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Renata Khelemsky, MD

Many of my patients have concerns about whether Botox is right for them and if their treatment might have unforeseen outcomes. They want guidance on dealing with these outcomes and help in addressing their concerns. Some patients are worried that if their result isn't ideal, they may not be able to return to the office for a "quick fix" due to travel or work plans, and they ask if it is best to hold off on treatment altogether.

My goal is to reassure patients that your curiosity on this subject is completely warranted! To help you answer the question of whether cosmetic Botox is right for you, I will highlight three key points that I personally review with each patient before and after treatment. In doing so, I hope to educate readers about what could make your treatment "right."

I’ve Never Had an Issue… But I Still Wonder

If you are like most people who have tried a cosmetic neuromodulator treatment such as Botox, you have probably not experienced any issues. Allow me to share a scenario that you or someone you know may find familiar: After learning about cosmetic Botox injections, or perhaps another brand-name neuromodulator on the market (for example, Xeomin, Dysport, or Jeuveau), you made the choice with your provider to give it a try! 

The results have been satisfying overall. You note smoother lines and wrinkles in the forehead, between the brows, and around your eyes. You feel more refreshed and secure about your appearance. After a couple of weeks, your provider re-evaluates the result in person and agrees with you that the treated areas have responded well. You are gently reminded about a re-treatment appointment in 3-4 months. “What an easy process!” you say to yourself. And for the majority of patients, it truly is.

Perhaps you have also learned of a different scenario. After several regular neuromodulator treatments, you or your friend notices a result that may appear “off” after several days. Sometimes, you feel certain that something in the region looks too high, too low, too tight, or even droopy. Other times, you may believe there is some asymmetry or a change that you did not expect. Whatever the issue, you are unsatisfied and you know it’s time for an office visit to discuss what can be done to fix it.   

Three Key Considerations

As you contemplate if Botox is right for you, here are three points that will confidently help shape your decision. 

KEY POINT #1: Cosmetic Botox May Not Be Right For You

There is such a thing as being a poor candidate for neuromodulator treatments. To understand this point, you must appreciate the delicate anatomy of the upper region of the face where Botox is most commonly used. 

To simplify a rather complex situation, I will summarize the anatomy of the forehead as a tug-of-war between two groups of muscles: those that lift up (towards the ceiling) and those that pull down (towards the floor). The center of the tug-of-war “rope” would be the brows, which are directly affected depending on the kind of treatment you receive. 



Let’s apply this information to neuromodulator treatment. Botox, Xeomin, Dysport, and Jeaveau all function in the same way: they relax the muscles into which they are injected. Hence the name “muscle relaxers.” What happens when you relax muscles that naturally pull up? If you go back to my tug-of-war analogy, this is the equivalent of weakening the “players” that are trying to pull upward. As these muscles become weaker due to Botox, the opposing set of muscles, or those that pull down, will have a stronger net effect and will win the tug-of-war. The same is true in reverse. Relaxing the muscles that naturally pull down with Botox will effectively produce a lifting of the brows. Finally, by injecting both sets of opposing muscle groups, it is possible to keep the brows in their natural position, which is a common goal during most treatments.

The art of injecting a neuromodulator lies in understanding this anatomy. When visiting an experienced injector who is trained in facial plastic and cosmetic surgery, you can be assured that he or she will assess your unique anatomy. I find it beneficial to review the position and strength of each patient’s facial muscles, and assess the skin quality and aging, prior to a neuromodulator treatment. In doing so, I evaluate just how much the muscles can be relaxed with Botox while at the same time keeping the skin and brows in an ideal position. 

A unique situation that makes someone a less-than-ideal candidate for neuromodulator treatment is when a great deal of excess skin is present in the forehead region, a common finding in patients with advanced facial aging. In this situation, injecting Botox along the muscles of the forehead will relax these muscles and similarly relax the overlying skin. As a result, the patient may experience heaviness and sagging of the brows after treatment. While the Botox worked exactly as it should, it failed to produce a satisfactory cosmetic result.

The purpose of any consultation is to find the best solution for a particular problem. As a facial plastic and reconstructive surgeon, I have the unique opportunity of comparing nonsurgical to surgical treatments during the same visit. When I meet patients who show signs of forehead aging but who are also seeking more dramatic results from their treatment, I discuss one of several types of brow lifting procedures that may easily be performed in an office setting, too. 

It is critically important to have a discussion with your provider regarding whether Botox is indeed right for you. Remember, Botox is one of several tools that can be used to correct lines and wrinkles of the upper face. But note that it is not the only tool! You can now appreciate the fact that in a select number of patients who demonstrate excessive aging of the upper face, Botox may not be the “right” tool. Exploring the entire spectrum from nonsurgical to surgical treatment ensures that you will get the result you are looking for. 

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KEY POINT #2: The Past Is Not the Present

Because aging is a global process that occurs continuously, it is safe to say that what was right for you 10 years ago may not be right for you today. This notion also applies to your ongoing neuromodulator treatments. 

For some people, the number of required units may vary from treatment to treatment. This may have to do with the amount of aging and skin excess that is present, or it may simply have to do with the kind of result you desire. While patients may be expecting to obtain the same amount of cosmetic Botox at every treatment, I do not “copy and paste” my previous treatment every time I see them. Instead, I take many factors into consideration to form an ideal treatment plan, such as: 

  • The overall facial appearance
  • New or worsening signs of aging
  • The overall pattern of lines and wrinkles
  • Patient preference about which areas to treat and which, if any, to leave alone
  • Prior surgeries or cosmetic treatments
  • Daily skin care routine 

Based on what I gather from my evaluation, I strive to make additional recommendations in order to build upon the last treatment. To prevent disappointing results, it is paramount to avoid a cookie-cutter approach from patient to patient, and even with the same patient. Even the most well-versed patient needs the utmost attention to detail from their provider.

KEY POINT #3: More Botox May Not Help

If you have ever had the unpleasant experience of being dissatisfied with your treatment, you may have heard that using additional Botox will not help. This may be true. Unfortunately, treatments such as Botox, Xeomin, Jeaveau, and Dysport can perform only one function: muscle relaxation. Therefore, undoing this relaxation is not possible with further injections.

There may be additional ways to improve upon the result, however. Several issues that can be treated with additional injections include findings of asymmetry and overly arched or peaked brows, to name a few. Depending on the concern you have, the best fix may be to wait until the effects of Botox wear off, rather than adding additional units which may further worsen the problem you are experiencing. 

As a provider, I anticipate the techniques that are required to prevent poor cosmetic results each time I see a patient. This includes a detailed examination of the skin and muscle factors that contribute to the overall facial appearance. A comprehensive evaluation is paramount during even the simplest of treatments, such as Botox. 

For this reason, if you are concerned about having issues related to your next neuromodulator treatment, especially if you maintain a busy lifestyle that may not allow for additional time to address them, you will benefit from seeing a provider who has an in-depth knowledge of facial anatomy and cosmetic treatment. It may indeed be difficult to provide a “quick fix” for a result achieved by an outside injector while the Botox is still in effect. 

As the saying goes, the best treatment is prevention! In fact, my experience has taught me that a large number of poor results stem from a complication of consultation, rather than the treatment itself. 

Bottom Line

The bottom line is that getting great results with neuromodulator treatments has everything to do with a two-way dialogue between patient and provider. I hope that I have demonstrated with several key points how cosmetic Botox may work just “right,” although it may not achieve the right result for you. 

My advice to readers is to get curious! Ask questions! The more you can inform your provider about any previous experiences you may have had, positive or negative, the better. After reading this blog, you may feel more empowered to ask questions like the following: 

  • How will this treatment compare to the last one?
  • Will Botox be sufficient for the kind of result I am looking for?
  • Am I a candidate for surgery?

Openly discussing your provider’s recommendations regarding your goals is essential to getting your cosmetic Botox “just right.” Start with a private consultation today, and get all of your questions answered, so you can make an informed decision that’s right for you.


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