Botox Frequently Asked Questions

Our 5 physicians often answer questions from people like you posted on Realself.com about Botox and Dysport.  We thought some of their answers might be useful for you.

---

Q: Is there such a thing as “Frotox”?

A: We are presently conducting the 10 year safety study on Botox in our practice, and its safety profile for cosmetic indications is extremely high.  I think time will tell if a device that is meant to work by freezing your nerves works the same and has as high a  safety profile. I would stick with neuromodulators for now.

Q: Will Botox in my ‘Marionette Lines’ and Corners of Mouth Help to Uplift the Profile of my Mouth in General?

A: Botox to the muscle that pulls the corners of the mouth downward (depressor anguli oris), can help decrease the appearance of the “marionette lines,” but depending on the depth of these lines, I typically couple the Botox with fillers. You should be assessed by a board-certified Dermatologist or Plastic surgeon, to ascertain whether this muscle is causing the appearance you don’t like.

Q: Can some Botox injections last only 4 weeks?

A: The peak effect of botulinum toxin is 2 weeks, and from there new nerve endings start to sprout to regain normal activity, but wrinkles from movement take about 3 months to be seen again (if the right amount is used to begin with) and full movement typically comes back shortly thereafter.  Antibodies can occur, although usually in those who have had large doses used for other indications (ie: cervical dystonia, muscle spasms, etc) for a long period of time.  I would consider seeing a board-certified Dermatologist or Plastic Surgeon for a second consultation and treatment.

Q: Can Botox make the eyebrows flat instead of arched?

A:  Depending on the initial shape of the brow and frontalis movement, one can place Botulinum toxin A in a distribution that would flatten the brow instead of arch it. If one already has heavy brows to begin with, which is possibly contributing to the “arched look” as it is compensation from the Frontalis muscle to allow one to open the eye and see more, you run the risk of feeling like your brows are heavy if you try to flatten them. You may want to consider something like ULtherapy (FDA-approved for a nonsurgical brow lift) that takes 20 minutes to perform, and could be done on the more medial aspect of your brow to even out the shape.

Q: Can Botox stop rosacea flare ups around the cheeks and eyes?

A:  There was a study published in the JDD that showed that botulinum toxin A could help with Rosacea with no adverse events, but one should exercise caution on where it is placed to avoid problems with animation and facial function.  The best thing, and obviously the gold-standard is a treatment with either a pulsed dye laser or IPL in the hands of an experience board-certified Dermatologist and laser surgeon.

Q: Can watery eyes be a side effect of Botox?

A: If you had Botox injected in the inner corner of your eye this can happen, as the duct responsible for draining your tears is in this area.  Side effects related to Botox are typically temporary so this should resolve, but it is always good to notify the Ophthomologist who treated you and let them know.

Q: Where is the best place to receive Botox injections to help with tension headaches?

A: There are specific points that are typically injected to alleviate tension headaches that include within the scalp and over the back of the head, as it is typically posture and position that contribute to these headaches.  Nevertheless, I do have patients who I treat for cosmetic indications, such as the forehead and glabella, and their headaches do improve.  You can always try to first treat the cosmetic areas you are concerned with and see if it truly does make a difference in your headaches. If not, you can see a neurologist to inject the specific headache points throughout the scalp.

Q: Is Botox helpful as a forehead and under eye rejuvenation treatment?

A: Some forehead wrinkles can be relaxed with some neuromodulators like Botox, Dysport or Xeomin. Studies have shown that using neuromodulators before fractionated C02 treatments enhance the results noted from the laser. A fractionated C02 treatment to the full face, utiliizing a Fraxel Repair, would help stimulate collagen production superficially, helping to  smoothening the deep wrinkles on the forehead and crepiness under the eyes. The use of a filler such as Restylane under the eyes would help soften the transition between the under eye skin and cheek skin.  Good luck!

Q: Is it normal to not see results after Botox to the 11 lines after five days?

A: Most neuromodulators have their peak effect at 2 weeks, so I typically encourage my patients to wait a full 2 weeks before adding more.  Depending on the strength of the muscles, I have seen complete relaxation of the 11′s with as little as 12 units, but most patient typically need 18-30 units for complete relaxation.  I’d follow up with your treating physician at 2 weeks for re-evaluation.

Q:  Every time I go outside in the sun, my forehead wrinkles together. It bothers me so much! If I get Botox will it make it go away?

A:  Yes, these lines are being caused my muscle in your glabellar complex, which is where neuromodulators, such as Botox, Dysport and Xeomin, are FDA-approved to treat. After injection, your peak affect will be at 2 weeks, and can last for 3-4 months.

Q: Are facial filers or Botox better for pronounced under eye wrinkles?

A:  It would be great if one thing could address all your concerns, but unfortunately factors that contribute to the aging face are a little more complex.  Botox over the lateral aspect of your eyes, would help with relax the crow’s feet that are contributing to the wrinkles you see around your eyes.  You can consider Ulthera, which is approved for a nonsurgical brow lift, in combination with a fractionated CO2 treatment, to help with both lifting the brow, and the crepiness of the skin above and below your eye, respectively.

Q: Can Botox correct a dimple on the side of my cheek that shows when I smile?

A:  It is unlikely that placing botox in the crow’s feet, which is where it is typically used to relax the smile lines, will be enough to relax a dimple.  Putting enough Botox to relax a dimple that is accentuated when you smile, may actually cause the corner of your mouth to drop and cause more functional defects. I would consider seeing a board-certified dermatologist or plastic surgeon, to see if a combination of Botox and volume enhancement may help, but a dimple is secondary to muscle/ligament adhesions to your skin, and therefore you can’t truly eliminate the dimple unless you sever those adhesions. Anything else you do, can just improve the appearance of the dimple.

Q: Can Botox be a positive treatment for headaches?

A: Botox is FDA approved for chronic migraines, and there are specific points in the head and neck that one can inject into to alleviate the condition.  I would consider seeing a neurologist who specializes in the treatment of Botox for headaches for treatment.

Q: I had Botox for my frown (glabellar) lines about a month ago and have been experiencing dry and gritty eyes on and off now. Is this related to the Botox? Can Botox affect tear glands or impair blinking when used to treat frown lines?

A:  Dry eyes after Botox placement has been reported, but is more common when treatment is done for wrinkles around the eyes, not the glabella.  I typically have my patients who do experience this after their crow’s feet treatment, lubricate with artificial tears.  It would be prudent to be examined by an ophthalmologist to rule out any other causes of the ocular symptoms you are experiencing

Q: I had Botox injected 6 months ago into my forehead and near the lower eye area. Now, I’m noticing that my right eye lid is pulling upwards, and my face is appearing asymmetrical. Is this temporary?

A: Most of us are asymmetric and neuromodulator placement may accentuate these asymmetries temporarily, as their effects typically only last 3-4 months. When these asymmetries become highlighted, patients can return to their treating physician 2 weeks after initial injection for simple correction. It is difficult to say without evaluating you, but the initial treatment may have made you more aware of this natural asymmetry. Also, as we lose volume in our temples with age, lateral forehead lines become more prominent, and lines that may have not existed before, or were less prominent, may become more noticeable , as we lose the fat in our face with age.  It’s best to see a board-certified dermatologist or plastic surgeon for an opinion on how to improve your concern.

Q: I am ten weeks post Botox and beginning to notice shelves under my eyes with lots of wrinkles, even though I’ve had the procedure done several times before. Is this normal?

A:  It is difficult to say definitively what was different.  The good news is that the effects of the neuromodulators themselves generally only last 3-4 months. So if this is strictly related to the neuromodulator, it will go away.  The onset of your symptoms correlate with injections, but you can’t rule out that something else may be accounting for your puffiness that happened to come on around the same time, as this is rare after neuromodulator injections, especially if such a little amount was used and it was injected so high.  It’s best to go back to the physician that treated you and ask for the appropriate referral if the neuromodulator can’t account for your symptoms.

Q: Is fractional laser compatible with Botox? 

I applied urbium laser 1 week after Botox for forehead and eyes. Only 3 weeks later the effect of botox disappeared and wrinkles recurred. Is this due to laser that might have denatured botox?

A: Botox and fractional laser work well together

No. Having a fractional laser treatment will not cause the Botox to wear off. In fact, used together they can create great results and provide and a more rejuvenated look.

---

Q: Had Botox For Crows Feet, But Would Like To Smooth Wrinkles Under Eyes, and All Around?

I’ve recently had Botox for crow’s feet and I’m pleased with the results (I’m 36). However, I would like to have a total smooth eye area. Now I still have under eye wrinkles, lines under my inner eye corner and ‘creping’. I see movie stars without it, so I know it’s possible to do something about those last three. The question is: what? Fillers (Restylane?) (Fraxel) laser? Something else? Thank you!

A: Treatment to smooth under eye wrinkles

Crepiness of the lower eyelid skin can be improved with fractionated CO2 lasers. You should be evaluated to make sure you are a good candidate for the procedure. Good luck.

---

Q: Can I Still Move my Forehead After Botox?

I am self-conscious of the lines on my forehead and am desperately looking for a way to reduce them however I am a 29 year old actress and am cautious of using botox. Is it possible to get such a treatment where the muscles are weakened but not totally paralysed so expressions are still possible?

A: Maintaining forehead movement with Botox

If the treatment is done appropriately, one can still have facial expression while maintaining a relatively smooth forehead.  It is best to start conservatively with the amount of neuromodulator used, as more can always be added.

---

Q: Is Botox my best bet for pebble chin treatment? Costs?

I’m 19 years old and have developed what I believe is called “pebble chin”. When I smile my chin has little bumps and lumps on it and it makes my chin look deformed. I thought it was from falling on my chin a few years back and getting stiches causing my chin to become bumpy, but it could be from the fact that I have TMJ and ‘clench’ my jaw often? I’m not sure. Is Botox the best solution and what would the cost be approximately? Thanks! A picture wouldn’t really help because the flash.

A: Botox for a pebbly chin

Your pebbly chin may represent a hyperactive mentalis muscle which has nothing to do with a previous fall. If that is the case, a few units of Botox or any comparable neurotoxin would work just fine. 4-8 units are all that you would need at a cost of $100-200. See your dermatologic surgeon or cosmetic surgeon to get a proper diagnosis and treatment.

---

Q: Can you exercise after Botox or will It decrease the results?

A: Exercising with Botox injections

Exercising the same day as Botox injections is completely fine. You can continue with your normal workout routine after Botox without it interfering with the Botox results.  

---

Q: Deep Lateral Lines Under Eyes- Other Options?

I had Botox on my eyes, it cleared up the lines at the sides of my eyes, but the lines underneath my eyes and wrinkles that run under my eyes and from the side of my eyes in straight lines down to my cheek bones are so bad. I have been told they don’t use Botox under the eyes, so how can U clear up this problem? I look so old and its making me unhappy!!

A: Lasers for under eye wrinkles

Laser treatments for wrinkles under the eye can provide great results, but you need to see a very experienced laser physician when treating this delicate area.

---

Q: How Safe is Botox when Applied to the Upper Lip for Smoker’s Lines?

Considering the fragility and the sensitivity of the skin area, is Botox a recommended option?

A: Fillers are best for smoker’s lines

Generally, smoker’s lines are treated with dermal filler like Restylane or Juvederm not Botox. Smoker’s lines appear due to a loss of volume in the area, so using fillers will restore the volume and decrease the appearance of the unwanted lines. In some cases, Botox can be used as well to treat the lines, but you should see an experienced injector to see what is best for your situation.

---

Q: When can you exercise after getting Dysport?

I’ve heard 12 hours. I have also heard just to not turn upside down… no headstands as with yoga or gymnastics.

A: Exercise after Dysport injections

ANY exercise after Dysport, Botox or any neuromodulator injections is fine. Its ok to go on about your normal workout routine and daily activities immediately after a Dysport treatment.

---

Q: I have mild worry lines and no crows feet, but I have deep nasolabial lines. Is Dysport right for me?

Can you use Dysport for naolabial lines. They are vertical like worry lines between the brows?

A: Fillers for nasolabial folds

Dysport is best used to treat fine lines caused by facial expressions, like crow’s feet, frown lines, worry lines, 11 lines, etc.  Filler injections are a much better treatment for your nasolabial lines. A filler like Juvederm is great for softening deep folds and adding volume back to your face for a more youthful appearance.

---

Q: I have vertical lines under my eyes, will Botox improve these?

These lines run from the outside corners of my eyes to the middle. I also have regular crow’s feet.

A: A combination of treatments is best

The vertical lines are probably sleep lines from sleeping on your side.  They do not usually improve significantly with just Botox.  We use a combination of treatments for these types of lines depending on how they look clinically.  We often use Botox and fillers in that area as there may be a loss of volume there and that’s why it wrinkles up.  Laser tightening is also often useful with a fractionated C02 laser for the fine lines.  Trying to sleep on your back may also help.  The crow’s feet usually respond nicely to Botox alone, but if they show when your face is at rest, you may need fillers and/or lasering for optimal correction.

---

Q: Can too much Botox cause eyebrows to drop?

I have been getting Botox for about 4 years and everything has been great. This time when I got it, it made my one eyelid look like it was a double eyelid (kind of baggy). However, I though I noticed that my eyelid needed a lift before I went this time, but now it’s worse. And both my eyes are baggy in the corners. Both my eyes feel heavy. I’m 40 years old but never had any of these problems before. Will this go away when the Botox is out? Did she give me too much?

A: Too much Botox in the forehead

I suspect that too much Botox was injected into the forehead.  The frontalis muscle holds up the eyebrows and occupies the entire forehead.  Although it is good to smooth out the horizontal forehead lines with some Botox, sometimes too much is placed in the forehead and the brows drop and the eyes appear heavy.  There is a another injection that can sometimes be helpful to raise the brow back up so check with your doctor.  Fortunately, the effect is temporary and can be avoided next time with less Botox to the forehead.

---

Q: Can smile lines be treated with Botox?

The smile lines are really pronounced on my face. The lines really bother me. Can you share how I can best get rid of smile lines, Botox for example works well?

A: Fillers are best for treating smile lines

Since Botox relaxes muscles, it is not good to use for smile lines because it would affect your ability to smile!  So, fillers are usually the best solution for these lines, like Restylane or Juvederm.  Lasers may also be utilized in some cases.

---

Q: Is it normal to have swelling after Botox?

I had Botox injections 4 days ago in my forehead, and around my eyes. Today I noticed that everywhere I had the injection it looks lumpy and swollen. When I do my “surprised” face, I also get this lump right in the middle of my forehead just above where they do it for the crease between the eyes. I have had Botox before and in some places it seams to leave an indentation. Can anyone tell me what might be happening? I am getting very nervous and am wondering if I should make an appointment to see a plastic surgeon. The Dr. that did it this time is qualified, but is a GP. Thanks for any information on this!

A: Botox may have been placed unevenly or too forcefully

It sounds like the Botox was placed unevenly and maybe too forcefully causing the swollen areas. You should follow up with your doctor as it is usually possible to smooth this out. Wait at least 2 weeks as it may smooth out on it’s own.  If you don’t want to go back to that doctor, see a physician very experienced with Botox, usually a dermatologist or plastic surgeon.

---

Q: Wrinkles under eyes?

I have wrinkles under my eyes and crow’s feet wrinkles on the outside of my eyes. What’s the best treatment for these areas?

A: Botox, lasers and fillers are all great treatments for wrinkles under the eyes

There are 3 main treatments for this problem.  The first is Botox or Dysport to reduce the muscle movement that makes the crow’s feet. The second is a laser to tighten the skin under the eye like a fractionated C02 laser, and the third is using a filler like Restylane or Juvederm to fill in the tear troughs that cause shadows and dark circles.

---

Q: Puffy eyes after Botox lasts for how long?

Hi, I am a first time Botox user from Ireland. I had some injected for frown and horizontal forehead lines. I am happy with the smoothing effect however I feel my right eyelid is puffy and heavy looking. I’m also finding the frozen feeling incredibly frustrating. Does the puffy look go away or do I have to wait it out until the Botox is gone? Also how long does it take to get used to the ‘frozen’ feeling?

A: Botox and the frozen forehead and puffy eyes

Injection of any neuromodulator, like Botox, Dysport, Xeomin or Puretox is a scientific art. The object is not to make you feel frozen or cause your eyelids to be puffy. The main reason for both is injection of either too many units of the product and/or injection in less than perfect places. Fortunately, both of these unwanted effects go away in a few weeks. Next time, tell your doctor exactly what happened so that he or she can perform the procedure better on you.

---

Q: When a doctor injects Botox around mouth for smokers lines, are they injecting into the lips or the muscles around the mouth?

I had this done once and was extremely pleased with results, then the second time (last week) had it done at the same place but by the NP instead of Dr. One side of my mouth doesn’t turn up and the other does! Help.

A: Botox for lip lines

While any of the neuromodulators like Botox, Dysport, PureTox and Xeomin can be used to minimize the muscles around the mouth, this is a VERY technical injection that is best done by a VERY experienced physician. I rely more on fillers like Juvederm or Restylane to soften lip lines. These products are placed both in the lips and diluted to be able to be placed into the vertical lines. Again, I recommend only seeing a physician who is expert in this procedure.

---

Q: Best way to get rid of wrinkles – Professional strength solution?

I’m looking for a wrinkle treatment that really works. I’ve given up on the wrinkle creams and lotions, spending tons of money only to see my facial lines get deeper and my wallet get skinnier. I am aware of Botox and Restylane, but not many other wrinkle solutions (professional strength!!).

A: Superficial wrinkles and fine lines – In addition to topical skin care with growth factor and antioxidant creams, a variety of non-invasive lasers have been found to be very helpful. These include the Affirm, CoolTouch, Fraxel, Active FX, Titan, and the like. Topical skin care takes at least 2 months to show an improvement. Depending on the type of laser, 1-6 treatments may be necessary to achieve the best effect. Topical skin care in addition to lasers works best.

Deep wrinkles, facial folds and creases – Surgery, such as face-lifts and the many names doctors call it like the “life-style lift” or mini-facelifts, are all very similar. The more invasive the procedure, the better and longer-lasting the results. Only your dermatologic or cosmetic surgeon can advise you if surgery is necessary or if the use of filling substances, such as Sculptra, Fat, Radiesse, Juvederm, or Restylane, will be best for you. At times a variety of fillers are used in one session.

Dynamic wrinkles – Botox or, when it is approved by the FDA in 2008, Reloxan are the only non-surgical methods for improving dynamic wrinkles. Endoscopic surgery may also work but is much more invasive.

---

Q: Too much Botox in smokers lines – no movement, cannot speak properly?

I have smokers lines, which I’m deeply unhappy about. Was recommended Botox; $180 worth; and now only 1 day later my top lip is so numb I cannot speak properly. She said in 7-10 days I would see affects of it. I’m so worried its going to get worse. Is there ANYTHING I can do? Please please help. I wish I had got fillers; but was $600, that’s why I opted for Botox at $180. Please please any help/advice for now to stop it or lesson it? Or advice for the future?

A: CO2 and Ebrium laser resurfacing is the treatment of choice for smoker’s or lip lines

CO2 and Erbium Laser resurfacing is the treatment of choice for smoker’s or lip lines.  Fillers and Botox don’t do a great job, and the results are temporary.  One treatment with these lasers can last for many years, and will end up costing less in the long run, and looking much better than the results obtained with fillers/Botox.  See my photos posted on my RealSelf profile for some examples of this treatment. I hope your problem resolves quickly!

---

Q: Where to get Botox injected for horizontal lip line? Could surgery be a better option?

Have tried Botox injections on inside of cupid’s peak and on outside. Have heard mixed reviews on best place (and amount) of Botox to inject. Suggestions? I am considering having surgery to permanently take care of line (ie. cutting of depressor nasi septi muscle), recommendations for doctors in Canada who do this?

A: Laser resurfacing is excellent for lip lines

If surgery is not an option (you need to see a plastic surgeon to determine this), laser resurfacing could be an excellent option.  Laser resurfacing can soften eliminate lines in this area. Seek out a dermatologist in your area with lots of laser experience, particularly in the use of CO2/Erbium lasers.

---

Q: Can Botox be used to correct marionette lines? Is that possible?

What’s best for marionette lines? Botox or fillers? I’ve heard a small amount of Botox can be injected to correct marionette lines, is that true? If so, how about the tight feel it leaves? Is it safe? I had Botox in between my eyebrows and crow’s feet. I even like that tight feel it brings, but around the mouth area I feel it might be a different story. My doctor said I don’t need any correction to marionette lines, but suggested a small amount of Botox there if I really insisted.

A: Botox can reduce the appearance of marionette lines

In some patients, Botox can reduce the appearance of marionette lines.  Fillers like Restylane, Perlane, or Juvederm can be used as well.  Often times I will use Botox in combination with a filler to get the best result.  Injecting Botox is this area is tricky and you can have complications which can be temporarily disfiguring so be sure to go to dermatologist or plastic surgeon that has a lot of experience with injectables.

---

Q: Is it safe to get Fraxel and Botox at the same time?

I am interested in Fraxel for the face, and would also like to get Botox. Will Botox interfere with any of the healing process?

A: Get Botox at least 2 days before laser treatment

To be on the safe side, I would leave 2 days between.  We have seen patients that have had the Botox migrate, most likely from the swelling associated with the laser procedure. This can lead to undesired results.

---

Q: Drooping eyelid caused by error or allergic reaction?

I’ve had Botox 5 times and 3 of those times I had drooping eyelid. The last time very serious and lasted for 4 months. Could I be allergic, or is it more likely an error by the doctor administering it?

A: It sounds like poor placement

I would definitely suggest trying a new injector, preferably a dermatologist or plastic surgeon that does a lot of injections. If the botox is diluted too much it can diffuse to the wrong areas. If you had facial plastic surgery, it change change the diffusion as well. I hope this resolves quickly for you.

---

Q:  Did I have too much Botox?

I have had Botox several times. I just turned 50 and it has worked well in the past. Two weeks ago, I had the following injections that did not really do the trick:
Forehead -  8 units (very few wrinkles on forehead)
Glabella – 15 units (pretty deep 11′s)
Crow’s Feet – 10 units (5 each side)
Total units: 33
Two weeks later I had additional injections for further correction:
Glabella – 9 units (24 total)
Crow’s Feet – 12 units (22 total)
Eyebrow Lift – 2 units (had not done this before)
Total units in 2 weeks: 56
This seems to me like a TON of Botox. I was a bit nervous, but was assured by the doctor that this was not excessive; average or slightly above, but not excessive. He explained some patients get upwards of 70 units for correction without the frozen appearance. I trusted him; but sit here and wonder what I will look like in 7 days. Any feedback appreciated.

A: No, actually not enough Botox

These initial doses are extremely low and I wonder what the specialty of the treating physician is……this sounds like an inexperienced injector. The crow’s feet area can easily require 12 units on average per side, the glabella can require 25-40 units, and the forehead sometimes needs 15-20 units or so. Of course these numbers can fluctuate a bit but the number of units he/she used on you in the initial visit, are low. You will know for sure in 7-10 days.

---

Q: Botox for sweating – how long do the effects last?

I know that Botox Cosmetic lasts a few months, but how long does Botox last when it is used to treat excessive sweating?

A: Depends on the does and the number of units placed

Factors which will influence duration:

1. How diluted is the Botox? 2. How many units are being used? 3. What area is being injected? 4. Who is doing your injections? (an inexperienced injector may place the product too deep, which will diminish the effect).  Talk to your dermatologist or plastic surgeon about these issues and go to someone who is doing this everyday.

---

Q: I am pregnant and do not use Botox right now. How long should I wait?

A: Hold off on Botox until finished breast feeding.

I would wait until you are no longer pregnant or breastfeeding before considering botox.  No studies have been performed to determine the safety of having botox during pregnancy or while breastfeeding, as such a study would not be ethical and be considered taking an unnecessary risk. It’s recommended to hold off for now.

---

Q: Is Botox safe to use if I have Reumatoid Arthritis?

A: No studies show lack f Safety. 

Rheumatoid arthritis is not a contraindication for having any of the neuromodulators, like Botox.  To date, there are no studies showing a lack of safety in Rheumatoid arthritis patients. Good luck!

Want more information about Botox or Dysport?

Please contact Goldman Butterwick Fitzpatrick Groff & Fabi, Cosmetic Laser Dermatology at 858.657.1002 for more information on Dysport and to schedule a consultation. We are located in the UTC area of San Diego, minutes from La Jolla, Del Mar, and Downtown San Diego.