Botox doesn’t work as well anymore – what to do?

I’ve decided to tackle on another question in a public forum about Botox.

I’m a Botox user but over the last 3 – 4 times I’ve had Botox it hasn’t worked as well. What unit of Botox would I ideally want?

I’ve been getting Botox for a few years,recently its not worked as well ,getting top ups is a hassel, especially when it doesn’t work again.i asked my doctor what units he used, what type and the dilution solution , ‘ Azzalure which is the same as Dysport. Diluted with bacteriostatic saline solution to produce 200 Speywood units per ml. ‘frown 50-60units’ is this good? I’m thinking of changing doctors, what would the best thing to ask them?how many units do i want injected if this didnt work?

My Answer:

There are so many different ways to inject a neuromodulator and there are so many possibilities for a neuromodulator injection to work less effectively.  I’m going to use the word neuromodulator to describe Botox, Dysport, or Xeomin.  I agree that Dysport is sometimes called Azzalure.


​Patient factors

  • ​Is the patient Zinc deficient?  Zinc seems to play a role in neuromodulator
  • Did the patient develop antibodies to the product?
  • How long ago was the patients previous neuromodulator treatment.  Often, when the treatments are close enough together, there’s a synergistic effect of the previous injection along with the new injection.  Thus don’t wait too long between injections where to facial muscles have gained back all their strength.

Product factors

  • ​Dilution of the product.  Was it diluted appropriately.
  • Age of product.  How long has it been on the shelf?  Shelf life can matter.
  • Which product?  I feel that the neuromodulators are somewhat different from each other.  The units cannot be interchanged very easily.  It’s sort of like asking – how many tangerines does it take to make a washing navel orange?  Similar, yet different for the discriminating injector/patient.

Injector factors

  • ​Where were the injections made?
  • Was there waste of product?
  • Was the measurements accurate?
  • Three dimensional injection, was the neuromodulator placed within the muscle or right under the skin, or right above the bone?
  • How many injection points were chosen?

​I’m probably forgetting a few variables.  But you can see that there’s so much going on here.

THE ANTIBODY QUESTION:  Try more Dysport and/or go back to Botox.

​Consider going back to your injector and asking for a higher dose of Dysport.  If that still doesn’t work, then consider asking your injector to switch back to your original – Botox – which seemed to work for you.  If both the higher dose and switching back to Botox – this might point to an antibody problem.  This will degrade the product faster.  This is a very rare possibility.  I think in the past, this happened more because of the higher percentage of albumin mixed in with the Botox.  But it’s a much lower amount of albumin used now and thus the antibody reactions are much rarer.  If antibody reactions occur, I believe that you’d be forming reactions to all Botulinum Toxin Type A’s:  Xeomin, Dysport, and Botox.  These are the ones available in the USA.


​But if you have doubt about your injector.  You can switch.  Neuromodulator injection styles are incredibly different – this might be what you’re looking for – something different.  And hopefully better results.  I think you have a good idea on this one.

​Consider spending even more time talking to your injector.  Perhaps he/she will come up with a comprehensive plan of figuring out what’s happening with your new dissatisfaction.  Above is just my own plan of what I do with my patients who present with such a scenario.  But most of the time, it’s because I’ve gotten patients who have decided to switch to me due to dissatisfaction with results from another injector.


​How many units of Botox for frown lines?  I call these lines glabellar lines.  I usually inject anywhere from 10-36 units of Botox for this one area.  Every person is different, but usually I am sticking to the same general amount of units for each treatment session.  Thus if a patient is a 36 unit user – they tend to be a 36 unit user for a few years.  I have found that they can usually space the treatments further apart though as they keep using Botox.

​On average, I use 20 units of Botox for the glabellar complex.  The numbers written above in the question are probably Dysport units which could be about 3 times more than the Botox units to achieve a similar (not same) result.  I’m not entirely sure because I am nearly 100% Botox in my own practice.  My experience with Dysport spans only about 3 months in my practice.  I was pretty happy with the Dysport results, but my patients seem to want Botox more, so I caved into consumer demand.  I am happy with both products.  But I do not use the terms Botox, Xeomin, and Dysport interchangeably.  They are different products and have different effects and require different care.
​Thank you for your question. Without having seen you in person, I’m answering the best I can without physical examination info and a one-on-one dialogue. My comments are meant for a general public discussion to help others who may have similar concerns. I’m also using my answers to build up library of information for my own patients and also to see how my answers compare with other doctors. There is always much for us to learn from each other. My answers are generalized medical information only, not directed medical advice. For medical advice please see your doctor/surgeon in person.

​Calvin Lee, MD
​Botox injections Modesto, California

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Dysport vs. BOTOX comment on FaceBook

Personally in my hands, I like BOTOX

Today, I received on FaceBook, a question regarding a comment regarding Dysport vs. Botox.  I was invited to give my personal thoughts and I would like to share them.  For the most part, I disagree with what’s written in the screen capture below:

reasons to make the switch from Botox to Dysport


My response to the question:

I like all of them! Botox, Dysport, and Xeomin

Dysport is excellent.  So is Xeomin.  Dysport, Xeomin, and Botox are neuromodulators.  In my opinion they work very similarly.  I have personally injected all three products and have personally received injections of Botox and Dysport.  I have come to the conclusion when using the products, much of the differences come down to four things:

1. How much was used.

2. Who is the injector.

3. What precise 3-D location was it injected (muscle/fascia all have depth).

4. How was it injected.

How to Compare? pound for pound?

I’m not certain that you can convert one unit of one product to another unit of another product.  For example, how many Hondas equal one Toyota?  Would it be 1.5 Hondas is the equivalent of 1 Toyota because of horse power rating or based on gas mileage – or the other way around.  I have owned both Hondas and Toyotas – and I like both.

So that’s the first problem when comparing neuromodulator.  Do we really know if we have equivalency?  Is 2.5U of Dysport really the same as 1U of Botox?  Or have we now changed it to 2.9U of Dysport to equal 1 U of Botox.  I jumped at the chance to try Dysport in January 2013.  I think the results were great.  But I think that in my own hands, the results of Botox was better.

I agree that Dysport spreads more.  But for me, I see that as a disadvantage.  The way I inject, I like a bit more pin-point accuracy.  But then again, that’s my personal way of injecting.  I like planning my injection sites whenever possible – thus I’m not looking for a wide diffusion pattern of the neuromodulator.

There will be people who say that a Toyota is better than Honda – or the other way around. I think both are good car companies.  But I would say that currently for me, I drive my own Honda a lot better than I would drive a Toyota because that’s what I drive every day.

Botox is my Violin

Schindler’s List Played by Calvin Lee, MD, guest concertmaster Taipei, Taiwan

Yep, that’s me and my violin.

I have been a violinist most of my life.  I frequently say that Botox is my violin.  When I’m using my violin, I can create results more predictably.   My Violin is what I prefer when I concertize.  I would be a bit timid when using a different violin.  But this is not to say that other violins are inferior.  But I have confidence to say that I would make other violins sound quite good!

Thus said in a different way.  I prefer to inject BOTOX because I’m comfortable with it and I can predict the outcome better.  But if I had to use Dysport or Xeomin, I would still get great outcomes, but I would have some uncertainties with it because I don’t use it every day.

Many of my patients and my entire staff prefer their BOTOX results over other products.

Their reasons are multifactorial.  Perhaps in another entry of my BOTOX blog, they can chime in.

I leave you with one more thought:  The injector plays the biggest role in the outcome.

It’s the violinist that makes the sound, not the violin.  Just like it’s the surgeon that makes the surgery, not the scalpel.  Thus we can debate on and on regarding which violin to use or which scalpel to use.  As long as the violin is of high quality and the scalpel is too, then the results lay on the shoulders of the artist.

Here’s a quote from master violinist, Jascha Heifetz:

After a concert, a member of the audience went up to Jascha Heifetz. He said, “Wow, your violin sounds really great.” Heifetz then held the violin up close to his ear and replied, “Funny, I don’t hear anything.”