• Aesthetic Ai, NP

How does Botox really work?

Updated: Nov 4, 2021

Thinking about getting your first Botox treatment? Or have you been a loyal Botox client for years but never really understood how Botox works? Or are you just curious and just want to educate yourself? Let’s chat! You should feel comfortable with any elective cosmetic or medical treatment you decide to have. As a patient, you have the right to advocate for yourself and ask your aesthetic injector any questions you may have. Furthermore, you should also have a complete understanding of the potential risks and benefits of your treatment so that you can make the best informed decision for yourself. Aside from cosmetic injectables, there are other treatments available that can also help to achieve your aesthetic goals, including: facials, microdermabrasion, lasers, and last but not least- medical grade skin care.

Within the aesthetics industry, neurotoxins are also known as neuromodulators or wrinkle relaxers. But they are more commonly known by their well-known product names, Botox, Dysport, Xeomin and Jeuveau are the big household names you are likely familiar with. Neurotoxins are prescription medications that are only to be administered by licensed healthcare professionals such as a physician (MD), dentist (DDS), nurse (RN), nurse practitioner (NP), or physician associate (PA). A licensed healthcare professional will have advanced education on facial anatomy, injection technique, as well as medical knowledge of how underlying medical problems or medications can increase the risk of adverse events or undesirable results. Licensed healthcare professionals also have adequate medical training on how to manage potential complications.

When our faces animate (smile, frown, excite, etc.) we activate the various facial muscle groups that are responsible for the many expressions we make by contracting those muscles. Over time, when we constantly engage these muscle groups, we in turn cause fine lines and wrinkles to develop on the skin overlying the muscle, eventually etching deeper into the skin as time goes on. Aging, sun exposure, diet, and activity levels play active roles in fine line/wrinkle development, as well as your overall skin health. These various muscles all have different jobs. For example, one group is responsible for lifting the facial muscles, while another group is responsible for pulling the facial muscles medially towards the center of the face. In addition, these muscles all have different lengths, depths, and in some cases interdigitate with other muscle groups. This is why your aesthetic injector will have you make all those funny faces!

When I repeatedly have my client animate, I am learning your specific anatomy, very carefully evaluating your unique muscle strength, muscle function, and how all your facial muscles work together. I also like to understand your aesthetic preference and how you prefer to look. There is no right or wrong answer here, it is simply client preference.

- Some clients desire the "frozen" appearance (frozen muscles, no wrinkles/lines), this

dosing will get you closer to 3-4 months of treatment duration, longer in some


- Others prefer more of a natural appearance (airbrushed/softened lines, ok with some

muscle movement), this dosing likely may not get you to 3-4 months of treatment

duration, however I have had success with several clients

All of this information is taken into account when determining your dosage and how much neurotoxin you require. I personally prefer to utilize a conservative approach to neurotoxins. I believe conservative dosing is an imperative piece to your treatment plan, especially if it's your first neurotoxin treatment, or my first time injecting you. Although a conservative approach may require an additional treatment, or may not get you to the coveted 3-4 months of treatment duration, I prefer this approach because we can closely monitor how your specific anatomy responds to neurotoxin and specific dosing.

Although I can see how other injectors may disagree with this approach, injectors must remember that this is a medication, and dosing clients is not a one size fits all approach. As you can see, there are several factors that determine your neurotoxin dosing. I have always adopted the “start low and go slow” approach even when prescribing medications for patients as a Family Nurse Practitioner in Immediate Care. When providing a neurotoxin treatment, no matter the number of times you have previously received neurotoxin from me, or another injector, there are always risks involved with any medical procedure; and my job as your injector is to decrease your risk of adverse effects or undesired results. As stated by Frampton & Easthope (2003), “the lowest effective dose of toxin should be used” (pp. 709-725). Once neurotoxin is injected, time is usually the only thing that can "reverse" your treatment. I cannot remove neurotoxin, but I can always add more. This is also how we build our client/injector relationship and achieve your aesthetic goals over time. Once we determine your unique dosing, and you are pleased with your results, we have found your special recipe for neurotoxin- a balance between the appropriate dosing for your anatomy and appearance you desire. We now have a record of how to adequately dose you for future treatments, with a goal of a customized treatment plan that will get you to that coveted 3-4 months of duration. A few common areas clients seek treatment include:

- Glabella: area in between the eyebrows, also known as "frown lines" or "11s"

- Frontalis: horizontal forehead lines

- Crow's feet: wrinkles that develop on the lateral or outside areas of the eyes, especially

when you smile

When neurotoxins are injected, they are injected into the muscle responsible for the animation. At the site of the muscle, the neurotoxin works by inhibiting acetylcholine release within the neuromuscular junction. This essentially paralyzes the muscle, which in turn diminishes the appearance of fine lines/wrinkles because the muscle is no longer able to contract. This focal muscle paralysis can last for 3-4 months, longer in some patients. Neurotoxins are potent muscle paralyzers, which is why their use is contraindicated in medical conditions such as Myasthenia Gravis, Muscular Sclerosis, Amyotrophic Lateral Sclerosis (ALS), and Eaton Lambert Syndrome. All of these medical conditions are neuromuscular or neurodegenerative diseases, neurotoxins have a high likelihood of acutely worsening these diseases.

Aside from cosmetic indications for Botox, it is currently FDA (Food and Drug Administration) approved for the following therapeutic indications (therapeutic meaning Botox is utilized for medical reasons, not for cosmetic purposes): overactive bladder, bladder issues due to neurological conditions, pediatric bladder issues due to neurological conditions, pediatric upper limb spasticity, adult spasticity, chronic migraine, cervical dystonia, Blepharospasm, Strabismus and primary axillary hyperhidrosis.

Botox has been around since the 1970s, first used in the field of ophthalmology. It has several indications for use, including both cosmetic and therapeutic indications. Since I work in both aesthetics and medicine, I have a deeper appreciation for Botox specifically, and its broad application in both of these fields. I hope you found this post insightful and educational. You’re now prepared for your first neurotoxin treatment, ready to share the new 411 with your friends, and ready to strike up a conversation with your aesthetic injector (or ready to drop a few knowledge bombs)!

Feel free to ask any questions below or contact me to book your neurotoxin treatment or consultation today! =)

Additional resources to feed your brain/curiosity if you’re a nerd like me!

Chen, S. (2012). Clinical uses of Botulinum neurotoxins: Current indications, limitations and

future developments. Toxins, 4, 913-939. https://doi.org/10.3390/toxins4100913

Frampton, J.E. & Easthope, S. E. (2003). Botulinum toxin A (Botox Cosmetic) A review of its

use and in the treatment of glabellar frown lines. American Journal of Clinical

Dermatology, 4, 709-725. https://doi.org/10.2165/00128071-200304100-00005

Satriyasa, B.K. (2019). Botulinum toxin (Botox) A for reducing the appearance of

facial wrinkles: A literature review of clinical use and pharmacological aspect. Clinical,

Cosmetic and Investigational Dermatology, 2019(12), 223-228.


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