Beauty Director Ingeborg van Lotringen shares - from experience - the good and bad about wrinkle-relaxing toxin injections such as Botox

Botox is the most famous of the ‘toxin’ injections, so much so that, although it's a brand name, it's become a byword for smoothing your forehead and having your fine lines zapped. Considered the original ‘tweakment’ and, some say, still the best, wrinkle-relaxing injections give almost instant results (the toxin kicks in at about four-to-seven days). Few treatments give a more satisfying return on your investment.

I’ve dipped in and out of having these jabs for about 12 years – in my forehead, frown lines, crow’s feet, lips, chin and neck - and written about them for over 20. I’ve learned that what works for one person may very well not for another; forehead Botox, for example, makes my brows drop. 

So, here’s the stuff I personally think you should understand about toxin injections (also called wrinkle-relaxing injections or neuromodulators) -  from how often to have them to surprising uses, and everything in between.

What exactly is Botox? 

First off, Botox is just a brand name for cosmetically licensed botulinum toxin type A, which blocks nerve messages to treated muscles and so temporarily knocks them out. The two other brands of this same toxin available in the UK are Azzalure and Bocouture and they all cost roughly the same. The latter two are less widely available, so I myself have only ever been injected with market leader Botox.

The treatment costs an average of £200 for a small area like your frown lines, while the entire forehead area and crow’s feet would cost more like £500 (significantly more in London). So on a four-times-a-year basis, you could easily be looking at a budget of £2000 annually.

Is Botox safe?

Would I have them if they weren’t? According to the NHS website, “the risks of botulinum toxin injections are small if it's done correctly by a suitably qualified practitioner.”

You should get it from a doctor as it’s a prescription medicine; you need your injector to be thoroughly trained in facial anatomy and in responding to medical emergencies, or you can (very rarely) get paralysed, go blind, suffer breathing problems – you name it! But generally, botulinum toxin injections such as Botox are very safe if done correctly.  Generally, any adverse effects are limited to a droopy or lopsided brow, looking a bit too ‘frozen’ for a few weeks or bruising where the needle went in.

What’s a good time to start Botox?

As late as possible, is what I think. You can legally start on Botox from the age of 18, but that doesn’t mean you should. Respected cosmetic doctors such as Dr Sophie Shotter would suggest you can consider it from the moment the first fine lines start to set in. But (and she would agree) no face is supposed to look like a shiny boiled egg, and if you give in to a mindset that considers lines or changes to the face an abomination, you’re probably not going to feel all that happy inside your own skin as time goes by… am I wrong?

So while most of Shotter’s patients start in their early thirties or even mid-twenties, I would suggest late thirties or forties (or never, of course). That way, you at least learn to live with the inevitable ageing process while also knowing that once you look more tired and worn-out than you feel, a few toxin injections will instantly open up your face. Because whether they’re superficial or deep, lines and grooves don’t stand a chance against toxin – it will relax them at any age.

I first had Botox at age 42, having resisted it precisely because I wanted to embrace at least some of the aging process. But when I began to look more haggard than I felt, I dipped in. It took quite a few years before I settled on exactly the areas that work for me, and the amounts that were just enough to take some of the stress off my face without making me look freaky-frozen.

What’s the difference between Botox and fillers?

The only similarity is that they are both injectables. They work in entirely different ways and on different issues. Toxin paralyses muscles, thereby preventing ‘dynamic’ or ‘expression’ lines that, over time, set into wrinkles and crow’s feet. This was its first cosmetic application and it still is why most people have toxin treatments. But as you’ll see below, it can also be used in other ways, such as preventing facial muscles being pulled down and so contributing to sagging skin. For me, I love how treating my frown lines slightly opens up my eyes, and how injecting my neck makes it look less ‘stringy’.

Dermal fillers are used to add or restore volume to your face. They are not used specifically to treat wrinkles - you cannot actually ‘re-fill’ lines with filler. Fillers can be used subtly, for example when you fill hollowed-out temples (this gives a less ‘gaunt’ look and corrects sagging in the area), and more obviously – think of pumping up lips and cheeks. Fillers can also be injected under the skin to gently support and raise the area above it. It achieves a ‘lifted’ effect, as in, for example in the case of a lip corner lift to banish ‘resting bitch face’.

What is baby Botox?

It’s simply the practice of injecting muscles with smaller amounts of toxin than is usually prescribed, in order to ensure a more ‘natural’ effect.

There’s no standard for what a ‘baby’ amount is – it depends on what your doctor (and you) consider to be subtle. I go for ‘baby’ amounts as standard as I don’t want my lines obliterated to end up like a gleaming bowling ball. Others might want to start with small amounts to see how they like the effects. A good doctor will offer you the option to start on a moderate amount and adding a bit more two weeks later (for the same price) if you’re not entirely satisfied.

How long does Botox last?

Toxin injections last around three to four months, however, the smaller the amount of toxin, the less long it will last. Its staying power is mostly determined by your metabolism – the faster it is, the faster the toxin will be removed from your system.

What is Micro Botox?

Micro Botox is not the same as baby Botox; it’s a treatment mostly aimed at those with oily skin. Also referred to as ‘mesobotox’, ‘dermabotox’, ‘cloudless skin’, or the Botox Mist Facial, it’s the originally Korean practice of injecting tiny, superficial injections of toxin all over the face into the lower dermis (not the muscles, where it normally goes), to block the neurotransmitter that sets off oil production.

This can reduce sebum production and so decrease pore size if you have oily skin, meaning you see less oiliness and clearer (‘cloudless’), more radiant skin. It also reduces facial sweating – but all of it only as long as the microdroplets of toxin last, which is two to four months.

Should you get ‘preventative Botox’?

Starting toxin before you even have any expression lines (it doesn’t address other types of wrinkles, such as those that form when skin slackens) will indeed help keep them at bay for longer. But it will also make you lose touch with what a normal face full of expression looks like and teach your brain to freak out over lines no-one else notices. Plus, if you inject too much, and or have it too often, it can give you that slightly impassive ‘identikit’ look that’ll make people wonder if you’re actually 45 with a lot of work done – when you are in fact 25. Think, for example, of how much Love Island contestants and Real Housewives of Wherever look alike. I just don’t believe in this type of ‘prevention’.

Do you need a break from Botox?

I believe in going for a ‘hard reset’: going back to your ‘natural’ face as much as possible between treatments. So if you know that toxin will only last for three months on you (it depends on your metabolism and how much you exercise), wait at least that time until you book your next treatment. That way you don’t fall into the trap of getting used to an increasingly ‘unlikely’ face that everyone but you notices.

This is not what most practitioners will advise: they want to get you in before your treatment stops working. But I always make sure it does, to stay in touch with reality.

Can you stop Botox once you start?

Yes, of course. In fact, there are drawbacks to having toxin injections constantly. If your facial muscles are ‘switched off’ for years on end, they eventually weaken and flatten. This leads to a heavy, drooping brow that even mega-doses of toxin can’t fix. It can even lead to thinning skin, says US dermatologist Dr Patricia Wexler repeatedly on her channels.

Meanwhile, your face will over-recruit muscles surrounding the paralysed area, so you can develop unexpected lines in unexpected places: having toxin in my frown lines deepens the lines above the tails of my brows, as they have to work harder at pulling my brows up. You have to choose your battles!

Also, the rest of the ageing process – pigmentation, loss of tone and volume, dull skin – will march on regardless, so your face can end up oddly distorted: looking more mature yet with an incongruous lack of lines.

Of course, a conservative toxin regime executed by a great doctor can help manage all this (as can a load of additional tweakments to volumise, smooth and brighten). But not jumping the Botox gun is definitely worth considering, even if only for cost reasons.

Does Botox improve skin quality?

No. Despite lots of toxin giving you a shiny smooth forehead (a texture-free surface reflects the light better, hence the shine), it doesn’t hydrate or soothe skin, like good skincare does, nor does it protect it from environmental assault and sun damage. It doesn’t stimulate collagen and elastin so won’t give skin plumpness, firmness or a healthy glow, and it won’t diminish pigmentation. It can make your skin slightly less oily, as we’ve seen in the case of Micro Botox. But for tweakments that are designed to improve skin quality, you need to look for collagen-boosting heat-based treatments such as laser, or injectable skin boosters such as Sunekos.

Can you use Botox in the lips?

Toxin is used in the lips not to fill them or make them plumper, but to correct a ‘gummy smile’. It means injecting a few tiny drops in the lip line stop your top flip from ‘rolling in’ and disappearing when you smile. Your lip will look slightly fuller without being puffed up. Even people without gummy smiles have embraced this ‘lip flip’ as an alternative to fillers. I certainly have, as I think it’s the subtlest ways to optically off-set the lip thinning that comes with age. It just takes a few sharp jabs in the top lip edge – not the best fun but nothing unbearable either.

Can anyone have a Botox eye lift?

A 'Botox eye lift' paralyses the muscles around the eyes that push downwards - such as those in the upper forehead and between your brows. This ought to make the upward-moving ‘frontalis’ muscles above your eyebrows ‘overactive’ and go up, lifting the brow and even the lids. For many people this works well, but some people get more of an ‘eye droop’ instead. This can happen if the frontalis muscles naturally sit low on your forehead (you’ll need a doctor to diagnose this) and/or aren’t particularly strong. If this is you, toxin can make your brow, and as a result your lids, move down instead of up.

This has happened to me on several occasions, leaving me with tiny piggy eyes with no visible lids for three months as I waited for the toxin -which cannot be reversed- to wear off.  An honest doctor who has plenty of experience assessing facial anatomy will tell you if toxin will or will not lift your eyebrows and lids, and if not, suggest what’ll work for you instead.

What is a Botox ‘face lift’? And a ‘Nefertiti lift?

‘Botox face lift’ was long used to describe the upper face lift-effect that some people get from an eye lift using toxin injections. But more recently, experienced doctors have been using more sophisticated techniques, focusing on injecting toxin into in the jaw and neck to lift the lower face.

“The toxin relaxes the jaw and neck muscles, and as a result, an upward pull of all the facial muscles takes place. This then tightens jowls and tautens the jawline,” says cosmetic physician Dr Sarah Tonks. “It really does work; it’s often referred to as a ‘Nefertiti lift’ because the death mask of this Egyptian queen displays such a perfectly taut jawline”.

But there is more, says oculoplastic surgeon Dr Jonathan Roos. “Lower-face toxin relaxes the face as far up as the eye area,” he says. “It helps open it up.”

He’s also had great results on some younger people (it gets harder when skin slackens with age) who naturally carry weight in their lower face. “When strong muscle activity consistently pulls down the tissues here (because the person subconsciously pulls their chin in and their mouth corners downward), you can develop a double chin,” says Roos. “Judiciously applied jaw toxin can make this practically disappear while giving a lift to the entire face.”

I’ve seen Roos’s pictures of a young woman’s double chin (which resulted from a consistently grumpy, withdrawn expression) disappearing entirely through toxin injections that prevented her making this expression.

Like any toxin procedure, this is not a ‘paint-by-numbers’ jobbie (although many lesser practitioners will try). Personal anatomy is key to a good result, and you should always ensure your doctor is honest about what is and isn’t possible for your individual face.

Can Botox cause eye bags?

If you are having toxin for crow’s feet and it’s injected too low, near the lymph vessels and nodes in the area, this can cause problems. These lymph vessels are responsible for draining fluids and toxins, and they rely on movement and muscle contractions. Badly placed toxin slows the lymph, which can result in puffy eye bags that look saggy. It should fix itself in a month or two after the toxin stops working – although I’ve seen the issue happen to a friend and her eyes never properly recovered. So be very careful.

Does jaw Botox for teeth grinding work?

Subconscious teeth grinding (or bruxism) tends to be stress-related and builds up the jaw muscle, much like daily exercise. The result can be a wider, squarer jawline that some consider ‘too masculine’. It can also cause headaches and a tender-feeling jaw. A few shots of Botox in the jaw’s masseter muscles will relax them to bring quick relief and, after a few weeks, a visibly more V-shaped and therefore ‘feminine’ jaw.

My former colleague Cassie even noticed that not being able to stress-grind her teeth helped her snap out of her anxiety cycle. Anxiety had caused grinding which, in return, triggered more anxiety, and masseter Botox helped fix it.

Jaw or masseter Botox has also become popular for those who simply don’t like the square jaw they were born with, as injecting the masseters with toxin will reduce their size even if they’re not ‘over-worked’ through teeth grinding (or even excessively chewing gum). With the results of the procedure often described as a ‘slimming’ effect, some people wrongly believe it will reduce chubby cheeks – it doesn’t.

Can you exercise after Botox?

You want toxin to stay precisely where it’s been injected and not migrate (in other words, allow it to settle), the advice is not to do any strenuous (driving your heart rate to over 130) exercise such as hot yoga or running for 24 hours after your treatment. Skip moderate exercise as well for at least four hours after – so don’t hit the gym straight after seeing your Botox doctor.