Marilyn with necklace, 2018. Oil on Botox vials in resin on clear Perspex.
Artist Linton Meagher

Whether through cultural osmosis or whispers of mouth, everyone has heard of Botox®. You know, it’s that injection that is supposed to remove wrinkles and when it isn’t done right it can freeze your face into a single, shiny expression? Maybe you noticed your best friend’s mother was incapable of smiling at her wedding last fall (even though you know she was overjoyed). I have a friend who had the procedure done, and even afterwards, her only working knowledge of it was that it was “shark poison.” (False. Botox® is NOT shark poison.) My personal favorite representation of Botox® comes in the form of pictures like this one where a flawless, unwrinkled woman stares serenely into space, unphased by the large needle hovering in precarious proximity to the corner of her eye.

botox needleSerene As Fuq

Before we talk about Botox® and what it is (and isn’t), let’s clear the air about the name. Botox® is actually a brand name (like Kleenex® or Band-Aid®) that has become a catch-all for an entire product class. Just like Kleenex® is any soft tissue that you carry in your pocket during allergy season and Band-Aid® is any gauzy sticker you apply to a child’s knee, the term “Botox®” is used to describe any injection used to calm overactive muscles that cause facial wrinkles. “Botox®” is often used as a catch all for all neuromodulators (a fancy word for a substance that affects nerve cells), including not only Botox® (onabotulinum toxin A), but also Dysport® (abobotulinum toxin A) and Xeomin® (incobotulinum toxin A). While there are some differences between the products (a topic for another day), they all work in essentially the same way. To keep things neutral, I’ll use neuromodulator unless I am talking about a specific brand.

In this article, we’ll explore the cosmetic issues that neuromodulators treat, how they work, and the risks and benefits of these procedures.

What Do Botox and Other Neuromodulators Treat?

In aesthetic medicine, neuromodulators treat a very specific type of wrinkle: those that are caused by “hyperkinetic” muscles. That’s medical speak for muscles that move too much for their own good, you know, like when people tell you that you shouldn’t go on a trip alone and you raise your eyebrows and BLAM forehead lines. Or, you are thinking all day about how to double your company’s revenue and out of nowhere, hitchhiking on your best thinking face, are lines between your eyebrows.

Neuromodulators relax the muscles that cause wrinkles.

While neuromodulators are super helpful for chilling out hyperkinetic muscles (to either minimize or even prevent wrinkles), they cannot treat wrinkles caused by skin sagging with age or the fall-out from skimping on sunscreen. These wrinkles are not a result of hyperkinetic muscles, so freezing muscles can’t treat the problem.

Most often, neuromodulators are used to treat three specific types of wrinkles. The first are the glabellar lines between the eyebrows, sometimes referred to as the “angry 11” because it looks like you have an 11 between your eyebrows when you get pissed off:

glabellar wrinklesThe “Angry 11”—Not Just Quentin Tarantino’s Latest Film

They also to deactivate the muscles that cause crows’ feet—those lines that pop up on the sides of your eyes when you smile:

crows feetCaw, Caw, Crows’ Feet

Another type of wrinkle that can be targeted by Botox® and other neuromodulators is the forehead lines that appear during facial expressions of disbelief or worry. I know I have disbelief lines pretty much all the time these days.

forehead wrinklesWhat do you mean you don’t have soy milk!?

Neuromodulators are also used to treat other types of wrinkles caused by hyperkinetic muscles (one day soon I promise to write an article about on- and off-label use). Additionally, they can be used to treat some types of facial asymmetry or to address other types of facial imbalances. These are generally specialized cases.

Those Lines Are the Worst, But How Exactly Do Neuromodulators Get Rid of Them?

In order to explain the “how,” let’s talk about what neuromodulators actually ARE. Botox® (and all the others) refers to botulinum toxin.

Botulinum toxin is produced by the bacterium Clostridium botulinum, which causes botulism, a paralytic disease. You know how you aren’t supposed to eat canned food when the can looks puffy and full of air?

puffy canned food botulism and home canning

That’s because C. botulinum might be growing in the can and producing loads of toxin. This sounds bad, but it gets crazier. The toxin produced by C. botulinum is really, really good at paralyzing muscles. In fact, botulinum toxin is one of the most potent neurotoxins known to man… ever. Not like, this is the best day ever. But that it is some really strong s#*t that in high enough concentrations is deadly. If nothing else, you have now learned about food safety!

C. botulinumHi, I’m C. botulinum, and I Produce a Toxin That Causes Paralysis.
Wanna Be friends?
Wait… Where Are You Going?

Even though public health campaigns have been launched to keep people from EATING the toxin from C. botulinum, it can be purified, diluted, and locally injected to act on a hyperkinetic muscle, like the ones we discussed above, to reduce the movement of the muscle. If the muscle doesn’t move as much, neither does the skin above it, and the wrinkle doesn’t show on the skin.

Even though neurotoxins like botulinum toxin act specifically on nerve cells in the body, muscles, including the ones in your face that are responsible for crows’ feet and frown lines, don’t do anything without signals from nerves. Muscles are innervated (that is, they have nerves), and nerves are like telephone wires through which the muscles get the signal to contract, so you can walk, dance on a table, AND make that killer boss lady face that ensures everyone knows you are not f*^%ing around.

boss lady faceThat’s right—the word deadline has DEAD in it.

So neuromodulators essentially result in selective “paralysis” of the nerves. Neuromodulators have a long medical history. Before they were adopted as tools in aesthetic medicine, neuromodulators were used to treat lazy eye and muscle spasms in the eyelid. All of the available neuromodulators are also used to treat other issues caused by overactive nerves, like overactive bladder or facial spasms. More recently, the US Food and Drug Administration (FDA) approved Botox® for use in the treatment of headaches, muscle stiffness in the ankles and wrists, and overactive bladder symptoms.

There’s no question that neuromodulators can effectively and selectively block the activity of nerves. The medical applications of botulinum toxin are restricted to well-defined areas where specific amounts (or concentrations) of toxin can be injected to achieve predictable results (like my predictably youthful disbelief face).

Neuromodulators can be used not only to eliminate lines, but also to prevent them from occurring in the first place by stopping muscles from developing habitual facial expressions that pull on your skin. So, if you’re thinking “I don’t have persistent wrinkles,” it can still be something to consider to keep these lines from forming in the first place.

I saw an episode of Absolutely Fabulous where Patsy’s face gets frozen! How do I keep that from happening to me??

Absolutely Fabulous Patsy

This brings up a couple of different topics: one is 
communicating your aesthetic goals with your physician so everyone is clear up front about what you expect from the procedure. The other is the experience of the injector. Though some of the adverse events associated with neuromodulators are inherent to the nature of the chemical itself, an awful lot of them are directly linked to the skill (both technical and communicational) of the injector.

The reason treatment with neuromodulators works out so well is the toxin you find in a doctor’s office is purified and diluted. When it is injected into muscles in the right place and at the right concentration, it blocks the communication from nerves and essentially causes a temporary (between 4 and 6 months), localized paralysis. The dose of toxin is adjusted so that the muscles aren’t paralyzed, but instead relaxed. This is referred to as neuromodulation, and this is the approach that injectors use to avoid a “frozen” appearance.

Oh good. I’m going to do it next time I’m at the spa!

Woah there.

Neuromodulators are serious chemicals being injected into your face. The side effects of each neuromodulator are listed on the drug’s label, and they don’t just add stuff to that list for no reason. If you are really in the mood to know it all, the information can be found on the package insert documents cited at the end of this article. The list of side effects come from clinical trials and reports from physicians using these treatments in their practices. They do happen. This blog is all about information without judgment, but if ever there was a time I really struggle with it, it is here. I would recommend against practitioners who “do it on the side” and urge you to treat this part of your self-care with the same seriousness you would any other medical intervention.

Oh man, I looked at the long list of side effects and they are scary. Why does anyone ever do it?

The overall incidence of side effects is actually very low, about 1.85% (1), and there is agreement in the medical community that this number is far lower for skilled injectors. That said, the decision about acceptability of the risk-to-benefit ratio is highly personal, and one best discussed with a physician.

Most of the adverse events reported for each of the neuromodulators are pretty similar. Some of the most common side effects (you can find these on the Product Information Sheet – a document approved by the FDA, so there’s no marketing funny business involved) are pain at the injection site and related issues (like inflammation, tenderness, swelling, redness, bleeding/bruising, or in some cases infection), because you know, you’re getting a face injection. This is yet another fabulous opportunity to add that the skill of the injector has a lot to do with these types of outcomes. Other relatively common side effects include headache (between 5 and 10 in 100 patients, depending on the product and the clinical trial), or in the case of Dysport®, in particular nasopharyngitis (also known as a runny nose-style cold) that occurs in about 10 of 100 patients. Each of the above-listed adverse events is generally short-lived (2-4).

Less commonly, when neuromodulators are injected around the eyes, migration of the toxin can cause the eyelid to droop or cause muscle weakness in the face. This is relatively uncommon, but it can happen, and while most side effects resolve quickly, they can remain as long as the neuromodulator is active in the body (so about 4 months). In a broad sense, you want the right amount of toxin right where it belongs… and nowhere else. In cosmetic applications, there have been no reported cases of systemic spreading. This type of adverse event is restricted to other clinical applications that require much, much larger doses.

Now you know!

So, now you know! You have a firm grasp on what neuromodulators are and how they work, the type of wrinkles they treat, and some of the side effects (and how to look up ALL of them if you want to). Not to keep everyone awake at night, but we have just scratched the surface of what these agents are and what they can do. With this information in hand, you can walk into the doctor’s office knowing what you are talking about so that you can ask questions and discuss your treatment with confidence!



  1. Sundaram H, Signorini M, Liew S, et al. Global aesthetics consensus group: botulinum toxin type A—evidence-based review, emerging concepts, and consensus recommendations for aesthetic use, including updates on complications. Plast Reconstr Surg. 2016;137(3):518e–529e.
  2. Botox [prescribing information]. Irvine, CA: Allergan; October 2017.
  3. Dysport [prescribing information]. Fort Worth, TX: Galderma Laboratories, L.P.; June 2017.
  4. Xeomin [prescribing information]. Raleigh, NC: Merz Pharmaceuticals, LLC; July 2018.


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