One year of Botox treatments and I still have lines with relaxed expression, possibly developing more lines. (photo)
Doctor Answers 11
This is an important topic. Physicians use the word “refractory” to refer to cases where the initial treatment hasn’t achieved adequate results. To properly answer all of your related questions related to Refractory Botox, it will take a bit of explanation. For clarity, please allow me to organize the concepts in outline form:
- Botox considerations
- Other treatment options
- Skin texture treatments [ie. laser skin surfacing, chemical peels (e.g. Obagi)]
- Finding the right injector for you
The scientific data on quantity show that increasing the amount (the “dose”) of Botox will increase the effectiveness and duration, but only up to a certain limit. In other words, you can “max out.” If you truly got 35 units 14 days ago in your glabella, you have pretty much maxed out. [See I.B. below.]
But for some other people, simply increasing the dose may produce the desired results. A lot of people under-treat for various reasons (ie., fear, cost, etc), especially their first time, and they go away never achieving the potential that Botox holds for them.
For many people, the first treatment or two doesn’t achieve adequate results, but after 3-4 treatments over a year, they get results. This is because the muscles start to atrophy (a good thing) as a result of the consistent relaxation; it takes time to get there. Since you’ve had treatments for a year now (I’m assuming they were at regular intervals, each time treating again before the muscles come back to full strength), then this is not the problem.
We’ve all heard the saying, “less is more” -- well sometimes “more is more!”
I’m skeptical that all 35 units went into your glabella though. Typically the treatment of the glabella (between and slightly above the brows) overlaps with the treatment of the frontalis (forehead). There is some finesse to treating both muscle groups simultaneously, which is difficult to describe in words. Some people have difficulty separating glabellar muscle (corrugator, procerus) control from frontalis, and both have to be addressed simultabeously, especially if you want brow balancing (and who doesn’t?)
The main glabellar muscles are the corrugators. In most people the tail of the corrugator muscles are normally not very active, but one of the basic principles of Botox is that when you relax part of a muscle the remaining part gets hyperactive. In other words, the tail of the corrugator can get more active, once the body has been treated; therefore the injection needs to be expanded to specifically address the tail of the corrugators. This will certain overlap the frontalis muscle and potentially affect the brows.
A small number of people seem to get better results (faster onset and/or longer duration with one brand of botulinum versus another. In my opinion, the 3 brands (Botox, Dysport, Xeomin) available here in the US are interchangeable. The units can be VERY confusing though. Most people that get an amount of Dysport equivalent to Botox, get the same results at the same price. Both scientific data and my professional experience confirm equivalent results for the majority of people, but any given person might be different. If you’ve maxed out your Botox dose, and your injector has mastered the subtleties of location, then you should consider Dysport or Xeomin. I have patients that specifically request these other brands.
There is some moderately good scientific evidence some people can develop resistance, though it is definitely unproven. The evidence that is there seems to suggest that overly frequent injections of small does of Botox can increase the risk. This is an important reason why we encourage getting a full treatment at regular intervals (say, 30 units every 3 months), instead of many little treatments (say 10 units every 4 weeks). If you’ve been having Botox for a year, it’s exceedingly unlikely this is a problem. You probably have a better chance of winning the lottery than to develop true resistance.
II.A.Alternative: Filler YES!
In your picture, I see glabellar creases that can be easily filled. For safety, the thinner fillers (Juvederm Ultra, Restylane, or Belotero) are preferred in this region. You will get immediate results. You should still get Botox, for two reasons: (1) this will prolong the duration of the filler results, and (2) this will prevent worsening of the glabellar creases over the years.
II.B.Alternative: Skin texture treatments NO!
The options you mentioned, laser skin resurfacing and Obagi, are two of many options to improve skin texture. None of them will do anything for glabellar creases, which are a dynamic issue.
II.C.Alternative: Surgery YES/NO
Surgery will definitely work, but is far too invasive to be considered appropriate for most people. An exception would be if you’re already having a brow lift, and the surgeon includes an extirpation of the corrugator muscles at the same time. Even brow lift surgery has been drastically less popular because Botox can achieve equivalent results more safely.
The proper credentials are of course indispensible, and legally vary from state to state. On the other hand, I don’t think you must be a board-certified this or that, or even an MD, to be a great injector. One of my chief competitors is an RN whose skill I respect greatly. You should select an injector based on word of mouth, whether that word of mouth is verbal or online. Injector skill is important, but so is the business setting in which the injector practices. You’re paying for it, insist on a high level of customer service!
I think this is the single most important long term factor in maintaining a successful treatment program. You’re going to establish a relationship with your injector. You need to be heard and understood. Everyone’s facial muscles respond differently, everyone has their own preferences, and these preferences evolve over time. You may have a vision in your head of how you want your face to look, and you may choose certain words to describe a the vision in your head, but the injector may hear those words and see something different. Think about your first time with a new hairdresser; what are the chance they get it perfect on the first cut? You require someone that incorporates your feedback to get it just the way you like it!
Lines don't always go away with Botox
Deep Glabellar lines
The best way to treat these deep lines would be a combination of Botox and fillers. When the line in the glabellar area is deep, it can take several Botox injections repeated every six months followed by Restylane in that area to improve this area. Please consult a board certified dermatologist with a great deal of experience with Botox and facial injections for the best results.
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Alternatives to Botox
alternatives to softening your glabellar lines are:
1) direct excision of the muscles through a upper eyelid incision.
2) direct excision of the muscles through a scalp incision using endoscopic technology
3) nerve ablation using Thermi technology( no incisions)
4) trying Dysport ( similar to Botox)
The first 3 are a more permanent solutions.
Fillers, will only fill in contour depressions not stop the frown lines from deepening over time.
Lasers, creams and peels will improve texture of the skin not the frown lines.
I suggest you seek out a Board Certified Plastic Surgeon who has expertise and training in all of the above.
Not responding to Botox
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.