In My Chair: Why Isn’t My Botox Working Anymore?

“Laurie, I swear my Botox isn’t lasting like it used to.”

This is a conversation I am having more and more in my chair lately.

And if this is you, you may not be imagining it.

I have been injecting neurotoxins for over 20 years. Botox was the original. Then Dysport came along, followed by Xeomin, Jeuveau, and more recently Daxxify.

For years, many of us rotated between different neurotoxins. Myself included. As our industry continues to learn more about immunogenicity and resistance, we are also learning that sometimes the answer to a toxin that is not lasting is not simply adding more units.

Why Does Botox Stop Working or Wear Off Faster?

True resistance to botulinum toxin is rare, especially with the doses typically used in aesthetics.

I have seen it, but it is uncommon.

What I see much more often is a patient who tells me their treatment does not seem to work as well as it once did. Maybe their results do not last as long. Maybe the effect feels weaker. Or maybe we have gradually increased the dose and they still are not getting the response they used to.

This is when I start paying attention.

There are several reasons a neurotoxin can seem to stop working. Dose, placement, muscle strength, metabolism, treatment intervals, and changes in your facial anatomy can all play a role.

But there is another possibility we have to consider: your immune response.

Can Your Body Develop Resistance to Botox?

Yes, although true resistance is rare.

Botox and Dysport contain the active botulinum toxin along with accessory proteins. Those additional proteins may contribute to the overall immune exposure of the treatment.

Over time and with repeated exposure, some people can develop an immune response. In rare cases, the body can develop neutralizing antibodies against the botulinum toxin itself. When that happens, the treatment may become less effective or eventually stop working altogether.

That does not automatically mean you have developed antibodies or true resistance just because your Botox is not lasting as long as it used to.

But when I am consistently increasing someone’s dose and their results are still getting shorter or weaker, I start looking at other options rather than continuing to give them more of the same thing.

What About Daxxify and Xeomin?

This is where having more neurotoxin options becomes helpful.

Daxxify is one of the newer neurotoxins available in aesthetics. Its formulation does not contain human serum albumin or accessory proteins and instead uses a proprietary peptide as a stabilizer.

It also tends to have a fast onset and can provide longer duration for many patients. In my practice, I also love the skin quality I see with it.

Xeomin is another option. It contains the active botulinum toxin without the accessory proteins found in some other formulations. You may hear people refer to it as a “purified” or “naked” toxin.

That does not mean one toxin is automatically better than another.

It means we now have options.

And sometimes changing the formulation makes sense when someone is no longer responding the way they used to.

Should You Take a Break From Botox?

Sometimes I recommend what I call a toxin wash.

That means taking a full break from neurotoxins, sometimes for up to a year.

I know.

Nobody loves hearing that. 😂

But if you are spending money on treatments that barely work or disappear much faster than they should, I do not want to keep chasing the problem with more product.

After a break, I have had patients do beautifully when we reintroduce a different neurotoxin such as Xeomin.

I have seen better longevity and stronger, more consistent results.

If Your Botox Is Working, Don’t Fix What Isn’t Broken

My rule is pretty simple.

If your toxin is working and lasting well, stick with it. There is no reason to switch just because something newer exists.

But there is another conversation I have with patients all the time.

Sometimes your Botox is working. Your face has just changed.

As we age, we lose facial volume, collagen, elasticity, and structural support. Botox can relax a muscle, but it cannot replace those things. So adding more units is not necessarily going to give you the result you are looking for.

This is where looking at the entire face matters.

Maybe we need to restore some support with filler. Maybe we need to work on collagen and skin quality with treatments like Radiesse or PRF. Sometimes we need a combination.

And sometimes your toxin really isn’t lasting like it used to. That’s when we may talk about changing products or taking a break.

Think of it like deodorant.

You use the same one for years. It works great.

Then one day you’re halfway through the afternoon wondering if you even put it on. 😂

Sometimes it really is time to switch.

The point is, I don’t automatically assume you need more Botox just because you aren’t seeing the result you used to.

I want to figure out what changed first.

That’s the difference between treating a wrinkle and actually treating your face.

If something doesn’t seem to be working like it used to, ask me about it at your next appointment. That’s exactly the kind of conversation we should be having in my chair.

Laurie Peterson, RN, CANS

Aesthetic Nurse Injector | Carlsbad, California