sigmund-MQ2xYBHImKM-unsplash

Injectables are constantly evolving, and what was considered the gold standard yesterday may be passé by tomorrow’s standards. One class of injectables that has largely proven to be trend-proof: [Neuromodulators](https://aedit.com/aedition/comparing-neurotoxin-botulinum-type-a-injections-botox-dysport-jeuveau-xeomin) and their ability to limit muscle contraction and soften the look of fine lines, wrinkles, and other age-related concerns. In fact, [Botox® Cosmetic](https://aedit.com/procedure/botox) is celebrating the twentieth anniversary of its approval by the United States Food and Drug Administration (FDA) for the temporary improvement of the appearance of moderate to severe frown lines in adults. It was the first of its kind when it entered the market, and it’s since been joined by [Dysport®](https://aedit.com/procedure/dysportr), [Jeuveau®](https://aedit.com/procedure/jeuveau), and [Xeomin®](https://aedit.com/procedure/xeomin). 

Since no two faces are the same, no two dosages of these products are necessarily the same to achieve a desired result. That’s where so-called ‘Botox sprinkles’ – also known as ‘baby Botox’ – come into play. Not to be confused with [microbotox](https://aedit.com/aedition/aquagold-botox-microdosing-facial), the sprinkle technique is essentially just a smaller dose of a neuromodulator. A modest amount of Botox® and the like may produce a more natural result for younger patients or newbies who are just dipping their toe into the wrinkle-relaxing pool and concerned about appearing frozen.

So, what are the pros and cons of Botox sprinkles, and how can you tell if you are a candidate? We tapped top dermatologists and plastic surgeons for the scoop.

## **What Are Botox Sprinkles?**
A tongue-in-cheek reference for a smaller dose of a neuromodulator, the term ‘Botox sprinkles’ are injections of Botox®, Dysport®, Jeuveau®, or Xeomin® into a specific part of the face to soften the look of fine lines and wrinkles without eliminating all movement. “Botox sprinkles are great for smoothing fine lines and wrinkles on the face without completely removing muscle movement,” says [Michele Green, MD](https://aedit.com/provider/michele-green-md-34642), a NYC-based board certified dermatologist.

The trend of less-is-more shows no signs of slowing down, and some injectors and patients are preferring to use minimal amounts of neuromodulator to preserve expression. At his Arlington, VA, practice, double board certified facial plastic and reconstructive surgeon [Jonathan Cabin, MD](https://aedit.com/provider/jonathan-cabin-md-956), says a large percentage of his patients opt for these treatments to soften facial wrinkles and prevent traditional aging-related wrinkles while preserving natural movement. “It is the ideal option for [first-time Botox patients](https://aedit.com/aedition/everything-you-need-to-know-before-getting-botox-for-the-first-time) who are a bit nervous, younger patients interested in prevention, and patients who depend on powerful emotive facial expressions for their work,” he explains.

Like traditional injections of neuromodulators, the ultra-light dose version still requires a medical professional to inject botulinum toxin type A under the skin to temporarily relax the underlying muscle. A sprinkling of a neuromodulator within a particular area may provide a reduction of wrinkles and lines and their formation but not to the same degree as a standard treatment, says [Brendan Camp, MD](https://aedit.com/provider/brendan-camp-md-34645), a board certified dermatologist in New York City. Striking this balance is dependent on the [skill of the provider](https://aedit.com/aedition/botox-neuromodulator-safety). “An experienced injector will be able to determine the right amount of Botox to inject based on how strong your facial muscles are and how deep the wrinkles are,” Dr. Green says. 

The just-right amount of product will soften the visible appearance of wrinkles while limiting – but not paralyzing – the movement that causes them in the first place. Botox sprinkles aren't the best route if you want very little to no movement in the treatment areas. Using less Botox is less likely to completely paralyze the muscle and, therefore, results in more expression, says [Marisa Garshick, MD](https://aedit.com/provider/marisa-garshick-md-313), a board certified dermatologist in NYC. “Ultimately, with Botox sprinkles, you retain some movement and some wrinkles but soften the overall appearance,” she notes. Most injectable patients eschew the fully frozen look (though some want it) and the overarched eyebrows and difficulty moving that accompany it. If you specifically request baby Botox, you are less likely to have that frozen appearance since your doctor injects smaller amounts of the product.

Even though the name ‘sprinkle’ implies injecting a dusting or smidgen of neuromodulator into any one area, it's a little more precise than that. While there is no set requirement for what a sprinkle treatment consists of since each patient requires a different dose, expect about half the unit use compared to complete treatment. “For Botox sprinkles, I use as little as five units of Botox in the forehead and glabella, whereas the official dosing is 20 units for each,” Dr. Cabin says. “For the crow's feet, I use about 2.5 units per side, whereas the official dosing is 12 units per side.” Again, a consultation with your injector will dictate the best approach for you.

It should be noted that a full dosage doesn’t necessarily mean an unnatural or immobile result. If your doctor recommends using the standard dose of a neuromodulator, it still can provide a refreshed look that allows for facial movement. “However, if a patient is interested in maintaining a lot of movement, a lighter treatment with neurotoxin can be a great option,” Dr. Camp says.

## **Where to ‘Sprinkle’**
It's safe to ‘sprinkle’ the same areas of the face that providers commonly treat with larger amounts of neuromodulators – like the glabellar lines (a.k.a. the elevens), [crow's feet](https://aedit.com/procedure/periorbital-botox), and even the horizontal lines on the forehead. For the most part, smaller areas don't require as much product to begin with to erase wrinkles and lines seamlessly. Dr. Green prefers to use the sprinkle technique on areas of the face with lighter lines or where the skin is just starting to develop them. “It also works wonders in reducing mild to moderate wrinkles while still looking natural, but it often fails to yield the desired results for deeper lines etched in the skin,” she says.

## **Who’s the Best Candidate for Botox Sprinkles?**
Botox sprinkles are suitable for anyone who doesn't have many lines yet or has lines that aren't very deep but wants to prevent further wrinkles, Dr. Garshick says. “It's also good for someone who prefers a very natural look with minimal correction but still wants a refreshed appearance,” she explains. “And it can be helpful for older patients with a low-set brow or those who rely on the muscle movement to keep the eyelids and brows open to soften the movement without causing the brow to drop.”

Not everyone will benefit from a smaller dose of neuromodulator injections. While Dr. Camp says it may be a “good option” for those with minimal wrinkling who don’t require a full dose, others may find that a smaller amount of neuromodulator does not produce their desired result. Dr. Green says some patients come in expecting to get baby Botox, but, upon consultation, find out they have strong facial muscles and need more product to achieve optimal cosmetic effects. “The key to getting the best results from a neuromodulator is to go to an experienced injector, like a board certified dermatologist, who can give you natural-looking results,” she notes.

Generally speaking, the deeper the line, the stronger the muscle, and the more product needed to create smoother skin. Dr. Green explains that, with baby Botox, such small quantities of Botox are added to the muscle that it is not entirely relaxed. For deep wrinkles that are the result of overly active or strong facial muscles that repeatedly crease in the same spot for years, too little of an amount won't effectively smooth the area. “It's difficult to undo years of wrinkles with small quantities of Botox, so a regular amount is better for deep lines,” Dr Green shares. “But always ask your doctor what is best for you.”

That’s not all. As Dr. Garshick explains, Botox improves dynamic wrinkles or wrinkles that form with expression as opposed to lines at rest. Regardless of the amount of neuromodulator used, if a line is deeply etched in while at rest, it may not go away with Botox alone. “For these types of deeply etched lines, it can be helpful to also use [laser resurfacing](https://aedit.com/aedition/guide-to-ablative-laser-skin-resurfacing) or [microneedling](https://aedit.com/procedure/microneedling) treatments, which can be helpful to improve the appearance of lines at rest,” she adds.

Skin health may also play a role in who Botox sprinkles do and do not work well for. As Dr. Cabin shares, patients with mild-to-moderately etched-in wrinkles but otherwise elastic skin with healthy levels of collagen can eliminate and prevent deepening with consistent sprinkles. “But, in people with poorer skin or those that have significantly deep etched-in lines, this treatment may improve their lines a bit but will not be powerful enough for significant improvement or reversal,” he notes.

## **Does Less Botox Mean Less of a Result?**
In a single word: no. Just because you choose to go lighter on the amount of neuromodulator that is injected doesn’t mean the results are suboptimal. “Botox sprinkles can help the forehead look smoother, the wrinkles around the eyes less pronounced, and the lines between the eyebrows less deep,” Dr. Camp says. “However, the results are more subtle than standard treatments.”

Generally speaking, Dr. Green says baby Botox will yield a similar result to regular Botox, just on a smaller scale. “It is great for younger patients in their [twenties](https://aedit.com/aedition/best-cosmetic-procedures-plastic-surgery-to-consider-in-your-20s) and [thirties](https://aedit.com/aedition/best-cosmetic-procedures-plastic-surgery-to-consider-in-your-30s) who are looking to prevent fine lines and wrinkles from developing and subtly reducing the appearance of mild to moderate frown lines,” she shares.

Patient response to neuromodulators varies, and what may equate to a ‘lesser dosage’ for one person may be the standard treatment for someone else. “A ‘sprinkle’ for one could significantly decrease muscular movement for another patient,” Dr. Cabin notes. This is why first-timers are usually encouraged to come back for a follow up. “This is why I recommend two appointments with every new Botox patient,” he explains. “The first appointment is a conservative treatment, and the second appointment – two weeks later – is to see the response and if touch-ups are needed for undertreated areas.”

Certain features, like the forehead, actually respond better to smaller amounts of product versus larger quantities. For example, too much neuromodulator in the forehead can weaken the muscle in the area and force the brows to drop. “Injecting too many units can give the impression of a heavy brow,” Dr. Camp cautions.
 
As far as longevity goes, the lesser dose holds just as much weight in terms of results. It shouldn't wear away any faster or slower, so you can expect, on average, to stay wrinkle-free for about three to four months. In some patients, however, fewer units may equate to a shorter duration of results. This is especially true if the muscles are strong. But, “if the muscles are weaker, you will still notice some benefits for the same duration as expected with a full course of treatment,” Dr. Garshick says.

## **The Takeaway**
Whether it’s a preventative treatment, gateway procedure, or aesthetic preference, Botox sprinkles can serve many purposes. By using less neurotoxin, the muscle will retain more movement than a standard dosage, which can lead to a more natural-looking result. Depending on the depth of your lines, the quality of your skin, and/or your goals for treatment, baby Botox may be all you need to enjoy a more refreshed appearance. Consulting with a board certified dermatologist or plastic surgeon is the best way to determine how much neurotoxin you’ll need to achieve your desired outcome.

Aesthetics

Dermatologists and plastic surgeons weigh in on whether using a smaller dose of neurotoxin can still be effective.

The Pros And Cons Of Baby Botox (a.k.a. Botox Spinkles) For Fine Lines And Wrinkles

Are Botox Sprinkles The Way To Go?

haley-lawrence-T3eXp9mdTx4-unsplash

In the words of Hollywood, Botox is a multi-hyphenate. Botulinum toxin type A injections, including [Botox®](https://aedit.com/procedure/botox), [Dysport®](https://aedit.com/procedure/dysportr), [Jeuveau®](https://aedit.com/procedure/jeuveau), and [Xeomin®](https://aedit.com/procedure/xeomin), can reduce migraines when injected into the scalp, [curb underarm sweat](https://aedit.com/procedure/botox-for-hyperhidrosis) when sent to the pits, or [beat incontinence](https://aedit.com/aedition/botox-injections-for-vaginismus) via the bladder – not to mention one of their earliest credits, smoothing wrinkles. Some providers and small studies have also found that [neuromodulators](https://aedit.com/aedition/comparing-neurotoxin-botulinum-type-a-injections-botox-dysport-jeuveau-xeomin) can help reduce sebum (read: oil) production, putting a temporary end to the oily skin and breakouts that may have sent patients to the dermatologist in the first place. Here’s what you need to know about how Botox and the like affect the oiliness of the skin.

## **Does Botox Affect Oil Production?**
The short answer is yes, but it’s not as simple as going in for your regular wrinkle-reducing touch up. “Microinjections of Botox can be used to control oily skin, reducing sebum production and improving acne,” says [Michele Green, MD](https://aedit.com/provider/michele-green-md-34642), a board certified dermatologist in New York City. In this case, the emphasis is on the term ‘micro.’ “This treatment involves superficial injections into the skin barrier – not past the skin barrier or into the muscle, where neuromodulators are injected to treat fine lines and wrinkles – in areas where oil, sebum, and sweat production occur,” explains [Dendy Engelman, MD](https://aedit.com/provider/dendy-engelman-md-312), a board certified dermatologist in NYC. “This process ultimately helps reduce oil, redness, pore visibility, and [acne](https://aedit.com/concern/acne).”

In a [2012 study](https://pubmed.ncbi.nlm.nih.gov/23293895/#:~:text=Conclusion%3A%20Intradermal%20injection%20of%20botulinum,in%20patients%20with%20oily%20skin.), 25 patients with oily skin received Botox injections in the forehead, and 21 of them (that’s an impressive 91 percent) were satisfied with the way their skin stayed mattified for up to three months after being injected. In 2015, [researchers tested](https://academic.oup.com/asj/article/35/5/600/240008) 42 volunteers with oily skin by administering Botox in five injection sites across the forehead, then measured the change in oil production around the treatment areas using a device aptly named the Sebumeter. The study found the lowest amounts of sebum closest to the injection points, with more oil occurring farthest away from where Botox was administered. Bruce Katz, MD, a board certified dermatologist and founder of [JUVA Skin and Laser Center](https://www.juvaskin.com/) in NYC, says he has seen Botox help some of his patients with oily skin – but not all. When it does work, it’s because “Botox reduces the muscle movements surrounding the oil glands,” he notes. 

If you have oily skin, we’re preaching to the choir. But, if you’re curious, people with ‘oily skin’ have sebaceous glands in the dermis that produce too much oil, Dr. Green shares. While oily skin and acne-prone skin [are not synonymous](https://aedit.com/aedition/difference-between-oily-and-acne-prone-skin), increased oil can lead to pore congestion and breakouts. “The T-zone, which includes the forehead, nose, and chin, has a higher density of sebaceous follicles that contribute to higher sebum production,” Dr. Green says. With that in mind, it’s time to get more specific about how neurotoxin injections can treat oiliness.

## **Can Botox Be a Treatment for Oily Skin?**
Like we said, the Botox® you are getting to soften your forehead lines isn’t the same as the injections you would get to mattify your complexion. “Neuromodulator treatments for forehead lines and other wrinkles are injected directly into the muscle, whereas microinjections do not penetrate past the skin layer,” Dr. Engelman explains. “Therefore, someone who was receiving treatment for forehead lines would not experience a decrease in oil production as they would from microinjections.”

That’s not to say [microinjections](https://aedit.com/aedition/aquagold-botox-microdosing-facial) can’t offer a smoothing effect – it’s just not akin to traditional, full-dose treatment. “Depending on what you are being treated for, some injectors go a little deeper when administering microinjections so as to slightly soften the muscle for wrinkle reduction, but not paralyze,” she shares. While microinjections can be injected all over the face to improve skin texture, the T-zone is the most problematic area for most patients with oily skin. “Oil production is most common in the T-Zone, which includes the skin across the forehead and down the nose,” Dr. Engelman notes.

## **How Long Do the Mattifying Results Last?**
Like any neurotoxin injection, the results of microinjections are not immediate. They usually kick in over the course of five to 10 days. And, “similar to traditional Botox injections, the benefits of microinjections last up to three to four months,” Dr. Engelman shares. While you may be used to judging when you’re [due for a touch up](https://aedit.com/aedition/how-frequently-to-get-non-surgical-cosmetic-procedures-like-dermal-filler-botox-chemical-peel) based on how much your forehead or brows start to move again, the wearing off of microinjections for oily skin usually involves oiliness returning. “When Botox wears off, sebum production may return to the normal baseline,” Dr. Green says. 

If you are looking for a way to minimize oil production, micro-Botox can be a singular solution. “For those with oily skin, microinjections serve as a standalone treatment option, separate from neuromodulator injections for fine lines and wrinkles,” Dr. Engelman says. “Neuromodulator treatments for oil production are injected into the skin barrier – because oil production occurs in the skin – rather than into the muscle and, therefore, offer different benefits.” To put a finer point on it, you are not necessarily killing two birds with one stone. “A traditional Botox treatment should not affect your sebum production,” she adds.

With the average cost of neurotoxin injections priced at [$408 per visit](https://aedit.com/procedure/botox/cost), a quarterly trip to the dermatologist or plastic surgeon’s office is certainly more expensive than a prescription topical or a bottle of Clean & Clear. For that reason, it’s best to talk to your doctor about all of your skin-mattifying options first. In Dr. Katz’s opinion, “there are many more cost effective methods to control oil production.” But, if you’ve already budgeted for Botox, it can be a [shine-reducing solution](https://aedit.com/procedure/acne-solutions). “Neuromodulator injections, like Botox, can be used to reduce oiliness with just a few injections per year,” Dr. Engelman says.

Using neurotoxins to reduce sebum production is not the same as reducing wrinkles.

The Benefits Of Botox Microinjections To Treat Oily Skin

Can Botox Make Your Skin Less Oily?

shutterstock 730340866

Neuromodulators have been called everything from a miracle in a syringe to the ultimate skin smoother to a life-changer and everything in between. Yet, some say that long-term use of botulinum toxin type A injections (think: [Botox®](https://aedit.com/procedure/botox), [Dysport®](https://aedit.com/procedure/dysportr), [Jeuveau®](https://aedit.com/procedure/jeuveau), [Xeomin®](https://aedit.com/procedure/xeomin)) – particularly in the masseter muscle (read: the jaw) – can potentially lead to muscle atrophy. But does the claim hold up, or is it another one of those anti-aging tall tales that swirl around the world of aesthetics? We tapped the experts to dig deeper and unearth the truth about muscle atrophy from Botox.

## **What Is Muscle Atrophy?**
No matter where in the body a muscle lives, failure to exercise it and ‘flex’ it regularly (often daily) can render the muscle atrophied or pretty much useless — almost as though the muscle is wasting away and shrinking in size. Treating muscles with neuromodulators is no different. 

For a neuromodulator to work correctly, it must limit the activity of a given muscle or muscle group. For that limitation to be visible in terms of a wrinkle-free or slimming result, there must be some form of temporary paralyzation and, in turn, atrophy. It's only natural that the muscle inherently becomes smaller with less activity as a result of the neuromodulator — it’s expected to happen. After all, the goal of Botox® and the like ([in most uses](https://aedit.com/aedition/where-to-use-botox-from-head-to-toe)) is to minimize the appearance of fine and wrinkles. The less time there is between touch-ups and the more product added continuously to the face, the higher the likelihood for atrophy to set in.

Neuromodulators are perhaps one of the most popular aesthetic treatments available today, with more than four million Americans choosing to ‘get popped’ [in 2020](https://www.plasticsurgery.org/documents/News/Statistics/2020/plastic-surgery-statistics-full-report-2020.pdf) alone. BoNT-A injections work by blocking the nerve and muscle communication signals, and, without that interaction, the muscle does not contract. Just like when wrapping a limb in a cast temporarily shrinks the muscle, the same thing happens to a muscle at rest via neuromodulators, says [Dustin Portela, MD](https://www.instagram.com/208skindoc/), a board certified dermatologist in Boise, ID. “This is desirable when we want to diminish the appearance of lines and wrinkles,”he adds.

Some muscle fragility must occur for neuromodulator treatments to be effective. The muscle softening (which can happen in any area on the face) transpires when the muscles are injected with Botox and weaken, in turn getting smaller over time, says [Michael Schwartz, MD](https://www.drschwartz.com/), a board certified plastic and reconstructive surgeon in Westlake Village, CA. “However, once the muscle starts moving again, it tends to regain its size and strength,” he explains.

Neurotoxin-induced atrophy is when the muscle atrophies (i.e. wanes in strength or shrinks) as a result of treatment. It likely occurs temporarily in any muscle into which we inject Botox, says [Jonathan Cabin, MD](https://aedit.com/provider/jonathan-cabin-md-956), a double board certified facial plastic and reconstructive surgeon in Arlington, VA. “In general, Botox atrophy is most likely to be noticed when someone has a target muscle that is particularly defined or large or in muscles that more significantly contribute to the facial shape and shadowing,” he says. “The jaw, temple, [chin](https://aedit.com/procedure/botox-for-dimpled-chin), and [brow](https://aedit.com/procedure/chemical-brow-lift) muscles are the most common to have noticeable atrophy.”

In some cases, this is the desired effect that wears away over the lifespan of the injection. In others, it’s an unwelcome side effect that lingers Typically, within three to nine months, after treating the muscles with the chosen neuromodulator, they will begin to regain their normal function, says [Babak Azizzadeh, MD](https://www.facialplasticsbh.com/), a double board certified facial plastic and reconstructive surgeon in Beverly Hills. However, in particular (rare) cases, this does not occur for reasons that are still unknown. 

## **What Botox-Induced Muscle Atrophy Looks Like**
Just because you opt for treatment with neuromodulators doesn’t necessarily mean that the area will atrophy to the point that it’s noticeable or detrimental to how your face looks. “It can happen with the first treatment, but atrophy tends to be more common in patients who consistently receive Botox on a regular schedule in the same area,” says [Steven Williams, MD](http://trivalleyplasticsurgery.com/), a board certified plastic and reconstructive surgeon in Dublin, CA, and the vice president of the American Society of Plastic Surgeons ([ASPS](https://www.plasticsurgery.org/)). In this instance, the treated areas weaken, and the surrounding muscles may need to overcompensate for the loss of functionality. Plus, as the muscles begin to shrink, they will not fill out the space they consume and a lack of volume may ensue.

Certain parts of the face are more likely to show the effects of atrophy than others (if it even truly happens at all). “It's generally not noticeable in the area between the eyes, like the eleven [lines],” Dr. Portela says. “However, aggressively treating the forehead can cause the frontalis muscle to thin over time.” The impact of atrophied muscles can also lead to what some would describe as an undesirable appearance. For this exact reason, Dr. Portela recommends younger patients who seek out [preventative Botox](https://aedit.com/aedition/everything-you-need-to-know-before-getting-botox-for-the-first-time) do it one to two times per year. “This allows the muscles a chance to recover and move to prevent atrophy,” he says.

Why are some parts of the face more inclined to atrophy than others? It comes down to the fiber type of the muscle, Dr. Azizzadeh says. “For example, the neck muscles have different fibers — they contain a lower portion of type I fiber and a higher component of type IIb fibers — and these muscles respond differently to neuromodulators than those in the face,” he explains. “Skeletal muscles are composed of three types of fibers, type I, IIa, and IIb, and we could postulate that muscles abundant in type I fibers recover better.” It's also believed that certain muscle groups take longer to regain movement than others.
 
Atrophy may also be seen in the temple area when using neuromodulators as a treatment modality for migraine headaches. “The temporal muscle makes up a significant amount of volume in the temples, and volume loss in the temples can lead to a skeletonized, aged appearance of the upper face,” Dr. Cabin cautions. So, if you rely on Botox® to help alleviate the symptoms associated with recurring migraines, be aware that there is the potential for this to occur – especially in those patients who require long-term use. “We can easily correct any temple hollowness with temple filler,” he adds.
 
If some form of atrophy occurs, it doesn't take effect right away – it usually takes four to six weeks to become evident. “The muscle must first weaken, which takes up to two weeks before it starts to shrink from inactivity,” Dr. Cabin explains. Need an analogy to better visualize? “You can compare this to someone who works out a lot and then suddenly stops,” he shares. “Although the person's muscles will rapidly get weaker, there is a delay until the muscle size is actually impacted.”

### **The Botox-Masseter Relationship**
Let's talk about about the jaw for a moment. There's a small space where the angle of the ball-and-socket of the jaw meet that houses a muscle known as the masseter. Overactivity and an abundance of strength in the muscle can make the jaw appear square and even be the reason for persistent teeth grinding while you sleep. One of the easiest ways to tone down the muscle's hyperactivity is with a few injections of a neuromodulator. 

Years ago, doctors started injecting neuromodulators, specifically Botox®, to slim the jaw and create (in women) less of a square-shaped face and more of a heart-shaped one. This off-label use of the muscle-relaxing injectable provides benefits for three to four months before repeat injections are necessary. While there's still mobility and functionality in the jaw, force is put on a small part of the muscle to relax it and, in turn, soften the jaw. In addition to [slimming the jawline](https://aedit.com/procedure/jawline-slimming-with-botox), those who experience side effects from [temporomandibular joint (TMJ) disorders](https://aedit.com/aedition/botox-to-treat-tmj-disorders-and-jaw-slimming) also enjoy relief.

There is, however, research that suggests there could be ramifcations to long-term use. “When treating the masseter muscles to narrow the jaw and or to treat TMJ, if the muscle is kept weak over a while with repeated Botox injections, there is [some evidence](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466904/) to suggest that it can negatively impact the strength of the surrounding bone,” Dr. Cabin notes. Any changes to the muscle itself, meanwhile, are believed to be temporary. Dr. Cabin says neuromodulator-related atrophy poses no risk of direct long-term damage to the muscle. 
 
## **The Net-Net on Muscle Atrophy From Botox**
So, is short-term atrophy post-injections all that bad? No. True muscle atrophy – which depends on if the entire area is compromised – can carry risk. However, the chances of long-lasting muscle atrophy occurring from a neuromodulator is rare. Remember that facial paralysis from poorly injected toxins can cause droopiness, laxity, and a change in how the face looks. “But this is different than true atrophy that isn't related to Botox,” Dr. Azzizadeh says.

In the end, a reduction of lines and wrinkles is what everyone wants from Botox. Hence, most see any short-term atrophy as a positive event because the wrinkles they are treating tend to be less visible and potentially require either less Botox or less frequent treatments. On the other hand, once a patient stops using a neuromodulator, the muscle starts to reactivate slowly. With time, it will (with rare exception) regain full strength and size. “Additionally, the functions that that muscle is responsible for and the wrinkles the muscle is responsible for will also come back to typical pre-treatment strength over time,” he adds.
 
Patients need to know there is not a clinically significant problem since any muscle atrophy is temporary and is often even a desired effect, Dr. Schwartz advises. When it comes to neurotoxin injections, atrophying muscles isn't top of mind for most patients or providers. Plus, true ‘Botox atrophy’ is not commonly seen, Dr. Azizzadeh says. “I've done Botox on over 1,000 patients and have not seen this,” he shares. “Even the patients who are getting Botox don't experience this in their lifetimes.”

Why top plastic surgeons and dermatologists say there’s no need to worry.

The Truth About Muscle Atrophy From Botox

Is Muscle Atrophy From Botox A Thing?

sam-moqadam-GPvnJC6Idl4-unsplash

We rely on [neuromodulators](https://aedit.com/aedition/comparing-neurotoxin-botulinum-type-a-injections-botox-dysport-jeuveau-xeomin) and [fillers](https://aedit.com/aedition/everything-you-need-to-know-about-dermal-fillers) to stave off the hands of time, but could all their wrinkle-reducing and plumping powers change the look of your smile? Interestingly enough, the answer is yes. Sometimes, it’s for the better. Other times, it's not. The key to achieving a face-flattering smile — whether you intend to tweak it or keep it exactly the same — comes down to the [technique](https://aedit.com/aedition/guide-to-injectable-techniques-needles-for-botox-filler) of the injector and the products used, which is why it's in your best interest to be as well-versed in both as possible. Here, we’re breaking down everything you need to know about how injectables can impact your smile.

## **A Sudden Change**
If you undergo injectables and wake the next day (or soon after that) to what seems like a different smile, it's not your mind playing tricks on you. Strange but true, [cosmetic injectables](https://aedit.com/procedure/dermal-filler-and-injectable-solutions) (read: neurotoxins and filler) can make a noteworthy difference in the appearance of the mouth – whether you ask your injector for it or not. Depending on the products that your injector uses and the precise injection locations, a bit of filler or neuromodulator here or there can alter the lower face. 

Lip fillers are known (and loved) for their ability to address [lip shape](https://aedit.com/concern/lip-shape) and [lip size](https://aedit.com/concern/lip-size) concerns. They can help balance out any asymmetries and plump, but it is important to fill in moderation. Excess filler can hide the smile by bringing the lips down and casting a shadow over the teeth, explains [Sharon Huang, DDS](https://www.lesbellesnyc.com/), a board certified cosmetic dentist in New York City. Product placement should always be strategic and proportionate between the upper and lower lips.

Selecting the appropriate filler for the lips is vital. Flexible hyaluronic acid (HA)-based gels tend to fare best since they look and feel the most natural. However, when using too stiff of a filler, the smile can appear ‘overstuffed,’ says [Darren Smith, MD](https://www.darrensmithmd.com/), a board certified plastic and reconstructive surgeon in New York City. “Proper placement of mid-face and lower face filler should not significantly affect the smile,” he shares. With that said, “if an overly firm filler is used or if the region is [overfilled](https://aedit.com/aedition/how-to-correct-overfilled-facial-features), an unnatural appearance can result as the lips push against stiff surrounding tissues,” he adds.

Perhaps the most crucial component in maintaining a natural yet aesthetically appealing smile is symmetry. The lips are a vital component to the [balance](https://aedit.com/aedition/facial-harmony-in-aesthetic-medicine) and aesthetics of the face, says [Neda Mehr, MD](https://puredermoc.com/), a board certified dermatologist in Newport Beach, CA. “According to science, the lips ideally should take up 40 percent of the width of the lower face with the upper lip being half the size of the lower lip from the front view and projecting two millimeters further out than the upper lip from the side view,” Dr. Mehr explains. But that isn't the smile that most of us have naturally, which is where strategically placed injectables come in. 

## **What Comes First: Injectables or Cosmetic Dentistry?**
In the anti-aging smile game, many elements factor into how the pout, mouth, and lower face as a whole looks, including the proportion of the lips, the teeth, the gum lines, and even the degree to which the jaw and jawline extend. While injectables are a big part of the preservation and/or rejuvenation, cosmetic dentistry can be equally important. Whether you plan on incorporating a bit of both or just one, how do you know which procedure to do first?

Dr. Mehr recommends starting with the mouth. “Many times, having a tooth extracted or getting veneers can change the symmetry and contours of their face, she notes. Ideally, there will be synchronicity between your treatment plans. If not, instances can arise where fillers or injectables negate the effects of otherwise excellent dental work. For example, when the teeth are hiding under a layer of excessive filler, the work – be it orthodontics, whitening, or [veneers](https://aedit.com/procedure/veneers) – can be overshadowed by lips that are too large. Patients can't fully appreciate the dental work without the perfect frame to complement and enhance it, says [Anjali Rajpal, DMD](https://aedit.com/provider/anjali-rajpal-428), a cosmetic dentist in Beverly Hills. “Thus, the position of the lips is an important element in smile makeovers because they serve as the essential frame,” she notes.

By doing dental work first, the structure of the teeth will be in place. This will allow the Botox® or fillers to be injected accordingly, meaning the proportions shouldn’t need to be adjusted. Even so, less is still more. “You can always add more filler,” Dr. Rajpal shares. “It is better to do a little initially and add more if wanted.”

## **Enhance Your Lips, Maximize Your Smile**
When injected judiciously, hyaluronic acid-based fillers and/or neurotoxins (read: [Botox®](https://aedit.com/procedure/botox), [Dysport®](https://aedit.com/procedure/dysportr), [Jeuveau®](https://aedit.com/procedure/jeuveau), and [Xeomin®](https://aedit.com/procedure/xeomin)) can enhance the smile as a whole. Below are some of the ways cosmetic injectables can be used to improve the lower third of the face in a cohesive and proportional way.

### **1. Fill-er Up**
Lip injections using HA filler are a common request in most dermatology and plastic surgery offices as a quick and reliable way to shape and plump the lips. “Fillers in the lip can be an excellent option to provide both volume or hydration to the aging or asymmetric lip and highlight a person's natural smile,” Dr. Mehr says. And there’s a way to do it that doesn’t alter the smile — unless that’s the end goal.

Natural asymmetries in the lips or the smile — due to genetics, age, volume loss, and even past cosmetic dental work — can cause the mouth to fall over the teeth and lips. Sometimes, one side of the mouth is fuller or more prolonged than the other, making the smile appear crooked or heavier. [Lip filler](https://aedit.com/procedure/temporary-lip-fillers) can be used to restore a more balanced pout, but discounting these asymmetries while attempting to correct the smile can throw off the entire balance of the face. This is where the expertise and artistry of the injector are key.

### **2. Flip That Lip**
You’ve no doubt seen the so-called ‘lip flip’ on your social media feeds. The ideal candidate? Those with a thin smile and a top lip that seems to disappear when smiling. If this is the result of naturally pulling or bending the upper lip inward when smiling, Dr. Rajpal says Botox® in the top lip may be able to help. It can prevent the curling under without the need to augment the size. Injecting neuromodulators into the [cupid’s bow area](https://aedit.com/aedition/cupids-bow-cosmetic-surgery-fillers-for-lip-augmentation) and at the corners of the mouth can relax the muscles that allow the lips to curl outward so that they appear more defined in shape. 

Unlike filler, there is no additional volume added to the lips. The size will remain the same while improving the shape and, ultimately, the smile. Keep in mind that, while a lip flip can enhance the appearance of the smile, it can, in some cases, affect lip function. Visiting a highly skilled injector with a deep understanding of the anatomy of the area will help to ensure a safe and effective result that lasts about three to four months.

### **3. Turn That Frown Upside Down**
As Dr. Huang explains, filler helps lift the corners of the mouth so that the mouth doesn't appear to be frowning. “We can also fill the marionette lines for less of a downturned smile or droopy mouth,” she adds. Whether or not you consider frowning or RBF (IYKYK) to be a concern, some providers consider it part of a lip filler treatment. Dr. Mehr, for example, injects filler into the lower corners of the mouth almost every time so that “patients look happy at rest.” As a result, “any attention we draw to their lips is positive,” she adds.

### **4. Gummy Smile Be Gone**
Increasing the volume in the upper lip with filler is often the go-to for minimizing a gummy smile. But, while it works well for some, it's not the best solution for everyone. If a patient's upper gum excessively shows when smiling, injecting Botox® helps soften and lower the upper lip muscles so they can't pull down on the lip. For more extreme cases, an in-office procedure performed at the dentist's office, known as laser gum contouring, can remove a small amount of gum tissue to correct discrepancies between teeth gum levels.

### **5. The Right Way to Relax the Jaw** 
There is a reason more and more people are opting for [jawline slimming with neurotoxins](https://aedit.com/procedure/jawline-slimming-with-botox). It can non-surgically contour the jawline for three to four months at a time, while also [relaxing a clenched jaw or correcting TMJ](https://aedit.com/aedition/botox-to-treat-tmj-disorders-and-jaw-slimming). But, as with anything, too much of a good thing isn’t good. Injecting directly into the area where the jawbone and muscle meet is crucial; otherwise, specific facial muscles can become temporarily paralyzed and throw the smile off-kilter. 

In addition to limited movement in the mouth and around it, poorly placed neuromodulators can also cause the smile to be noticeably uneven. When that’s the case, patience is required. Father time has to work his magic. After about three months, the toxin effects should wear off, and the smile should return to normal. 

## **How to Tell If You’re Overfilled**
At this point you’ve likely gleaned that adding volume to the lips doesn't affect just their size. It can [alter their proportion](https://aedit.com/aedition/plastic-surgery-results-are-about-proportion-not-perfection) and cause the upper lip to become larger than the bottom one, especially if too much product is injected. Plus, as Dr. Smith shares, an overfilled lip can restrict movement and interfere with facial expression. In extreme cases, it may interfere with the ability to close the lips. The goal of lip filler is to enhance the smile, not to push the upper lip further up. That can actually create a gummy smile or force the lips down and cover the teeth. 

When smiling, an overfilled lip can make the teeth appear almost nonexistent and create the illusion that the lip is overrunning the smile. “Some patients with excess filler notice that their teeth seem to disappear because the lips have become so thick that they push down from the filler and completely hide the teeth even when smiling,” Dr. Rajpal cautions. If overfilled lips have reduced visibility of the teeth, your dentist may lengthen the teeth slightly – so long as it does not compromise function. “[Porcelain veneers](https://aedit.com/aedition/guide-to-modern-porcelain-dental-veneers) and crowns can be designed in a way to help support the lip and improve the fullness as well,” she adds.

Another issue that can arise from disproportionate amounts of filler is harsh lip lines that blur the line between where the lips start and end. Patients that become obsessed with filling their lips blunt the lines around their lips — the vermillion border — and the lipstick lines almost bleed into their upper lip, Dr. Mehr says. “When this happens, they lose an element of their natural beauty,” she laments.

But that’s not all. Filler migration happens when a product placed in the upper lip slowly shifts from one area to another in a matter of millimeters or less. Although it’s not life-threatening and does not require treatment, migrated filler can distort the look of the lips and cause the mouth as a whole to take on a duck-like or rolled up and out appearance – especially when smiling. 

Any time excessive filler use is the problem, [hyaluronidase injections](https://aedit.com/procedure/hyaluronidase) are usually the answer, as they dissolve hyaluronic acid in a short period. This is not a solution, however, for Botox® and like. If you are unhappy with those results, you’ll have to wait it out.

## **The Takeaway**
Dental work is permanent. Fillers and neurotoxins are temporary. If poor or overdone fillers are impeding your smile, it's best to dissolve them with hyaluronidase and, if needed, start fresh. Meanwhile, let your neurotoxin injections wear off. This way, your dermatologist and dentist can assess your lower face as a whole and determine the best course of action to enhance and maximize your smile.

The smile staring back at you may not be the one you once knew.

How Lip Filler And Botox Can Affect Your Smile

Are Injectables Changing Your Smile? 

shutterstock 1840685299

We often joke about appointments for [Botox®](https://aedit.com/procedure/botox) and its fellow neurotoxins (hi, [Dysport®](https://aedit.com/procedure/dysportr), [Jeuveau®](https://aedit.com/procedure/jeuveau), and [Xeomin®](https://aedit.com/procedure/xeomin)) being as routine as hair color touch-ups or mani/pedis. While it’s great that it may be true, it’s important not to overlook the fact that even a treatment as (relatively) quick and painless as Botox is still a cosmetic procedure that requires the expertise of a skilled injector. With more options on the market and handfuls of injectors offering every type of [injectable neuromodulator](https://aedit.com/aedition/comparing-neurotoxin-botulinum-type-a-injections-botox-dysport-jeuveau-xeomin) possible, it’s more pertinent than ever to fully understand the ins and outs of the minimally invasive procedure — including what can go wrong. 

Of course, not just anyone should be injecting you, nor should just anything be injected into your face (remember, you only have one face). So, before you let the needle touch your skin, make sure that you [have answers to all of your questions](https://aedit.com/aedition/everything-you-need-to-know-before-getting-botox-for-the-first-time), you’ve [done ample research on your provider](https://aedit.com/aedition/finding-the-right-plastic-surgeon-dermatologist-or-cosmetic-dentist), and you see the product being injected to make sure it’s 100 percent the real deal. Beyond the basics, what else do you need to know about your neuromodulator appointment? Read on for all of our safety tips and considerations.

## **The Social Effect**
Social media is a consortium for all types of images, including neuromodulators gone wrong and the scary side effects that they produce. Case in point: the [latest set of terrifying photos](https://www.instagram.com/p/CWePhmMDE_a/) show a patient’s forehead covered in lesion-like scabs as the result of illegal botulinum toxin injections. 

Neuromodulators are one of the most popular non-surgical procedures for a good reason. In 2020, injectors performed [more than 2.6 million](https://cdn.theaestheticsociety.org/media/statistics/aestheticplasticsurgerynationaldatabank-2020stats.pdf) botulinum toxin type A procedures according to the Aesthetic Society’s annual statistics report. Botox® and the like are a [valuable tool](https://aedit.com/aedition/where-to-use-botox-from-head-to-toe) in nearly every aesthetic doctor’s toolbox. 

But as elective cosmetic procedures become more common and socially accepted, it creates openings for unlicensed providers to offer bogus services, says [Brendan Camp, MD](https://aedit.com/provider/brendan-camp-md-34645), a board certified dermatologist in New York City. That opening also paves the way for an increase in unsatisfactory and, in some cases, dangerous results. “Sadly, the incidence of ‘botched’ neuromodulator injections has dramatically increased as unqualified injectors enter the industry,” says [Jessica Weiser, MD](https://aedit.com/provider/jessica-weiser-md-34640), a board certified dermatologist in NYC. 

Besides the fact that counterfeit injectables are not anything close to the real thing, the fakes can consist of anything from other drugs and bacteria to bleach and plain old water. In addition, these illegally obtained products are not typically purified and may contain contaminants. Once contaminants enter the skin, they can lead to allergic reactions, foreign body granulomas, serious infections, skin necrosis, and other complications with severe long-term ramifications, Dr. Weiser cautions.

The net-net: “As the amount of counterfeit product has skyrocketed, unlicensed injectors have started to enter the arena, purchasing product illegally from unauthorized sources or foreign countries and more,” she shares. This has led to what she calls “a completely uncontrolled injection market.”

## **Don’t Fall for Faux-tox**
Years ago, the school of thought was that Botox® and other neuromodulators were just for the rich and famous. But that's no longer the case. With more younger patients dabbling in minimally invasive procedures — like injectables and lasers — the supply and demand for neuromodulators increases. 

The growing demand creates a black market (fake injectables are often known as ‘faux-tox’) and an easy entry point for those who are not well-versed in the procedure to be swayed easily, says [Roberta Moradfar, NP](https://www.instagram.com/effacebyroberta/), a board certified aesthetic nurse practitioner and the owner of [EFFACÉ Aesthetics](https://effacebyroberta.com/) in Los Angeles. “Sadly, several injectors are offering fake versions of the neurotoxin and passing it off as the real thing to either cut their costs or because they are not qualified even to purchase injectables,” she says. 

Another reason for the recent rise of counterfeit and illegal neuromodulators is a considerable price increase in the real thing and the supplies associated with them. Syringes, needles, and other medical supplies have skyrocketed in price, especially during the pandemic, says [Macrene Alexiades, MD](https://www.nyderm.org/biography), a board certified dermatologist in NYC. “In contrast, prices have hit a limit, and it is simply not possible to increase prices much further despite the presence of record-breaking inflation in recent months,” she explains. “As a result, it has become challenging for doctors to generate profits, which has led to less reputable doctors and shady operations to resort to black market botulinum toxins, which are extremely dangerous.” 

Dr. Weiser adds that, with each subsequent year, the cost per vial rises for Allergan-branded Botox® Cosmetic, Galderma’s [Dysport®](https://aedit.com/aedition/dysport-vs-botox-for-wrinkles), and other neuromodulators approved by the United States Food and Drug Administration (FDA). “As more people desire to work in the aesthetic space but want to undercut industry pricing, they buy products cheaper and often without a license,” she says. 

Black market injectables have always existed, yet the use of these products is surging right now. “I observed and informed the companies that manufacture injectables of Instagram, Twitter, TikTok, and Facebook accounts posting videos of people injecting themselves with illegal forms of Botox® and fillers,” Dr. Alexiades says. And in this social media-driven world, utilizing black market products opens up Pandora’s box to the world of copycats, which will only lead to problems. Not to mention the rise of DIY injectables and fillers — a scary thought indeed. “There are numerous internet pop-ups that are mailing ‘DIY Botox’ kits for people to self-inject, posing additional levels of concern,” Dr. Weiser notes.
 
Just because you think you're getting the real deal, even if you're not, doesn't mean that whatever ersatz injectable follows the same production, testing, manufacturing, and FDA-approval processes as their legitimate counterparts. “Unregulated products are not manufactured at the same standards as branded products, and, as a result, the concentration of neurotoxins in an illegal product may be too high,” Dr. Camp warns. “This can cause botulism poisoning, which can present with muscle weakness, trouble swallowing, and difficulty breathing.” 

It goes without saying that non-FDA-approved products should never be injected into the face (or body). This is because these products lack the multi-phase approval process to ensure that a drug is safe and does what it is supposed to, says [Peter Vila, MD](https://aedit.com/provider/peter-vila-md-16177), a double board certified facial plastic and reconstructive surgeon in San Rafael, CA. “Injectables that have not gone through FDA approval are huge unknowns that can potentially cause harm or just not work because we simply don't know if they are safe or effective," he says.
 
## **What Can Go Wrong**
One of the more severe and painful known reactions to faux-tox is pyoderma gangrenosum. Dr. Alexiades describes it as a festering wound associated with inflammatory and autoimmune disorders. Yet, there are [reports](https://pubmed.ncbi.nlm.nih.gov/31957116/) of ulcers forming at injection sites with illegal botulinum toxin injections. It's rare yet severe, and failure to treat pyoderma gangrenosum can lead to further problems and complications. There's also the potential for scarring and pigmentation formation, which causes a whole other host of issues that can trigger long-term management. 
 
In the event of a mishap (especially with black market neuromodulators), the wrong dose, or a contaminated vial, redness, pain, and the formation of a pimple about 24 hours following the injection can occur. In extreme cases, “if it is an overdose within a short time, the patient can have trouble breathing due to paralysis of the diaphragm and muscles of breathing,” Dr. Alexiades shares. Less severe yet still disheartening effects can take upwards of two weeks post-injection to set in. However, any muscle weakness or fatigue symptoms usually become apparent about a week after treatment and may be accompanied by a heavy feeling in the treated area or asymmetries.

And, of course, the worst-case scenarios are the most extreme ones. Dr. Alexiades says that there have been black market botulinum toxin cases causing people to end up on respirators or even dead. “You must be intubated if you go into respiratory failure,” she explains. “And you must have wound care and antibiotics for infection.”

The takeaway is simple: Don’t let just anyone inject just anything into your face — it’s just not worth it.

## **Neuromodulators Done Right**
It seems as though anyone with a pulse can inject fillers and injectables into the face and call it a success. But, truth be told, it's not that simple, nor should it be. Dr. Vila calls injecting neurotoxins “both an art and a science.” As he describes, “the key to getting good results and avoiding complications comes down to good injection technique.”

Precise and accurate product placement is vital to maintain [facial harmony](https://aedit.com/aedition/facial-harmony-in-aesthetic-medicine) while eliminating the appearance of unwanted wrinkles. “Injecting too much neurotoxin or injecting it in undesired areas can cause unwanted effects such as eyelid drooping, the appearance of heavy brows, or, in some cases, an uneven smile,” Dr. Camp says. Overly arched eyebrows, often called ‘Spock eye,’ [droopy eyelids](https://aedit.com/aedition/guide-to-eyelid-ptosis-drooping), and upper eyelids that appear heavy and hang down low, creating a tired look that can interfere with vision, are other signs of poorly administered neuromodulators. “Additionally, poorly placed Botox around the eyes can result in an unusual smile and ‘shelf’ effect,” Dr. Weiser notes. Even though nobody wants subpar results, the only positive matter is that, usually, these effects are temporary and will slowly start to correct themselves as the body metabolizes the injectable product in the coming weeks.

Hygiene and technique are also crucial to avoid infections and severe [bruising](https://aedit.com/aedition/how-to-treat-prevent-bruising-after-lasers-filler-botox). “You must use an immaculate technique and sterile delivery methods,” Dr. Alexiades says. “Injectors must always cleanse the injection area and only administer the drug with sterile needles and syringes.” These rules apply to all treatment areas of the face since not a single square inch of skin is off-limits nor immune to an adverse reaction, no matter how minor or extreme it may be. Also, your provider should always draw the injectable into a new, sterile syringe and fully clean the treatment area with alcohol, Dr. Weiser advises.

## **How to Fix Bad Results**
When it comes to correcting the effects of black market products or just a bad result, there are a few different approaches to take:

- **Time heals all wounds.** You can let the effects of the product wear away on their own, which takes about three months. Dr. Camp says that, for the most part, the goal is to encourage the body to metabolize the injected product so that the unwanted effects fade faster. “This can include applying vibration to the treated area, warm compresses, increased contractions of the affected muscles, and exercising, which may also help,” he shares.
- **Use special drops to mitigate the effects.** According to Dr. Weiser, you can use alpha-adrenergic drops, like iopidine, to give mild relief of droopy eyelid or brow by activating the Muller's muscle in the eye to help create a subtle lifting effect. 
- **Correct it with additional injections.** In the case of a droopy lid, the issue should resolve in a few weeks. When there’s an unnatural appearance from poorly injected toxins, Dr. Vila says that the area can usually be treated with a touch-up of extra toxin to create a more natural look.
- **Immediately intervene when necessary.** “Infections and foreign body reactions are much more serious concerns because they can leave behind permanent tissue damage and scarring,” Dr. Weiser warns. They “require immediate intervention with antibiotics, steroids, debridement, or more,” she adds.

## **Why You Always Need to Do Your Homework**
No matter what injections you are considering, it’s of the utmost importance to always do your research, which includes:

1. **Vetting Your Injector**: Search for a good, reputable provider in your area. It’s okay to ask around and get recommendations, but make sure the injector you choose is in good standing and does not have a reputation for using fake products or inferior results. “It is the patient’s responsibility to ensure they are seeking care from a vetted professional, such as a board certified dermatologist,” Dr. Camp says.
2. **Avoiding Price Shopping**: We love a bargain, too, but aesthetic medicine is not the area skimp. If you’re purchasing deeply discounted injectables, there’s always the threat of it not being the real deal, which leads us to...
3. **Getting the Real Thing**: Only seek treatment from a licensed physician who buys brand-name, FDA-approved injectables directly from the manufacturer. Don’t be afraid to ask your injector to show the bottle and its packaging. 

At the end of the day, a little research goes a long way. Even in the best hands, it is always possible for something to wrong, but finding a qualified provider who you trust (and [not doctor hopping](https://aedit.com/aedition/dangers-of-doctor-hopping)) is one of the best ways to ensure the safety and efficacy of your treatment.

From finding a qualified provider to ensuring the product is legit, here's how to ensure your neuromodulator injections are as safe and efficacious as possible.

How To Prevent Botox Complications From Unskilled Injectors And Counterfeit Product

What You Need To Know About How Botox Can Go Wrong

shutterstock 1935178430

If ever a miracle injectable existed, it may just be the [family of neuromodulators](https://aedit.com/aedition/comparing-neurotoxin-botulinum-type-a-injections-botox-dysport-jeuveau-xeomin). Best known by their brand names — [Botox®](https://aedit.com/procedure/botox), [Dysport®](https://aedit.com/procedure/dysportr), [Jeuveau®](https://aedit.com/procedure/jeuveau), and [Xeomin®](https://aedit.com/procedure/xeomin) — botulinum toxin type A injections are most celebrated and widely used as effective wrinkle reducers, but new findings point to yet another benefit. 

If you are planning to go under the knife for a cosmetic surgery, don’t be surprised if your surgeon brings up Botox® and the like as both a preventative and corrective step for [scar care](https://aedit.com/aedition/minimizing-scars-after-surgery). Here’s what you need to know about the benefits of Botox® for minimizing the appearance of scars.

## **What the Science Says**
Scientific data is the pinnacle of measuring the capabilities of a drug (cosmetic or not). Current research on neuromodulators to improve the look of scars is looking up. The use of neuromodulators for alleviating scars first became talk when a [2018 study](https://pubmed.ncbi.nlm.nih.gov/29481395/) tested the effects. “The results showed that the scars that received Botox injections were rated higher on their appearance than those that did not receive injections," says [Marina Peredo, MD](https://www.skinfluencenyc.com/), a board certified dermatologist in New York City. 

The [report](https://journals.lww.com/plasreconsurg/Fulltext/2018/03000/Effects_of_Botulinum_Toxin_on_Improving_Facial.14.aspx) in *Plastic and Reconstructive Surgery* detailed the benefits for patients who received treatment for four months, specifically after reconstructive surgery of the face (a procedure that often results in a bevy of distinct scars). The clinical trial showed that when these patients were treated with Botox early on, the injections produced narrower, better, and flatter surgical [scars](https://aedit.com/concern/scars). However, common scar characteristics such as color and vascularity were not notably different.

## **How Does Botox Minimize Scarring?** 
Let's take it back to the basics for a moment. Surgical sutures are the option of choice when a scar or laceration requires closure. When it comes to stitches, however, it is known that tension and movement around the edges of the scar lead to less optimal scarring, says [Jonathan Cabin, MD](https://aedit.com/provider/jonathan-cabin-md-956), a double board certified facial plastic and reconstructive surgeon in Arlington, VA. 

Plastic surgeons have long known that certain types of facial scars naturally heal better than others. One reason is the scar's direction, and how it’s positioned compared to the underlying muscles, says Esther Yoonah Kim, MD, a board certified plastic and reconstructive surgeon and co-founder of [Advanced Institute for Plastic Surgery](https://www.aiplasticsurgery.com/) and [Bloom Spa](https://www.bloomspa.com/) in Temecula, CA. “If the scar lies against the pulling muscles, there is a tug-of-war across the scar,” she explains. “This tension will pull the scar apart, leading to a widened, thicker, and uglier scar.”

We know that Botox® (and other neuromodulators) temporarily reduce muscle movement to limit wrinkle formation. Dr. Cabin explains that this same theory works to help reduce the tension and movement around healing wounds, thus reducing the forces that can worsen scarring. While neuromodulators won’t totally stop the muscles from ripping at a scar, they will help create less stress and allow the scar to heal properly. 

When repetitive tensile forces in any direction by muscles under or around wound edges or tissue might negatively affect the overall healing processes, botulinum toxin injections can have an impact, says [Ava Shamban, MD](https://aedit.com/provider/ava-shamban-md-2325), a board certified dermatologist in Santa Monica, CA. “Wound healing is a complex range of processes from homeostasis to inflammatory response and the dermal cell remodeling,” she explains. “Interruptions to these processes can lead to disruption and complications, such as derailing fibroblast activity or prolonging the inflammatory response, and delays in healing can result in scar hypertrophy or increased pigmentation.”

To make the most of the treatment, your surgeon should inject the to-be-operated-on area *before* the procedure to limit the mobility of the muscles in the region. “If I am planning to make an incision in an area, like the forehead, where Botox® can safely reduce movement, I always inject Botox® (or an equivalent toxin) two weeks before the planned procedure, since it takes that long for toxins to kick in,” Dr. Cabin shares. 

This approach creates an ideal situation where most movement in that specific area is significantly reduced right at the onset of the recovery process, but the injections can also occur post-op. “The treatment works best when injected early in healing — preferably before creating a scar — but within the first few months when the wound is going through its initial healing process and is most sensitive to tension and movement," he adds. This way, the resulting scar will heal thinner and flatter.

## **Not All Scars Are Equal**
Using neuromodulators to improve scars falls under the bucket of off-label (read: not approved by the United States Food and Drug Administration yet relatively safe and well-documented) [neurotoxin uses](https://aedit.com/aedition/where-to-use-botox-from-head-to-toe). But unlike many of Botox® and friends’ non-FDA-approved benefits, scar improvement is one treatment that provides significant physical *and* emotional benefits. Scars come with memories, some of which can be debilitating or a sign of a remembered trauma.

While all neuromodulators will theoretically have the same effect on the scar, [Jennifer Levine, MD](https://www.drjenniferlevine.com/), a double board certified facial plastic and reconstructive surgeon in New York City, says some patients and providers prefer Xeomin® in this case. "Xeomin® is often embraced because it is a [cleaner alternative](https://aedit.com/aedition/clean-injectable-filler-neurotoxin-trend) to other neuromodulators," she says. Unlike Botox®, Dysport®, Jeuveau®, it is a pure form of botulinum toxin formulated without stabilizing proteins.

Treating older scars with Botox probably won't produce the same result, but, like everything in life, there are exceptions to the rule. In some instances, scars that are mature and more than one year old may respond positively. “It really depends on the orientation of the scar,” Dr. Cabin says. “Reduction of expression through the use of Botox can temporarily reduce the repeated reinforcement of the scar and minimize its noticeability, especially in the forehead or central brow.” But, in these cases, improvements in the appearance of the said scar are more temporary in nature. Repeat treatments every few months are required.

Neuromodulators aren't compatible with [every type of scar](https://aedit.com/aedition/how-to-treat-every-type-of-scar). Even if they are new and fresh, keloid scars won’t respond positively. They need to be treated with a laser or corticosteroids. When used directly on the scar, a [corticosteroid solution](https://aedit.com/procedure/intralesional-steroid-injection) may help improve the texture and tone of the skin where an existing mark exists due to a cut or abrasion. Furthermore, Dr. Shamban says corticosteroids may help reduce the scar's height, density, and overall size since steroids break the woven bonds between collagen fibers, thus reducing the amount of scar tissue beneath the skin.

Neurotoxins, meanwhile, works best on certain new scars, such as skin cancer removal, [Mohs surgery](https://aedit.com/procedure/mohs-surgery), and reconstructive surgery, though timing is everything. In some cases, a neuromodulator alone isn’t enough to make a dramatic improvement in the appearance of the scar and additional treatments may be needed. "Some people use a combination of Botox, lasers, and [skincare](https://aedit.com/aedition/scar-minimizing-skincare-to-use-after-surgery) to get the skin in optimal condition," Dr. Peredo explains. She also stresses that using good skincare before surgery is vital to encourage better healing. “Keeping the body hydrated and reducing caffeine and alcohol intake can help with wound healing,” she says.

## **How Long Botox Lasts**
If you get Botox® and co. for wrinkles, you are accustomed to [routine maintenance](https://aedit.com/aedition/how-frequently-to-get-non-surgical-cosmetic-procedures-like-dermal-filler-botox-chemical-peel) sessions every three to four months. When it comes to treating fresh scars, however, Dr. Cabin says that only one appointment is needed because the treatment lasts about two to four months. “This provides a large window of activity, during which the initial phase of healing will occur,” he explains. After this period, neuromodulators are less critical. 

Follow-up sessions every two to four months for the first year can be beneficial for some patients, but they’re not always necessary. “It’s about minimizing movement around the healing wound during a window of time when the scar is forming, reducing the final scar,” Dr. Cabin says. When done correctly, one initial treatment can have a lifetime impact on the outcome. 

Is there anything neuromodulators can’t do?

Botox Injections To Minimize The Appearance Of Plastic Surgery Scars

How To Use Botox To Minimize Post-Surgery Scarring

josue-escoto-jn4dzVGeweQ-unsplash

As a beauty editor, there’s not much I wouldn’t try when it comes to smoothing [fine lines and wrinkles](https://aedit.com/concern/fine-lineswrinkles). I’ve been obsessed with my anti-aging skincare regimen since my [late twenties](https://aedit.com/aedition/best-skincare-routine-products-ingredients-for-20s), and I started getting Botox® in my forehead and [around my eyes](https://aedit.com/procedure/periorbital-botox) as another preventative measure by the time I was 30. Every 12 weeks, I would sit in my dermatologist’s chair in New York City and smile as I faced one of my biggest fears – needles. As the years went on, I noticed my Botox® wasn’t lasting as long, and, as someone who is Type A, I began going in every eight to 10 weeks. That’s when the switch from Botox® to [Dysport®](https://aedit.com/procedure/dysportr) was recommended. 

## **What’s the Difference Between Botox & Dysport?**
The truth is, at a chemical level, there isn’t much of a difference between Botox® and Dysport®. The active ingredient in both [neurotoxins](https://aedit.com/aedition/comparing-neurotoxin-botulinum-type-a-injections-botox-dysport-jeuveau-xeomin) is botulinum toxin type A, which means they work in the same way. “All type A botulinum toxins have the same mechanism of action: blocking the release of acetylcholine and preventing the muscles from contracting to maintain the aesthetic effect,” explains [Dennis Gross, MD](https://www.dennisgrossmd.com/), a board certified dermatologist and founder of his [eponymous skincare line](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fdrdennisgross.com%2F). 

[Botox®](https://aedit.com/procedure/botox), or onabotulinumtoxinA, was first approved by the United States Food and Drug Administration (FDA) to temporarily improve the appearance of frown lines between the eyebrows in April 2002. It has since received more aesthetic approvals, in addition to its therapeutic uses. [Dysport®](https://www.dysportusa.com/what-is-dysport) (a.k.a. abobotulinumtoxinA), meanwhile, was first approved to treat glabellar lines in April 2009. Other cosmetic neurotoxins on the market include [Xeomin®](https://aedit.com/procedure/xeomin) and, the newest to the scene, [Jeuveau®](https://aedit.com/procedure/jeuveau).

While the active ingredient in each product is BoNT-A, they also feature unique protein blends that can affect the diffusion and wear of the injection. “The amount of core active neurotoxin in each on-label dose is different,” Dr. Gross says. “Dysport® has shown to include more core active neurotoxin compared to other neurotoxins.” 

Another point of difference? The appearance they each give is very different to my editorial eye. When treating my forehead lines, I find Botox® to give a more localized freezing, whereas Dysport® spreads evenly throughout for a more air-brushed effect. “I love the results that Dysport® gives since the results are natural-looking — fresh but not frozen,” Dr. Gross notes.  

## **How Long Does Dysport Last?**
For me, Dysport® lasts about 12 weeks just like [Botox® used to](https://aedit.com/aedition/botox-immunity-neurotoxin-resistance). For some, it can last up to five months (yes, I’m extremely jealous of those people). For others, it may be less. “The time length varies from patient to patient depending on genetics – some people break down neurotoxins at quicker rates than others,” Dr. Gross shares. 

But that’s not all. How you take care of your skin [in between appointments](https://aedit.com/aedition/maintaining-skin-with-devices-skincare-products-between-cosmetic-procedures) matters, too. He recommends using a consistent skincare regimen that includes active ingredients like [vitamin C](https://aedit.com/aedition/guide-to-topical-vitamin-c-in-skincare), [retinol](https://aedit.com/aedition/guide-to-vitamin-a-retinol-retinoids-in-skincare), hydroxy acids ([alpha](https://aedit.com/aedition/guide-to-topical-alpha-hydroxy-acids-in-skincare) and [beta](https://aedit.com/aedition/guide-to-beta-hydroxy-acids-salicylic-acid-in-skincare)), and [niacinamide](https://aedit.com/aedition/guide-to-topical-niacinamide-vitamin-b3-in-skincare) to stimulate collagen production and prolong the life of your treatment. 

## **The best part…**
If ever there was a ‘[lunchtime procedure](https://aedit.com/aedition/everything-you-need-to-know-before-getting-botox-for-the-first-time),’ neurotoxin injections are it. Dysport® is a quick 10- to 20-minute non-surgical treatment with little to no downtime (you may experience localized swelling, redness, or tenderness at the injection site for about 24 hours). And, unlike some of its competitors that take five to seven days to kick in, Dysport® results start to show in just 48 to 72 hours. Living in a world of instant gratification, I love the quick turnaround. 

Patient Perspective

Consider this my love letter to an air-brushed forehead.

Why I Switched From Botox To Dysport To Treat Forehead Lines

Why I Switched From Botox To Dysport To Treat My Fine Lines

shutterstock 1753026176

From the calves to the brows and everywhere in between, there’s a multitude of places where neurotoxins work wonders.

All The Places On The Face And Body To Use Botox Injections

21 Places To Use Botox From Head To Toe

shutterstock 41563432

There’s no question that Botox® and its fellow [neurotoxins](https://aedit.com/aedition/comparing-neurotoxin-botulinum-type-a-injections-botox-dysport-jeuveau-xeomin) (hi, Dysport®, Jeuveau®, and Xeomin®) are among the most efficacious and popular non-surgical wrinkle reducers in aesthetic medicine. Botulinum toxin type-A (BoNT-A) has come a long way since its accidental cosmetic discovery by ophthalmologist Jean Carruthers, MD, and her dermatologist husband Alastair Carruthers, MD, in 1987. The couple noticed a smoothing and anti-wrinkle effect on the forehead of patients who were being injected with Botox® to treat uncontrollable blinking and eye spasms known as blepharospasm. 

Fast forward to today, and the toxin has drastically advanced in terms of both its approved and off-label uses. The uses of [Botox®](https://aedit.com/procedure/botox) and its competitors are seemingly endless. They have been used to address everything from [minimizing crow’s feet](https://aedit.com/procedure/periorbital-botox) and migraines to [slimming the jawline](https://aedit.com/procedure/jawline-slimming-with-botox) and [reducing the amount of sweat](https://aedit.com/procedure/botox-for-hyperhidrosis) your body produces with little to no downtime and minimal pain (the injection feels like a pinprick). 

When it comes to lines and wrinkles, neurotoxins work by temporarily paralyzing muscles for cosmetic effect. By injecting BoNT-A into areas where repeated muscle contractions occur (think: in-between the middle of the eyebrows, the outer corners of the eyes, and the forehead), the lines, folds, and furrows that would normally etch themselves into the skin are softened. The results are not immediate — initial benefits start to be visible at the five-day mark, with full results at two weeks — and they don’t last forever. For most patients, Botox® and the like naturally degrades over the course of three to four months, which is why [upkeep is essential](https://aedit.com/aedition/how-frequently-to-get-non-surgical-cosmetic-procedures-like-dermal-filler-botox-chemical-peel).

But what if the effects of the wrinkle-reducer start to fade after only a few weeks? Or what if, after years of success, you are hardly seeing a result anymore? You may be resistant to Botox®, and we’re talking to experts to understand why. 

## **What Is Botox Resistance?** 
Known as ‘Botox resistance,’ some patients may develop an immune response to Botox® that reduces the effectiveness of the treatment, says [Steve Fallek, MD](https://www.fallekplasticsurgery.com/), a board certified plastic and reconstructive surgeon and medical director of [BeautyFix MedSpa](https://www.beautyfixmedspa.com/). “The protein complex in the product may stimulate neutralizing antibodies,” he explains.

While BoNT-A is the primary active ingredient in cosmetic neurotoxins, the exact formulation of each brand is unique. Botox® (a.k.a. [onabotulinumtoxinA](https://media.allergan.com/actavis/actavis/media/allergan-pdf-documents/product-prescribing/20190626-BOTOX-Cosmetic-Insert-72715US10-Med-Guide-v2-0MG1145.pdf)), for example, features a proprietary blend of protective proteins alongside inactive ingredients like human albumin (i.e. plasma proteins) and sodium chloride. As such, it’s not just Botox® that can stop working — the effect can occur with any injectable neurotoxin. “Therapeutic proteins, including the core neurotoxin found in all neuromodulators on the market today, can induce immunogenicity, or an unwanted immune response,” says [Brian Biesman, MD](https://drbiesman.com/), a board certified oculofacial plastic surgeon in Nashville, TN. “Yet, the critical factors for neutralizing antibody formation are not well characterized.”

Neurotoxin resistance is nothing new. There are [scholarly publications](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872090/) dating back to 2013 referencing Botox® immunity and the potential for antibody formation in certain individuals, says [John Layke, DO](https://aedit.com/provider/john-layke-645), a board certified plastic and reconstructive surgeon and co-founder of [Beverly Hills MD](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fbeverlyhillsmd.com%2F). The first incidents came from medical uses of Botox®, which employs higher doses of the neuromodulator. “Usually, immunity is a very dose-dependent thing,” notes [Paul Jarrod Frank, MD](https://pfrankmd.com/), a New York City-based board certified dermatologist. “For cosmetic uses, Botox® doses tend to be rather small, which is why it is not very common to develop a true immunity to the product.” 

As Dr. Frank explains, there is a difference between actual resistance and patient satisfaction. “The development of antibodies causes true Botox® immunity,” he says. “However, many people claim to experience Botox® immunity because they symptomatically feel that Botox® — or another neuromodulator — does not do what it used to do.” This is especially common among those who have been going under the needle for years. “As we get older, some of the simpler cosmetic treatments become a law of decreasing return,” Dr. Frank shares. “Some people will assume that if things don't give the same effect at age 40 as they did for them at age 30, they are now immune to the product.” While the treatment may not be as effective, such patients are not immune. “That is a psychological thing and not so much of a true immunological antibody immunity,” he notes.

If the body does in fact develop antibodies, the patient will not see as dramatic of a result — or any result at all. “Actual immunity, when people get less sensitive to Botox®, is that the body responds with antibodies to the product,” Dr. Frank says. “Once those circulating antibodies are in the bloodstream, they will attach to the Botox® molecule.” So, as the immune system produces the antibodies, repeat injections of Botox® or other neurotoxins begin to become less active in the treated areas. 
 
Unfortunately, the only way to tell if you are producing antibodies is with visible evidence (i.e. lack of results). [Clinical trials](https://media.allergan.com/actavis/actavis/media/allergan-pdf-documents/product-prescribing/20190626-BOTOX-Cosmetic-Insert-72715US10-Med-Guide-v2-0MG1145.pdf) released by Allergan (the manufacturer of Botox®) show that no more than 1.5 percent of patients develop any “neutralizing antibodies.” In short, only about one in 10,000 people have a natural resistance to the drug. “It’s an extremely rare phenomenon,” Dr. Biesman says. “I have been injecting for over 30 years and have seen very few true cases. Most often, the patients who feel they are non-responders require treatment of a different dose or distribution."

## **Why Botox May No Longer Be Working For You**
Many patients use neuromodulators for decades with good results, and it is unclear what precisely about Botox® makes patients believe they are more immune to it than other toxins, Dr. Layke says. “Botox® is made of the active ingredient botulinum toxin A and other nontoxic complexing or binding proteins,” he explains. “Any one of these may induce an immune or ‘foreign’ response leading to antibody formation.”

Perhaps it’s less about the product and more about the patient. According to Dr. Frank, it’s not that the neuromodulator itself becomes less effective. Instead, we age and our anatomy changes, which limits our ability to get the effect that we want. “Neuromodulators are never going to be as effective on a patient who’s been using them for 20 years,” he shares. “That has less to do with the immunological aspect and more to do with the fact that we are fighting time and the muscles change, so the relaxation of the muscle doesn’t always give the same clinical effect.” In some patients, neurotoxins may begin to produce less desirable results. “As we get older, neuromodulators can cause an over-relaxation of the muscles and lead to adverse reactions, like flattening the eyebrows, weakening of the smile, and motion limitations,” he adds. 
 
Every doctor we spoke to for this story agrees that there is no connection between injector technique and product storage and a lack of visible results. “Injections at more frequent intervals and higher doses may have an effect on immunogenicity, but this is such a rare phenomenon and impossible to study,” Dr. Biesman notes. 

Besides developing toxin-inhibiting antibodies, it is also possible for the body to naturally metabolize the toxin at a faster-than-normal rate. “The normal amount of time it takes the body to metabolize Botox® ranges from two to four months,” Dr. Layke says. While no clinical data supports the claim, there are anecdotal reports that Botox® is shorter-lived in avid exercisers. If you’re someone who spins relentlessly on the Peloton bike and follows it up later in the day with a Pure Barre class, all that working out may be doing wonders for your body but little to no good for your wrinkles. 

## **What to Do If Botox Is No Longer Working For You** 
Botox® isn’t the end-all, be-all when it comes to neuromodulators. Other toxins that are just as, if not more so effective are available. “If you feel that Botox® no longer gives you the results you want, I recommend trying an alternative neuromodulator,” Dr. Layke suggests. “Many times, patients that are unresponsive to Botox® see effective wrinkle reduction with Xeomin® or Jeuveau®.” Both of those and Dysport® work towards the same end goal of smoothing out lines and wrinkles. However, each contains a different molecular structure, so people may be sensitive to one and less to another. 

Other types of ‘allergies’ to Botox® and the like can occur. A lot of times, this happens not due to the botulinum toxin type A but to the additive proteins or preservatives in the saline used. It’s all a matter of trial and error. 

If the toxin route isn’t the right fit for you, filler may be an alternative. While neurotoxins and fillers are both injectables, it’s important to note that they do not act in the same way. [Dermal fillers](https://aedit.com/aedition/everything-you-need-to-know-about-dermal-fillers) will not soften wrinkles where there is a loss of collagen in the skin. “They will not have the same effect as Botox®, but they can lift and create a rejuvenated look and feel,” Dr. Fallek explains. 

Another possibility is a [thread lift](https://aedit.com/procedure/thread-lift), which Dr. Fallek says “will not have the same effect as an anti-wrinkle injection, but they will lift and tighten loose, sagging skin tissues.” Other alternatives? Any treatment or procedure that improves wrinkles on the upper part of the face. “That could be getting your [eyes done](https://aedit.com/procedure/eye-rejuvenation-solutions), a [laparoscopic brow lift](https://aedit.com/procedure/endoscopic-brow-lift), or using [fillers for fine lines](https://aedit.com/procedure/under-eye-filler) in areas,” Dr. Frank shares. “It’s certainly best to always offer a patient several options if they see less efficacy from neuromodulators as they get older.”

## **Is It Time to Take a Botox Break?** 
Believe it or not, if there isn’t a viable solution that works for you, it might be time to take a bit of a Botox break. A pause doesn’t mean you can’t ever get Botox® (or another neurotoxin) again; it’s just that your body may need a hiatus from it. In some cases, a respite allows any remaining product to leave the body so that you can start from a clean baseline.

There are also rumors of a connection between zinc supplements and an increase in effectiveness in Botox®. While the jury is still out, an April [2012 clinical study](https://jddonline.com/articles/dermatology/S1545961612P0507X) in the *Journal of Drugs in Dermatology* found that 92 percent of subjects supplemented with zinc 50 milligrams and phytase experienced an average increase in toxin effect duration of nearly 30 percent. Only time will tell if popping a few milligrams of the cold suppressant prolongs the life and betters the results of neurotoxin injections. 

Until then, stick with what works for you, be it Botox®, a different neurotoxin, or another rejuvenation technique — as long as the results are evident enough for you, that’s what matters most.

*All products featured are independently selected by our editors, however, AEDIT may receive a commission on items purchased through our links.*

Even if you’re diligent about staying on top of your appointments, is it possible to become less responsive to neurotoxins and see fewer results over time? All signs point to yes — but it’s complicated.

The AEDITION

Botox