What everyone still gets wrong about Botox, according to experts

Kaitlin Reilly
Someone wearing medical gloves holds a needle to a woman's forehead.
Everything you need to know about Botox. (Getty Creative) (Prostock-Studio via Getty Images)

Botox is a neurotoxin that changed the game of aesthetic medicine — and became a cultural phenomenon in the process. It’s now more popular than ever, with some people as young as in their early 20s lining up at dermatologists’ offices and medical spas to prevent or reduce the appearance of wrinkles, all for between $10 and $25 per unit. (A syringe holds three to five units.)

Here’s the science behind the syringe: Botox blocks the signals from nerves that make muscles contract. By interrupting these signals, Botox temporarily relaxes targeted muscles, which can reduce the appearance of wrinkles caused by repetitive movements when injected in, say, the forehead.

Botox isn’t the novelty it was when it first was approved by the FDA in 1989. In fact, between 2000 and 2020, Botox use went up by 380% — and people on social media aren’t shy about discussing all the latest trends when it comes to this aesthetic intervention.

While more people are using Botox to smooth out fine lines and wrinkles (as well as for other purposes, including reducing sweat, easing migraines and even relaxing their trapezius muscles), not everyone is as familiar with how it works and what it can — and can’t — do. Here’s what experts want you to know.

Nousha Salimi, registered nurse and facial rejuvenation artist based in L.A., tells Yahoo Life that she thinks this is the “biggest misconception” when it comes to people who haven’t tried Botox — that it will make your face look very different from when you went in. But Botox isn’t a surgical procedure, and while it can relax the muscles in your face, it’s not meant to give you a dramatically different look the way a procedure like a facelift, rhinoplasty or cheek implants might.

Dermatologist Dr. David Kim at Idriss Dermatology in New York City agrees, telling Yahoo Life that when “done correctly, Botox shouldn’t change the way you look, but it should soften the deep wrinkles and fine lines to make you look more rested.” Popular spots to get Botox include the “crow’s-feet” lines on the outside corners of your eyes, between the eyebrows (where “11 lines” can form), and the forehead.

Botox also has limitations, Kim notes, as it can’t help with skin laxity (when the skin loses its firmness and tightness) or collagen production (a lack of collagen can lead to sagging skin when it decreases over time). “If you want to lift the jowls or smile lines, Botox isn’t the right treatment,” he says.

That being said, there are times when an injector (the person injecting you with Botox) can give you a look you don’t necessarily want, says Salimi. She explains that people who are wary about Botox changing their face for the worse often see people who have bad results from their injector, such as “Spock eyebrows” — which refers to a specific look where the eyebrows are raised dramatically at the outer corners, resembling those of the Star Trek character — or “hooding,” which is the drooping of the upper eyelids. This is a possibility with Botox, she says. However, all of this can be avoided by picking an experienced provider.

“It’s so important to pick a provider who is not just doing the standardized dosing to each person — each person needs a customized amount of Botox,” Salimi explains. “That’s how you avoid ‘changing’ your face. If you do Botox super light, nothing is going to change on your face besides you looking like you’ve used a really good skin care cream. You’re just softening the lines, and you can still have movement.”

Fake Botox exists — and it’s dangerous

Recently, there have been several reported cases of people being injected with counterfeit Botox and getting sick from it. Six of the people who received these fake Botox injections were treated for botulism, which is what happens when botulinum toxin gets into the bloodstream. This potentially deadly disease includes muscle weakness, difficulty breathing, dry mouth, blurred vision, fatigue and gastrointestinal issues.

“Real Botox has been approved by the FDA, and there have been rigorous clinical trials over the years,” dermatologist Dr. Elizabeth Bahar Houshmand tells Yahoo Life. “We don’t know what is in the ‘fake Botox,’ however.”

While it’s technically possible for Botox to cause botulism, it is very rare since the toxin is highly purified and diluted. The forms of purified botulinum toxin that are used by licensed health care providers meet medical control standards. However, it’s important for consumers to ensure they are going to a reputable injector.

“Know who is injecting you,” says Houshmand, who recommends going to a board-certified dermatologist. “If the price is too good to be true, it probably is. There’s a cost for the raw materials. If it’s significantly out of line, that’s not good. This is not the time to use a Groupon.”

It’s also not a time, she says, to go to “Botox parties” that are not done in a medical setting, which can increase the risks of botulism.

Botox smooths lines because it relaxes the muscles and stops them from moving dramatically. However, deeper-set lines may still be present, even if you are using Botox.

“I think of Botox like opening up a tablecloth that has been folded in your closet,” Dr. Joshua Zeichner, an associate professor of dermatology at Mount Sinai Hospital in New York City, tells Yahoo Life. “If it hasn’t been folded for long, then the creases will improve on their own. However, if the tablecloth has been tightly folded for many years, then opening it up may not be enough to get rid of the creases.”

Depending on the location of those lines, you may be able to find better results with other treatments like injectable filler, such as ones made with hyaluronic acid.

Some experts recommend “preventative Botox” in order to avoid deeper-set lines. This refers to “the use of small doses of the product before lines start to develop, or at the first sign of a wrinkle,” says Zeichner. He recommends the practice, which can start as early as in your 20s, noting, “The earlier you treat facial expression lines, the easier it is to get rid of them.” He says that “once lines become deeply etched into the skin, even with regular Botox treatment, it may be impossible to completely eliminate them.”

Houshmand says that preventative Botox is a decent option for treating the skin on younger patients, especially those who see a strong family history of wrinkles. Many patients, she says, will bring in photos of their mothers to show what lines they wish to avoid. While Houshmand says “using a very small dosage very precisely” can be helpful, she first recommends that her patients begin with a solid skin care routine.

However, not everyone is convinced this practice is worth the cost, since in order to prevent lines from forming at all, you need to consistently keep up with Botox treatment for years — which can be pricey. Kim doesn’t recommend preventative Botox, stating that from his perspective, “you should only get Botox if you have wrinkles with movement.”

Not everyone gets Botox purely for aesthetic reasons. “I do a lot of Botox for hyperhidrosis, which is excessive sweating,” says Houshmand. “I can put Botox in the underarms, palms and soles of the feet. People love it.”

Another popular use of Botox, says Houshmand, is to treat migraines. Exactly how Botox works to treat migraines is not entirely understood, but it appears to work by blocking the release of certain chemicals involved in transmitting pain signals. Treatments can help reduce the frequency and severity of migraine headaches.

Houshmand also treats patients who want “Barbie Botox,” which is Botox injected into trapezius muscles in the back. The procedure went viral online for its ability to elongate and soften the shoulders. However, Houshmand says she primarily uses it on her patients who have a “knot in their back” from “being crunched over their laptop” and need a way to relax the tension in the upper back and neck area.

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