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The Expert Guide To Botulinum Toxin Do’s & Don’ts

Botulinum Toxin was first approved for cosmetic use nearly 20 years ago. At first, there was a certain stigma surrounding it — people assumed it was only for wealthy older women afraid of aging, and people joked about the “frozen” appearance of an overly-Botulinum Toxined face. These days, Botulinum Toxin use has become so widespread and popular that in many parts of the country, it is a standard component of an anti-aging regimen. At our plastic surgery practice in Beverly Hills and Sacramento, Botulinum Toxin injections remain one of our most in-demand procedures, both for women and men for men. Here’s a guide to Botulinum Toxin do’s and don’ts for optimal results.

What is Botulinum Toxin?

Botulinum toxin is an FDA-approved product that is injected into facial muscles in small quantities to reduce the appearance of lines and wrinkles, usually in the forehead, brow, or around eyes and mouth. It is also used to change the size of the eye opening, the aperture, or to change and elevate the position of the eyebrows. Botulinum toxin is most frequently used to treat forehead wrinkles, frown lines between the eyebrows, and “crow’s feet” or “smile lines” around the eyes. 

The term “Botulinum Toxin” is both a specific brand name owned by a pharmaceutical company and the general term people use to describe all cosmetic formulations of botulinum toxin. Since the year 2000, Botulinum Toxin injections have been performed so commonly, that most people think Botulinum Toxin is the generic name of the substance injected. In fact, it is not. Between 2002-2009, Botulinum Toxin was the only botulinum toxin available for cosmetic use, and it became branded as such. It is similar to thinking that Kleenex is the term for facial tissue. In fact, Botulinum Toxin and Kleenex are brand names. Since 2009, other formulations, namely Dysport, Jeuveau, and Xeomin have been FDA-approved, and are now competitors with Botulinum Toxin — and are used in much the same manner as is Botulinum Toxin.

Is Botulinum Toxin safe?

While Botulinum Toxin is technically a toxin, this should not cause patients any concern in a practical sense. It’s true that botulinum toxin is dangerous when used in very high doses. However, the number of units needed to weaken most facial muscles to diminish wrinkles, is actually quite small — and there is very little to no toxic potential, especially when used at this dose. The way I explain this to patients: Any medicine we use is toxic when used in doses outside the prescribed amount. For instance, if we took 30 aspirin in a day, we would have toxic side effects. Similarly, if we were to use a dose of botulinum toxin above the prescribe dose, there may be a toxic side effect. But at appropriate dosage, toxic side effects do not occur.

Having said that, botulinum toxin should only be administered by an expert professional, in a formal office setting, to avoid potentially serious complications. See our “Botulinum Toxin Don’ts” section below for more on how to ensure your injections are done safely and with optimal results.

How long does Botulinum Toxin last?

The method that botulinum toxin works is by denervating the nerve muscle junction. The small amount of material is injected at the base of the muscle, and the nerve muscle action potentials are denervated. The body then grows new nerve muscle fibers, and regenerates the ability of the muscle to contract. The time that it takes to regenerate these action potentials is about 3-4 months– with some presence of the toxin for up to 6 months. Each patient will decide their own personal “sweet spot” of time to readminister botulinum toxin to achieve their desired effect. For this reason, I give patients the general range that botulinum toxin will work, based on the strength of their muscles and the dosage. The unknown factor is their “tolerance” when the wrinkles reappear. That is to say, they reappear slowly. If the patient is cosmetically aggressive, it may require botulinum toxin earlier. If they’re more tolerant, they may wait 5+ months for reinjection. 

How much does Botulinum Toxin cost?

The cost of Botulinum Toxin is based on the amount used, and the injector’s price per unit. Some injectors charge per region, while others charge based on the number units used. The units of Botulinum Toxin, Xeomen, or Jeuveau are all the same, while the number of units of Dysport are 2.5-3x the number required for the desired clinical effect of the other three products. For instance, if I were to use 20 units of Botulinum Toxin for the area between the eyebrows, I would use 50-60 units of Dysport for an equal effect. Below are some general estimates for the Los Angeles area:

  • Frown lines: $200 – $600
  • Frown lines, forehead, and crow’s feet: $500 – $900
  • Botulinum Toxin lip flip: $80 – $200

Never hesitate to ask about costs when booking your appointment for Botulinum Toxin injections. At your actual appointment, you will have a one-on-one consultation with your doctor, nurse practitioner, or surgeon to discuss the areas of your face you want to address, and learn what techniques can be used to improve them and what results you can realistically expect. After talking to your doctor about your options, you will have a more precise estimate of costs, and can make an informed decision about what you want done according to your budget.

What age should I start getting Botulinum Toxin?

I think patients of any age can receive Botulinum Toxin. If patients are young, it’s important they’re aware of the psychological effects of getting a cosmetic procedure. If patients are older it’s important to ensure that no functional impairment occurs. For instance, many patients who are older, or patients with eyelid droop, require use of the eyebrow elevators to “clear” their visual field. If too much Botulinum Toxin is used in this patient, the elevators of the eyebrow (frontalis muscle) may be affected, and the patient may feel their eyebrows are heavy and experience a decreased visual field. 

Botulinum Toxin DO’s:

  • DO your homework when deciding where to get Botulinum Toxin and who to get it from. Be sure to choose a licensed and reputable surgeon, doctor, or nurse practitioner with plenty of experience and a before-and-after photo gallery of their work. 
  • DO consider getting injectable fillers at the same time you get Botulinum Toxin. While Botulinum Toxin works to diminish the appearance of lines, wrinkles, and creases by paralyzing facial muscles, dermal fillers work differently by volumizing sagging areas of an aging face. The two work very well in tandem to effect more total facial rejuvenation. 
  • DO get a referral from someone whose Botulinum Toxin results you like. If your friend or family member looks fantastic after their treatment, chances are you will, too. 
  • DO call your doctor if you experience any of the following after Botulinum Toxin injections:
    • Trouble breathing or swallowing
    • Headache or flu-like symptoms
    • Double or blurred vision
    • Drooling or trouble pronouncing words
    • A drooping eyelid or uneven eyebrows
    • Loss of bladder control
    • Muscle weakness
    • Change or loss of voice 

Botulinum Toxin DON’Ts: 

  • DON’T go to a “Botulinum Toxin party” for Botulinum Toxin injections. Certainly, the injections can be performed correctly in various settings, but it’s my opinion that the wrong situation may have inadequate sterility, lack of lighting, and incorrect patient position. These can add up to a higher incidence of complications.
  • DON’T rub, massage, or get a facial following your procedure. If possible, avoid applying makeup to the injection site for the first 12-24 hours afterward.
  • DON’T sleep with your face down for the first couple of days following Botulinum Toxin treatment. 
  • DON’T take NSAID pain relievers, blood thinners, or drink alcohol excessively the day before and after injection, if you can help it. This will reduce bruising and bleeding at the injection site. 
  • DON’T sit in direct sunlight, engage in strenuous physical activity, or expose yourself to extreme heat or cold for the first 24 hours after injection. 
  • DON’T have any beauty treatments to the face for two weeks following injection, if possible. Things like spa facials should especially be avoided, as the massage techniques used may cause the Botulinum Toxin to migrate into other facial muscles unintentionally.

Do I need a Botulinum Toxin doctor near me?

Patients interested in Botulinum Toxin and other cosmetic facial procedures may wish to travel to a competitive location like Beverly Hills, just to ensure they have the very best in the business working on them. At our practice in Beverly Hills and Sacramento, it is not uncommon for us to have patients flying in from elsewhere for all kinds of facial plastic surgery. 

About Dr. Jonathan Sykes

Dr. Jonathan Sykes is a world-famous expert plastic surgeon who performs all cosmetic and functional plastic surgery procedures on the face and neck. He is a past president of The American Academy of Facial Plastic and Reconstructive Surgery, and served on their Board of Directors for over 10 years. He is also a Professor Emeritus in Facial Plastic Surgery from UC Davis Medical Center, and the former Director of Facial Plastic Surgery at that institution. He is known as the expert’s expert, and is often called to consult and advise other plastic surgeons in both Northern California and Beverly Hills. He has a special interest in eyelid and browlift surgery, facial rejuvenation surgery, including facelifts and rhinoplasty.