Botox is the only FDA approved neuromodulator to treat frown lines, forehead wrinkles, and crow’s feet. For a medication like Botox to get FDA approval there has to be a standard dose and placement guideline that is used on all patients throughout the study. This dosing structure has the target outcome which is to temporarily improve the appearance of moderate to severe wrinkles for an average of 3-4 months. Now that we know what the standard dosing is, how do we decide patients’ personalized Botox dose?
Botox Dosing per Treatment Area
A few factors influence our recommendations but ultimately it boils down to size and strength of the muscles. The frown line muscles (glabella) that cause people to have “elevens” are generally strong and can vary in length. Twenty units in this area is an adequate dose for many people, however, if the muscle is very long and strong a 20-unit dose isn’t going to be enough to provide optimal results. Not only will under-dosing a muscle not give great results but it will also not last 3-4 months as it should. Under-dosing in the frown lines in particular can also cause the muscles to continually try to work which leads to noticeable bulges at the ends of the muscles… not a good look.
Crow’s feet (lateral canthal lines) are fairly easy to assess and treat with the average dose of 12 units per eye on many patients. Again, muscle size and strength vary patient to patient and have to be assessed. Occasionally patients will ask for their crow’s feet that have migrated down their cheeks to be treated. Unfortunately the muscles involved with making the smile lines on the cheeks are extremely strong and integral to moving the corner of the mouth so treatment is not advised in this area.
The forehead is the newest FDA approved area and probably has the biggest variation in dosing per patient. Let’s do a quick anatomy lesson of the forehead muscle (the frontalis). This muscle is responsible for creating the pesky horizontal wrinkles in the forehead. It’s often shaped like two separate sea shells extending up to the scalp. Wrinkle production is secondary to the function of the frontalis because its main job is to elevate the eyebrows and skin of the forehead while also directly opposing the depressor action of the glabella. In fact it’s the only lifting muscle in the entire upper third of the face. With that information you can understand why a good injector is hesitant to inject the forehead without simultaneously injecting the frown line muscles. If we were to knock out the ability of the forehead muscle to lift without also knocking out the depressor action of the glabella, a heavy brow and hooded eye could easily result… also not a good look.
The variability in dosing the forehead comes from the usual suspects; differing sizes and strengths of the muscle, but it also depends on how much a patient rely’s upon their forehead muscle to keep their eyes appearing to look fully open. All of these factors play into our ultimate dosing recommendation. Over my injecting career, I’ve treated patients with as little as 4 units and as many as 40 units in their foreheads. Patients are happiest when we find the dose that smooths the lines, keeps their eyes looking open and pleasant, and lasts for 3-4 months.
Special Situations for Botox Dosing
There are certainly patients that fall outside the general parameters of standard botox dosing, myself being a good example of that. I have an extremely strong muscle complex in my frown lines and require 25-30 units every 3-4 months. However, the muscles in my forehead and around my eyes aren’t very big or strong. I didn’t start treating those areas until I was in my 30’s and I generally can use lower doses of Botox and have a great result for the full 3-4 months.
We are only going to recommend Botox dosing that is customized to your face and aesthetic goals. If you want to get rid of your elevens with 5 units, that’s simply not possible. Sure there is the occasional patient that does fine with 15 units in that area but that’s not common. A knowledgeable and experienced injector is capable of determining the proper botox dose without under or over dosing, both of which may result in an unhappy patient. Proper dosing will actually lead to a natural and youthful look without looking “frozen”.
Sometimes patients come to our practice after being treated elsewhere with “only 20 units all over,” meaning they tell us that their injector used 20 units in their frown lines, forehead, and crow’s feet and still managed to have some left for their lip flip. That’s a magical unicorn injector that I’ve never had the pleasure of meeting! Under-dosing multiple areas on the face may result in the Botox only lasting 1-2 months, an unnatural appearance, and asymmetries.
Patient Considerations for Botox Dosing
Botox can be a costly expense and so it’s important to be budget conscious, but under-dosing leads to sub-optimal clinical outcomes and shorter duration of effect, which can end up costing you more in the long run. Patients who negotiate on dose often come back and let me know that it “never worked,” or “wore off really fast.” This is the last thing we want as our results are the basis of our reputation. If a patient has a tight budget, we recommend treating one area with the proper dose every 3 months.
beyond|AESTHETICS wouldn’t have gotten to be in Allergan’s Top 50 practices nationwide with negative outcomes and dissatisfied patients. Ultimately, we want to give you results that are natural and simply enhance your features, boost your confidence, and last for 3-4 months.
Here are some examples of how much Botox each of our staff require to have the optimal look and duration:
“One of the most well-known myths of Botox is that it may lead to a “frozen face” appearance. A good injector can determine the proper dose. Botox treatments should relax your muscles and smooth your fine lines for 3-4 months. If the dose is too low, your muscles will continue to move, and your results will not last as long as expected.”
-Megan Reider, NP
“If you are under-dosed you will not get the results that you are looking for and therefore may not love your Botox. Medical professionals trained in Botox always dose according to each patient- their muscles’ strength, length, and size. The amount may sound like a lot, but it’s what is appropriate and FDA approved to be the best dose per area.”
-Heather Hatch, RN
“When I was new to Botox and timid about getting the amount that I actually needed, I started to see that the effects wore off sooner than I expected. At first I thought that maybe because I am active that I might be “burning through” my Botox faster than most… that was not the case. Increasing the amount of units to my upper face, and NOT changing my exercise habits allowed me to see the results I wanted last a full 90 days or more.”
-Corinne Case, PA
“I didn’t know much about Botox prior to working at b|A so the first time I received Botox I was a little nervous. I was only 27 and I didn’t want to look fake or weird. But I trusted Leslie and now I can’t imagine not having Botox. At this point all the practitioners at BA have injected me and I completely trust them to dose me properly!”
-Kim Bickly, LE
“I am not a medical professional so I put my trust into the practitioners when dosing my Botox. I know that they are extremely educated and skilled. Their continued education in the newest techniques and protocols keep me very confident in knowing I will love my treatment results.”