After Botulinum Toxin: Lying Down, Exercise, Massage, Alcohol

The short answer: which rules rest on research, and which on habit?

Botulinum toxin temporarily relaxes the muscle it is injected into by binding to the nerve endings of that muscle. Most of the aftercare rules arise from a single concern: that the medicine might spread beyond the target muscle before it binds and also affect neighbouring muscles. Unwanted effects such as a drooping eyelid are associated with this spread. For details of these effects, see our article “Side Effects after Botulinum Toxin”.

However, aftercare recommendations have been shaped over the years by theoretical considerations and the experience of practitioners. Researchers who have examined the subject state that the common recommendations are largely based on observation and habit and that there are no controlled clinical studies testing them. The table below summarises how much evidence supports each recommendation today.

This table does not mean that 'if there is no evidence, the rule is unnecessary'. A recommendation not having been tested does not show that it does not work; it only shows that we do not know how necessary it is. So if your physician has given you more cautious instructions, it is wisest to follow them.

Is this normal? What to do depending on the symptoms

If you have one of the emergency symptoms in the table, call 112 (or your local emergency number). These symptoms are very rare at aesthetic doses; however, they may be associated with the medicine spreading to distant muscles and can start hours or even weeks after the treatment. This picture is described in detail in our article “Side Effects after Botulinum Toxin”.

Lying down and bending over after botulinum toxin: where does the 'four-hour rule' come from?

The most widely known rule is to keep your head upright, not lie down and not bend forward for about four hours after the treatment. For example, a patient leaflet from a public health body in the United Kingdom (Scotland) includes the recommendation not to lie down or bend forward for four hours. The idea behind this rule is that gravity, or blood flow in a head-down position, might carry the medicine towards neighbouring muscles. Although this idea seems logical, it has not been tested in humans in a controlled study.

The data we have are limited:

• In a retrospective study of about 5,000 people from six centres in Italy, people were only observed for the first 10 minutes after forehead and frown-line treatment and were given no further restrictions. Among the 4,000 people who came to the follow-up two weeks later, no upper eyelid drooping was seen, and the rate of side effects was about 6 per cent (mostly mild bruising and temporary headache). The authors state clearly that the result is not strong because there was no control group and no statistical comparison was made.
• In a computer modelling study, bending over, light exercise, superficial rubbing and mild heat in the first four hours were calculated to change the area over which the medicine spreads by only fractions of a millimetre. This is a simulation; it has not been confirmed in real patients, and some of the authors have financial relationships with drug manufacturers.
• An old case report describes no problem in a person who lay down for an afternoon nap shortly after the treatment. Single cases do not allow generalisation.

The practical conclusion is this: in the first hours, deliberately not lying face down for long and not putting pressure on the treated area is a reasonable precaution. However, bending over to tie your shoes or lying down briefly is not, according to current knowledge, expected to spoil the result. For sleeping face down at night and for items that press on the area, such as headbands or helmets, follow the period your physician gives; this topic is also covered in our article “Botulinum Toxin”.

Massage and rubbing after botulinum toxin

This is the recommendation on which the sources agree most. The American Academy of Dermatology (AAD) explicitly recommends not rubbing or massaging the treated areas. Rubbing and pressing are thought to be able to push the medicine into the surrounding tissue before it binds to the muscle. In the model mentioned above, the effect of superficial rubbing was calculated to be small; however, this reflects only light rubbing, not vigorous massage or prolonged pressure on the area.

So on the day of the treatment, pat your face dry with a towel without pressing, and do not rub when applying make-up or cream. Ask your physician on which day you can return to facial massage devices, face yoga or skin care treatments that involve massage. If a side effect develops, for example if an eyelid droops, massaging the area is not the solution; this is explained separately in our side effects article.

Exercise after botulinum toxin: when can I go back to it?

The periods given for exercise after the treatment vary from source to source. The AAD recommends waiting two hours for strenuous exercise that raises the heart rate and for heavy lifting; in the hospital leaflet mentioned above, this period is six hours. This difference shows that the period rests on expert judgement rather than on research. Strenuous exercise is thought to be able to carry the medicine away from the treated area by increasing blood flow; no clinical study has been found that tests exercise straight after the treatment.

A study that is often misinterpreted also needs explaining: in a study of 60 women in Brazil, the effect was observed to last for a shorter time in people who regularly did very intense physical activity. This study is not about exercise on the day of the treatment; it compares people’s general activity level, the groups were not formed by random allocation and the sample is small. In other words, it does not support the conclusion 'if I exercise after the treatment, the medicine will be wasted'; it is, however, a preliminary sign that the effect may be shorter in people who do very intense exercise.

The reasonable approach is to postpone intense training on the day of the treatment and to go back to your exercise after the period your physician gives. Light everyday activity such as walking usually needs no restriction; if you are unsure, ask your physician.

Facial expression exercises: should you raise your brows, or not move them at all?

Two opposing recommendations circulate on this subject: some practitioners recommend making facial expressions in the first hours so that the medicine binds to the muscle faster, while others recommend not moving the face at all. This is the question that has been researched most directly.

In a small, randomised crossover study with 22 women in the USA (each participant did the exercises after one treatment and not after the next), intermittent brow-raising and frowning exercises were done for four hours after forehead and frown-line treatment. When the exercises were done, the improvement in the wrinkles was noticed about a day earlier, but at two weeks there was no difference between the two conditions and the duration of the effect did not change. A consensus statement by experts from Australia and New Zealand states that neither exercising the muscles nor keeping them completely still is necessary.

In conclusion, facial expression exercises are not compulsory; doing them does not appear to spoil the result and may only make the effect start slightly earlier. It is enough to use your face naturally. If your physician has given you specific instructions, follow them.

Heat, saunas, Turkish baths and sun

Avoiding saunas, Turkish baths, hot baths and long periods in the sun on the first day is a common recommendation. The main reasoning behind it is that heat widens the blood vessels and can increase redness, swelling and bruising at the needle points. No clinical study has been found showing that heat reduces the effect of the medicine or markedly increases its spread; in the computer model, the effect of mild heat on spread was calculated to be small. For general recommendations on this subject, see our article “Aftercare Following Medical Aesthetic Procedures”.

Alcohol after botulinum toxin

No study has been found showing that alcohol reduces the effect of botulinum toxin or increases its spread. The main reasoning behind the recommendation 'do not drink alcohol in the first hours' seen in hospital leaflets is bruising: in some people, alcohol can increase bruising and swelling at the needle points. For medicines and habits that increase the risk of bruising, see our article “Bruising and Swelling”. Do not stop a blood thinner or another medicine you take regularly on your own; that decision is made by your physician.

Facials, skin procedures and other treatments in the same period

• Facial cleansing, skin care devices and procedures that act on the skin surface: the expert consensus statement recommends postponing such procedures for one day after botulinum toxin. Ask your physician about treatments that press on the area or involve massage.
• If filler was done in the same session: the aftercare rules for filler are usually longer and stricter; follow those rules. For details, see our article “Botulinum Toxin or Filler?”.
• Another botulinum toxin treatment: according to the US-approved product information, the effect of giving different botulinum toxin products at the same time or a few months apart is not known, and a treatment given before the previous effect has worn off can lead to excessive weakness. If you have had a treatment elsewhere in recent months, be sure to mention it.
• New medicines: the product information states that medicines such as muscle relaxants and some injectable antibiotics may increase the effect. If a new medicine is to be started, tell your physician that you have recently had botulinum toxin.

Air travel after botulinum toxin

Some hospital leaflets recommend avoiding long flights in the first 24 hours. No study has been found showing that cabin pressure changes the effect or spread of botulinum toxin; in the medical literature, there is only a single case report on this subject, describing no problem in a pilot who returned to work straight after the treatment. In other words, the flight restriction has no scientific basis.

Even so, there is a practical point to consider when planning a journey: unwanted effects are usually noticed in the first days and weeks, as the effect begins. Choosing a time when you can reach your physician and go for a check-up if needed is more important than the flight itself. Before an important event or a holiday, discuss the timing of the treatment with your physician.

Make-up, washing your hair and driving

According to the AAD, make-up can be applied straight after leaving the treatment room; it just should not be applied by pressing it onto or rubbing it into the area. Some leaflets, on the other hand, recommend waiting a few hours. Similarly, when washing your hair, doing so without rubbing your face and without bending forward for long is a sufficient precaution.

Driving is not restricted by the treatment itself. However, the US-approved product information recommends not driving or operating machinery and avoiding dangerous activities if loss of strength, muscle weakness, blurred vision, dizziness or a drooping eyelid develops hours or weeks after the treatment.

What should you do if you break a rule by mistake?

1. Do not panic. According to current knowledge, bending over briefly, a short nap or touching the area by mistake usually does not change the result.
2. Do not rub, massage or apply heat or cold to the area to 'fix' it.
3. Over the following days, watch in the mirror for any change in your eyelid, brow or smile.
4. If you notice a change or you do not feel reassured, call the physician who performed the treatment; tell them when and what you did.
5. If there is a new problem with swallowing, breathing, speaking or vision, call 112 without waiting.

Why do you hear different rules from different physicians?

Hearing different instructions does not mean that one is right and the other wrong. Because most rules have not been tested, each physician leaves a safety margin based on their own experience and the injection technique they use. The area treated, the dose and the product used can also affect the recommendations; for example, more cautious instructions may be given for sensitive areas such as around the eyes. The expert consensus statement advises that instructions be given in writing and that people having the treatment for the first time be offered a check-up after about two weeks. For what to ask when you go to a clinic, see our article “A 10-Point Safety Checklist for Choosing a Clinic and Physician for Medical Aesthetics”.

Limits of the evidence: a randomised controlled study directly testing behaviour rules after botulinum toxin exists only for facial expression exercises, and it is small (22 people). The information on lying down, bending over, heat and alcohol is based on a retrospective series without a control group, a computer model, case reports and expert opinion. So the phrases 'limited evidence' on this page do not mean that the rules are unnecessary, but that it is not known how necessary they are. This page is for general information and does not replace an examination; for your own situation, your physician’s instructions apply.