How Does Botox Treatment Work?

by , last modified on 4/17/21.

Please note that our office ONLY uses the brand-name BOTOX purchased directly from Allergan Corporation in the United States. We do not use generic, replacement, or alternative botulinum toxins nor do we purchase from a third party reseller.



In a nutshell, BOTOX is a neurotoxin that prevents muscles from contracting. There are several different types of BOTOX, but the only ones used clinically are types A and B. The name "BOTOX" is actually the product name for botulinum toxin type A made by Allergan Corporation and is the most common form used to treat patients. MyoBloc (botulinum toxin type B) is made by a different company and rarely used except in Europe.

In essence, BOTOX is used to treat any problem where inappropriate muscle contraction is the problem. In the cosmetic world, BOTOX is used to INDIRECTLY help with wrinkles. Wrinkles are caused by muscle contractions under the skin. Paralyze those muscles and the wrinkles can't happen. BOTOX is also used for medical reasons which insurance will pay for including drooling and other spastic disorders (eye ticks, torticollis, spasmodic dysphonia, globus, etc) as well as conditions most insurance will not pay for (migraine headaches, severe TMJ, excessive sweating, etc). The complete list of conditions we treat can be found here.

Billing for cosmetic use of botox can be found here.

No matter what reason one injects botox, it WILL wear off in about 2-6 months before the injection needs to be repeated. It usually takes about 3 days before the BOTOX effects appear.

Factors to Consider with BOTOX Treatment

Regardless of the problem, the amount of botox injected is unique to each patient. There is no such thing as standard injection amount to produce relief, though one may arbitrarily always use the same amount to start a new patient with.

For example, one patient may require 10 units to achieve a good effect. Another patient may require only 2 units to achieve the same desired effect. There is NO correlation with age, severity of problem, and gender. The only known pattern is that larger dosages are required the bigger the muscle being injected is.

For the new patient, this may be quite disconcerting as I can not predict what the right dose is for that person. SO, I always start on the low side to minimize potential side effects. There are 4 possible outcomes after a patient's very first injection:

  • Patient may experience absolutely no improvement because they required more botox than I injected.
    • Response: Repeat injection at a larger dose after 3-6 weeks.
  • Patient may experience some improvement which wears off quickly (<3 months)
    • Response: Repeat injection at a larger dose once effects wear off
  • Patient may experience a perfect outcome with good effects for 3-5 months.
    • Response: Repeat injection at same dose once effects wear off.
  • Patient may have severe side effects for a prolonged period of time.
    • Response: Once effects wear off, perform injection at a lower dose.

As one can see, it may take several injections over one year before the perfect dosage is determined for that particular patient.

Generally speaking, for small muscles, a response (and potential side effects) is expected within 5 days. For large muscles, a response is expected within one month.

How Many Injections (Dose) are Required?

The BOTOX effects only spread about 1 cm circumference from the point of injection. As such, if the wrinkles are localized to a single region that is about 1 cm in size (ie, Crow's Feet), only one injection is required. However, if the region to be treated is large (ie, forehead wrinkles), multiple injections every 1 cm need to be performed for adequate coverage.

The more injections performed, the more expensive it is going to be.

Another factor to consider is how large the muscle is. The bigger the muscle (ie, neck muscles), the larger the dose required in a single injection (2.5 - 5.0 units per injection). The smaller the muscle (ie, muscles for Crow's Feet), the smaller the dose required in a single injection (1.25 - 2.5 units per injection).

The larger the dose, the more expensive it is going to be.

Side Effects With BOTOX Treatment

There are potential side effects. Side effects experienced depends on the location where the injection is performed. If done on the face, complete paralysis of the injected muscle (facial paralysis, eyelid drooping, etc) may be an undesired outcome. When done in the voicebox for spasmodic dysphonia, difficulty swallowing or breathy voice are EXPECTED side effects. In fact, in this situation, if a patient does not experience any side effects, the BOTOX injection either didn't work, or the beneficial effects will last for only a very short time.

The good news even if a person experiences severe side effects (whether expected or unexpected) is that the BOTOX will wear off with time!!! It is not permanent... but it also cannot be resolved more quickly through medications or "antidote" if it happens. In other words, time is the only cure for side effects.

KEY POINT! In instances where side effects are expected (as in the case for botox injections for spasmodic dysphonia), generally speaking, a large dose of BOTOX injected will result in longer-lasting relief, BUT the side effects are usually more severe and longer-lasting as well (though always resolve). Smaller amounts of BOTOX injected minimizes the side effects, but relief would last for a shorter period of time requiring more injections per year. The goal is to find the right balance of side effect duration and desired outcome duration.

Very rarely, there have also been deaths as well as breathing problems reported after BOTOX injections in kids. The main factor contributing to this morbidity and mortality in these kids were the large amounts of BOTOX injected relative to their small body size; they were being treated for muscle spasms of the extremities. Remember, big muscles require more BOTOX.

You can read the Medication Guide for BOTOX here.

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Great! So What Is Treated with BOTOX?

At least in our office, the following conditions are treated:

  • BOTOX for facial wrinkles (Cost)
    • Crow's Feet
    • Forehead Wrinkles
    • Chin Pebbling
    • Wrinkles Between the Eyebrows
    • Lip Wrinkles
  • BOTOX for palatal myoclonus, oro-mandibular spasms, lingual dystonia, and other forms of head & neck dystonia
  • BOTOX for vocal cord dysfunction (ie paradoxical vocal cord motion)
  • BOTOX for spasmodic dysphonia (Watch Video)
  • BOTOX for drooling and Frey's syndrome
  • BOTOX for migraine headaches and headaches due to muscle spasms unresponsive to more traditional treatments (Cost)
  • BOTOX for TMJ unresponsive to more traditional treatments (Cost)
  • BOTOX for cricopharyngeal spasms
  • BOTOX for head, neck, and facial muscle spasms/dystonia
  • BOTOX for torticollis

Financial Assistance

Reimbursement assistance for those who are uninsured or otherwise unable to afford BOTOX can be found here ( Or call 1-800-44-BOTOX, option 6. The form you will be required to complete can be downloaded here.

BOTOX injections are performed by Dr. Chang after an initial patient evaluation for the following conditions.

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