Botox does not work? These are the reasons!

Missing effect with Botox

Are you annoyed that Botox doesn’t work for you? Or does not work anymore? Although the treatment was only a few weeks ago? A so-called “therapy failure” happens in medicine all the time, and unfortunately also with Botox. We speak of it when the patient, the doctor or both are not satisfied with the result of the treatment. And if Botox has no effect, then that is certainly the case.

It is true that one can assume that the Botox effect usually occurs very reliably. Because studies have often proven that. But if it happens to you, you stand in front of the mirror and realize disappointed: “Botox does not work for me”, then it is very annoying. After all, you have invested time and money and had to endure a procedure that is not pleasant. In addition, one had high expectations of the cosmetic result, which now fails to materialize. When patients complain, in forums or social media, that they had negative experiences with Botox, the lack of effect is often the reason.

Primary therapy failure: Botox effect fails to materialize completely

There is always a broad spectrum of reasons for dissatisfaction with the results of a therapy. One can divide these roughly in a first step, in which one primary and SECONDARY Therapy failure distinguishes. If the Botox effect fails to appear from the outset, even though the physician did everything correctly in preparing and administering the Botox injections, this is referred to as “primary therapy failure.” This includes, for example, the incorrect indication in which the goal of the treatment could not be achieved with Botox in the first place. The attempt to treat sleep wrinkles with Botox would be mentioned here. Since they are not of mimic origin, Botox will not achieve any effect on them.

Secondary therapy failure: Botox effect initially present.

In contrast, “secondary therapy failure” is when Botox remains without effect in an ongoing treatment: The therapy is initially successful and the results are as expected. But from one time to the next, the Botox effect stops. Or its effect fades after a short time. There can also be many reasons for this: from incorrect preparation of the syringes by the doctor to the emergence of resistance in the patient.

Let’s look at the reasons for a fading of the Botox effect one by one. And let’s first address two important aspects that lead to primary therapy failure: too high expectations and indication errors. Then we will look at secondary therapy failure. And in doing so, we will take a closer look at the possibility of Botox resistance.

These are the topics:

  • Botox effect quite reliable
  • The doctor in criticism
  • Rare: Botox doesn’t work because of resistance
  • Botox does not work for me – What can I do?
  • FAQ: When does Botox work?

Botox effect quite reliable

Studies: Botox almost always works

The good news first: the finding that Botox remains without effect is rare. On the contrary, the therapy even shines with high satisfaction rates of 80-90%. Studies prove this time and again. One study, for example, reports that 9 out of 10 people treated with Botox are satisfied with the effect and still feel significantly better 4 months after treatment. Only a few subjects reported negative experiences with Botox. Significantly more were convinced of the effect and would definitely recommend Botox to others.

Another study demonstrates that people who had their foreheads treated with Botox were significantly happier afterwards than the control group. This coincides with the now well-documented suggestion that Botox can help against depression. Can these studies always be generalized to every point? Perhaps not. But nevertheless the conclusion remains: Botox works very reliably in most cases.

Botox does not work – in individual cases

And yet it happens that Botox has no effect. Or that the effect at least falls short of expectations. Patients are then justifiably disappointed. Not least for financial reasons: Costs of several hundred euros are not matched by a result that is worth the effort. But often there is more at stake than just money: those who have Botox used to treat certain ailments, such as spasms, dystonia or migraine and bruxism, hope for a real increase in their sense of well-being. The frustration is all the greater when the therapy fails and the hoped-for effect does not materialize. And in neurological therapy it is unfortunately the case that Botox quite often does not work as hoped.

Failure of Botox to have an effect on migraines

For example, when Botox was approved for chronic migraine, it was already clear that the therapy would fail in a high percentage of patients. But whether one is such a patient is usually known only in retrospect. And with all that is known today about the exact mechanisms behind the Botox effect, one can then often only say: unfortunately, bad luck! Because the concrete reasons for the failure are usually not even clear. The prudent physician will guide his patient’s expectations accordingly by pointing out the possibility of a lack of effect even before the therapy begins. In addition, he will design the therapy plan in such a way that discontinuation occurs at predefined points if the effect fails to materialize. In the case of chronic migraine, for example, this is planned after the third unsuccessful treatment.

Unrealistic expectations

One of the central tasks of the physician is to keep the expectations of his patients at a realistic level. And in aesthetic medicine, this is often enough a challenge. After all, one’s own appearance is judged emotionally, and expectations of a cosmetic procedure are not infrequently exaggerated. In addition, aesthetic medicine and many of those who make money from it also like to exaggerate their own promises.

The whole thing is flanked by thousands of beauty influencers on Instagram, who make everyone believe in perfectly styled photos: “You can look like that, too!” And just as many “before and after pictures” that are supposedly taken from real treatments. But in which the professional recognizes at first glance that only one was active as a therapist: “Dr. Photoshop”! The doctor must objectify all this. If he does not manage to realistically guide the expectations of his patients, then in many cases the disappointment will be great after the treatment.

The doctor at the center of criticism

At this point in the text, it can already be seen that the physician must usually take responsibility for a primary therapy failure of Botox. Namely, if the expectations of the result were too high, then the physician should have trimmed them to a realistic level. And if the indication was wrong and Botox was not a suitable means of achieving the goal of the therapy in the first place, then it is simply a case of misdiagnosis. In practice, it will be safe to assume that the vast majority of cases in which Botox has no effect fall into one of these two categories.

Finally, a third reason, for which the physician is also responsible, is failure to prepare and use the toxin correctly. This includes errors in storage. While Botox is not an overly sensitive drug, it does need to be stored at a certain temperature in the refrigerator to retain its full effect. And before being used on patients, Botox must be diluted with saline in an exact ratio. In a diluted state, however, it may then only be stored for a short period of time. Can mistakes be made in all of these actions that cause Botox to lose its effectiveness? But of course!

Dissent between doctor and patient

Another point in which the physician plays the decisive role is in the question of the assessment of the result. It may well be that the doctor and patient have different opinions on this. Sure: If a frown line is still just as clearly visible despite Botox as it was before, then there is no need to argue about it. But it is not always so obvious. And if the patient thinks that the effect of Botox has failed to appear, but the doctor sees the success very clearly, then there is obviously a disagreement. How do you get away from that and reach a common judgment? In fact, studies have shown that doctors and patients assess the Botox effect very differently compared to placebo. However, the doctors were correct more often than the patients treated.

Correctly assessing the Botox effect

In such a situation, only the clarifying conversation will help. The prudent physician has documented the initial condition, verbally and with photos. It should therefore be possible to compare the result with the initial condition. And to discuss the differences objectively. In my experience, the personal conversation is necessary for this. If only to ensure comparability. Because with all the selfies that patients spontaneously send via e-mail or messenger in such cases, you can immediately see that the lighting conditions when the picture was taken mean that there is no longer any question of comparability. As a doctor, you can only plead for the actual condition after treatment to be assessed under the same conditions as the initial condition. With approximately the same lighting conditions in the doctor’s office. Only in this way will it be possible to discuss results objectively and prevent dissent.


Misdiagnoses and application errors are the fault of the physician. There is no need to discuss this. If Botox was injected against wrinkles that are not of mimic origin, then failure is preprogrammed. The muscular relaxation that the toxin was supposed to cause may occur exactly as planned. Alone, it will not be able to contribute to the improvement of the wrinkle appearance. Sleeping wrinkles should be mentioned here. Or the nasolabial fold. Both are not treatable with Botox. There are other techniques with which they can be successfully softened. But with Botox, negative experiences are pre-programmed.

A similar problem, probably quite common, is likely to be that muscle tone is underestimated. And the Botox effect thus overestimated. As Muscle tone is the basic tension of a muscle, which is present even in a state of relaxation. Botox then leads to relaxation, but this is not sufficient to eliminate wrinkles completely. Or the wrinkles are gone at first, but already after 3 months the effect of Botox seems to be gone again. This should not happen to the experienced doctor. There may be cases whose evaluation is difficult and the effect is not exactly predictable. But then again it is up to the doctor to point out the risk to the patient in order to guide his expectations accordingly.

How long does Botox last?

In this context, Brazilian surgeon and Botox expert Mauricio de Maio distinguishes between “kinetic,” “hyperkinetic” and “hypertensive” patients. In kinetic patients, the wrinkle pattern corresponds to the mimic expression, i.e. wrinkles appear when laughing or frowning, but not otherwise. In such patients, it can be assumed that the Botox effect will occur, as is commonly expected. And then lasts for a full 6 months.

In hyperkinetic patients, facial expressions are overactive. Their face is practically constantly in motion when they tell something or are even attentive. According to de Maio, the Botox effect should initially begin to work properly in them as well. But how long the effect lasts is questionable. As a rule, only for 3-4 months.

Finally, hypertonic patients are already so tense in their muscles that Botox can no longer provide complete relaxation. The wrinkle appearance will improve, but never completely disappear. And the Botox effect will only last for a very short time, around 3 months.

As seen in the following screenshot from an online training, de Maio strongly advocates telling the patient about this from of the treatment. Only then can he form realistic expectations. And is not condemned to have negative experiences with Botox because the effect does not meet his too high expectations.

The Botox effect depends essentially on the muscle tone. Brazilian physician and expert Mauricio de Maio distinguishes 3 groups of patients: kinetic, hyperkinetic and hypertensive. (Screenshot Allergan Medical Institute/Mauricio de Maio, June 9, 2021)

Application Error

Application errors occur whenever treatment with Botox is correctly indicated but then not correctly performed. Again, several cases are conceivable:

  1. The Botox dosage was too low
  2. The injections did not hit the right muscles
  3. The injection technique was not correct
  4. The Botox syringe had quality defects (e.g., due to improper storage)

Again, one can only conclude that such mistakes usually do not happen to the physician experienced with Botox. As earlier with the indication, there may be borderline cases in which the muscular anatomy carries a risk that the wrong muscle will be injected and the desired effect on the wrinkled appearance will fail to materialize. The physician must address this in advance and point out the risk to the patient. This is because injecting the wrong muscle by mistake can not only result in the cosmetically desired effect not being achieved. It can also lead to cosmetically undesirable consequences. Examples include “Spock eyebrows” or drooping corners of the mouth. Leaving the patient in the dark about the risk can therefore not only lead to the patient complaining about a lack of effect. But also that he is horrified by unforeseen effects. Comprehensive information will therefore prevent the patient from having negative experiences with Botox on both counts, which are unnecessary.

Botox does not work because of resistance

Botox effect inhibited

So far, we have talked about too high expectations on the part of the patient and treatment errors on the part of the physician. We have also stated that false expectations on the part of the patient, which are not corrected by the physician, are also attributable to the physician. Now we come to a third possible cause, which in most cases is not the doctor’s fault: Botox resistance. It occurs when the patient develops antibodies against Botox. This leads to an immune reaction that prevents Botox from working. This happens much less frequently with Botox than is generally assumed. And in cosmetic Botox therapy, almost never. The few cases of Botox resistance almost always involve patients who are treated with it for spasms or dystonia. This is explained by the very high doses of active ingredient used. In studies with dystonia patients, for example, Botox resistance occurred in 3-10% of cases after multiple treatments. How does Botox resistance develop?

Antibodies bind to active molecules

Botox contains biologically active as well as biologically inactive protein molecules (proteins). For Botox to take effect, the active proteins must remain intact. However, both types can be recognized by the immune system as antigens. It responds by producing antibodies. The antibodies bind to the Botox proteins and inactivate them. If these are molecules that were biologically inactive anyway, then this has no influence on the effect. If, on the other hand, the antibodies bind to the biologically active part of the Botox, then its toxic and therapeutic effect is blocked. However, recent studies show that the blockade also fades over time. In the course of 2 to 3 years, the number of antibodies decreases again, so that a therapy may then be successful and Botox shows effect where it previously failed.

How to avoid Botox resistance?

Antibody formation is problematic when Botox is injected at high doses and short intervals. This can be a challenge in neurologic therapy. However, in cosmetic applications, hardly so. 50-100 units of Botox every 4-6 months does not pose much risk for antibody formation. The experienced physician will take this into account and will be advised by Botox to be injected at very short intervals (“Botox Booster”). If he does not do so, he is at least complicit in the resistance as well.

Botox does not work for me – What can I do?

So let’s get back to the starting point of this post: you’re standing in front of the mirror and you realize with disappointment, “Botox doesn’t work for me.” What can you do?

Clarifying conversation with the doctor

First of all, seek a discussion with your doctor. If he agrees with you that the treatment with Botox has no effect, then it is important to find out the causes. Your patient file and the photos of the initial condition should provide information on whether your doctor’s procedure was correct in principle. In addition, you should have the batch number of the preparation used, which you can use to ask the manufacturer whether there are any known problems with this batch. As a result of the conversation, you may want to try a second time. Possibly with a higher dosage or a modified injection regimen if you suspect that this may have been the cause.

Change of doctor

However, you may withdraw your trust from your doctor and try again somewhere else. This will depend on how good the trust relationship was with your previous doctor and what impressions you gained from the conversation. “Doctor hopping” is usually not a good idea, but if you have lost trust in your doctor, then you have no choice. Many doctors today inject Botox for wrinkles, even those whose specialty and focus has little to do with cosmetic wrinkle therapy. A certain risk of having fallen in with the wrong person can therefore not be completely dismissed.

Get tested for resistance

If further treatment also shows no effect, although it can be assumed that everything has been done correctly, then you should consider getting tested for Botox resistance. You may indeed belong to the small band of people who are immune to botulinum toxin A. For whatever reason. As mentioned before, this is unlikely. But it cannot be completely ruled out.

The test for Botox resistance is performed by means of Surface Electromyography the electrical activity of muscle fibers is measured. The result obtained is a Electromyogram. The procedure is as follows: First, the amplitude of the measured action potential of a muscle is recorded and documented. Then Botox is injected into the muscle. 4 weeks later, measurements are taken again. If the new measurement shows a lower amplitude than in the first measurement, then the Botox has had an effect and there is no resistance. If, on the other hand, the amplitude is unchanged, then there is resistance.

Consider Botox alternatives

If it turns out that there is resistance and you are immune to Botox, don’t be too disappointed. There are a number of other options for treating wrinkles. Cosmetically excellent results can be achieved with these as well. Injections with hyaluron would be the first to mention, but also thread lifting or PRP. For smaller wrinkles, you can even achieve good results with microneedling and chemical peels.

FAQ: When and how does Botox work?

I attach a short FAQ to my text as a digression. In it I explain how Botox works and when the effect starts. This information may help to classify the above contents even better.

How does Botox work?

Botox is a neurotoxin. It acts on the “cholinergic synapses“. The cholinergic synapses mediate communication between a nerve cell and a downstream cell. The communication between the cells takes place via messenger substances. They are also referred to as “Neurotransmitters“. The neurotransmitter that interests us in Botox is called “Acetylcholine“.

Botox now inhibits the secretion of acetylcholine. And thus interrupts the communication between cells. More precisely: between nerve and muscle cells. Since communication is interrupted, nerve impulses no longer reach the muscle. It is paralyzed. Maybe not completely. That depends on the dose. But at least partially. The strong pull on the skin is therefore absent. It is now no longer wrinkled. This is what the effect of Botox is based on.

When does Botox work?

After injection, it takes between 24 and 48 hours for the toxin to bind to and penetrate the nerve cells. The process is complicated and involves the 2-part Botox molecule splitting. Only the lighter part, the “L-chain,” penetrates the nerve cell. There, Botox cleaves a protein that is important for the release of acetylcholine. This prevents the release.

It therefore takes 1-2 days for injected Botox to take effect and the first initial paralysis of the muscle to occur. There are patients in whom the appearance of wrinkles improves already from then on. However, this is certainly not the case for all patients. Many therefore wonder how quickly Botox works. And become nervous already after a few days. Especially patients who are treated with it for the first time.

But how long it takes to see the full Botox effect depends on individual factors. Especially the strength of the muscles involved plays a role. But also their basic tension at rest. In my experience, it takes 7-14 days until the full effect is seen. In men rather longer than in women. Therefore, if you find that Botox does not work for you after 3, 4 or 5 days, do not be alarmed right away. This is normal. Only if you still do not see any effect after 14 days, then you should contact your doctor. Usually, however, he or she will have made an appointment with you for a check-up anyway. There you can clarify the lack of effect.

Are there Botox late effects?

Short answer: no, Botox does not cause any late effects. The process of Botox action outlined above is completely reversible. This means: the toxin gradually loses its effect until it is completely gone after 4-6 months. No traces or “memory” remain in the body. The fear of Botox late effects is therefore unfounded. Long-term studies have also often shown that: there are no Botox late effects.

However, muscles lose strength if they are not active for a long time. You know this from arms and legs. It’s no different with mimic muscles. They also become weaker when they are immobilized for a long time. If you like, you can call this a “Botox late effect”. But it has only indirectly to do with the toxin.