Let’s Talk about Tox

June 22, 2023
How Botox Works

Bear with me. This may get nerdy here for a sec…

What is a neurotoxin?

Neurotoxins are substances that damage the tissues of the nervous system.

However, in medicine and aesthetics, the use of botulinum toxin derived from the neurotoxic protein, clostridium botulinum, can be used for both therapeutic and cosmetic results. Allergan Therapeutic was first FDA approved in 1989 and was used to treat disorders of muscle spasticity, like overactive bladder, arm spasticity, and migraine headaches.

In 2002, Botox Cosmetic became FDA approved to treat frown lines and then was subsequently approved to treat crow’s feet (2013) and forehead wrinkles (2017). Since Botox, there are now 4 other FDA approved manufacturers of botulinum toxins, Dysport, Xeomin, Jeavueau, and Daxxify.

How do Botulinum toxins work?

Botulinum toxins work by inhibiting the release of a neurotransmitter called, acetylcholine, from the presynaptic terminal of motor neurons to muscle fibers at the neuromuscular junction. Acetylcholine is the messenger that signals muscle contraction, so by blocking its release, botulinum toxins prevent muscle contraction.

Botulinum toxins

Why do we get wrinkles?

Wrinkles are lines or folds in your skin caused by the underlying muscles moving. Dynamic wrinkles are transient and when the muscle contraction relaxes they are not visible on the skin. Static wrinkles are deeper and are noticeable, even at rest. Muscle contractions aren’t the only factor that contribute to wrinkles, damage to skin caused by the sun, environmental factors, and genetics can play a role.


According to the American Society of Plastic Surgeons there are 7.4 million Botox (or similar) injections administered every year just in the US. It is the #1 non-invasive cosmetic treatment. There are conflicting viewpoints on when to start preventative tox, however studies show that when neuromodulators (another name for Botox-like drugs) are used prior to static wrinkle formation, it slows their development.

So when do you start?

My suggestion is to start when it feels right for you, but with the caveat that once deep wrinkles are formed it may take several treatments to correct those lines, and even then, additional treatments like chemical peels and microneedling are likely needed to help minimize the appearance of deep lines.

Let’s talk about dosing – How long does it last?

When FDA suggested dosing is used, neuromodulators are effective up to 3 months. By FDA dosing that means:

  • Frontalis – 20 units
  • Glabella – 20 units
  • Crow’s feet -24 units

But, wait I never get that much..or maybe you do. We all have unique anatomy, from the size of our face and foreheads to the strength of our facial muscles. Then, there is metabolism and there’s even evidence that covid vaccines contribute to shorter duration of action in neuromodulators to consider.

Additionally, we all have different goals such as keeping natural appearing movement, yet minimizing deep line formation to correcting formed static wrinkles. There are many factors that go into assessing client dosing. One person can have 12 unit dosing to their frontalis (forehead) and it lasts 4 months and someone else may need 25 to get their 3 month duration.

Everyone is different!

This is why finding an injector that spends time assessing you, your anatomy, your goals, and does a follow up to ensure optimal outcomes is so important!

There are a few important concepts to convey to clients:

The first, it’s not a light switch and at 90 days your muscle movement all comes back. It’s a gradual return of muscle function, just like any other medication, there is an onset, peak, the duration that receptors are blocked, and then a period of time where more receptors are formed, therefore not blocked, and the ability for muscle contraction comes back.

The second is DOSE = DURATION. So if dosing patterns are underdosed due to budgets or fear of being frozen, you may not last the full 90 days. Think about it this way, if areas are under-dosed, then you aren’t blocking the majority of receptors. It will be enough to minimize some muscle contraction for a little bit of time, but because a minimal amount of receptors are blocked, it won’t take many more receptors being formed to get those action potentials to fire.

Botox Misconception

How Botox Works

There are many other areas on the face that can be treated with neurotoxins. All of these areas rely on the injector’s knowledge of the underlying facial muscles and anatomy.

  • Bunny lines – nose wrinkles when you smile, often more noticeable with glabella treatment due to muscles compensating
  • Nasal Flaring – dilator naris can be treated, thus slimming the nostrils.
  • Lip curling/lip wrinkles – often called a “lip flip” because it allows the upper lip muscles called orbicularis oris to relax and evert allowing more lip to show
  • Gummy Smile – showing too much of your gum line? Relaxing the muscles responsible for pulling up your top lip can help
  • Downturned smile – the muscle called depressor anguli oris to contracted causing frown at rest.
  • Dimpled chin – the mentalis muscle is too tight causing a “pebbled chin”
  • Masseters – are treated for teeth clenching, migraines, and jaw slimming
  • Neck Lift – Platysma bands in the neck pull skin and jaw line down contributing to a sagging neck or lower face jowls
  • Hyperhidrosis – excessive sweating can be treated with neurotoxins

how much botox do I need?

Did you know there’s also a thing called BOTOX resistance? Thankfully it’s not that common, but it can happen when clients build up an immune response to the toxin and/or are able to metabolize the neurotoxin exceptionally fast. Xeomin which is known as the “naked neurotoxin” does not have the accessory protein that is associated with “tox resistance”. Additionally, if you are taking prescription or OTC drugs that acts as stimulants (Adderall, weight-loss drugs) can also effect Botox metabolism. There is some data to support taking zinc supplements to prolong the effect of your tox.

Preventative Tox

Preventative tox or, baby tox, is a new term in aesthetics, weakens muscle movement enough to avoid deep lines, but also keeps natural movement. There is conflicting evidence on whether baby botox is effective. My advice would be to focus on skin health and anti-aging methods, like frequent application of medical grade SPF and antioxidant serums, regular exfoliation, and collagen induction therapy to maintain collagen and elastin production to counteract what we lose as we age. Then, when the formation of wrinkles is starting to become more prominent and bothersome, start incorporating neuromodulators into your aesthetic routine.

My broken record rant…

I realize this post is about Botox, but I’ll take this moment to be really honest and to really drive this point home. Minimizing muscle contraction with neuromodulators has its place in slowing the appearance of aging, there is a reason why its the number one aesthetic treatment performed annually. However, maintaining skin health and slowing collagen, elastin and hyaluronic acid degredation with the application of SPF and reducing oxidative stress, as well as, increasing collagen production through good skincare, collagen induction treatments like microneedling, chemical peels, certain fillers, and finally addressing volume loss through aging is also very important. The goal is to maintain a balanced and healthy approach to slowing aging and improve skin health and integrity.

Consults are an important aspect of establishing client relationships, educating clients on how we age and simplifying skincare maintenance, and finally creating treatment plans that work with clients budgets and goals. Consults are complementary and can be booked by clicking the button below.

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