My Botox Doesn’t Work Like It Used To
I got Botox for the first time the year I turned 30. Have I aged in the six years since? Absolutely. Does it look like I have? That’s debatable. I’ve tried a plethora of facial aesthetic treatments (most with very favorable results), but none of them has had the impact of Botox for the way it smooths my fine lines—or at least, the way it used to. For about a year now, I’ve noticed Botox doesn’t unfurrow my brow as effectively or for as long as it once did.
Can you become less responsive to neuromodulators over time? The answer to that question is not a simple yes or no. There are many nuances that influence the effect that neuromodulators like Botox have on your muscles. (And for the record, when we say Botox from here on out, we’re referring to the family of all five FDA-approved neurotoxins—also called neuromodulators—currently on the market, including Xeomin and Dysport.) And while there have been some initial clinical studies on the topic of so-called “Botox resistance” (the majority of which looked at onabotulinumtoxin A—also known as Botox), there’s still so much more that we have to learn.
To shed some light on what we do know about Botox resistance, I asked experts to weigh in on how common the phenomenon actually is, what factors can contribute to it, and what to do if you find that your muscles aren't quite responding to neuromodulators the way they used to.
Before we delve into the idea of Botox resistance, let’s refresh ourselves on how neuromodulators like Botox actually work. “Botox works on dynamic wrinkles,” says David Shafer, MD, a double board-certified plastic surgeon based in New York City and a trainer for Allergan Aesthetics, the makers of Botox. Those are the lines that appear when you express emotions, and are invisible when your face is at rest. Neuromodulators inhibit the release of acetylcholine, a neurotransmitter that relays nerve signals to the muscle. As a result, “you get a temporary weakening or paralysis of the muscle,” says Connie Yang, MD, a board-certified dermatologist at PFRANKMD by Dr. Paul Jarrod Frank in New York City. “This effect is localized to the injected area, preventing the muscles there from fully contracting and forming wrinkles or lines.” Over time, the nerve signals gradually resume their normal function—and the lines return.
The same chemical reaction occurs in everyone after the needle penetrates your skin—but its effectiveness in terms of wrinkle-reduction lies in where the neuromodulator is placed and how much of it is used. No one’s facial anatomy is identical and an assessment of muscle movement by a highly skilled and experienced practitioner is essential to receiving the right treatment for you. (Allure recommends seeing a board-certified dermatologist or plastic surgeon for any treatments that go into or past the skin barrier, neuromodulators included.) “Every person is different in their anatomy and how they animate,” says Dr. Yang. “These are the factors that determine Botox dosing for each individual, not so much their age.”
When Dr. Yang evaluates a patient for neuromodulator injections—she most often uses Xeomin as she finds it produces the “most natural-looking” result—she looks at their facial movements and the strength of their muscle contractions. She takes note of any asymmetries and features like low-set brows. “The muscles on the face have opposing functions and there’s an art to facial balancing with neuromodulators,” she says.
Dr. Shafer notes that Allergan Aesthetics has recently worked with the FDA to update the injection pattern they recommend to providers to help them further individualize treatment for patients. This way, Allergan can “train providers on the nuances of each patient and [encourage a] less cookie cutter approach to injecting,” he says. (Allergan Aesthetics declined to comment on this story, but put forth Dr. Shafer as an expert resource.)
You can typically expect to see the effects of neuromodulators kick in between two to seven days post-injection. They reach “peak strength” after 10 to 14 days but “look best—settled, loosened, and natural—around six to eight weeks,” says Mark Murphy, MD, a board-certified facial plastic surgeon and founder of Palm Beach Facial Plastic Surgery in Florida.
Of course, everyone is different—and there are a handful of people who seem to not respond to neuromodulators at all.
The medical community uses various terms—neurotoxin tolerance, Botox resistance, and the tongue-twisting Botox/neurotoxin non-responders—to refer to what happens when a patient doesn’t respond to neurotoxin injections, or does not respond to them in the same way that they used to. In the simplest terms, resistance is defined as full movement returning to the muscles before three to four months’ time, which is how long one neuromodulator treatment lasts on average. (Though Daxxify, the newest one on the block, may last as long as six months.)
“Botox resistance is a rare and not yet well-understood phenomenon that occurs when the body develops neutralizing antibodies,” explains Dr. Yang. The development of antibodies can be in response to either the active ingredient botulinum toxin or the supporting proteins in the given formula, adds Dr. Murphy. The idea is that over time—and with repetitive injections—your body is overexposed to the complex proteins that are bound to the neurotoxin. “With these repeated exposures, your body can develop an immune response to these foreign proteins and form neutralizing antibodies,” says Dr. Yang.
By Aliza Kelly
By Patricia Tortolani
By Marci Robin
Botox resistance has been recorded in neurology literature, particularly during instances in which the drug is used to treat chronic conditions such as migraines, explains Shari Marchbein, MD, a board-certified dermatologist in New York City. (Botox was FDA-approved as a treatment for migraines in 2010.) That said, in therapeutic cases much higher doses of botulinum toxin are used than in cosmetic patients. For the treatment of migraines, upwards of over 100 units can be used at a time, compared to the 20 to 70 units used to immobilize muscle movement in the face, explains Dr. Marchbein. It’s thought that the significantly higher dosage used for therapeutic cases can place a patient at greater risk of developing Botox resistance.
Evidence of developing neutralizing antibodies as a result of aesthetic use of Botox is scarce: A recent analysis found that the occurrence hovers around 0.5%. “In my practice—and I’ve done hundreds of thousands of Botox injections—[Botox resistance] is extremely rare. I’ve maybe seen it one or two times in the last almost 30 years,” says Ramtin Kassir, MD, a board-certified facial plastic and reconstructive surgeon in New York City.
The jury is still out on what mechanisms in the body or individual traits (like the speed of your metabolism) can cause someone to develop neutralizing antibodies, if they do at all. For the time being, however, the good news is that while neutralizing antibodies may impact how well your Botox “takes,” their development has not been shown to have other health impacts, says Dr. Yang.
Consensus from the medical experts that I spoke with was that too-frequent dosing, under-dosing, and maybe even the COVID-19 vaccine (more on that in a minute) are all possible contributing factors to Botox resistance. Keep in mind though: as with any scientific phenomenon, correlation does not mean causation.
If you’re the type to run back to your injector at the first signs of movement (something I’m guilty of, and perhaps the reason for my own resistance), this can increase your risk of developing Botox resistance. You should always wait at least three months between neuromodulator treatments. “It’s going really frequently [that] can increase the risk of developing neutralizing antibodies,” says Dr. Marchbein, who says that out of the thousands of patients she sees in her practice, a “handful” have become resistant to neuromodulators over time.
By Aliza Kelly
By Patricia Tortolani
By Marci Robin
Dr. Marchbein also points to the rise of medspas as a possible reason for an uptick in Botox resistance. She explains that patients may be receiving “cookie cutter” dosing—as in, a set number of units that does not account for the individual’s unique muscle movement or facial anatomy. She explains that in her experience, medspas tend to inject fewer units, which enables them to offer a lower price for services—and prompts clients to return for more injections, more often. As someone who has visited medspas over the years, I can’t help but wonder if this, too, contributed to my own experience. In any case, Dr. Marchbein stresses the importance of making sure that you seek out a highly qualified injector and to “really stick to that three month mark, don’t do it sooner”—even if you’re starting to see more movement than you’d like.
There may also be a correlation between the COVID-19 vaccine and the effectiveness of Botox—but before we say another word about it, let’s be clear that this is not a reason not to get vaccinated. In 2022, a small study of 45 patients found that muscle movement resumed about two weeks sooner among those who had gotten the COVID-19 vaccine versus those who had not yet received the vaccine. In another case, a patient under observation received Botox after getting the vaccine. Though the patient had been receiving Botox injections successfully for five years, this time, she reported a lack of response. This case suggests that the introduction of foreign proteins via the vaccine (intended to help the body build an immune response against the virus) may have led to the development of neutralizing antibodies. But one case is far (extremely far) from a study from which we can draw conclusions.
If you’re finding that you’re not responding to neuromodulators as well as you used to, there are a few tactics you can try.
The expertise of your injector plays a key role in how your muscles respond
- Last
News by day
2 of May 2024
