Botox Isn’t Working? Here Are the Reasons!

Are You Dissatisfied with the Effects of Botox?

Aesthetics Expert Dr. Eva Maria Strobl Explains Why it Doesn’t Deliver the Expected Results in Some Cases.

Lackluster Results of Botox: When the Magic Fades Away

Unveiling the Truth: Botox Disappointments and Treatment Outcomes

Are you frustrated that Botox isn’t working for you? Or no longer working? Even though the treatment was just a few weeks ago?

“Therapeutic failure” is a recurring issue in medicine, including Botox. It occurs when the patient, the doctor, or both are not satisfied with the treatment outcome. And if Botox shows no effect, then that is certainly the case.

While it is generally assumed that the effects of Botox are highly reliable, as numerous studies have shown, it can still happen that one finds oneself standing in front of the mirror, disappointedly realizing, “Botox isn’t working for me.” It is truly frustrating because time and money have been invested, and one has undergone a procedure that is not pleasant.

Moreover, there were high expectations for the cosmetic outcome, which is now not being achieved. When patients complain in forums or on social media about their negative experiences with Botox, the lack of effectiveness is usually the main reason.

Primary Therapeutic Failure: When Botox Falls Short

There are various reasons for dissatisfaction with the outcome of a therapy. In a first step, these can be roughly categorized by differentiating between primary and secondary therapeutic failure.

If the effects of Botox fail to occur from the beginning, even though the doctor has done everything correctly in terms of preparation and administration of the Botox injections, it is referred to as “primary therapeutic failure.” This includes, for example, incorrect indications where the desired treatment outcome cannot be achieved with Botox from the outset. An attempt to treat sagging wrinkles with Botox would fall into this category. Since they are not of mimetic origin, Botox will not produce any effects on them.

Initial Success, Subsequent Disappointment: The Curious Case of Botox

In contrast, “secondary therapeutic failure” refers to cases where Botox remains ineffective during an ongoing treatment. The therapy is initially successful, and the results are as expected. However, from one session to the next, the effects of Botox diminish or completely disappear. There can be many reasons for this, ranging from incorrect preparation of the injections by the doctor to the occurrence of resistance in the patient.

Let’s examine the reasons for the absence of Botox effects one by one. We will first address two important aspects that lead to primary therapeutic failure: high expectations and errors in indication. Then we will explore secondary therapeutic failure, focusing specifically on the (rare) possibility of Botox resistance.

Unlocking the Reliability of Botox Effects: A Game-Changer in Aesthetics

Promising Results: High Satisfaction Rates and Positive Feedback

The Good News First: The finding that Botox remains ineffective is rare. On the contrary, the therapy even shines with high satisfaction rates of 80-90%. Studies confirm this again and again. For instance, one study suggests that 9 out of 10 people treated with Botox are satisfied with the results and still feel significantly better four months after treatment. Only a few subjects reported negative experiences with Botox. Far more were convinced by the effect and would definitely recommend Botox.

Positive Effects Beyond Aesthetics: Botox and Improved Well-being

Another study proves that people who had their forehead treated with Botox were significantly happier afterward than the control group. This coincides with the well-documented suspicion that Botox can help with depression. Can these studies always be generalized and in every aspect? Maybe not. But the conclusion remains: Botox is usually very reliable.

Disappointing Results: Understanding Botox Treatment Failures

And yet, there are instances where Botox doesn’t show any effect. Or that the effect at least falls short of expectations. Patients are then rightly disappointed. Not least for financial reasons: costs of several hundred dollars are not met with a result that would be worth this effort.

Frustration and Hope: The Impact of Botox Treatment Failures

But often it’s about more than just money or a younger appearance: those who use Botox for certain ailments, such as spasms, dystonias, or migraine and bruxism, hope for a genuine increase in their well-being. Moreover, many patients have to overcome their fears of Botox first. The frustration is then all the greater when the therapy fails and the hoped-for effect does not occur. And unfortunately, in neurological therapy, Botox frequently does not work as hoped.

Managing Expectations: Botox Treatment for Chronic Migraines

One example: With the approval of Botox for chronic migraine, it was clear that the therapy would fail in a relatively high percentage of patients. However, you usually only know whether you are such a patient in retrospect. And with all that we know today about the exact mechanisms behind the Botox effect or don’t know, you can often only say: unfortunately, bad luck!

Realistic Expectations: The Role of the Doctor in Aesthetic Medicine

One of the central tasks of a doctor is to keep the expectations of his patients at a realistic level. And in aesthetic medicine, that is often enough of a challenge. Because one’s own appearance is judged emotionally and expectations of a cosmetic procedure are regularly exaggerated. Furthermore, aesthetic medicine is often accompanied by an overabundance of promises, with many individuals within the field seeking to capitalize on it.

Patience is Key: Understanding the Timing of Botox Effects

The question of when to expect an effect from Botox also contributes to false expectations. Unfortunately, many have become accustomed to having “everything immediately.” But that’s not the case with the effect of Botox. It only sets in after a few days. This has biochemical reasons, which I will go into in more detail at the end of the text.

Unveiling the Truth: Addressing Criticism Towards the Doctor’s Role in Botox Treatment

The Role of the Doctor in Treatment Failures

At this point in the text, it is evident that primary therapeutic failure of Botox typically falls on the responsibility of the doctor. If the expectations of the outcome were too high, the doctor should have tempered them to a realistic level. Additionally, if the indication was incorrect and Botox was not an appropriate treatment from the start, it simply amounts to misdiagnosis. In practice, the majority of cases where Botox shows no effect can very likely be categorized into one of these two scenarios.

The Importance of Proper Administration and Preparation

A third reason, for which the doctor is also accountable, lies in the improper preparation and application of the toxin. This includes errors in storage. While Botox is not an overly sensitive medication, it must be stored at a specific temperature in the refrigerator to maintain its full effect. Furthermore, Botox must be diluted with saline solution in precise proportions before being administered to the patient. However, in its diluted state, it should only be stored for a short period. Can errors be made in all these steps that could result in a loss of Botox’s effectiveness? Absolutely!

Bridging the Gap: Communication and Assessment of Results

Another aspect in which the doctor plays a crucial role is in assessing the treatment’s outcome. It is possible that the doctor and the patient may have differing opinions. Of course, if a frown line is still just as prominent despite Botox, there is no room for argument. However, it is not always so clear-cut. If the patient feels that the Botox had no effect, but the doctor sees success, there is clearly a disagreement. Studies have indeed shown that doctors and patients perceive the effects of Botox differently compared to a placebo. However, doctors were more accurate in their assessments than the treated patients.

The Importance of Communication and Documentation in Assessing Botox Treatment Results

In such situations, only a clarifying conversation can help. A conscientious doctor will have documented the initial condition verbally and with photos. Therefore, it should be possible to compare the outcome with the baseline and discuss the differences objectively. In my experience, this requires a personal conversation. This ensures comparability because with all the selfies that patients spontaneously send via email or messenger in such cases, it is immediately apparent that the lighting conditions during the capture render comparability impossible. As a doctor, one can only advocate for evaluating the post-treatment condition under the same conditions as the baseline. This includes similar lighting conditions in the doctor’s office. Only then can results be objectively discussed and disagreement prevented.

The Doctor’s Responsibility: Avoiding Misdiagnoses

Misdiagnoses and errors in application are the responsibility of the doctor. There is no need for debate on this matter. If Botox is injected for wrinkles that are not of mimetic origin, failure is inevitable. The muscular relaxation that the toxin is intended to produce may occur exactly as planned, but it will not contribute to improving the appearance of these particular wrinkles. Examples include sagging wrinkles or the nasolabial fold, which are not treatable with Botox. There are other techniques that can successfully mitigate them, but negative experiences are guaranteed with Botox.

Understanding Muscle Tone and Realistic Expectations

A similar, and probably quite common, issue lies in underestimating muscle tone and overestimating the effects of Botox. Muscle tone refers to the baseline tension present in a muscle even in a relaxed state. While Botox does induce relaxation, it may not be sufficient to completely eliminate wrinkles. Alternatively, the wrinkles may initially disappear, but the effects of Botox seem to vanish after only three months. An experienced doctor should not encounter such situations. While there may be cases that are difficult to evaluate and where the effects are not precisely predictable, it is then the doctor’s responsibility to warn the patient about the associated risks and manage their expectations accordingly.

Differentiating Patient Types: Insights from Dr. Mauricio de Maio

Brazilian plastic surgeon and Botox expert, Mauricio de Maio, distinguishes between three patient types: kinetic, hyperkinetic, and hypertonic.

For kinetic patients, the pattern of wrinkles corresponds to facial expressions, appearing only when they laugh or furrow their brows. With such patients, the expected Botox effects are likely to occur and can last a full 6 months.

In the case of hyperkinetic patients, their facial muscles are overactive, constantly in motion when they speak or even when they are attentive. According to de Maio, the initial effects of Botox should work well for them, too. However, the duration of the effects becomes questionable, typically lasting only 3–4 months.

Finally, hypertonic patients have muscles already tensed to such an extent that Botox cannot achieve complete relaxation. While the appearance of wrinkles may improve, they will never fully disappear. The effects of Botox in such patients are also significantly shortened, lasting approximately 3 months.

As seen in the following screenshot from an online training, de Maio strongly advocates informing patients about these variations before treatment. This enables them to form realistic expectations and avoids negative experiences with Botox due to unmet high expectations.

The effect of Botox depends significantly on muscle tone. Brazilian plastic surgeon and expert Mauricio de Maio differentiates 3 groups of patients: kinetic, hyperkinetic, and hypertonic. (Screenshot Allergan Medical Institute/Mauricio de Maio, June 9, 2021)

Identifying and Preventing Common Application Mistakes

Application errors occur when the Botox treatment is correctly indicated but not executed properly. Several cases can arise:

Insufficient Botox dosage

Injections not targeting the correct muscles

Incorrect injection technique

Quality deficiencies in the Botox syringe (e.g., due to improper storage)

Again, it can be observed that experienced Botox practitioners generally avoid such errors. As mentioned earlier regarding indications, there may be borderline cases where the muscular anatomy poses a risk of injecting the wrong muscle, resulting in the desired effect on wrinkles not being achieved. The doctor must address this issue beforehand and inform the patient about the associated risks.

Furthermore, injecting the wrong muscle can lead not only to the cosmetic effect being absent but also to undesired cosmetic consequences. Frequent examples include the dreaded “Spock eyebrows” or drooping corners of the mouth.

Leaving the patient unaware of these risks can result in not only the patient complaining about the lack of effectiveness but also being dismayed by unforeseen effects. Comprehensive patient education is essential to prevent unnecessary negative experiences with Botox, both in terms of effectiveness and unwanted outcomes.

Understanding Botox Resistance and Its Impact on Treatment

Overcoming Challenges: Exploring Botox Resistance

We have discussed the patient’s high expectations and the doctor’s treatment errors as potential causes for Botox treatment failures. However, now let’s explore a third possible cause for which the doctor is generally not at fault: Botox resistance. This occurs when the patient develops antibodies against Botox, resulting in an immune reaction that inhibits the effectiveness of Botox.

Dispelling Common Misconceptions about Botox Resistance

Botox resistance happens much less frequently than commonly believed and is almost non-existent in cosmetic Botox therapy. The few cases of Botox resistance primarily affect patients undergoing treatment for spasms or dystonias, which require very high doses of the medication. For example, studies with dystonia patients have shown Botox resistance in 3-10% of cases after repeated treatments.

How does Botox resistance occur?

Antibodies Binding to Active Molecules

Botox contains biologically active as well as biologically inactive protein molecules. For Botox to exert its effects, the active proteins must remain intact. However, both types of proteins can be recognized by the immune system as antigens, triggering the production of antibodies. These antibodies bind to the Botox proteins and render them inactive.

If the antibodies bind to molecules that were already biologically inactive, it has no impact on the effectiveness of Botox. However, if the antibodies bind to the biologically active portion of Botox, it blocks its toxic and therapeutic effects.

Recent studies indicate that this blockade can diminish over time. Over a period of 2 to 3 years, the number of antibodies decreases, potentially allowing for successful therapy and the manifestation of Botox’s effects in cases where it previously failed.

Preventing Botox Resistance

The formation of antibodies becomes problematic when Botox is injected in high doses and short intervals. This can be a challenge in neurological therapy, but is unlikely in cosmetic applications.

Administering 50–100 units of Botox every 4–6 months poses a minimal risk for antibody formation. An experienced doctor will take this into consideration and advise against frequent Botox injections in very short intervals (also known as “Botox boosters”). Failure to do so would make the doctor partially accountable for any resulting resistance.

Botox Isn’t Working for Me – What Are My Options?

Taking Action and Exploring Options for Disappointing Results

Returning to the starting point of this article: standing in front of the mirror, disappointedly realizing that “Botox isn’t working for me.” What can you do?

Clear Communication with Your Doctor

Initiate a conversation with your doctor if they agree that the Botox treatment is not producing the desired effects. Together, you can investigate the possible causes. Your patient records and initial condition photos should provide insights into whether the doctor’s approach was fundamentally correct.

Additionally, it is important to have the batch number of the used product, which can be used to inquire about any known issues with that specific batch. As a result of the discussion, you may consider a second attempt, possibly with a higher dosage or modified injection scheme if it is suspected that those factors may have contributed to the previous lack of results.

Considering a Change of Doctor

If you have lost confidence in your current doctor, you may decide to seek treatment elsewhere. This decision will depend on the level of trust you had with your previous doctor and the impressions you gained from the conversation. While “doctor hopping” is generally not recommended, if you have lost trust in your doctor, you may have no other choice. Many doctors today administer Botox for cosmetic purposes, even those whose specialization and focus have little to do with cosmetic treatments. Hence, there is a certain risk of ending up with the wrong provider.

Testing for Botox Resistance

If subsequent treatments show no improvement despite indications that everything was done correctly, you should consider getting tested for Botox resistance. Perhaps you belong to the small group of people who are immune to Botulinum toxin A for reasons yet to be understood. As mentioned earlier, this is unlikely, but it cannot be completely ruled out.

In a Botox resistance test, the electrical activity of muscle fibers is measured using surface electromyography. This results in an electromyogram. The process involves recording and documenting the amplitude of the measured action potential in a muscle, followed by injecting Botox into the muscle. Four weeks later, a second measurement is taken. If the new measurement shows a lower amplitude compared to the initial measurement, Botox has demonstrated its effectiveness, indicating no resistance. Conversely, if the amplitude remains unchanged, resistance is present.

Considering Botox Alternatives

If it turns out that resistance exists, and you are immune to Botox, do not be overly disappointed. There are several alternative options for treating wrinkles that can yield excellent cosmetic results. Dermal fillers with hyaluronic acid would be the first to consider, but thread lifting, platelet-rich plasma (PRP) treatments, microneedling, and chemical peels can also deliver positive outcomes for smaller wrinkles.

FAQ: Understanding How Botox Works and When to Expect Results

As mentioned earlier, unrealistic expectations contribute to the question of “When does Botox work?” I will now provide a brief FAQ section to explain how Botox works and when its effects become noticeable. This information may help better contextualize the content discussed above.

How Does Botox Work?

Botox is a neurotoxin that targets “cholinergic synapses,” which mediate communication between a nerve cell and a downstream cell. This communication occurs through neurotransmitters, with a key neurotransmitter of interest being “acetylcholine.” Botox inhibits the secretion of acetylcholine, thereby interrupting communication between nerve and muscle cells. With this communication disrupted, nerve impulses no longer reach the muscle, resulting in paralysis. This is the basis of Botox’s effectiveness.

When Does Botox Take Effect?

After injection, it takes between 24 and 48 hours for the toxin to bind to nerve cells and penetrate them. The process is complex and involves the splitting of the two-part Botox molecule. Only the lighter part, known as the “L-chain,” enters the nerve cell. Inside the nerve cell, Botox cleaves a protein crucial for acetylcholine release, thereby preventing its release.

Consequently, it takes 1–2 days for injected Botox to take effect and for initial muscle paralysis to occur. Some patients notice improvements in their wrinkle appearance from that point onward, but this may not be the case for everyone. Many patients wonder how quickly Botox works and may become anxious after just a few days, especially if it is their first treatment. The time it takes to see the full effects of Botox varies depending on individual factors, particularly the strength and baseline tension of the muscles involved. In my experience, it takes 7–14 days to see the full effects. Men may require slightly longer than women.

Therefore, if you don’t notice any effects after 3, 4, or 5 days, don’t be alarmed. It is normal. However, if after 14 days you still see no results, you should contact your doctor. Usually, a follow-up appointment is already scheduled to address any lack of effect.

Are There Any Long-term Effects of Botox?

In short, no, Botox does not cause long-term effects. The process outlined above for the action of Botox is entirely reversible. The toxin gradually loses its effect until it completely dissipates after 4–6 months. There are no traces or “memory” of Botox left in the body. Therefore, concerns about long-term effects of Botox are unfounded, as confirmed by numerous long-term studies: Botox does not have any long-term effects.

However, muscles can lose strength when they are inactive for a long time. This is a familiar concept for arms and legs. Mimetic muscles are no exception; they also weaken with prolonged immobilization. One could refer to this as a “late-effect of Botox,” but it is only indirectly related to the toxin.

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About the author:

Dr. med. univ. Eva Maria Strobl is the owner of LIPS and SKIN Aesthetic Medicine practice in Munich. She is a trained specialist in general medicine (MedUni Vienna) and has over 10 years of specialization in non-surgical aesthetic procedures. She is a member of the German Society for Aesthetic Botulinum Therapy e.V. (DGBT), the German Society of Anti-Aging Medicine e.V. (GSAAM) and of Network Global Health. She publishes regularly on her blog and on DocCheck.

Sources of this article:

Sommer et al, Botulinumtoxin in der ästhetischen Medizin (in German), Thieme
Shtefan et al, Causes of Botulinum Toxin Treatment Failure, Link

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