Botox not working? Here are the reasons! (and what you can do)

Botox showing no effect

Are you annoyed that Botox doesn’t work for you? Or no longer works? Even though the treatment was only a few weeks ago? So-called “treatment failure” occurs in medicine all the time, and unfortunately also with Botox. Treatment failure is the term used to describe a situation, in which the patient, the doctor or both are not satisfied with the result of the treatment. And if Botox doesn’t have an effect, then that’s certainly the case.

In general, it can be assumed that Botox works very reliable. That’s what studies have shown many times. But occasionally, it happens that it doesn’t work. And if of all people it is you that this happens to, then that’s very annoying. After all, you have invested time and money, and endured a procedure that is not pleasant. In addition, there were high expectations for the cosmetic result, which is still to be seen.

Primary treatment failure: Botox not effective at all

There is always a wide range of reasons for dissatisfaction with a treatment outcome. In a first step, the causes can be roughly divided into primary and secondary treatment failure. If Botox shows no effect from the first treatment, even though the physician did everything correctly in preparing and administering the Botox injections, this is called a “primary treatment failure.” A major root cause for a primary treatment failure can be an incorrect indication. This means that the treatment goal could not be achieved with Botox in the first place. For example: the attempt to treat sleep lines with Botox is bound to fail. Since sleep lines are not of mimic origin, Botox will have no effect on them.

Secondary treatment failure: Botox effect vanishes

In contrast, one speaks of “secondary treatment failure” when Botox works as expected in initial treatments, but then starts to lose its effectiveness. The treatment is successful at first, results are as expected. But from one time to the next, the effect disappears. Or it starts to fade after a short time. There can be many reasons for such a failure: from incorrect preparation of the syringes by the physician to the emergence of a resistance in the patient.

Let’s look at the reasons for a lack of Botox effectiveness one by one. And let’s first address two important factors that lead to primary treatment failure: Unrealistic expectations and indication errors. We then consider secondary treatment failures. And in doing so, somewhat more specifically, the possibility of a Botox resistance.

These are the topics:

Botox works reliably most of the time

The good news first: the unpleasant finding that Botox has no effect is rather rare. On the contrary, the treatment shines with high satisfaction rates of 80-90%. Studies prove this time and again. For example, one study talks about 9 out of ten people treated with Botox being satisfied with the effect and still feeling significantly better 4 months after treatment. Few subjects reported negative experiences with Botox. Significantly more were convinced of the effect and would definitely recommend Botox to others.

Another study demonstrates that people who had their foreheads treated with Botox were significantly happier afterwards than the control group. This coincides with the now well-documented suggestion that Botox can help with depression. Can these studies be generalized always and in every point? Maybe not. But the conclusion seems based on good evidence: Botox works very reliably most of the time.

When Botox does not work

And yet, it happens that Botox has no effect. Or that the effect is insignificant and falls short of expectations. Patients are then justifiably disappointed. Not least for financial reasons: Costs of several hundred euros do not yield results that would be worth the effort. But it’s often about more than just money: When Botox is used to treat certain neurological conditions, such as spasms, dystonia, or migraines and bruxism, patients hope for a real increase in their well-being. The frustration is all the greater when the treatment fails and the hoped-for effect does not materialize. And in neurological therapy, it is unfortunately true that Botox does not produce desired treatment outcomes frequently.

Failure of Botox treatment of migraine

For example, when Botox was approved for chronic migraine, it was already clear that the therapy would fail in a high percentage of patients. In the others, it would work very well and bring real relief. However, you don’t know at the outset which group you belong to as patient. Because the specific reasons for a Botox failure in migraine treatment are not completely clear. The prudent physician will manage his patient’s expectations accordingly by pointing out the possibility of failure even before therapy begins. In addition, he or she will design the treatment plan so that discontinuation occurs at predefined points if the effect fails to materialize. In the case of chronic migraine, for example, this is foreseen after the third unsuccessful treatment according to the respective guideline in Germany.

Unrealistic expectations

One of the central tasks of the physician is to keep the expectations of his patient at a realistic level. And in aesthetic medicine, this is often enough a challenge. After all, one’s own appearance is judged emotionally and expectations of a cosmetic procedure are not infrequently exaggerated. In addition, the medical aesthetics industry and many of those who earn their living in it also like to exaggerate their promises.

The problem is compounded by thousands of beauty influencers on Instagram, who make everyone believe in perfectly styled photos: “You can look like this, too!” And by just as many “before and after treatment” pictures, supposedly from real treatments. But the professional recognizes at first glance that many of these pictures document no more than the great work of “Dr. Photoshop”. All this must be put into perspective by the doctor. If he fails to realistically manage the expectations of his patients, then the disappointment could be great after the treatment.

All eyes on the physician

At this point in the text, it can already be deduced that the physician is usually responsible for a primary therapy failure. After all, if the expectations of the outcome were too high, then the physician should have trimmed them down to a realistic level. And if the indication was wrong, and Botox was not a suitable means to achieve the treatment goal in the first place, then it is simply a misdiagnosis, which also falls into the responsibility of the physician. In practice, I would be led to believe that the vast majority of cases in which Botox has no effect will fall into one of these two categories.

Finally, there is a third reason, why Botox could not be working. And it would also fall into the physician’s responsibility: the incorrect preparation and application of the Botulinum toxin. This includes handling and storage errors. While Botox is not an overly sensitive drug, it does need to be stored at a certain temperature in the refrigerator to retain its full effect. And before application to the patient, Botox must be diluted in a precise ratio with saline. In a diluted state, however, it may then only be stored for a short time. Could mistakes be made in all of these steps that cause Botox to lose effectiveness? Of course!

Dissent between doctor and patient

Another aspect of the problem lies in the assessment of the treatment outcome. It may well be that the doctor and patient have different opinions on it. Sure: If frown lines are still as clearly visible after Botox treatment as they were before, then there’s no need to argue about it. But it’s not always so obvious. And if the patient thinks that the effect of Botox has failed to appear, but the physician sees the success very well, then there is obviously a disagreement. How do you get away from that and come to a common judgment? In fact, studies have shown that physicians and patients assess the Botox effect very differently compared to placebo. However, the physicians were correct much more often than their patients.

Correctly assess Botox effect

In such a situation, only a clarifying conversation will help. The prudent physician documented the initial condition, verbally and with photos. It should therefore be possible to compare the state ex post with the state ex ante. And to discuss improvements factually. In my experience, the personal meeting is necessary for this. If only to ensure true comparability. Because with all the selfies that patients nowadays send you via e-mail or messenger in such cases, you can immediately see that different lighting conditions or amounts of contrast make a like-for-like comparison impossible. Therefore, as physician, one can only plead for assessing the actual condition after treatment under the same conditions as the initial condition. With approximately the same lighting conditions in the doctor’s office. Only in this way will it be possible to discuss results objectively and find common ground.


Misdiagnosis and application errors are the fault of the physician. There is no need to discuss this. If Botox has been injected for wrinkles that are not of mimic origin, then failure is inevitable. The muscular relaxation that the toxin was intended to cause may occur exactly as planned. Alone, it will not be able to contribute to the improvement of the wrinkles in question. I mentioned sleep lines already. The nasolabial fold is another example. Both are not treatable with Botox. There are other techniques that can be used to successfully smooth them. But with Botox, negative experiences are bound to happen in both cases.

A similar problem, probably quite common, may be that muscle tone is underestimated. And thus the possible effect of Botox overestimated. Muscle tone is the basic tension of a muscle that is present even in a state of relaxation. Botox then leads to relaxation, but this is not enough to eliminate wrinkles completely. Or the wrinkles are gone at first, but already after 2–3 months they unexpectedly return. This should not happen to the experienced physician. There may be cases where the assessment is difficult and the effect not exactly predictable. But then again, it is up to the physician to alert the patient to the risk and manage his expectations accordingly.

How long does Botox last?

In this context, the Brazilian surgeon and Botox expert Mauricio de Maio distinguishes between “kinetic”, “hyperkinetic” and “hypertonic” types of patients. In kinetic patients, the wrinkle pattern corresponds to the mimic expression, i.e. wrinkles appear when laughing or frowning, but not otherwise. Botox can be expected to deliver a textbook effect in these patients, which lasts for a full 6 months.

In hyperkinetic patients, facial expressions are overactive. Their face is constantly in motion when they are telling something or even just paying attention. According to de Maio, the effect of Botox treatment should be very visible at first, but then wear off faster than in kinetic patients. As a rule, the effect will last for 3–4 months in these patients.

Finally, hypertonic patients are already so tense in their muscles that Botox can no longer bring about complete relaxation. Wrinkles will be smoothed somewhat, but never disappear completely. And the Botox effect will also only last for a short time, at best 3 months.

As shown in the following screenshot from an online training with de Maio, he strongly advocates informing the patient about like treatment outcomes as a function of muscle tone before treatment. Only then can he form realistic expectations.

The Botox effect depends essentially on the muscle tone. The Brazilian physician and expert Mauricio de Maio distinguishes 3 groups of patients: kinetic, hyperkinetic and hypertensive. (Screenshot: Allergan Medical Institute/Mauricio de Maio, June 9, 2021)

Application errors

Application errors always occur when the treatment with Botox is correctly indicated but then not correctly performed. Once again, several cases are conceivable:

  1. The dosing was too low
  2. The injections hit the wrong muscles
  3. The injection technique was incorrect
  4. The quality of the injected Botox was impaired (e.g. because of incorrect handling or storage)

Again, one can only conclude that such mistakes usually do not happen to the physician experienced with Botox. As with the indication earlier, there may be borderline cases where the muscular anatomy carries a risk of injecting the wrong muscle and failing to achieve the desired treatment outcome. The physician must address this in advance and inform the patient of the risk. If only because mistakenly injecting the wrong muscle can not only result in the cosmetically desired effect not being achieved; but also because cosmetically undesirable consequences can occur. Examples are “Spock brows” or drooping corners of the mouth. Thus, keeping the patient in the dark about the risk may not only result in the patient ending up complaining about a lack of effect. But also, and worse, that he is horrified by unforeseen effects. Therefore, comprehensive education on both points will prevent the patient from having negative experiences with Botox that are unnecessary.

Botox does not work because of resistance

Botox effect inhibited

Okay. Thus far, we have identified unrealistic expectations on the one hand and treatment errors (in a wide sense) on the other as main reasons for disappointing results of Botox treatments. Let’s now look at a reason, that is much more often offered as explanation for a lack of effect, than it is the true cause in reality: Botox resistance.

Botox resistance occurs when the patient develops antibodies to Botox. And this leads to an immune reaction that stops the effect of Botox. In reality, this is a rather rare phenomenon. In cosmetic applications of Botox in particular. The few cases of Botox resistance that one reads about in studies or medical literature almost always involve patients who receive neurological treatments for spasms or dystonia. This is explained by the relatively high doses of Botulinum toxin used in these therapies.

Antibodies bind to active proteins

What causes a resistance? Botox contains biologically active as well as inactive proteins. For Botox to take effect, the active proteins must remain intact. However, both types of proteins can be recognized as antigens by the human immune system. It responds by forming antibodies. The antibodies bind to the Botox proteins and inactivate them. If these are the proteins that were biologically inactive anyway, then this won’t influence the effect of Botox. If, on the other hand, the antibodies bind to the biologically active proteins, then Botox loses its toxic and therapeutic effect. However, recent studies suggest that the blockage fades over time. In the course of 2 to 3 years, the number of antibodies decreases, so that a Botox treatment may then be successful again.

How to avoid Botox resistance?

The formation of antibodies is more likely when Botox is injected in high doses and at short intervals. This can be challenging in neurological therapy. But it is hardly an issue in cosmetic applications. 50–100 units of Botox every 4–6 months do not pose a grand risk for antibody formation. The experienced doctor will take this into account and advise against Botox in very short intervals (“Botox boosters”).

Botox does not work for me – What can I do?

With that, let’s get back to the starting point of this article: You stand in front of the mirror and realize, with disappointment, that Botox doesn’t work for you. What can you do?

Clarifying conversation with the doctor

Firstly, seek a conversation with your doctor. If he agrees with you that the treatment with Botox has no effect, then it is necessary to find out the causes. Your patient file and the photos of the initial condition should provide information on whether your doctor’s procedure was correct in principle. In addition, the batch number of the preparation used should be available, which can be used to ask the manufacturer whether there are any known problems with this batch. As a result of the conversation, you may want to give it a second try. Possibly with higher dosage or modified injection regimen.

Change of doctor

However, you may withdraw your trust from your doctor and try again somewhere else. This will depend on how good the relationship of trust was with your previous doctor and what impressions you gained from the conversation. “Doctor hopping” is usually not a good idea, but if you have lost trust, then you have no choice. Many doctors today inject Botox for wrinkles, even those whose speciality and focus has little to do with cosmetic wrinkle treatments. A certain risk of having fallen in with the wrong person therefore cannot be completely dismissed.

Get tested for resistance

If further treatment also shows no effect, although it can be assumed that everything was done correctly, then you should consider getting tested for Botox resistance. You may indeed belong to the small group of people who are immune to botulinum toxin A. For whatever reason. As mentioned before, this is admittedly unlikely. But you can’t completely rule it out.

In the test for Botox resistance, the electrical activity of muscle fibres is measured. The result is an electromyogram. The procedure is as follows: First, the amplitude of the measured action potential of a muscle is recorded and documented. Then Botox is injected into the muscle. 4 weeks later, measurements are taken again. If the new measurement shows a lower amplitude than the first measurement, then the Botox has taken effect and there is no resistance. If, on the other hand, the amplitude is unchanged, then resistance is present.

Consider Botox alternatives

If it turns out that there is resistance and you are thus immune to Botox, don’t be too disappointed. There are several other options for treating wrinkles. Cosmetically excellent results can also be achieved with these. Dermal fillers should be mentioned first, but also thread lift or PRP. For smaller wrinkles, you can achieve good results even with microneedling and chemical peels.

Frequently asked questions

I attach a short FAQ to my text as a digression. In it, I explain how Botox works and when the effect begins. This information may help to put the article itself into context.

How does Botox work?

Botox is a neurotoxin. It acts on the “cholinergic synapses“. The cholinergic synapses mediate communication between a nerve cell and a downstream cell. Communication between cells takes place via messenger substances. It is also referred to as “ Neurotransmitters “. The neurotransmitter that interests us in Botox is called “ Acetylcholine “. Botox now inhibits the secretion of acetylcholine. And thus interrupts the communication between the cells. More precisely: between nerve and muscle cells. Since communication is interrupted, nerve impulses no longer reach the muscle. He is paralyzed. Maybe not quite. It depends on the dose. But at least partially. The strong pull on the skin is therefore absent. It is now no longer folded. The effect of Botox is based on this.

Does Botox work immediately?

No. After injection, it takes between 24 and 48 hours for the toxin to bind to and penetrate the nerve cells. The process is complicated and involves the 2-part Botox molecule splitting. Only the lighter part, the “L-chain”, penetrates the nerve cell. There, Botox cleaves a protein that is important for the release of acetylcholine. This prevents the distribution. Therefore, it takes 1–2 days for injected Botox to take effect and the first initial paralysis of the muscle to occur. There are patients in whom the wrinkle appearance improves already from then on. However, this is certainly not the case for all patients. Therefore, there is no point getting nervous 2 days after treatment. A visible improvement should be seen after a week. The full effect will have set in after 2 weeks.

Are there any long-term effects of Botox?

Short answer: No. Botox does not cause long-term effects. The process of Botox action outlined above is completely reversible. This means that the toxin gradually loses its effect until it is completely gone after 4–6 months. No traces and no “memory” remain in the body. The fear of Botox late effects is therefore unfounded. Long-term studies have confirmed this. However, muscles lose strength when they are not active for a long time. You know this from arms and legs. It is no different with mimic muscles. They also weaken with prolonged immobilization.

Attractive at every age

LIPS and SKIN Aesthetic Medicine

Eva Maria Strobl, MD
Herzog-Heinrich-Strasse 34
80336 Munich