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Botox: The Ultimate Guide

Mr Debashis Ghosh

NHS Consultant
GMC Number: 4657664

Medically reviewed by a licensed NHS consultant
Last updated: 15/08/2019

Botox: The Ultimate Guide

 Table of Contents
What is Botox?
Facial Botox
-Why do people get Botox? 
Functional reasons for Botox
Am I a candidate for Botox treatments?
When should I not have Botox?
Pre-treatment Tips:
Botox Procedure
Botox Recovery
Before and After Photographs
Botox Results
The different types of Botox
Botox VS dermal fillers
How much does Botox cost?
Finding a practitioner
In Summary:
Frequently asked questions

What is Botox?

Botox injections are now one of the most popular cosmetic treatments in the world, accounting for 39% of non-surgical procedures carried out in the UK.

Botox is the short name for botulinum toxin, a group of molecules created by the bacteria clostridium botulinum.

In large amounts, this toxin can be extremely dangerous, causing muscle paralysis. However, by diluting the toxin, Botox has become a popular and safe procedure. Botox injections are now diluted with a mixture of botulinum toxin type A, human albumin and sodium chloride.

These small, diluted amounts of Botox can be directly injected into muscles, causing controlled relaxation.
This has been a popular cosmetic procedure to treat wrinkles and facial creases, by relaxing the muscle tension in the skin. Additionally, Botox has been successful in treating medical conditions. Botox can help treat issues such as neck spasms, excessive sweating and lazy eye by blocking the action of some of the nerves.

Facial Botox

Botox injected into the face is the most common procedure.

Botox is usually injected near the eyes, between the brows (glabella) and the forehead. These areas are subject to many muscles’ movements due to facial expressions which can create a tired and haggard appearance. Botox is used to reverse this look. The lower area of the face can also be treated (such as the jaw, around the mouth and chin). However, these treatments are less common and require a more skilled practitioner.

Why do people get Botox?

Botox is cosmetically used to reduce wrinkles and relax lines in the face.  This can help you maintain a youthful complexion.

However, Botox is injected for many other cosmetic reasons. Such as…

1.To manage acne. Botox can be injected into the problem areas reducing the amount of oil produced under the skin, and consequently reducing breakouts.

2.Get a temporary face-lift. Botox can shape the jaw and nose, giving appearance of a facelift.

3.Mimic a nose job. Botox can lift the nose by relaxing the muscles that pull the nose down, giving the impression of a rhinoplasty.

4.Narrow your chin and jawline. With age, your jawline can become wider, particularly if you grind your teeth. Botox can be injected into the area to reduce the muscle, narrowing the jawline.

5.Tighten the jawline. A little Botox can be used to tighten the muscles, giving the jawline a more defined appearance.

6.Lift your lips. Injecting Botox along the upper lip border can cause the top lip to roll out, so it appears plumper.

7.Remove Dimples - the quickest and simplest treatment available to correct the appearance of dimples.

Functional reasons for Botox

Botox injections can also be used to treat medical conditions. Such as…

1.Cervical dystonia. This is when neck muscle contracts/spasms involuntarily. Injecting Botox can block the nerves responsible for the muscle spasms.

2.Lazy eye. Botox can fix the imbalance in muscles responsible for positioning the eye.

3. Muscle contractions. Botox can be used to relax muscles for some neurological conditions, for example, cerebral palsy.

4.Chronic migraine. The exact way that Botox can relieve migraines is unclear, but it is believed Botox might relax the muscles around the head and thereby reduce blood pressure within the brain. Or Botox might reduce the nerves’ ability to send pain signals during a migraine.

5. Bladder dysfunction. Reduces the frequency of time needed to urinate.

6.Eye twitching.Botox injections can relieve the muscles responsible for causing twitches.

7.Excessive sweating (Hyperhidrosis)- Hyperhidrosis affects about 1 % of the population, usually the armpits or feet. Injecting Botox to these areas, blocks the nerves responsible for over activating your sweat glands.

Am I a candidate for Botox treatments?

If you're thinking about having Botox injections, be clear about what you want to achieve. It is important to understand theadvantages and disadvantages of cosmetic surgeryand be realistic about the results. Patients should realise that Botox does not actually erase lines but instead relaxes them.

Botox is given to people from a wide range of ages (around 18-65 years). The best candidates for cosmetic Botox treatments are usually healthy men and women who are concerned about facial lines and wrinkles and are eager to gain a more rested and/or happier appearance.

When should I not have Botox?

Botox injections are not recommended if:

• You have a skin infection
• Are pregnant or breastfeeding
• Are under the age of 18 years
• Have previously reacted to the Botulinum toxin A
• To treat Ptosis (drooping eyelids)

It should be used cautiously for:

• People at risk of bleeding, including people with blood clotting disorders, or who are taking medications that can thin the blood
• People with extreme weakness or wasting in muscles e.g. patients with a history of Strokes.
• People with breathing problems
• Very thick facial skin
• Deep facial scars

Speak to your doctors to discuss if Botox is right for you.

Pre-treatment Tips:

1. Stop taking medication containing fatty acids around 3-7 days before treatment. such as Aspirin and Cod Liver Oil, as these medications can increase bruising and/or bleeding.

2. Avoid consuming high levels of salt and sugar, refined carbohydrates and very spicy foods, 24 to 48 hours before and after your treatment. Alcohol and smoking should also be avoided. These factors can increase your chance of bruising and swelling.

3. It is recommended to stop taking Retin-A (often used to treat acne) 2-3 days before treatment to avoid any increased redness and irritation.

Consult with your doctor before stopping any prescribed medication and to discuss activities/exercises that may not be recommended.

Botox Procedure

Botox injections are usually an in-office, non-surgical procedure, with many patients scheduling the treatments in lunch breaks.

The procedure only takes around 10 minutes.

The patient is seated/laid in a raised position. The areas being treated are cleaned with a non-alcohol cleanser, such as Hibiclens or Betadine. Some doctors will also numb the areas using anaesthetic (such as EMLA cream) or other numbing agents.

The Botox is then injected into the desired areas using very fine needles. Several injections are injected into the desired area. For example, it is recommended to inject 20 units of Botox for the forehead and between the eyes individually (4 units of Botox in one syringe, injected 5 times). However, some patients (especially first-time patients) may receive a lower dose.

It is common for pressure to be applied after the injection to control bleeding and bruising after the injection. There is usually very little discomfort during the procedure.

Botox Recovery

After the injections, patients are usually asked to sit upright, or at least semi upright for a few minutes. This is to ensure that the patient is feeling well enough to leave. 

Botox requires little recovery time, taking approximately 48 hours to fully recover.

Top tips for a speedy Botox recovery:

1. Move and contract the areas treated, such as frowning and lifting the eyebrows to allow the Botox to reach all the desired muscles.

2. Do not touch or rub the treated area to prevent the treatment from moving

3. Avoid strenuous exercise, sunbathing (including using sunbeds), the sauna or other activities that can make you hot for at least 2 days. 

4. Avoid alcohol-based products on the treated areas for 48 hours.

5. Avoid alcohol and smoking until healed.

6. Apply anti-inflammatory medication to reduce any bruising. Bruises should heal within one to two weeks post treatment.

7. Take pain relief such as Paracetamol to reduce any pain/discomfort.

8. Wait around 3 months before having Botox again. Botox can stop working if you have it too often.

9. Avoid lying down for at least 4 hours after Botox.

10. Avoid fatty acids for at least 3 days to 1 week after treatment, to prevent increased bleeding and bruising.

11. Avoid caffeine, highly salty, spicy and/or sugary foods for 24-48 hours after your treatment- to prevent swelling or irritation.

12. Avoid the use of Retin-A or similar products for 2 days after treatment to avoid increased irritation or redness.

13. It is recommended not to wear makeup for around 24 hours. If you do need to wear makeup, try to use good quality mineral makeup to avoid any skin breakouts.

14. Do not wear headbands or hats immediately after treatment.

Before and After Photographs

Here are some examples of what facial Botox can look like. 

before and after Botox

before and after Botox

Botox Results

The results of Botox are not noticeable immediately. Results start to appear around 2-3 days post-treatment, and by around 2 to 3 weeks you should be able to see the full effects. Be patient.

Take a comparison photo before and after the procedure. It’s a useful way of seeing the results. Often patients do not recall how they looked before the procedure and are amazed at the difference.

Some patients may require additional work, such as dermal filler, to fill in the wrinkles that are now relaxed. Or additionally more Botox sessions (2-3) may be required to create the best results (especially when treating deep wrinkles).

Results will last for around 3-6 months (this will vary within individuals).

Although you can help increase how long your results last by avoiding smoking, consuming alcohol and/ or long exposure to sun or heat. These activities can cause collagen to break down faster, reversing the effects of Botox.

What are the risks of Botox?

Botox is generally a safe procedure, and serious side effects rarely occur.

Possible side effects of Botox include: 

• Pain/discomfort

• Bruising

• Headache and flu-like symptoms are common especially in the first 24 hours.

• Eye dryness or watering (for facial injections)

• A frozen look – if too much Botox is injected you may not be able to move your muscles in your face (facial injection).

• Temporary weakness and droopiness in your face (facial injections)

• Nausea: Around 45% of patients experience some nausea. This is normal as Botox is a foreign material and you body may not welcome the toxin at first.     

In rare circumstances Botox can cause serious side effects, such as:

• Muscle weakness

• Blurred or double vision

• Difficulty breathing

• Loss of bladder control

Serious side effects are very rare and if you experience any of these symptoms contact your doctor immediately.

The different types of Botox

Botox was the first drug to use botulinum toxin A. Other products now include Dysport, Xeomin and Myobloc.

Each product is slightly different, especially when it comes to the dosage required.

Advantages and Disadvantages of Each Type of Botox

Botox 

The advantages of Botox are:

Botox used for functional reasons can help patients solve long to short term medical problems.

Disadvantages

There are some disadvantages of Botox, including:

• Non-permanent results. Many patients need treatment every 3-6 months to maintain their results.
• Some patients do not receive the results they desire. Or require more than one treatment to achieve optimum results. 
• Botox can’t treat all signs of aging (e.g. saggy eyelids).
• It can be more expensive than other injections

Dysport

Dysport is mainly used to treat wrinkles on the forehead and frown lines. Dysport is diluted using different substances to Botox, meaning different units need to be administered to achieve similar results.

Advantages 

• Dysport is cheaper than Botox
• Quicker results than Botox
• Dysport affects only the targeted muscles, so the untreated facial muscles can still contract normally.

Disadvantages

• Botox typically lasts longer than Dysport. However, no head-to-head trials have been conducted.
• Dysport can only treat patients with severe-moderate cases of wrinkles between the eyebrows. Moderate cases are discouraged from using Dysport.
• More units are required. It takes a minimum of two times more units of Dysport to get the same effect as Botox

Xeomin

Xeomin is approved to treat facial wrinkles such as around the mouth, between the eyebrows and on the forehead. It is also used to treat adults with cervical dystonia and blepharospasm.

Unlike Botox, Xeomin is not mixed with any other substances it is a “naked” neurotoxin and only contains the botulinum toxin A.

Advantages

• Often lasts longer than Botox
• Unlike others, Xeomin contains no additives and does not need to be refrigerated.
• Patients less likely to become resistant to Xeomin injections because of its purity.
• Cheaper than Botox 

Disadvantages

• Xeomin can cause painful side effects when used to treat cervical dystonia and blepharospasm such as muscle weakening and headaches.

• Longer recovery- Xeomin takes up to 4 days to see initial results

Myobloc

Used mainly for cervical dystonia in adults. Also used to prevent excessive sweating.

Advantages

• Unlike other treatments, Myobloc contains botulinum toxin type B. Some have suggested that Myobloc may help people who've become immune to Botox and Dysport.

• Quicker results

Disadvantages

• Rarely used cosmetically, limited to functional reasons

Botox VS dermal fillers

Dermal fillers are the second most common cosmetic procedure, and account for 32% of non-surgical procedures in the UK.

Dermal fillers are used to "fill in" or plump areas that need extra volume for a smoother look such as facial wrinkles, dimples etc.

Dermal fillers are injected, with four types of dermal fillers being medically approved. These include, calcium hydroxylapatite, hyaluronic acid, poly-L-lactic acid and polymethylmethacrylate beads.

Botox and fillers are often used together, to create the most successful results. Both contain different substances making them safe to combine.

Advantages of Fillers

• Longer lasting results than Botox – (polymethylmethacrylate dermal filler is permanent).
• Can create a smooth complexion, filling out problem areas
• Can reduce the appearance of under-eye bags and dark circles (Botox cannot)
• Botox relaxes wrinkles. Fillers can erase them altogether
• Can erase dimples and scars

Disadvantages of Fillers

• Fillers are usually more expensive (£600-£1600 estimated costs per injection).
• Filler carry more side effects

How much does Botox cost?

costs

While available on the NHS for certain conditions, Botox is not funded for purely cosmetic reasons.

There may be a lot of variation in the cost of Botox. The cost depends on the number of injections required, the areas that are to be injected and the product used. It will also depend on the experience of the injector, the clinic facilities and location.

The NHS website estimates each Botox session costs £150-£350 per session.

Botox for facial wrinkles is usually the cheapest form of Botox, in comparison to Botox for the body.  The typical price for both armpits to be injected is around £400. This tends to be the most expensive part of the body to be treated.

Warning: Most clinics will add about 2-3ml of other liquid to the Botulinum toxin (that gives you the desired effect).  However, some add more liquid to make patients believe they are getting more Botox than they actually are. Clinics that charge units by a certain amount of pounds, are often diluting the Botox, to dramatically increase the price you are paying.

Finding a practitioner

Getting a well-trained experienced surgeon will ensure you get the results you desire. Your surgeon should have years of experience and up to date training in Botox.

facial consultation

Who can administer Botox?

Botox should be done by a medical practitioner who is registered (e.g. with the British Association of Aesthetic Plastic Surgeons), to show they meet set standards in training, skill and insurance. A practitioner must have a minimum of a Level 6 and level 7 qualification to legally administer Botox. Botulinum toxin can only be prescribed after a face-to-face meeting (not skype) with the trained practitioner (who will administer the treatment).

Avoid practitioners who have no training or have only completed a short training course.

Make sure you have a consultation with your practitioner, so you can ask them questions about:

• The amount of training, experience and qualifications the practitioner has.
• The name of the product they will use, if it’s licensed, and where/how they will source the product from.
• The risks and side effects
• What will happen if things go wrong
• Has something ever gone wrong?

Ask to see their portfolio of pictures to ensure that you like their work.

Trust your gut feeling and make sure you are comfortable with your surgeon/practitioner.

Read more about Choosing a Plastic Surgeon right for you.

In Summary:

Millions of Botox procedures are performed each year, and they have a good track record of safety.

Botox is a procedure approved and medicated by on the NHS. It is a very safe procedure when performed by experienced practitioners. A study in JAMA Dermatology found that side effects of Botox has only occurred in less than 1 percent of patients, with the majority experiencing only minor side effects.

Although Botox is one of the most common cosmetic procedures, it is not for everyone. Talk to your doctor – they may recommend this procedure or could advise that a different approach may be more suitable for you. 

Frequently asked questions

1. Is Botox bad for your health?

Botox does contain a toxin, which can cause paralysis and food poisoning. However, injected with a fully trained practitioner, Botox is a safe procedure. Trained professional will only inject a small amount of Botox making it a safe procedure with no long or short-term harm.

2. Can you smile with Botox?

Yes, you should be able to smile after Botox if a professional practitioner has administered Botox correctly. Incorrectly administering Botox (such as administering too much) can lead patients to look ‘frozen’. However ultimately Botox done by trained practitioner should allow patients to smile, leaving them with a fresher and younger appearance.

3. What is baby Botox?

Baby Botox is the term used when a smaller dose of Botox is injected. This is to treat moderate to fine wrinkles.
Baby Botox doesn’t last as long as regular Botox (approximately two months).

4. Does Botox work quicker the second time?

The recovery period for Botox remains the same and it will take the same time to see your full results.  

5. Does Botox work better the more you get it?

Botox can appear to work better the more you get it, as the muscles weaken slowing the movement.

6. Can you get Botox combined with other cosmetic treatments?

Botox can be combined with some cosmetic treatments such as filler however other treatments are not to be combined. It is recommended to wait at least 2 weeks after Botox to receive procedures such as laser treatments, ultrasound and facials.

7. How long do Botox side effects last?

Side effects usually resolve within a few days. With a full recovery often only taking 48 hours. However, this can vary depending on the individual.

8. What does Botox feel like when it starts to work?

When Botox starts to work you may experience a heavy or tight feeling in the treated areas. Your expression may also be slightly limited or stiff whilst the Botox settles into the areas. Once healed you will not feel anything in your face.

Mr Debashis Ghosh

Mr Debashis Ghosh, renowned breast and oncoplastic surgeon and consultant at The Royal Free NHS, UCL London, The Wellington Hospital & Harley Street - MS, FRCS(Edin), FRCS, FEBS(Breast), FEBS(Surgical Oncology). Over 25 years of expertise in breast augmentation, breast cancer treatments and reconstruction. In the forefront of clinical trials, research and has several publications in Kirk's Operative Surgery on breast surgery.

Royal Free London Consultant Profile:https://www.royalfree.nhs.uk/services/staff-a-z/mr-debashis-ghosh/

NHS Consultant Profile:https://www.nhs.uk/profiles/consultant/4657664

GMC Number:4657664