Botox side effects: is the dose really the cause?
"Won't botulinum toxin make my expression look unnatural?" "I heard that once you start, you have to keep having it." "It doesn't work well for me."
These are three concerns that regularly come up in consultations about botulinum toxin.
To be honest, unnatural expressions do occur. In most cases, however, the issue is disrupted balance rather than simply too high a dose. If one muscle is strongly suppressed, its counterpart works excessively.
I tend not to overreach at the first treatment. If the effect is insufficient, we can add more two weeks later. If it is excessive, however, we can only wait for time to pass.
Does botulinum toxin make muscles disappear?
The short answer is no. Facial expressions result from the balance of multiple muscles pulling and resisting one another. Frown lines deepen when the muscles that draw the brows together work particularly strongly, and a square jaw becomes prominent when the chewing muscles are overdeveloped. Botulinum toxin temporarily reduces the signals reaching these overactive muscles. Rather than disappearing, the muscle is closer to taking a temporary rest. The action gradually wears off, and movement generally returns over 3–6 months. My answer to "Does that mean I have to keep having it?" follows the same principle. Once the effect wears off, you return toward your original state; stopping treatment does not inherently make you worse. Whether to repeat it is your choice after seeing the result. I explain areas where muscle size itself is the concern, such as the square jaw, somewhat differently. When the chewing muscles work less, we can expect their volume to gradually decrease, much as a muscle does when exercise stops. Again, this is a result of reduced use, not the disappearance of the muscle, and it reverses over time.
Why do some faces look frozen?
If you ask why some faces look frozen, the problem is usually the dose and placement. Broadly suppressing even the muscles that are needed blocks movement itself rather than adjusting balance. That is where much of the unnaturalness comes from when the eye area does not join a smile or the forehead looks unnaturally smooth. Losing your whole expression in exchange for a few fewer wrinkles is not a good trade. My principle is therefore to divide small doses among precise sites. Even with similar frown lines, the combination of active muscles differs from person to person. Injecting the same dose at the same sites according to a fixed formula inevitably differs from selecting sites after observing that person's expressions. This is especially true for muscles that act in opposite directions, such as those of the forehead and glabella. Suppressing only one side makes the remaining muscle's force relatively stronger and can change eyebrow position or forehead tension. Even when treating a single area, we need to account for balance with surrounding muscles. The aim is to preserve expression while reducing excessive force, rather than simply erasing wrinkles.
Why is a conservative first treatment preferable?
Some people say, "If I'm going to have it, I want a strong, definite result." I understand the wish, but I advise particular restraint at the first treatment. The reason is that the two directions of adjustment are not equivalent. Botulinum toxin effects usually develop gradually between three days and two weeks. If the result is insufficient, a small addition can be made after the effect has settled. If it is excessive, there is no way to reverse it immediately; we can only wait several months for it to wear off. In other words, too little can be corrected after two weeks, whereas too much may require waiting half a year. I therefore believe satisfaction is generally higher when the first treatment starts within a range that lets us observe the person's response, and subsequent treatments are adjusted using that response. People respond differently to the same dose, so the first treatment provides both a result and information for the next plan.
At LUNN, we look at expressions before treatment. I ask patients to frown, smile and raise their eyebrows, then identify which muscles are overactive and select the injection sites. Because I personally perform treatment and follow-up, I can directly use the previous response to adjust dose and placement next time. I believe continuity based on personal recollection, not just records, is an advantage of a practice led by one doctor. Consultations take place in a private room, one minute from Exit 4 of Apgujeong Rodeo Station.
If you are concerned about side effects from botulinum toxin, I recommend asking not only which muscles will be treated and with what dose, but also which areas will be left active. A practice with clear criteria for what to preserve can offer reassurance.
Related column: Skin Botox: how does it differ from conventional botulinum toxin treatment? Related treatment information: Botulinum toxin
