Botox Resistance Is Real. Here’s How To Prevent It.

One of the scariest beauty horror stories out there? Your Botox suddenly stops working.

It happened to me about two years ago. I went for my usual round of neuromodulator injections, and noticed that though it was still freezing my forehead and crow’s feet, the movement there would come back a few short weeks afterward rather than the typical three to four months it was supposed to last. I didn’t know what was going on — and the fact that my face actually showed that I was upset about this made me even more upset. So, what gives?

This question has not only been plaguing me but has been floating around the aesthetics community and TikTok as of late. Neuromodulator injections were once again the top non-invasive treatment in 2023, accounting for almost 9.5 million frozen foreheads, according to a report from the American Society of Plastic Surgeons, and that number is only expected to grow. With this exponential increase in patients, it’s no wonder that many are starting to see a dip in their treatment effectiveness over time.

This dip is referred to as Botox (or neuromodulator) resistance. Read on to learn more about what this phenomenon is, what factors can contribute to it, and what you can do to prevent it from occurring.

What Is Botox Resistance?

To understand how it can stop working, it’s important to understand how it works. “Botox works by weakening muscle contraction by impairing the signaling between the nerve and the muscle,” explains Dr. Sean Alemi, M.D., a double board-certified facial plastic and reconstructive surgeon based in Long Island, New York.

Botox — and all neuromodulators (i.e. Daxxify, Dysport, Xeomin, and Jeuveau) — blocks the release of acetylcholine, a neurotransmitter essential for muscle contraction. Without this signal, the muscle doesn’t move, reducing wrinkles like crow’s feet and forehead lines, explains Dr. David Shafer, M.D., a double board-certified plastic surgeon based in New York City.

“Resistance occurs when the body forms neutralizing antibodies against the active ingredient in Botox.”

Once that neuromodulator is injected, it typically takes effect about three to four days post-injection and “reaches its peak around two weeks afterward,” says Alemi. Movement will generally return somewhere between three to four months later. In rare cases, however, you can experience Botox resistance — aka when your muscles no longer respond to injections, resulting in the faster return of movement.

“Resistance occurs when the body forms neutralizing antibodies against the active ingredient in Botox — botulinum toxin,” says Alemi. “The antibodies will target and neutralize the botulinum toxin to make it less effective or even ineffective.”

Though this is a possibility, it is extremely rare, Shafer says — especially in aesthetic applications. However, those who receive neuromodulator injections for therapeutic purposes (like the treatment of migraines) have a higher chance of developing a resistance since more units are used.

Overall, however, true Botox resistance occurs in only around 0.5% of patients. “After more than 20 years of administering treatments to tens of thousands of patients, I have encountered fewer than five individuals who have developed resistance,” says Shafer.

What Causes Botox Resistance?

Several factors can lead to Botox resistance. One is excessive use — which, according to Shafer, means getting neuromodulator injections more often than every two to three months or exceeding the FDA-recommended limit of 400 units in a three-month interval. “This can lead to reduced effectiveness or muscle atrophy,” he says. To avoid this, follow FDA guidelines and space treatments every three to five months.

“Overuse or poorly executed injections may cause the body to adapt, reducing Botox’s effectiveness over time.”

Incorrect dosing also significantly affects your response to Botox. The number of units you get depends on the treatment area, facial anatomy, and desired results. Too much can cause temporary muscle paralysis, product migration (resulting in drooping or unnatural expressions), or unnatural expressions. If too little is injected, you can have inadequate results that will leave you wanting more frequent appointments, thus creating a counterproductive cycle.

Shafer also stresses how improper injection techniques, such as incorrect placement of product or depth of injection, can reduce effectiveness and lead to potential resistance from overuse. “Overuse or poorly executed injections may cause the body to adapt, reducing Botox’s effectiveness over time,” he says.

The rise of popular injectable clinics may also be a contributing factor. This is not to say that these don’t serve their purpose (i.e. helping make treatments more accessible and affordable) — it’s that oftentimes at these spots, patients are paying for a set number of Botox units, which doesn’t account for an individual’s unique facial muscular structure.

How To Prevent It

Again, while true Botox resistance is extremely rare, there are things that you can do to give your Botox its best shot at working its magic on your muscles the way it should.

Go To A Qualified Injector

Getting yourself to either a board-certified dermatologist or board-certified plastic surgeon is paramount to making sure you receive the right, personalized treatment for you.

“The ideal neuromodulator treatment takes into consideration a patient’s anatomy, aesthetic goals, and whether they’ve had any prior treatments,” says Alemi. “Based on [a patient’s] anatomical evaluation, we can determine the appropriate number of units and distribution of injection sites for treatment.” He adds that age is another factor; younger patients tend to have less static lines and wrinkles, therefore requiring less Botox.

Shafer also stresses that visiting a highly qualified injector ensures that you are receiving authentic, FDA-approved toxins: “Choosing a non-experienced injector increases the risk of using outdated product and may result in less consistent or reliable outcomes due to limited experience.”

Don’t Overdo It

Dr. Paul Jarrod Frank, M.D., a celebrity cosmetic dermatologist and owner of PFRANKMD, says that it’s most important to keep your expectations realistic with treatment. This means not over-treating, not allowing yourself to have “frozen face,” and not going in too often for injections.

Switch Up Your Neuromodulator

With five FDA-approved neurotoxins on the market to choose from, it might be a good idea to try a different one if your go-to stops working for you. “While Botox, Dysport, Xeomin, Jeuveau, [and Daxxify] are all botulinum toxin type A products, each has a unique formulation,” says Alemi, noting that each neurotoxin has a small risk of developing a tolerance.

That said, Alemi says Xeomin has the lowest risk of resistance as it doesn’t contain the same complex proteins as the other neuromodulators on the market.

Take An Injection Break

If you feel that your body has developed a true resistance, you might want to consider skipping your next appointment. “I’ve seen patients take a year break and come back with some efficacy,” says Frank. Laying off the neuromodulators for several months can help to decrease antibodies.