Wrinkles are lines in the skin from repeated muscular activity. Intermittent at first, they become permanent with time due to a combination of the repetitive creasing effect and loss of collagen and elastin in aged skin. Frowning, squinting and smiling produce three well-known patterns:

  • Glabellar – vertical and oblique ‘frown’ lines above the root of the nose, between the eyebrows
  • Forehead lines – horizontal lines produced by the frontalis muscle repeatedly lifting the brows. These lines appear around the 4th decade and are more pronounced in those with low brows and excess upper eyelid skin
  • Crow’s feet – the fine lines radiating outwards from the eyes forming in response to squinting and smiling.

Botulinum neurotoxin type A (BoNTA) is a potent inhibitor of muscular activity by blocking the chemical signals from nerve endings that stimulate facial muscles. Despite causing a temporary effect it seems to allow treated skin to recover. The lines soften and regular treatment may even cause them to disappear, unless particularly deep. Additionally, after the first few treatments patients often find that successive doses last a little longer.

Like other prescription-only medications BoNT-A comes in a variety of formulations. Because each has its own particular characteristics the name is less important than the injector’s familiarity with the product.

More questions about Botox?


There is much misinformation about BoNTA, most of it probably due to its rapid rise to prominence and the need for the press to have a target ‘villan’.

It is certainly a very strong toxin that produces a severe food poisoning in nature. Its use in cosmetic treatments, however, is both highly controlled and very dilute, hence the importance of allowing only experienced practitioners to administer it.

In fact, BoNT-A started as a medical treatment for squint and has been used for over 40 years. Many are unaware that it is routinely used in a host of other medical conditions including excessive sweating, bladder instability, migraine and many overactive muscle conditions. Finally, it is frequently used in children for severe muscular spasm and at much higher doses than cosmetic usage.

In more than 20 years’ use in aesthetic medicine there has not been a death attributed to BoNTA, but it is still important to remember that it is a prescription-only medicine so qualifications should always be checked.


Your first consultation will explore your aims and objectives. Due to its very good safety profile, there is little that can go amiss, but the following are important contraindications, meaning you should not have neurotoxin treatment if:

  • you are, or may be, pregnant
  • you have any hypersensitivity to any BoNTA preparation or its constituents
  • there is active infection around the injection site

Whilst not banned, neurotoxin injection should be undertaken with care if you have neuromuscular disorders such as myasthenia gravis, motor neuropathy and others.

In common with all areas of aesthetic surgery it is very important to establish whether you have a clear understanding of what can, and cannot, be achieved. Realistic expectations and comprehension of the risk-benefit balance are key to ultimate satisfaction in aesthetic medicine and surgery.

In the early days it was common for the muscles to be completely paralysed, giving rise to the ‘frozen look’ (aka Fro-tox). Recently, people have moved away from such an obvious look and prefer to retain some degree of natural movement (No-Tox).


In the vast majority, BoNT-A administration is associated with minimal pain, but occasional patients prefer topical local anaesthetic (LA) cream. Because this takes time to act, you should request this in advance and attend 45 minutes earlier than your appointed time. You must also wear no makeup on the day.

Firstly, you will be asked to move your facial muscles to allow assessment of your individual characteristics. The skin will then be cleansed and an extremely fine needle used to inject the neurotoxin. Whilst it does sting momentarily the sensation passes rapidly and pressure will be applied. The whole process normally takes 10 – 15 minutes and you may have some slightly reddened and swollen areas around the injection sites that will settle within the hour.


You should avoid massaging or rubbing the treated areas for 24 hours, however, active facial muscle movements (e.g., smiling and frowning) help toxin dispersal into the target muscles. Whilst you can return to normal daily activities immediately afterwards strenuous activities such as the gym should be avoided for 24 hours.

You may also wash your face as usual, but makeup should be avoided for the next 12 hours.

The tiny red bumps will settle quickly, but you should not assess the effects of the treatment for 10 – 14 days. At this time a ‘top-up’ may be offered if required.

Effects start to become apparent around 4 – 7   days and you should expect it to last a minimum of 3 months. If you have BoNTA on a regular basis you will become aware that the interval between treatments gradually increases.


There are very few serious side effects if you have had the correct procedure performed by an experienced practitioner. The downside of BoNTA’s impermanence is also of great benefit because any adverse effects that do occur will pass given time.

An occasional few experience post-injection headache, however, this has also been reported with placebo injections, responds well to paracetamol and settles rapidly.

The other notable complication is a consequence of diffusion. That is, a spread of neurotoxin’s effect beyond the target area; most often seen as eyelid droop, which is inconvenient, but passes relatively quickly.

Much is made of resistance, but this is incredibly rare and seems to occur more with medical, not aesthetic, neurotoxin where doses are higher. There is another toxin, type B that may be tried if type A does not work.