Can you have too much Botox?

Demand for cosmetic treatments, including botox and fillers, has surged since the COVID-19 pandemic began. Dermatologists and plastic surgeons are attributing the boom to patients wanting to put their best face forward for online Zoom meetings, as well as increased time to attend appointments and recover from treatments.

Botox is now the most popular non-surgical cosmetic treatment in the U.S., with a market size valued at $4.7 billion. Over the past 20 years, the number of cosmetic Botox procedures have increased more than 700 percent, with over six million treatments performed every year.

Now trending with millennials, preventative Botox involves stopping wrinkles before they have a chance to form. And although women still use the most Botox, more men are trying it, a trend known as “brotox.”

As a board-certified dermatologist who frequently administers Botox treatments, I am often asked how it works, what it achieves, how to avoid “bad Botox” and if a person can have too much.

What is Botox?

Botox is a brand name of a toxin produced by the bacterium Clostridium botulinum. Other brand names for similar toxins include Dysport, Xeomin, and Jeuveau. In large amounts, these chemicals can cause botulism, an illness that may produce nausea, vomiting, and in severe cases, fatal paralysis of vital muscles.

Using small amounts, however, doctors can safely use the toxin to reduce the appearance of fine lines and wrinkles. In the 1980s, Jean and Alastair Carruthers, a Canadian ophthalmologist and dermatologist, accidentally discovered the toxin’s anti-aging properties when they noticed patients receiving injections for facial spasm were also losing their frown lines. Subsequent studies did not suggest long-term risk.

How does it work?

Botox is administered with a fine needle to the muscle under the skin. It blocks signals from nerves to muscles. This results in temporary paralysis of those muscles. Because the injected muscle can no longer contract, the wrinkles soften and relax. Over time, the skin becomes smoother with improvements in quality, tone and texture.

Botox is most often used for horizontal forehead lines and wrinkles around the eyes – the worry lines – and between-the-eyebrow frown lines — the “11s.” It is not FDA-approved for the lips. Wrinkles on the lower face caused by gravity and sun damage don’t respond as well to Botox.

There is no “average” cost for Botox. Distributors and practitioners have varying rates.

Beyond cosmetic applications, Botox is a treatment for more than 20 medical conditions, including eye spasm, Bell’s palsy, headache, excessive sweating and urinary incontinence.

The procedure takes only a few minutes. Some people prefer to use numbing cream, but no anesthesia is required and discomfort is minor. For four to six hours afterwards, patients must not lay down, manipulate the injected area or exercise vigorously. This keeps the Botox from migrating outside the treatment zones. But it’s OK to immediately return to work or resume normal social activities. Generally it takes one to two weeks for the Botox to take full effect, but some patients will notice changes after two or three days.

Typically, the effect lasts from three to six months. As muscle action gradually returns, lines and wrinkles begin to reappear and they can be retreated. Over time, returning lines and wrinkles often appear less severe; the muscles learn to relax and the overlying skin becomes less creased and folded.

Things to consider before the injection

The safety of Botox for pregnant or breastfeeding women has not been determined, so neither group should use it. Also, people with certain neurological diseases should not use Botox.

When an expert performs the procedure, patients generally tolerate Botox well. A recent study found less than 1% of patients experience problems if a board-certified dermatologist administers the treatment. Temporary bruising is the most common side effect. Headaches sometimes occur; they stop within one to two days. A small percentage of patients may develop eyebrow or eyelid drooping, but this usually resolves in a few weeks.

Because day spas and other nonmedical offices do Botox treatments, many people think a Botox injection is on the same level as a manicure, facial or haircut. This is not the case. This is a medical procedure requiring specific training and expertise in order to achieve safe and aesthetically pleasing results. Many doctors and medical paraprofessionals advertise Botox treatments after taking a weekend course in injections. But those courses are teaching their students to match a template – and Botox is not a “one-size-fits-all” treatment. An individual’s unique features and muscle patterns must be taken into account.

It’s best to choose an experienced provider with extensive knowledge of facial anatomy, an aesthetic eye and well-developed skills. A highly trained board-certified physician is also best able to manage any complications post-treatment.

Can you have too much Botox?

If you go to an unqualified provider, it may not look right, no matter what the amount. That said, when it comes to Botox, less is more. You want a subtle and natural look, with plenty of movement left in the face. Too much causes that stereotypical frozen appearance. Botox isn’t noticeable if it’s injected in small doses by a skilled practitioner. And when done just right, a good Botox treatment presents a patient who appears more rested, with more defined brows, more open eyes, and skin that takes on a smoother and more youthful appearance.

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Matthew J. Lin, M.D. has previously received research grants from Allergan.