Concerned About Your BOTOX Results?
My botox didn’t work.
My botox doesn’t seem to be working the same as usual.
My botox didn’t last as long as usual.
My injections hurt more than usual.
I have bruised and I usually don’t.
I had a different injector and I feel like my results aren’t the same.
I don’t feel I have the result I expected.
Over the many years we have provided neurotoxin injections at ArtMed (Botox and Xeomin), we have acquired a body of knowledge and experience providing such treatments. It is uncommon but not unheard of to receive feedback like the concerns I listed above.
At ArtMed we aim to provide patients with the very best care as well as excellent and consistent results. When it comes to injectables like neurotoxins we have found many factors can influence results. These factors fall into three key categories:
- Product factors
- Injector factors
- Patient factors
Patients sometimes express concern that they have received treatment from an ineffective batch of Botox. But in fact product related issues are extremely rare.
In Canada neurotoxin quality concerns are almost unheard of. Neurotoxins like Botox and Xeomin are prescription drugs regulated by Health Canada, consequently there’s a very high level of government oversight and thus products are reliable and safe. Is it a perfectly reliable system? Almost entirely but very, very rarely an ineffective drug lot may surface. A few years ago we had a group of patients (all within one week) report that their Botox hadn’t worked. When we reported this to Allergan (and we always report adverse drug reactions including a failure to provide a result) we learned that there had been a production issue with one batch of Botox and that that batch had a much weaker effect. It was totally safe, but not reaching the peak effectiveness Allergan demands. Although this kind of thing can rarely happen drug recalls are thankfully rare especially among industry leading companies like Allergan (Botox) and Merz (Xeomin).
At ArtMed we use a lot of toxin in the clinic therefore the product is always fresh. We always prepare our dilutions and dosing within manufacturer recommending guidelines for the intended use. Consequently, our Botox and Xeomin is always identical in quality, strength and character day over day, week over week. Botox must be kept frozen prior to reconstitution (Xeomin does not). To be assured of optimal storage conditions we have a dedicated industrial pharmaceutical freezer where we store all our Botox (residential type freezers are insufficiently consistent in their temperature regulation for pharmaceutical storage). Because we use so much neurotoxin at ArtMed, a newly reconstituted bottle never sits around for more than a day or two before it is used up. Often bottles are used up within an hour! According to Merz and Allergan reconstituted bottles are effective and safe to use for up to 4 weeks after reconstitution although using them up faster ensures an open bottle has virtually no risk of becoming contaminated (ie. unsterile). While we use up our toxin typically within hours of reconstitution, even at 3-4 weeks the neurotoxin is equally effective as on day 1.
Technique – For most people who have had their injections done by various injectors, it is obvious that technique can vary from injector to injector. Some injectors will have you believe they are much better at injecting than others. The truth is that there is very little difference between injectors and variance in technique almost never affects results. When toxins are injected they have an effective dose radius all around the point of injection. Consequently, injecting in precisely the same pattern from visit to visit isn’t necessary to achieve consistently good results.
Dose – The neurotoxin manufacturers make recommendations about dosing but must base this on averages. They cannot account for the wide variability in anatomy, muscle strength, age, desired result etc. among patient populations. Thus manufacturers rely on injectors having enough skill to determine what dose to use and where approximately to place injections to yield optimal results for any given patient. This is true for many prescription drugs – different doses are prescribed depending on if you are male or female, body weight, age, background health etc. I often explain to patients that dosing with neurotoxins frequently takes a little trial and error until you find the ideal dose for you. This is unique to you but each injector may take a slightly different approach in finding that ideal based on their experience.
Equipment – There are other variables as well such as the type of needles and syringes used. Some clinics may use different needles, of different sizes and gauges than we used at our clinic. At ArtMed all our injectors use the same needles which are the smallest commercially available (for precision dosing), and we use many of them to ensure they are very sharp (repeated injection with the same needle leads to dullness). By using many small needles we aim for injections that are extremely precise, less painful and have less potential for bruising.
Nurse versus Doctor – I believe a nurse and a physician are equally skilled at neurotoxin and dermal filler injecting. In medical practice generally, physicians diagnose and write treatment orders and nurses implement orders. This usually means nurses are doing more hands on work such as providing injections on a day by day basis than physicians do. In my experience a nurse who has nursed (and thus done IVs, vaccines etc.) and a doctor who has practised medicine before entering into aesthetics are often the most skilled with a needle due to their wide experience providing various kinds of injections to people of all ages and under all sorts of conditions. Experience in aesthetics is important mostly in determining dose and making adjustments to optimize results.
Right Side, Left Side – Who knew? Injections always hurt more on the left side of your face than on the right. This is due to brain laterality. The left side of the brain controls the right side of the body and the left brain is your rational, mathematical, scientific brain and when it feels pain it processes it as logical given the fact you’re having injections and it immediately downplays the pain. Your right brain is your artistic and emotional side so when you have injections on your left side your right brain heightens the experience through emotional activation. Interestingly, nurses tend to work from the left side and doctors from the right. So if you get your left side injections done first you’ll remember your overall injection experience as being quite painful, whereas if you get your right side done first you’re likely to remember your overall experience as less painful.
What can you do about it? If a nurse is doing your injections ask if she can do your right side first. A doctor is likely to start on the right side anyway.
While I have listed patient factors last, in my experience they are the most common cause for variability in neurotoxin results. It makes sense – the product is always the same, the injector places the product very nearly the same every time, so it should work the same each time, right? Well, the patient is highly unique and their physiology is not static. That is to say, your body can behave in many different ways at different times depending on many factors – health and wellness in that moment, what you’ve eaten, hormones, medications, outside factors like heat and pressure etc. etc. The patient is always a moving target and their condition is changing all the time.
In many ways we’re lucky that neurotoxin treatment results are as consistent as they are given the myriad of changes in the human body from day to day, week to week.
So which patient factors affect the results of Botox or Xeomin? And is there anything you can do to try to optimize results, and minimize side effects like pain and bruising?
Hormones – We have consistently observed that when a woman has her botox or Xeomin injections done the week before her period or the first couple days of her period she will find the injections more painful and bruising more likely. Avoid all types of injections (toxin, dermal fillers etc.) the week before and first few days of our period if possible.
Exercise – While we warn patients to avoid strenuous exercise in the 24 hours after having toxin injections we have found any kind of exposure to excessive heat in the 24 hours after botox/Xeomin may decrease its effectiveness. This includes hot tubs, tanning beds, fever due to illness etc.
Stimulants – Similarly, for some patients even drinking coffee or taking cold medicine containing decongestants in the few hours before and the 24 hours after toxin injections may lead to a suboptimal toxin result. Why? Like heat, if your metabolism is running high your immune system may clear away your toxin from the target muscles before it has a chance to settle in facial muscle receptors.
Bleeding/Bruising – Many patients note that at certain toxin injection visits they experience a lot more bruising than at others. This is not due to poor injecting skill on the part of the injectionist but due to a tendency on the part of the patient to bleed at that time. Needles are sharp, they will cause you to bleed and if you are slow to clot a bruise will be the result. Where a bruise forms you may also find you have a bump which is the clot that finally forms.
What kinds of things impact your ability to clot? ASA, Ibuprofen, Aleve, prescription blood thinners, alcohol (especially red wine and hard liquors), foods containing omega 3’s including fatty fish, supplements like fish oil, Vitamin E, gingko biloba, ginseng, ginger, garlic, glucosamine, tumerica and angelica.
Dosing Interval – The first time you have treatment with a neurotoxin it will definitely work. However, the muscles are very strong at that time and so when it wears off the muscles will bounce right back. Consistent use over time (every 3-4 months regularly) leads to gradual muscle weakening and your results will be better and better, your lines will smooth out more and more over 6-12 months. Even when your toxin wears off it will take a little while for the muscles to bounce back and grow strong again.
When you use toxin inconsistently results are less predictable. I have commonly found that patients who stop using toxin for an extended period (say 6 months or more) and then treat again they often say the results weren’t as good as their last treatment. Typically that’s because they were using Botox or Xeomin regularly or even just regularly for 3 or 4 treatments and they had excellent results at that point. They often recall their most recent treatment and compare the current result with that. But if you’re inconsistent in your dosing schedule it’s very difficult to compare one treatment to the next. Stopping for a length of time is like starting over. And if you’ve stopped for years, you’re likely need a higher dose than the last time you were treated and not see those great results again until you’ve done 3 or 4 rounds of treatment again.
Dose – As I mentioned, your body is not static. The way you use your facial muscles of expression is not static over time either. It is not uncommon to need higher doses as you age. Some people have very strong habits of use that can be hard to break. After their initial treatment they may need a higher dose at each successive treatment until they achieve the results they’d like.
A perfect example is your jaw muscles. How many children suffer from TMJ issues? Virtually none. How many teens? A few. How many adults? Many. Grinding and clenching is a learned behavior (often in response to stress) and this habit can be so trained in that we do it in our sleep. Facial muscles are similar. As we age we tend to have stronger habits of use. So you may find that you need a higher dose at 50 years old than you would have needed at 30 years old. Often we’re able to retrain the facial muscles with consistent toxin use and for those individuals their dose is likely to be quite stable over time.
But again, if you stop using toxin and your habits of use carry on, you may find you need a higher dose of toxin to achieve the results you previously had at a lower dose.
Stress – This is a big one! Many people report to me that their Botox or Xeomin has worn out prematurely in January. The culprit? Christmas. I have found consistently over the years that times of high personal stress (good or bad stress) lead to less predictable toxin results and shorter duration of results. Weddings, also very common culprit. This is a why I often recommend brides do their toxin injections 3-4 weeks before their wedding not 2 months before. Toxin should last 3-4 months but in a high stress time it can often be metabolized by your body much faster. When you’re under stress your immune surveillance is temporarily elevated and your body is likely to break down your Botox/Xeomin sooner than usual. BTW, we also see this effect with dermal fillers!
Expectation – this is a tough one. Some people expect miracles. This is not a criticism, it’s just something I’ve observed over time. Some patients hope or expect a tiny amount of toxin will have a major impact. Rarely it can – 2 or 3 units to treat a gummy smile for example. But for facial muscles of expression (forehead, frown, crow’s feet), a small amount of toxin can only go a small way. As a rule, for cosmetic treatment results are dose dependent. More toxin means more control of the muscles. If you are disappointed in your results it may mean you just need a higher dose. There is some anecdotal evidence that if you dose for optimal results your toxin may last longer as well. This is likely because at higher doses you can more effectively and quickly weaken the muscle and retrain habits of use faster.
Nonetheless, at ArtMed we always aim to provide the lowest effective dose when we treat. “Effective” varies from patient to patient though. Some people want a little movement, others want no movement at all. It’s important to let the injector know what you’re hoping for so we can dose you appropriately. Cheating lower on dose (ie. The injector recommended 22 units and you’d like to use 15) usually leads to a suboptimal outcome and the client feels they’ve wasted their money. The amount we recommend to use is based on what we observe in your face, what you hope to achieve and our own professional experience.
Adjustments especially for new users are to be expected however. If we think you might need just 6 units to treat your forehead and the result is not what we had hoped for, then you’re someone who needs to dose on the higher side of things. How you respond to toxin, especially the first time, is a bit of an unknown because each person’s response is unique.
Some clinics dose on the higher side from the start to be sure to have a certain result. They often get less complaints about ineffectiveness. However, with that kind of an approach a good many of those patients will be using a much higher dose than they actually need which is unnecessarily expensive for patients. We generally dose on the lower side to start and go up if needed. Our aim is to find the lowest effective dose for you. As you can imagine for some people it’s quite a low dose and for others it may be quite a high dose. Most are in the middle. So if we suggest you may need to go up to a higher dose it’s because that’s what’s right for you and your physiology. It is not a failure of the product or the injector or the patient. It’s just dose titration.
Resistance – Very rarely a patient can develop to resistance to neurotoxin over time. This can happen when the patient’s immune system has developed antibodies against that specific neurotoxin. It has been observed with Botox but not Xeomin. If you have been using Botox for many years especially in a higher dose range (50+ units for cosmetic, hyperhidrosis treatment, migraine treatment) and you are noticing a slowly evolving attenuation of your results it may be that you’re developing resistance. As I said, this is rare. The best option is to switch to Xeomin since it is not prone to antibody formation.