Botulinum Toxin (Commonly Called “botox”): What It Is, Who It Suits and What to Watch For

What is botulinum toxin and how does it work?

Botulinum toxin is a medicine derived from a protein produced by a type of bacterium; it is purified and used in very small doses. In aesthetic treatments, “botulinum toxin type A” is the most commonly used.

Nerves pass the “contract” command to muscles through a chemical messenger. Botulinum toxin temporarily reduces the release of this messenger in the area where it is injected. As a result, the muscle contracts less, and the lines formed by that muscle contracting again and again soften.

The effect is not permanent. Over time the nerve endings form new connections and muscle movement gradually returns. For this reason, if you want the effect to continue, the treatment needs to be repeated at certain intervals.

What is it used for?

In aesthetics, botulinum toxin is used especially for wrinkles that appear with facial expression, that is, “dynamic” wrinkles:

• Vertical lines between the eyebrows (lines that become more visible when you frown)
• Horizontal lines on the forehead
• “Crow’s feet” lines at the corners of the eyes
• Some other areas of the face and neck, depending on the doctor’s assessment

The same active substance is also used for medical purposes outside aesthetics. Examples include excessive sweating (hyperhidrosis) and some forms of chronic migraine. These uses require a separate medical assessment and are not the subject of this article.

Who may it be suitable for?

In general, it may be considered for adults who are bothered by lines that become visible with facial expressions, who are in good general health and who have realistic expectations of the result. Only your doctor can decide whether it is suitable for you, after an examination.

In cases such as deep lines that are visible even when the face is at rest, sagging skin or loss of volume, botulinum toxin alone may not be enough. In these cases your doctor may also discuss other options.

Who is it not suitable for, or who needs extra caution?

If any of the following applies to you, be sure to tell your doctor during the examination. Some may rule out the procedure, while others call for extra caution:

• Pregnancy or breastfeeding (generally not recommended during these periods because its safety is not sufficiently known)
• Active infection, inflammation or an open wound in the treatment area
• A previous allergic reaction to botulinum toxin or to any ingredient of the product
• Diseases affecting the muscles or the neuromuscular junction, such as myasthenia gravis
• A history of difficulty swallowing or breathing
• Medicines you take regularly, including blood thinners
• Another aesthetic or medical procedure done recently

This list is not complete; tell your doctor about all your health conditions and the medicines you use. Mention herbal products and vitamins too. Do not stop any medicine on your own; if needed, your doctor will plan this.

Who should perform it, and where?

Botulinum toxin is a prescription medicine. It should be administered after an examination by a doctor who knows facial anatomy, dose adjustment and how to manage possible complications. In Turkey, these matters are regulated by the Ministry of Health; the treatment must be performed by a doctor and in a licensed healthcare facility.

Treatments done in places that are not healthcare facilities, such as homes, beauty salons or hairdressers, and products bought online carry serious risks. Serious cases of poisoning have been reported abroad with counterfeit products or products of unknown origin. For a detailed checklist on choosing a doctor and a clinic, see the related article in our safety section.

Preparing for the procedure

• Discuss your expectations openly during the examination; say what you want to change and what you do not want to change.
• Share your medical history, the medicines you use and any previous aesthetic procedures.
• If your doctor has advised it, plan with them whether to pause certain products that may increase the risk of bruising in the days before the procedure.
• Having no make-up on your face on the day of the procedure makes things easier.
• If you have an important event, consider scheduling the procedure at least two weeks before, so the full effect can show and any bruising can fade.
• Take time to read the informed consent form and to ask your questions.

The day of the procedure, step by step

1. Your doctor listens to your concern and assesses your face at rest and while making expressions.
2. Risks, the expected result and alternatives are discussed; the consent form is signed.
3. If needed, photographs are taken for comparison (for medical records only).
4. The skin is cleaned and disinfected; the injection points are marked.
5. Small amounts are injected into the selected muscles with a very fine needle. The pricking sensation is usually brief.
6. If there is bleeding or mild swelling, gentle pressure is applied for a short time.
7. Aftercare is explained and, if needed, a follow-up appointment is set.

After the procedure: the first 24 hours and the first week

Most people can return to their daily activities immediately after the procedure. Still, a few simple precautions are recommended in the first hours. The details may vary depending on the doctor and the treatment area; the instructions your doctor gives you take priority.

• Do not rub, massage or press on the treated area.
• Avoid intense exercise for the first few hours.
• Avoid anything that presses on the area (such as a tight band or a helmet) and lying face down for as long as your doctor recommends.
• If you need make-up, apply it gently.
• In the first days, follow your doctor’s advice about saunas, Turkish baths and very hot environments.

Expected and usually temporary side effects

Side effects are mostly mild and temporary. The most common ones are:

• Redness, mild swelling or tenderness at the injection points
• Small bruises (usually fade within a few days to a week)
• A mild headache in the first days
• Temporary drooping of the eyelid or eyebrow due to an effect on neighbouring muscles
• More stiffness in facial expression than expected, or slight asymmetry between the two sides

Unwanted effects such as a drooping eyelid or eyebrow are also temporary, but they may last several weeks. If this happens, see your doctor rather than trying to do something yourself.

These symptoms are rare; however, it has been reported that they can appear even hours or weeks after the procedure. If any other change worries you, call the doctor who performed the treatment straight away. Tell the healthcare facility you go to that you have had botulinum toxin treatment.

When will I see the result, and how long does it last?

The effect usually begins within a few days and becomes noticeable in about two weeks. So it is too early to judge the result in the first days.

In most people the effect lasts about 3–4 months; in some people it may be shorter or longer. The duration is influenced by the treated area, the dose, muscle strength and individual differences. Decide on the frequency of repeat treatments together with your doctor.

Realistic expectations: what botulinum toxin cannot do

• It does not give a permanent result; the effect wears off over time.
• It does not correct sagging skin or lost volume.
• It does not change sun-damage spots or skin texture.
• It may not completely erase deep lines that are visible even when the face is at rest.
• It does not give the same result in everyone; when a natural look is the goal, lines may soften rather than disappear completely.

Alternatives

Which method suits you depends on the type and cause of the lines. The table below is a general comparison; the choice should be made together with your doctor after an examination.