A frozen face, an artificial expression, treatment reserved for older people, permanent results: few aesthetic medicine treatments remain surrounded by as many misconceptions as botulinum toxin.
These misconceptions often stem from confusion between the product itself and certain particularly noticeable results. Yet the principle of botulinum toxin is relatively simple: it temporarily reduces contraction of certain muscles responsible for expression lines. It does not create volume and is not intended to transform a face.
The result depends above all on the indication, the muscles selected, the doses used and how treatment is adapted to each patient's anatomy. This personalisation is precisely what now makes it possible to move away from the frozen faces once readily associated with botulinum toxin.
Does botulinum toxin necessarily freeze the face?
No. A botulinum toxin injection does not necessarily have to eliminate facial expressions.
This is probably the most common misconception. Botulinum toxin reduces activity in the injected muscles, but the reduction can be adjusted. It depends on the dose used, injection sites, muscle strength and desired result.
It is therefore possible to soften forehead lines, frown lines or crow's feet while retaining some movement. The face then continues to express surprise, smiles or displeasure, but the contractions responsible for wrinkles are less pronounced.
A very frozen face can reflect a substantial reduction in muscle activity, sometimes deliberately sought. However, it is not an inevitable consequence of treatment.
Modern aesthetic medicine instead tends towards more subtle results.
Does botulinum toxin add volume to the face?
No. Botulinum toxin is not a filler and does not add facial volume.
This confusion is common because hyaluronic acid and botulinum toxin are both injectable products. However, their mechanisms of action are completely different.
Hyaluronic acid is notably used to restore certain volumes, alter contours, correct certain disproportions or perform non-surgical lifting techniques. Botulinum toxin acts on muscles. It therefore does not fill a wrinkle, plump the lips or increase cheekbone volume.
Excess facial volume is therefore generally not associated with botulinum toxin.
Does botulinum toxin erase every wrinkle?
No. Botulinum toxin does not treat every wrinkle. It mainly acts on wrinkles caused by repeated facial muscle contractions.
It is notably used for forehead lines, frown lines between the eyebrows and crow's feet around the eyes. These wrinkles appear or deepen during facial expressions.
Over time, they may become visible even at rest. Botulinum toxin can then soften them by reducing muscle activity, but does not always eliminate them completely when the skin is already deeply marked.
Wrinkles associated with volume loss, sagging, reduced skin density or changes in skin quality require other treatments.
Treatment of a wrinkle therefore depends on its cause, not just its location.
Can botulinum toxin change facial features?
Botulinum toxin can change certain expressions, but its aim is not to transform facial features.
Facial muscles function through subtle balances. Some lower the eyebrows, others raise them; some contribute to smiling or squinting. Changing the activity of one can therefore influence the overall expression.
This is why an injection is not simply about treating the place where a wrinkle is visible.
Excessive reduction in certain muscles' activity can change eyebrow position or make an expression less noticeable. Conversely, treatment adapted to anatomy and muscle dynamics softens wrinkles without unnecessarily suppressing the movements that give the face its character.
Assessment before an injection must therefore take place both at rest and in movement.
Should you wait until you have deep wrinkles before starting botulinum toxin injections?
No. There is no need to wait until a wrinkle is deeply established before considering botulinum toxin. Treatment may be offered when muscle contractions start to mark the skin.
Age is not the main criterion. Some people develop forehead lines, frown lines or crow's feet early: these first appear during expressions, then gradually become visible at rest. In others, these wrinkles appear later.
At this stage, botulinum toxin can reduce repeated contractions and limit the progressive deepening of wrinkles.
However, routinely injecting a young person without early wrinkles or marked muscle contractions is not useful. Prevention means treating when movements start to leave a mark on the skin, rather than starting injections as early as possible.
Does a higher dose of botulinum toxin give a better result?
No. A higher dose of botulinum toxin does not necessarily give a better result. The dose must be adapted to the treated area, muscle strength, anatomy, the patient's sex and the movement to be retained.
An insufficient dose can produce an effect that is too weak or less lasting. Conversely, an excessive dose can reduce muscle activity too strongly and limit facial expressions.
The aim is therefore to use the dose needed to soften wrinkles while retaining natural movement.
Are the effects of botulinum toxin permanent?
No. The effect of botulinum toxin is temporary and gradually wears off.
The first effects appear in the days following the injection. Results are generally assessed around two weeks after treatment.
Muscle activity then gradually returns. For the main facial areas, the effect generally lasts between four and six months, depending on the patient, treated muscles and injected dose.
Botulinum toxin therefore does not cause permanent muscle paralysis. As its effect wears off, the muscle gradually regains its activity.
Do wrinkles worsen after stopping botulinum toxin?
No. Stopping botulinum toxin does not cause wrinkles to worsen suddenly.
As the effect fades, the muscles gradually start contracting again.
Expression lines then reappear.
However, after several years of treatment, the face may differ from its appearance before the first injections because skin ageing has continued during this period.
The return of wrinkles after stopping therefore reflects resumed muscle activity and natural facial changes, rather than worsening caused by botulinum toxin.
Can you become dependent on botulinum toxin?
Botulinum toxin does not cause physical dependence.
However, it is possible to become accustomed to your face with softer wrinkles and wish to maintain that result. This aesthetic preference should not be confused with pharmacological dependence.
There is no obligation to repeat injections as soon as the first movements return.
Some people wish to maintain a relatively constant effect. Others prefer to space sessions further apart and allow muscle activity to return more fully between treatments. Frequency can therefore be adapted to the patient and desired result.
Are botulinum toxin injections dangerous?
Botulinum toxin has a well-established safety profile when used for an appropriate indication, at the correct dose and with the correct technique. Like any medical treatment, however, it can cause adverse effects.
Redness, a small bruise, tenderness at the injection site or headaches may notably occur after the session. These effects are generally temporary.
More rarely, the effect can reach a neighbouring muscle and temporarily cause asymmetry, a drooping eyelid or a change in eyebrow position.
Precise anatomical knowledge, selection of injection sites and dose adjustment are therefore essential. Because treatment acts on muscles directly involved in facial expressions and balance, a few millimetres or units can matter.
Does botulinum toxin give every patient the same result?
No. Muscle strength, expressions, eyebrow position and facial anatomy differ considerably between individuals.
Two patients may have apparently similar frown lines yet very different muscle dynamics. Injection sites, doses or even treatment objectives will then not necessarily be identical.
Expectations also vary. Some patients want strongly softened wrinkles, while others prioritise retaining plenty of movement.
Personalisation therefore does not simply mean changing the amount of product. It involves understanding how the face moves and deciding which contractions actually need to be reduced.
Routinely reproducing the same injection pattern on every face would be precisely the opposite of this approach.
Is botulinum toxin only for women?
No. Botulinum toxin injections can also be performed in men.
The treatment principle is the same, but male anatomy must be taken into account. Upper facial muscles are often stronger and may require different doses.
Eyebrow position and shape must also be respected. Unsuitable injection sites or doses can alter their position and change facial expression.
For men and women alike, the aim is therefore to soften expression lines while preserving the face's natural characteristics.
How can you achieve a natural result with botulinum toxin?
A natural result relies above all on precise facial assessment, choosing the muscles to treat and using doses adapted to each patient.
Before an injection, observing the face at rest alone is not enough. It must be assessed in movement: asking the patient to frown, raise the forehead and smile, and observing how the different muscles interact.
These dynamics explain why a wrinkle appears and help determine how far it is appropriate to reduce the contraction responsible for it.
In my practice in Geneva, I therefore aim to adapt treatment not only to anatomy but also to the patient's expectations. Some wish to retain plenty of movement; others prefer a greater reduction in certain contractions.
Article written by Dr Valeria Romano
Dr Valeria Romano supports each patient through a comprehensive approach to facial, body and intimate aesthetics, as well as skin and hair quality. Every treatment is based on a personalised medical assessment.
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