One year of Botox treatments and I still have lines with relaxed expression, possibly developing more lines. (photo)

I have been getting botox for a year. The picture you see is 14 days post last treatment. 35 units in my gabbella and 5 units each side brow lift. I have had a range of 25 units to 50 units. Noting helps. I need treatment again within 8 weeks. Now I even think I'm getting more lines. Should I try a different type ? Different injector? Surgery? Filler? What filler is safe? How do I find a reliable/ experienced filler? Also, can I smooth them out with laser resurfacing, Obagi or something like that?

Doctor Answers 11

Refractory Botox

First of all, don’t lose faith! I believe to the core that Botox helps everyone, but it may take a little more work for some than others.
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:

  1. Botox considerations
    1. Quantity
    2. Location
    3. Brand
    4. Resistance?
  2. Other treatment options
    1. Filler
    2. Skin texture treatments [ie. laser skin surfacing, chemical peels (e.g. Obagi)]
    3. Surgery
  3. Finding the right injector for you
    1. Reputation
    2. Communication
I.A. Botox Quantity
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!”

II.B.Botox Location
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.
I.C.Botulinum Brand
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.

I.D.Botox Resistance?
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.
III.A.Injector Reputation
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!

III.B.Injector Communication
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!


Bakersfield Ophthalmologist
1.0 out of 5 stars 1 review

Lines don't always go away with Botox

Your lines must have been very deep.  Your PHYSICIAN injector needs to consider some Juvederm Ultra.  This will be a great help.   Choose a PHYSICIAN injector that is a plastic surgeon  (ABPS) or a dermatologist.  My Best,  Dr C

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.

Botox and Filler Combination

From your picture it looks like you need a combination of Botox and filler. The lines that you make when showing expression will be improved with Botox injections, if you have lines at rest then the addition of filler would give you best results. Your at rest lines are considered folds and need to be filled to improve the depression. If you just fill the line without the toxin the muscle contraction will break down the filler very quickly. The combination of the two will give the best longest lasting result. I like to inject Juvederm, but Belotero and diluted Restylane are also good options. Consult with a Board Certified Dermatologist to see which option will work for you.

Nissan Pilest, MD
Irvine Dermatologic Surgeon
4.7 out of 5 stars 17 reviews

Botox and filler

It appears that you do have decreased muscle movement after your Botox treatment.  You have depressed creases and require filler, which is used off-label in this area.  You need a very experienced injector for the glabellar area and should find a board certified dermatologist or plastic surgeon.  An experienced injector will know which filler to use.

Martie Gidon, MD, FRCPC
Toronto Dermatologist
5.0 out of 5 stars 21 reviews

Botox not completely getting rid of wrinkles

I would first make sure you have your frown muscles properly assessed by an expert injector such as a dermatologist or plastic surgeon. A higher dose of Botox may be required, and/or adding some filler (e.g. Restylane fine lines or Juvederm Ultra). Another option is to try a different botulinum toxin such as Dysport which may give you a better result in some cases. Obagi won't help, and laser resurfacing may help a bit.  ~ Dr. Benjamin Barankin, Toronto Dermatology Centre.

Benjamin Barankin, MD
Toronto Dermatologic Surgeon
4.9 out of 5 stars 44 reviews

Lines and Botox

Botox can treat lines of animation, but if the lines are deep as what I call "etched in" then you  may need some filler to help soften them.  Good luck.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

Easy solution...you just

need a filler...botox can only accomplish so much...once the creases become permanent, it's time to take the next step...Juvederm, Restylane or Belotero are ideal options...

Ken Landow, MD
Las Vegas Dermatologist
4.6 out of 5 stars 9 reviews

Alternatives to Botox

Thank you for your question?
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

A small subset of patients (about 1%) develop antibodies to Botox over time and their body essentially reject the toxin and you lose the effect of Botox.  You will then require higher and higher doses with less response and shorter response time. Make sure you confirm  the dose you have been receiving because 25 to 50 units in the glabella is a very high dose.  You can ask your doctor to try alternatives such as Dysport or Xeomin.  Also, the vertical lines in the glabella can be improved with fillers.  I do not recommend surgery unless you have exhausted all noninvasive treatments.  Lasers adn topical treatents will not addres the muscle movement causeing your vertical glabellar lines.

Daniel Yamini, MD
Los Angeles Plastic Surgeon
4.7 out of 5 stars 20 reviews

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.