Duration of Neuromodulators – What You Need to Know

There is renewed interest in neuromodulator/neurotoxins because of 2 newcomers to the US aesthetic market. Jeuveau is FDA approved and Revance will be approved early 2020. To differentiate themselves, these 2 have focused on duration of action of their products. Here’s the lowdown on what patients need to know about these wrinkle eradication injections.

There is a well-recognized scale that grades the glabellar lines at full contraction. Grade zero being no lines and 4 being the most severe dynamic lines. Keep in mind that this scale references only lines which appear during motion, not the static lines found at rest. In order for the FDA to approve injectable neuromodulators for the glabellar lines, there must be a demonstrable 2 point improve in this scale after 30 days. The take home messages of these FDA studies are:

The FDA considers a one-point improvement a failure, but the companies do not. There is literature and marketing by several companies stating their 4 or even 5 month duration for one-point improvements.
At FDA approved dosing, most grade 4 glabellar lines will not relax to the grade-zero score. In fact, with any dosing, grade 4 patients will most likely still have movement and wrinkles after treatment.
Not all patients had a 2 grade improvement in the FDA trials of any of the neuromodulators. Approximately 88-92% of patients responded to the FDA approved dosing.
The effect of muscle relaxation peaks at about 2-4 weeks, and then gradually tapers off. Muscle strength eventually returns to baseline at 3-6 months, depending on the dosing and the product used.
At 3-4 months, the FDA approved duration of the current modulators, a minority of patients still have 2 grade improvements in their glabella grade.

A well-established phenomenon with all the neuromodulators is the dose-response curve. The higher the dosing, the more effective the relaxation of the muscle injected. Additionally, the higher the dosing, the longer duration of the relaxation. Dr. John Josephs has performed studies on Dysport using dosing of 120 units (FDA approval is 50u) and has shown up to 6 months of 2 grade improvements in a significant proportion of patients. One “trick” he used when using these higher doses was to minimize the reconstitution volume to only 1cc. (Most practitioners use 1.5-3cc). Dr. Joseph refers to this technique as “A big dog on a short leash”. In other words, high dosing with limited spread in order to limit adverse events.

An as yet to be approved neuromodulator from Revance will be after a 6 month approval of their product. While at first glance, their 40 unit dosing will appear to be using the phenomenon of higher dosing – longer duration, this is not the case. Neuromodulators units, unfortunately, are not uniform between companies. A study Revance performed on the actually molecular weight of the active neurotoxin in their dosing showed that it was equal to that of the 20 unit dosing of Botox. They also evaluated Dysport’s weight, which was shown to be 50% higher than Botox and Revance, while Xeomin was actually 50% less than Botox/Revance.

What makes Revance’s neuromodulator last longer? It’s an associated proprietary protein that does not dissociate upon reconstitution. It is hypothesized that this protein’s ionic charge leads to better attraction to the receptor at the neuromuscular endplate. Revance’s product is essentially “more efficient” at binding, and therefore blocks more of the muscle movement than the other neuromodulators on the market at FDA approved dosing. Normally, there is some “wasted” neuromodulator which doesn’t bind and is swept away by the lymphatics and blood stream. The proprietary protein mimics what higher dosing would accomplish.

Neuromodulators work by blocking the release of acetylcholine at the neuromuscular endplate of the nerves. Return of function of the muscle is established when new nerve fibers are grown and re-establish contact with the muscle. If more nerves are blocked, it will take longer for the return of muscle function. If all the endplates were blocked to a muscle, studies have shown it takes 9 months for return of function.

After explaining all the numbers, it must be remembered that each patient reacts differently to the neuromodulators. As previously explained in another blog, once water/saline is added to the vials of Botox/Dysport/Xeomin/Jeuveau, there is only active protein in the vial within about a minute. The differences between the products are related to dosing, spread, and experience of the injector. As previously mentioned, Dysport has the highest weight of active neurotoxin in its FDA approved dosing and is the author’s choice amongst the current FDA approved neuromodulators.

Dr. Steven F. Weiner answers questions about Botox

Q: Shouldn’t 30 units of botox be sufficient for glabellar 11’s? (Photo)

A: Movement persists after 30u of Botox – several reasons

Someone with a very strong glabella can’t expect to have complete movement cessation with Botox. There is a scale 0-4 and you can expect 1-2 drops in the scale with proper placement and dosing of Botox. Some people will not respond as well as the general population. Also, placement and dosing could be incorrect. In the future you can try Dysport or Xeomin and see if they work better.

Q: Is it safe to have Botox if you have SLE?

A: SLE/Lupus – Safe to have Botox

There should be no problem getting Botox if you have SLE. Mainly neurologic diseases are what you have to be careful with like MS or ALS. Steve Weiner, MD, Facial Plastic Surgeon.

Q: 1 week post op. I just got 20 units of botox around my eyes & crows feet, I don’t see a difference yet. Is this normal?

A: No effect from Botox around crow’s feet – either not enough time, they aren’t treatable with Botox, or you need more.

Botox can take up to 10 days for kicking in fully. Some of the wrinkles around the eyes can’t be treated with Botox. If you have etched in lines or lines that occur when you smile that are formed from the cheek moving up, these can’t be treated. Only the lines that form when you squint are the lines that can be treated. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Side of my face looks like I had a stroke – Botox or bell’s palsy?

A: Facial paralysis 4 weeks after Botox is most likely Bell’s Palsy and not due to Botox

Bell’s Palsy is when all or a portion of one’s facial nerve doesn’t function properly and there is NO OTHER CAUSE FOUND. Not all facial palsy is Bell’s. You need to see an ENT doctor to get properly treated and to rule out other causes such as: tumors, autoimmune disease, zoster, systemic disease, trauma, botox. A hearing test and balance test might be needed and nerve testing too. Botox as a cause, if it was Botox you got, would lead to problems within 10 days. It would be very unlikely that is was due to Botox but I’ll never say never.

Q: Hard lumps on head after botox which are still swollen after 3 days. Why did this happen? (Photo)

A: Bumps after Botox are either an infection or allergy

I have seen a similar reaction on a patient that was allergic to the preservative in the saline which is mixed with Botox at most offices. I proved it by injecting just the saline with preservative in the patient’s arm and got the same reaction. Most docs use the saline w preservative because it is less painful. I think it’s about 1-3% will be allergic. Allergy to Botox would be extremely rare. Infection is possible and would be associated with warmth, fever, and pain. They are treated differently so you need to go to the doctor to determine what is going on.

Q: 20 units of Botox were injected into my forehead for horizontal lines. Will my brow drop improve? (photos)

A: Heavy brows and upper lids after Botox injection to forehead can be improved with more Botox

I know it might be the last thing you want to do, but injecting the lateral brows and the depressor supracilii can improve the lowered brow. If you do nothing, it will get better in about 3-4 weeks in most cases. Steve Weiner, MD.

Q: The corner of my mouth is no longer raising when I smile. What went wrong with my Masseter Botox?

A: Botox injection for slimming masseter caused abnormal smile – Botox improperly injected is reason.

There are a couple muscles which could cause this problem, the zygomaticus or the risorius muscle. If injected too high, the zygomaticus will be affected, to anterior, the risorius will be affected. Either way, time will heal the problem and you have no worries about it being permanent. Steve Weiner, Facial Plastic Surgeon.

Q: How much of a brow lift can botox alone achieve? (photo)

A: Brow lifts from Botox will give about 2-3 mm of lift

I think that most patients expect more from Botox for brow lifting then can be realistically achieved. It will give about 2-3 mm of lift. In a young person like you, that should be sufficient. Steve Weiner, MD, Facial Plastic Surgeon.

Q: Can botox cause dry skin?

A: Can Botox cause dry skin? Possibly

It is well known that Botox can help improve acne. This is due to the fact that it decreases sebum production. Sebum is an oil that has been found to be excessive in acne patients. It is possible that you might need that sebum production to maintain a healthy feel to your skin.

Q: Is it safe to use Botox when you have been diagnosed with Hepatitis C?

A: I have injected patients with Hepatitis C with Botox without any problems

I think that you are at risk to have more bruising than the normal Botox patient, but other than that, it’s perfectly ok to have Botox. There is no metabolism of the Botox by the liver so you are fine. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Eyes drooping after Botox?

A: Drooping eyelid or eyebrow after Botox will be seen within 2 weeks, not 60 days.

The effects of Botox take about 10 days to be fully appreciated. At 60 days, it is already starting to wear off. There are 2 different problems that can occur, drooping of the eyelid or lid ptosis, and drooping of the eyebrow, brow ptosis. If the forehead is injected incorrectly – (too much, too low, in a poor candidate for the injection), the brows will fall. If the Botox is placed too close to the brow, some could leak down into the elevator of the eyelid and cause the lid to fall. This is a major cosmetic problem that reverses over a few weeks. In any event, you need to see an eye doctor to see why there is drooping that is unrelated to your Botox injections.

Q: What treatments can be used for excessive groin sweat that are not injections?

A: For groin sweating, I would wait for Revance approval, topical “Botox”, otherwise try Miradry, Sweat X treatments

I think the perfect solution for you is Revance which is a topical neurotoxin that will be approved sometime this year. True, it won’t be a permanent solution, but it will be painless and effective. For more permanent results, Miradry is very effective, but you need more than one treatment and they are painful. Numbing the area with injections helps. There is also some swelling afterwards. More treatments but less downtime is the soon to be approved Sweat X from Alma. I heard that you will need up to 6 treatments for results, but the pain is minimal. Ulthera is coming out soon with a hyperhidrosis indication, but that could be painful too in that area. Steve Weiner, MD, Destin, Florida.

Q: How long does 2 units of Botox last?

A: 2 units of Botox in crows feet? Not worth the pain or $$$

I doubt that you will see much difference in the crows feet after treatment with 2 units per side. The usual dosing is 5-15 units per side. Duration of action, if you see any, will be less than one month. I’d get another opinion from someone more familiar with Botox. Yes, the more units used, the longer the duration of action. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: Under eye wrinkles, hollows and dark circles. What are my options to restore youth? (photos)

A: To rejuvenate the eye area, use Restylane and consider skin tightening with the Infini RF

You have loss of volume around the eye which is best treated with Restylane. I would recommend using someone that uses blunt cannulas for this injection so the chance of bruising or complications is reduced. For crepey skin around the eye, I would use the Infini, which is a new microneedling RF device. Botox might help as well. I written a blog all about this very situation, see below. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: I just purchased a Botox package, and Radiesse from a separate place. Should I get Botox first or fillers first?

A: The best way to get cosmetic treatments such as Radiesse and Botox is to get them from the same physician

Trying to scope out the absolute best deal for filler and Botox is the wrong way to do cosmetic procedures. You need to research the physician and figure out if he/she is qualified and has the experience you are looking for. It’s your face and you can’t hide a poor result. If there is something that needs attention after the procedure, how available is that person, and how long do you have to wait to see them? “Time is money” as well. Customer service, experience, reviews, outcomes, friends experiences should be much more important than price. Also continuity of care is very important and when you get things done at different offices, it’s very difficult to tell what results are from one doctor’s work and what are from another doctor. It doesn’t matter what procedure you have first, I often do filler and Botox at the same visit.

Q: The corners of my mouth turn down. Will Botox help with this or is there another non surgical treatment which will help?

A: Turning a sad smile into a happy smile can be done with Botox or Fillers, or both

Downturn of the corners of the mouth can be corrected by injecting the DAO with Botox but the best result will be also to add a filler like Restylane or Perlane. The Botox lasts only about 4 months max and won’t have as dramatic a result unless the filler is also added. Steve Weiner, Facial Plastic Surgeon, Panama City Beach, Florida.

Q: What should I do about crooked smile after Botox to treat bruxism and TMJ?

A: Nothing you can do to fix smile after poorly placed Botox for bruxism

Without a picture it is difficult to tell what exactly is the problem but my guess is that the risorius muscle was hit with the injections. Either the injection was too anterior or the Botox migrated and hit it. I have not heard of anyone mixing Botox with lidocaine and I don’t think its a good idea. Lidocaine is acidic and can partially inactivate the Botox. I’d seek another injector in the future. Everything should return to normal in about 3-4 months. Facial Plastic Surgeon, Dr. Steve Weiner, Destin, Florida.

Q: The corners of my mouth turn down. Will Botox help with this or is there another non surgical treatment which will help?

A: Turning a sad smile into a happy smile can be done with Botox or Fillers, or both

Q: What should I do about crooked smile after Botox to treat bruxism and TMJ?

A: Nothing you can do to fix smile after poorly placed Botox for bruxism

Q: Is it safe to do Botox injections around the same time as my Carpal Tunnel surgery?

A: Safe to get Botox around the time of carpal tunnel surgery.

I don’t see any problems with what you are proposing. I wouldn’t probably do on same day incase the anesthesiologist does some neck positioning or rubbing that could move it around. Otherwise, good to go.

Q: Will the muscles around the corner of the mouth recover from Botox paralysis? (photos)

A: Remember that Botox is not permanent, all things will go back to the way they were.

It sounds like the injector hit the DAO on the right side to turn up the corner of the mouth on that side. Perhaps you only needed it on the one side. This is routinely done in my office but almost always done on both sides. You are right that it affects the way you make a sad face (but why do you want to do that?). You can get the other side done for symmetry or just let it gradually wear off. Steven Weiner, MD, Facial Plastic Surgeon, Destin, Florida

Q: Alternatives to botox for the “11” wrinkles between eyebrows?

A: I really wouldn’t worry about Botox in the “11’s” but there are alternatives, ThermiRase and Frotox.

There are 2 alternatives to neurotoxins for the frown lines. The first is using radiofrequency to ablate the nerves that cause the muscles to contract. This is promoted by the company ThermiRase. It gives a long term correction (a few years) but will cost you in the $1500 range. The other technology uses a freezing solution to cause injury to the nerves and this has been dubbed “Frotox”. I don’t think this is available yet in the states. I think it also isn’t giving as long a result – months. I wouldn’t worry about dropping brows if just injecting the 11’s and you go to an experienced injector. There are millions of people who have had Botox treatments.

Q: Need to raise the tail end of my eyebrows

A: Droopy brows (brow ptosis) from Botox can be helped with further injections

Having brow ptosis after Botox can be improved by injecting the crows feet (if that hadn’t been done), and further injection around the tail of the brow, and even more medial in the brow area (this is a delicate injection). Also, injecting the depressor supracilia with a couple units can raise the medial aspect of the brow. If nothing works, it does improve before the Botox completely wears off, at about 3 weeks. Steven Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

Q: When reconstituting the botox with saline, does it matter whether or not it is with preservative, or preservative free?

A: Mixing Botox using saline with preservative is what most doctors use

Even though the FDA approved why to reconstitute Botox is with normal saline, most doctors use saline with preservative because it hurts less when injected. There have been no studies that I’m aware of that says the Botox is negatively affected by this.

Q: Do I keep the botox frozen? The doctor said the injections would hurt less.

A: Botox needs to be kept within a certain temperature range after reconstitution and it’s above freezing.

Freezing Botox after adding saline may affect the effectiveness of it. I don’t think this is a good idea. Adding saline with preservative to reconstitute it does decrease the discomfort when compared to saline without. Also applying ice to the area treated is helpful. I have seen an article that states topical lidocaine can decrease the effectiveness of the Botox so I don’t use that.

Q: Droopy eyelid and hard sore lump on eyebrow after botox

A: Need to see another Botox provider

It doesn’t sound like they know what they are doing or that you are getting the real Botox. If you indeed have eyelid droop (not eyebrow droop), injecting further Botox would not have helped. The lump is also unusual. Eyelid droop is extremely rare and related to poor placement of the Botox.

Botox – When will my brows lift again?

I had an unfortunate experience in that I had Botox injected in my forehead, and it fell. I asked the woman three times if she was sure my brows wouldn’t fall. She said they wouldn’t. They did. Now I have a tightness in my forehead above my eyes, and I’m getting headaches. I also look angry and tired. To compound matters further, I’d just had an upper bleph to lift my sagging lids and they looked great. Do I have any recourse with her or the PS for whom she works? I’m not happy…

Having brows fall from Botox is due to one of these 4 issues

Unrecognized need for the forehead to lift the brows because of an inherent heavy brow. There are many people who subconsciously lift their brows and get wrinkles in their forehead. If you take that ability away with Botox, the brows assume their “normal” position which is low. Many middle aged men have this problem so I treat this group with less Botox or not at all.
The placement of the Botox was too low. If Botox is placed too close to the brows, your brows will drop. In general, injections need to be about 2cm above the orbital rim (brow bone).
Too much Botox was injected.
Didn’t use the microBotox technique. Using the microbotox technique, the Botox is more evenly spread across the forehead and there is less chance for brow drop.

I generally treat the forehead with a conservative dose that that there still is movement. Some people prefer the frozen look but that’s not my style. By treating with less Botox in the forehead, the duration of action is somewhat less, but the results are more natural.

Corrugator botox problems?

I have had botox for glabella frown lines. I have had repeated doses after 2 weeks and it makes little difference. I am told I am mail using my corrugator muscles and that botox here would cause eyelid drooping and I should have dermal fillers instead, is this the case (I’m only 33yrs)?

Botox for someone with very strong glabellar muscles (corrugator) will not completely relax muscle

For someone that has very strong corrugator muscles, Botox treatment will improve but completely resolve the movement. Strength/”degree of frown” is graded from 0-3 with 3 being “severe”. In Botox clinical trials, a responder is considered to move at least 2 grades. So, if you have gone from a 3 to a 1, you still are a responder but you will still have movement. Also, there are about 15-20% that won’t respond, according to their (Allergan’s) studies (less than a 2 grade improvement). Over time, the people who respond but don’t go to 0, will have continued improvements with subsequent treatments at 3 month intervals in my experience. If you are a non responder, I would try Dysport or Xeomin. Hope this doesn’t confuse you. Steve Weiner, MD, Facial Plastic Surgeon, Destin, Florida.

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

Lines in frown area after Botox are called “etched in” or static lines and are not treatable with Botox

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.

Botox and Chin Implant?

Botox is fine with a chin implant

There is no problem in treating the chin area with Botox if you have a chin implant. Botox is sterile and should not pose an infection risk.

Head Ache After a Botox Injection?

Headache after Botox can usually last a few days

A headache after Botox injection is not that uncommon and can last a few days. It is actually not related to Botox but the injection because injection saline in similar areas can produce headache as well. I would take tylenol and it should get better.

Could You Please Tell Me How Long the Effects of Botox in the Jaw Muscle for TMJ Will Last?

“Just over a couple of months ago I had my upper and lower jaw muscles injected with botox to relieve the symptoms of TMJ, however about 2 weeks after the treatment I noticed I can’t smile as wide as I used to and one side of my mouth looks like it is drooping when I smile. I have had the treatment before and it was successful, but I only had botox injected in the lower jaw muscle that particular time. I am a little concerned as I don’t want to look like this permanently.”

Botox in masseter muscle for TMJ will last 3-4 months

If the Botox is injected too anteriorly, you hit the risorius muscle, which will affect your smile. I’m sorry you have this side effect but emphasizes that Botox in this area needs to be done by experts, experienced in the anatomy of this area. I’ve been injecting for TMJ with Botox since 1995. A Facial Plastic Surgeon is perfect to see for this injection.

When I Laugh my Upper Gum Show Which I Don’t Like. Can I Get Any Treatment in Botox to Numb my Upper Lip Muscles?

Gummy smile can be helped with Botox with 2 small injections

The muscle that needs to be weakened is the Levator labii superioris alaeque nasi muscle. About 2 units on either side of the lateral nose can help a gummy smile. I warn you that your smile is definitely different which some people don’t like.

Will Botox Be Suitable for Me? I Am 24 Years Old with Forehead Lines and Don’t Want to Look ‘Frozen’.

“I have had TMJ for years, chronic jaw clenching during the night. I noticed my forehead also feels very tight and sore when I wake up! I think I am clenching my forehead too. This may be why I may have so many fine horizontal forehead lines despite my efforts to stay out of the sun and wear SPF daily Will botox or dysport be best and how many units of each to correct the forehead. Also should the glabella be treated? (No lines here yet but it is tense)”

Sounds like you have a muscle tension issue: Face, jaw – TMJ, forehead. Botox is a great solution

I think you can have benefit from Botox without getting a frozen look. The application of Botox years ago led to frozen looks, but now less is being used and results look more natural. Specifically for you, I’d inject massters (10-20u ea), temporalis (20-25u ea), glabella (25-35u), and forehead (8-12u). Breaking the cycle of tension is needed. The dosing could be increased from those recommended if results are what you want.

Botox for Bruxism – As a Side Effect Will This Also Slim the Face?

“Hi there, I had 25 units of botox injected to the masseters (in each side – 50 units in total) – to help with bruxism. However, I’ve since learnt botox to the masseters can also slim the face. I have quite a thin/narrow face so am a bit worried about slimming my jawline any further. Is 25 units a big dose? Is there a chance this can just help with bruxism, without slimming down my jawline too much? Thank you!”

Botox in masseters for bruxism will cause a slight slimming effect of the face.

25 units of Botox in each masseter will reduce the bulk of the masseters and leave your face slightly slimmer. The goal is to weaken these muscle so you don’t clinch. By weakening them, there is some atrophy is this is done repetitively. If you notice too much slimming, it will fill out as the muscle regains it’s function when the Botox wears off. Standard doses for slimming the face are 30-40 units per side.

Can Botox Be Used to Widen the Smile?

“I was wondering whether it is possible to use botox to change the shape of the nasal labial fold lines so that the smile widens. I have quite a small smile for a wide face and so was wondering if this is possible.”

Botox to modify smile – you can help a downturn, gummy smile, but not widen it.

Botox is useful to help lift the corners of the mouth by injecting the DAO muscle and improve a gummy smile by injecting the levator labii superioris alaeque nasi muscle. However, widening the smile is not possible to my knowledge. You can make the mouth slightly smaller by injecting the risorius muscle, but I haven’t done this and its probably not a good idea.

Is It Ok to Have a Bath 28 Hours After First Botox Injections? Also is the No Alcohol Rule Only for 24 Hours?

No problem bathing and drinking alcohol after Botox

I would probably wait about 3-4 hours after Botox to bathe, but alcohol is fine after the treatment. The reason for no alcohol is that it can thin the blood, but after the injection, it’s OK. As for bathing, if its hot, it can potentially cause the Botox to spread. Also, it the needle holes are not closed, there is a very small risk of infection.

I Had a Facial Massage Right After Botox, Will This Damage Eyes, Eyelids Permenantly?

Facial massage after Botox is one if the few things you shouldn’t do

A facial massage can move the Botox if its done within 3-4 hours of the injection. There is nothing that can be done at this point. If it did move, all side effects will not be permanent and go away in 3-4 months. Other things you shouldn’t do after Botox: no hot tubs, no saunas, no working out, no placing your face in a horseshoe for massage for 3-4 hours. I also avoid procedures which cause swelling like Fraxel Dual on same day because I’ve seen diffusion into areas where I didn’t inject.

Botox Side Effects Injecting Hands, Sweaty Palms?

Botox for sweaty palms works very well

Using Botox for sweaty palms works very well. Side effects are usually minimal, and consists mostly of soreness and bruising at most. Although none of my patients have experienced this, you can possibly have some minor weakness of the hand. In the past, I did nerve blocks which was unpredicatable and painful. Now, with using an ice technique, it goes very smoothly and quite comfortably. You can expect between 3 and 6 months improvement, and the more times it is done, the longer the results. I use 50 units per hand.

Botox Caused Droopy “Captain Spock” Eyes – Help!

“It has been a 5 days since botox and I look like Captin Spock. I have very expressive eyes and over the last couple days when I talk my outer brow will raise up while my inner brow does not move. It looks horrible. In addition my eyes are droopy and I feel a heaviness between the bridge of my nose. I called the Dr and she thinks I need more botox. I am terrified that this will make the droopy eyes even worse. Help. I am getting Married in 2 weeks. I can’t look like this.”

“Spocking” from Botox is easily corrected

By injecting a very small amount of Botox on the lateral forehead (towards the sides) “Spocking” can be corrected. Drooping of the brows in the middle is harder, but sometimes injecting between the brow and the the nose can lift the medial aspect of the brow when done judiciously. Congrats!

I Am on Amoxcillin for UTI Treatment and I Have Had a Botox Injection in Forehead 11 Months Ago. Is This Ok?

Antibiotic 11 months after Botox is fine

There is nothing to worry about with taking an antibiotic 11 months after Botox. Antibiotics will not interact with Botox. I would probably not inject a person who is on antibiotics, but it depends on the person and the reason for the antibiotic.

Can Have Botox in Bunny Lines Cause Deformation on the Nose?

Treating bunny lines with Botox does not change your nose

Bunny lines are the lines on the side of the nose you see when you smile. They are treated with injections on the side of the nose. They will usually improve but do not completely go away. There is no change to the shape of the nose.

Can Botox Be Used to Change the Shape of my Eyes?

“One eye is perfectly almond shaped and the other is slightly larger and too round. I want both to appear almond shaped. Can botox and/or fillers help with this?” By injecting in the lower lid a small amount of Botox, you can loosen up the lid and make the eye look more rounded. You want the other effect, which you might be able to achieve by injecting filler in the upper cheek or tear trough area. However, it might look asymetric with unilateral filler, so be careful.

Will Injecting Botox Only in the Brow Area in Turn Help with Forehead Lines?

“I have had Botox done before but went to a different Dr recently. I told him I was interested in Botox for my forhead however he seemed to only inject my brow area. I believe he injected 25 units”

25 units of Botox for the forehead is plenty to improve the lines

I typically inject 6-12 units in the forehead and about 10 in the glabella area to treat the forehead wrinkles. I believe that 25 should do it. I would wait the 7-10 days until the Botox is fully effective before I go back to evaluate the treatment.

Can Botox in the Masseter Be Permanent and How Is This Muscle Different Than Others?

“I had a botox injection into my masseter muscle a week ago, I heard that usually one only needs 2 botox injections to achieve a permanent dystrophy for this muscle. Can anyone please confirm if this is true and if so, how is the masseter muscle different to other muscles on the face in terms of its reaction to botox? Thanks”

Botox in the masseters (for slimming the face and tension) is similar to all other muscles – lasts only 3-4 months

Botox is used in the masseter muscle for 2 reasons. One is to reduce the tension in it that might be leading to headaches and TMJ. The other is to decrease the hypertrophy in some people to make the profile a little thinner in that area. I don’t know where you got your infomation but the masseter behaves like all other muscles and the Botox results are only temporary.

Is It Possible for Me to Still Have Botox when I Get my Period Next Month, Even Though I Have Plans to Have Baby?

Is it possible for me to still have Botox when I get my period next month, even though I have plans to have a baby? I believe although Botox is a bacteria, it is concentrated only in the injected site, and won’t get into the blood stream. I’m just wondering if it will have any effect on my baby if I have Botox on October and happen to conceive around November or December.

Botox is not a good idea if you are trying to get pregnant

There have been no studies with Botox and pregnancy, but it’s not a good idea to have Botox injections at the same time you are trying to get pregnant. Having said that, there are probably thousands of women who have had Botox when they didn’t now they were pregnant and I haven’t heard of any problems with babies born to these women. The Botox would only be in your circulation for a few hours after the injection and then it is bound and incorporated into the nerves in the area injected.

Can I Have Filler or Botox Above the Lip Line As I Have Wrinkle Lines There?

Upper lip lines (smokers lines) are treated fairly well with combo of Botox and Filler

Probably the most common treatment of lip lines in my practice is the combination of dermal fillers (Restylane or Juvederm) and Botox. I like to treat this area using blunt cannulas in a horizontal fashion and no “chase” each individual line.

Are Botox Results Permanent After Long-term Use?

“I read somewhere that Botox results become semi-permanent after perhaps 8-12 treatments. Is this true? If so, would it only be true for certain areas or for any area treated with Botox? I’m getting Botox for down-turned corners. Thank you!”

BOTOX results are usually not permanent

Botox causes weakness of muscles which are causing wrinkles or in your case, downward turning of the corners of the mouth. Over repeated treatments, the muscles will atrophy, provided there is not a long period between the time the effect of Botox wears off and your next injection. I tell my patients you can think of Botox as a chemical cast on the muscles. Just like when you wear a cast on your leg or arm, the muscles get weak and smaller over time. But when the cast comes off, you can build your muscles back to the same shape they were in before. What you can expect over repeated injections is that the dosing might lessen, and potentially the length between treatments might get longer. In some cases, longer might be 9 months or more, but usually not permanent.

Can You Have an Allergic Reaction to Botox?

“I recently get Botox injections in my upper forehead, and all of a sudden I am getting whitish welts under the skin, and purplish brown pigmentation on random places of my face. Can this be the Botox going through my system? I have been to 4 Dermatologists in a week and no one seems to have any answers for me. Please Help!!

Allergic reaction to Botox is extremely rare, hadn’t seen it…but did you really get Botox?

This does sound extremely unusual to me. I don’t think this is an allergy to Botox. The only issue I’ve ever seen with Botox is an allergy to the preservative in the saline used to mix it up. The reason I know this was not the Botox and was the saline is because I injected the saline with preservative only and it gave welts. These were immediate, before the patient left the treatment room. I have subsequently injected the same person several times with Botox mixed with nonpreserved saline. I would question whether you got real Botox or a knock off.

Side Effects from Botox for Under Eye Wrinkles?

“Does Botox cause thinning of the skin or a reduction in collagen over time? I am considering it for under eye wrinkles.”

Botox for undereye wrinkles won’t affect the collagen

The only risk that is different for injecting the undereye wrinkles with Botox is that the injector must be very careful with dosing, placement, and selecting the correct candidate. If you don’t have strong enough lower eyelid tension, you can get ectropian, which is when the lower lip everts. Although this will be temporary, it’s a problem for several weeks with tearing and possibly drying of the eye. No skin issues can be caused by this injection.

Can to Many Units of Botox for Crows Feet Make Condition Worse?

“I go evey 6 weeks because I have a high metabolism. Dr put in 25 units it didnt work so I went back 4 days later for another 25 units. wrinkles look worse and have a bruise. What can I do to improve my lines?”

Yes, too much Botox in crows feet can make it look worse. You might have wrinkles from cheek which don’t respond.

You might have wrinkles from raising your cheek that will not respond to Botox. The best way to tell which wrinkles will and won’t respond to Botox is to squint. The wrinkles you see with squinting are those which can improve with Botox. If you smile and your cheek raises and creates wrinkles, some of those can not be improved. Filler may or might not help for those. Also, adding too much filler can sometime make the under eye area look worse because some people need some tension in the lateral aspect of the eye. 50 units is too much for crows. I usually use 10-25 total for both sides

Can You Get a Professional Facial As Well As Botox Done on the Same Day?

Botox is fine on days you have a facial

The only caveat is that the facial is done first. After Botox, I tell my clients to avoid strenuous activity, avoid putting yourself in a horseshoe for a massage, avoid hot tubs and saunas, and caps for 3 hours.

Botox on the Depressor Anguli Oris Muscle?

“Hello! I am 21 years old yet I have downturned corners of the mouth and what seems to be like a very slight marionette line. I was wondering if putting botox on the Depressor Anguli Oris muscle would reduce the marinette line and the downturned corners of my mouth. How much should be injected and how difficult is it? Any side effects or risk of deformation or lumps? Thank you!”

Putting Botox in DAO helps with downturn of corners of mouth and slight marionette lines

But….the combo with Restylane is better. When you are putting a total of 5-6 units of Botox in the DAO’s and spending about $60, you can’t expect huge changes. If you keep up with it about every 3 months and consciously avoid that “frowny” motion, it will gradually improve.

Took Mesobotox on Cheeks for Open Pores. After 2 Weeks I Notice Cant Smile or Laugh from One Side of my Face. Is This Permanent?

Mesobotox was done improperly, either too deep or too much, and caused smile abnormality

Mesobotox is a very dilute Botox injected very superficially to help with pores, acne, or fine lines. If not done properly, it will affect the deeper muscles in the cheek, which will affect your smile. Over the next 2-3 months, this should resolve back to normal. There is nothing which can be done in the meantime.

Cannot Smile After Botox for Migraines

“I Had Botox Injected in my Cheeks for Migraines and Now I Can’t Smile. Is This a Normal Side Effect?”

Botox should not be injected in the cheeks, it will affect the smile muscles

As stated earlier, you shouldn’t inject Botox in the cheeks because it will affect the movement of the zygomaticus muscle which raises the corners and the upper lip. There is nothing which can be done except let the Botox wear off over the next 3-4 months.

Doctor Rubbed Botox Area to Massage It In?

“I recently got botox done for the second time. She injected my 11’s and the muscle above my brow. It was much more painful then the first time and she massaged the area to spread the botox out. It didn’t work well at all I still have faint lines and can move my one eyebrow. She reinfected it again 2 weeks later and still no results. I feel she’s injecting too deep and that the massaging is hindering it as well.”

To massage or not to massage after Botox…no consensus for forehead, other areas NO

When attending the Carruther’s (Jean and Alastair) symposium about 7 years ago, they debated whether or not to massage the forehead injection (not glabella). The two were split, one did and the other did not. I personally massage only the forehead injection so as to spread the Botox more evenly in this area because it is such a large and wide muscle. I also do massage in the masseter and temples for the same reason when doing TMJ Botox. (For those who don’t know the Carruthers, they are the authority/discoverers of Cosmetic Botox.) Massage in any other area of injection is highly NOT recommended because it can cause migration of Botox into areas not intended to be affected

Why Does Botox Make Forehead Look Shiny?

Botox is being used off label for acne

Botox works for acne by inhibiting the sebaceous glands secretions. This might be why your skin becomes shiny. Also, less wrinkles mean a smoother, shinier surface. It also decreases the sweat gland secretions. Probably a combination of all these factors.

Unable to Smile After Botox and Fraxel Laser

I had Botox injected for frown lines, forehead lines, and crow’s feet. The following day, I hadFraxel Laser on my face. I’m 16 days post-procedure, and unable to smile. My upper lip turns under when I try to smile, and I’m unable to raise my cheeks. My doctor is experienced with Botox and has never had this adverse reaction occur. Have you seen this happen, and if so, how long will it take before my smile will return? I’m depressed, anxious, and look like a freak.

I heard of this before

Even though botox is supposed to be absorbed after a few hours, there have been a couple people I’ve heard of that have had similar stories with the 2 procedures very close together. I guess that the edema from the Fraxel has caused migration of the Botox, but can’t be sure. In that case, it might take a few months to resolve.

Can Botox Caused a Crossed Eye, and if So How Can It Be Corrected?

I got one unit of botox above each eyebrow to correct and eyebrow that when I lifted, appeared to overcorrect with a fold above it. Immediately after at home my opposite eye began to cross and I developed a migraine headache. The Dr would not return my call and had a nurse assure me it was not botox related. I saw an eye doctor who thought it was a strong possibility. Three days later the eye is still turning inward and I’m having difficulty focusing.

Botox causing a “cross eye” is possible if injected too close to orbital rim

I’ve heard only case reports of this problem, but if the Botox diffuses into the orbit and weakens one of the muscles which moves the eyes, it can cause “cross eye” problems. People that have had childhood “lazy eye” will be at greater risk for this. It will reverse, but it won’t be pleasant for the time it takes to wear off. You might need to wear a patch to avoid seeing double. One of the earliest FDA approvals for Botox was to fix strabismus, which is lazy eye. You would inject the stronger eye muscle to weaken it and make it equal strength to the opposing muscle.

Is Botox for Crow’s Feet Less Likely to Cause Eyelid Droop?

With Botox for crow’s feet are there more or less chance of getting eyelid/eyebrow ptosis (drooping)? My question is, is there more chance of getting ptosis from crow’s feet treatment compared to frown lines or forehead treatment?

Botox around crows feet cannot cause eyelid droop

The only way to get eyelid droop from BOTOX is by injecting too close to the browline in a line that is vertically placed from the pupil. This should be an extremely rare problem from BOTOX. Injecting the crows feet will not cause eyelid droop.

Can Botox Treat Facial Sweating?

I understand Botox can be effective in treating hyperhidrosis for underarms and palms. But can it be injected to treat facial sweating? My entire face gets drenched in sweats even when I’m sitting still, maybe due to medication I’m taking. It’s really embarrassing and starting to affect my social life… Please give advise. Thank you!

Sweating of all areas can be treated with Botox

Botox can be used to treat facial hyperhidrosis. The Botox must be injected superficially so as to not affect the muscles if expression. This is done with multiple small injections with dilute Botox.

How Can Experienced Botox Injector Get It Wrong? Are There That Many Injection Techniques for Same Area?

Had Botox 8 wks ago. Used it 7yrs with PS, always loved results. Decided to try new Dr offering new patients $9 Botox. After researching, He was thought to be Best Botox injector in Utah, Runs Botox blog & been on local TV. I felt certain I could save $ & still get great results. NOT! Fastest Botox ever 42u under 5 min. Injections felt much different & Results – visible dents in forehead, deep dents around eyes, 11’s still visible & eyebrow droop. Can I get botox to correct his Botox injections?

Results from Botox on sale were bad. Don’t always go for the cheapest price!

Sometimes, the only way for a practice to attract new clients is to put their Botox on sale. Be warned, it doesn’t always get you to the results you were expecting. Just because someone is in the news or advertises a lot, does not mean they are good injectors. Often, it just means they have a great marketing department. Correcting bad Botox can be done in certain cases but not all. It’s unfortunate that this happened to you. When you go in for a cosmetic procedure you expect to look better, not worse, after getting treated. This is an all to familiar story that I see almost everyday. It ends up costing even more than going to the regular priced physician, as well as more time, and frustration. Best advice, go to someone you are comfortable with, your friends recommend, and has been doing it for years. I’ve been injecting since 1994 and have previously taught other physicians how to inject.

Doctor Injected Botox in Zygomaticus Major/minor?

I had one session of botox for bells palsy around my eye and forehead area. The second time the neurologist said that she has a little left and can inject it on my Zygomaticus major to see if it releases the very slight pull that I had in my lips. After a week my face was completely paralyzed and it is six weeks not but still cannot lift my upper lip. I have been reading a lot here and am very worried that because of my history of bells palsy would this by any means cause permanent damage

The effects from Botox are temporary and should last 3-4 months

For a Botox injection gone bad, there is no need to worry about permanent side effects or paralysis. In 3-4 months after the injection the normal movement will start to return.

Side of Face is Paralyzed After Botox for Crow’s Feet

I had botox for crow’s feet and now the right side of my face is paralzed. Will this get better? 6 days after botox the right side of my face felt numb. When I smile my mouth pulls down severely on the right. My doc said she believes the botox migrated to the nerve in my cheek and will be fine in a few weeks. Have you ever seen this before and is it reversible?

Very important that you get BOTOX from an experienced injector

The only reason BOTOX “migrates” is because it was placed inaccurately. The paralysis of the face you mention can last up to 3 or 4 months. There really is not much that can be done. I sorry you have this issue. It sounds like it was placed too low on the cheek.

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

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?

Lines in frown area after Botox are called “etched in” or static lines and are not treatable with Botox

Can Botox Be Used to Treat Assymetry in Upper Lips?

I had thin lips which I’ve recently had subtly plumped with juvaderm. I love the effect. It’s not too much and it’s smooth, no lumps. The only thing is that one side of upper lip lifts more than the other. I was already uneven to behind with but they were so thin, it wasn’t noticeable. But now it is. It has been 2 wks since injection,all swelling is down. Can a tiny bit of botox on the weaker upper lip make it even up with the other side? I don’t want to make it worse or unable to smile properly

Asymmetry in smile is hard to correct, wouldn’t do Botox

Many people have asymmetry when the smile which is more noticeable after having their lips enhanced. Outside of injecting the filler to correct small differences, there is not much to do. Botox might make the matter much worse. Your smile makes you unique and I would try to change it that much.

Can Botox Make You Feel Ill?

I had Botox yesterday and felt fine, I was shopping for clothes afterwards and became very hot but I was still feeling well,then I had to run for the bus home and was worn out,a few hours later I felt unwell and as the night went on I got worse,sore throat head aches and feel run down,is this the cause of botox?

A rare side effect from botox is flu symptoms

Some people will experience symptoms of the flu after boots. Symptoms can include aches, headaches, weakness, and headaches. It is usually self limited to a day or two. Tylenol can help. I have had a few people experience this. It seems to be dose related, more units means more symptoms. I switched a couple clients to dysport and they had no symptoms with it. Xeomin is another option too.

How Often Should One One Use Botox if You Are 34 and a Smoker?

As far as I know, smoking doesn’t affect Botox. Recommend follow up treatments every +/- 3 months

Botox does not appear to be affected by smoking. It will last about 3 months, a little more in glabella, a little less in the forehead. If you allow the muscles to regain their full activity, you lose out on the long term benefits of weakening these muscles. This is the average time it takes for the Botox to wear off but I have some people that it last for about 6 months. You can wait longer if you wish with not detrimental effects.

What are realistic expectations for noninvasive cosmetic procedures?

As the number of physicians providing noninvasive cosmetic services increases, there is a tendency for many to make unsubstantiated claims as to what outcomes can be expected. This ultimately can lead to unhappy patients and certain procedures can be tarnished in reviews or in the press for not living up to what was promised. Patients need to be careful if something sounds too good to be true. In addition, patient’s sometimes expect way too much from a procedure, often well beyond what the procedure is capable of, and need to discuss what they want, in detail, with the physician before agreeing to it.

Some of the most common misconceptions are:

Most people need several different procedures, not just one to become more youthful. Don’t expect one treatment (or series) with a laser or skin tightener to be all that is needed. The Fraxel (Dual, re:pair) will make your skin less wrinkled, tighter, and more clear. Will it make you look “10 years younger” as some physicians claim. Probably not. The majority will look better but not by 10 years and will need other modalities such as filler and Botox to complete the youthful correction.
Don’t expect to have significant results from any cellulite treatment except for Cellulaze. All other treatments (Velasmooth, Velashape, Endermologie) are very temporary and end up being costly and time consuming. From the presentations I’ve seen with Cellulaze, there are significant long term results which are impressive.
Laser hair removal will not allow you to “throw away your razor”. Complete hair removal is not possible with any of the lasers which remove hair. You can expect up to 75-80 improvement with a series of about 6 treatments in the bikini and underarm area in most cases. Back, chest, and legs require more treatments, maybe up to 10. Darker skin individuals can require more treatments too because the laser needs to be turned down on these patients. Extremely fine hair on the face probably shouldn’t be treated at all because of the risk of making the problem worse. For all areas, touch ups every 6-12 months are required.
Some physicians were claiming Zerona was a weight loss (“fat zapping laser”) and slimming technology. This claim was completely unsubstantiated. There were no studies which showed long-term improvements with the technology and none which showed weight loss. The company is now bankrupt. Enough said.
A syringe of Restylane or Juvederm can’t usually make a significant improvement in volume in the face. Keep in mind that a syringe of these fillers is 1cc. There are 5cc in a teaspoon. So a syringe of the filler is a fifth of a teaspoon. In severely volume depleted patients, it’s not uncommon to use 4-8 syringes in one sitting. Some dissatisfaction commonly expressed on RealSelf.com are from patient’s which feel that there was no result with a filler procedure or that the filler was metabolized in a week or two. In actuality, they were expecting way too much from that fifth of a teaspoon. (In the lips, one syringe can make a noticeable improvement. This discussion is directed towards the patient needing volumization of face.)
Botox or Dysport is great for improving wrinkles which appear with expression but the wrinkles which are there at rest are helped to a much lesser degree. If you spread out your frown line and there is still a groove, this will not improve with Botox at one session and either requires multiple treatments to improve or the use of dermal fillers. Also remember, everything returns back to baseline unless injections are repeated every 3-4 months.
For an extremely strong frown line, complete “freezing” of the muscles is not possible. Studies show Botox can improve the frown line 1 or 2 grades (there are 4 grades/degrees of strength). You can’t go from a 4 to a 1 in one session.
Ulthera won’t give you a result that is comparable to a facelift. It will however give noticeable improvements for a procedure which takes about an hour with no long-term risks or downtime. Repeated treatments will give even further improvements. We send patients to be evaluated for surgery if they want tightening beyond what we can deliver with the Ulthera. Most still come back and request treatment from us.
Acne scars cannot be eradicated with any laser. You can expect up to about 50-60% improvement with the Fraxel Dual. This can take up to 10 treatments for the severely scarred patient.
Results for treating a smoker’s face will be diminished when compared to a nonsmoker. Smoking decreases the circulation to the facial skin by up to 60%. With this decreased “nourishment” to the skin, healing, collagen stimulation, tightening are all going to be significantly less. Smoking accelerates the aging of the face.
If you are 60-65 and are considering cosmetic procedures for the very first time, it’s been my experience that expectations from noninvasive procedures are unrealistic. Multiple procedures are required including: dermal fillers, Ulthera, skin care, peels, and possibly laser to turn back the clock. Thinking that a Botox treatment or a syringe or 2 of filler will do the trick is very unrealistic. I suggest that these patients consider surgical intervention, but if that’s not what they desire, we can definitely make noticeable improvements, but it takes time and multiple procedures.

In conclusion, this is an era of the minimal invasive cosmetic procedures. The future looks even more promising as to new procedures with even greater results and with more indications. Just make sure that you go to a trusted physician that can give you realistic expectations.