on how deep the creases are to start with. Be sure to keep up with your botox every 3-4 months to maintain the improvement. You're going to love it.

Why my Frown Lines Are Still There After One Week of my Botox Injection?

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