Why Some Patients Stop Responding to Botox

[mediK / HEALTH IN NEWS] Botulinum toxin injections—widely known as Botox—remain the most popular nonsurgical cosmetic procedure worldwide. From softening frown lines, forehead creases, and crow’s feet to slimming a square jawline or reducing bulky trapezius muscles, the treatment has become a cornerstone of aesthetic medicine. Yet as its use has exploded, so have concerns about antibody resistance, product selection, and long-term safety.

The mechanism is straightforward: the toxin temporarily blocks the release of acetylcholine at the neuromuscular junction, preventing muscle contraction. Wrinkles relax, overdeveloped muscles atrophy slightly, and the effect typically lasts three to six months. With repeated treatments, however, a minority of patients develop neutralizing antibodies that blunt or eliminate the drug’s effectiveness—a phenomenon known as immunoresistance or secondary non-response.

Resistance tends to emerge when injections are spaced too closely or when products containing higher amounts of accessory proteins are used repeatedly. These complexing proteins, though inactive, can trigger the immune system to produce antibodies that also neutralize the core neurotoxin.

In recent years, highly purified formulations with minimal complexing proteins have gained traction because they lower the risk of antibody formation while delivering more predictable results at the same dose. The growing availability of multiple botulinum toxin type A products—each with distinct potency, duration, and diffusion characteristics—has given physicians greater flexibility, provided they understand these pharmacologic differences and tailor dosing accordingly.

As botulinum toxin treatments grow more common, minimizing antibody resistance and ensuring precise, natural results have become top priorities for experienced injectors. (Credit: Dr. Yang Ho-joon, Makkeun Yoon Dermatology Clinic, Guui Branch)

Beyond cosmetics, botulinum toxin is FDA-approved for chronic migraine, hyperhidrosis, muscle spasticity, and other medical conditions. In aesthetic practice, however, patient expectations run particularly high, and even minor adverse effects—frozen expressions, brow or eyelid ptosis, or asymmetry—can erode trust. Overinjection or poor anatomic knowledge can lead to complications ranging from unintended muscle weakness to, in rare cases, dysphagia or respiratory issues.

At its core, botulinum toxin treatment is not merely wrinkle erasure; it is a form of precise neuromuscular modulation. Outcomes hinge on the injector’s experience, mastery of facial anatomy, and judicious product selection.

The convenience and immediacy of results ensure the procedure’s enduring appeal, but the conversation has shifted. Today, mitigating resistance and safeguarding long-term efficacy have become central priorities—for both patients and practitioners who rely on evidence rather than trends.

Lim Hye Jung medi·K TEAM press@themedik.kr

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Why Some Patients Stop Responding to Botox — and How to Prevent It

[Physician's Column] By Dr. Yang Ho-joon, Director, Makkeun Yoon Dermatology Clinic, Guui Branch