Botulinum Toxin

Part of our complete guide to Periocular Rejuvenation — this page covers botulinum (Botox®) treatment in depth.

Botulinum Toxin — Neuromodulators

Botulinum toxin type A reversibly blocks acetylcholine release at the neuromuscular junction, producing temporary, controlled weakening of injected muscles. In cosmetic practice, this smooths dynamic wrinkles — lines created by repetitive facial muscle contraction. In therapeutic use, it provides lasting relief from involuntary muscle spasms. Oculoplastic surgeons are uniquely qualified to administer periorbital injections given their deep anatomical expertise in the eyelid, orbit, and surrounding facial musculature.

Botulinum toxin is also the first-line treatment for Blepharospasm and hemifacial spasm. For volume restoration with injectable fillers, see Dermal Fillers. For surgical rejuvenation, see Blepharoplasty and Brow Lift.

How Botulinum Toxin Works

Botulinum toxin blocks acetylcholine release at the neuromuscular junction by cleaving SNARE proteins inside the nerve terminal — proteins essential for vesicle fusion. Without fusion, acetylcholine cannot be released and the muscle cannot contract. Effects are temporary because nerve terminals eventually sprout new axon branches that bypass the blocked junction, which is why results last 3–6 months rather than permanently.

Mechanism of Action — Illustrated

SNARE protein complex — toxin target — SNARE complex — molecular target

Toxin internalization blocking acetylcholine — Acetylcholine release blocked

Muscle Anatomy & Product Differences

Complexing proteins — product comparison — Complexing proteins by product

Xeomin — naked toxin, no accessory proteins — Xeomin — no accessory proteins

Toxin complex dissociation at physiologic pH — Complex dissociation at physiologic pH 7.4

Product Comparison — All FDA-Approved Botulinum Toxins

Six botulinum toxin type A products are currently FDA-approved in the United States. While all share the same mechanism, they differ in formulation, unit potency, onset, duration, and specific indications. These products are not interchangeable on a unit-for-unit basis — dosing must account for the conversion factor for each product.

Brand	Generic Name	Manufacturer	Unit Conversion	Onset	Duration	Key Feature
Botox® / Botox Cosmetic®	onabotulinumtoxinA	Allergan / AbbVie	1:1 (reference)	3–5 days	3–4 months	Most studied; broadest FDA approvals including blepharospasm, cervical dystonia, hyperhidrosis, migraine
Dysport®	abobotulinumtoxinA	Galderma	2.5–3:1 vs. Botox	2–3 days	3–4 months	Faster onset; greater diffusion radius — useful for forehead and large surface areas; FDA approved glabellar lines & cervical dystonia
Xeomin®	incobotulinumtoxinA	Merz Aesthetics	1:1 vs. Botox	3–5 days	3–4 months	“Naked toxin” — no complexing proteins; may reduce antibody formation; room temperature stable before reconstitution; FDA approved blepharospasm
Jeuveau®	prabotulinumtoxinA-xvfs	Evolus	1:1 vs. Botox	2–4 days	3–4 months	FDA approved glabellar lines (cosmetic only); competitive pricing; similar efficacy profile to Botox
Daxxify®	daxibotulinumtoxinA-lanm	Revance Therapeutics	Not unit-equivalent to Botox (approximately 2 Daxxify units per 1 Botox unit for glabellar)	2–3 days	6 months	Longest clinically demonstrated duration (median ~6 months in glabellar trials); stabilized with RTP004 peptide — no human albumin; FDA approved glabellar lines & cervical dystonia
Letybo®	letibotulinumtoxinA-wlbg	Hugel / Croma	1:1 vs. Botox	3–5 days	3–4 months	Newest FDA approval (February 2024); widely used in Korea as Botulax for many years; FDA approved glabellar lines

Units are not interchangeable. Dysport units and Daxxify units are not equivalent to Botox/Xeomin/Jeuveau/Letybo units. Physicians convert doses based on the specific product used. Do not compare doses between different products without knowing the conversion factor.

Cosmetic Treatment Areas

Facial muscles targeted by botulinum toxin — anatomy diagram — Facial muscles targeted in botulinum toxin treatment — surgical anatomy

Glabellar Complex (“11 Lines”)

The corrugator supercilii and procerus muscles between the brows create vertical glabellar furrows — the “11 lines” — that impart an appearance of anger or worry. This is the most common treatment area and was the first FDA-approved cosmetic indication for all products. Typical dose: 20–25 units Botox-equivalent. Reduces frowning lines and softens the glabellar area. All six FDA-approved products have at least a glabellar line indication.

Forehead Lines

The frontalis muscle creates horizontal forehead creases. Treatment requires careful dose titration — weakening the frontalis too aggressively causes brow ptosis (lowered brows), particularly in patients who habitually elevate their brows to compensate for heavy upper lids or brow ptosis. Typical dose: 10–20 units Botox-equivalent across 4–6 injection points. Brow position must be assessed before treating the forehead. Dysport may spread more than desired in this area; precise injectors may prefer Botox or Xeomin.

Crow’s Feet (Lateral Canthal Lines)

The lateral orbicularis oculi creates fan-shaped creases at the outer corners of the eyes with smiling. Small doses (6–12 units Botox-equivalent per side) injected 1 cm lateral to the orbital rim reduce these lines while preserving natural animation. Over-treatment produces a flattened, unnatural appearance. Botox Cosmetic has explicit FDA approval for lateral canthal lines.

Brow Lifting

A non-surgical brow lift is achieved by injecting small doses into the lateral orbicularis oculi just below the lateral brow tail. This relaxes the brow depressor effect of the orbicularis, allowing the frontalis to elevate the lateral brow by 1–3 mm — a subtle but effective improvement in brow arch. Best combined with conservative forehead treatment.

Bunny Lines

Diagonal creases across the nasal bridge from the nasalis muscle. Treated with 4–6 units at the nasal bridge. Commonly appear as a compensatory contraction after glabellar treatment and can be addressed at the same visit.

Standard botulinum toxin injection sites diagram — Standard injection points for periorbital and upper-face cosmetic treatment

Lower Face & Neck

Small doses to the lip lines (orbicularis oris), chin (mentalis dimpling), and neck (platysmal bands) extend perioral and lower face rejuvenation. These areas require precise technique — functional compromise of lip movement or chewing is possible with incorrect placement. The lower face is not an area for beginners.

Choosing a Product — Clinical Guidance

For the Periorbital Area

Botox or Xeomin are generally preferred — their more localized diffusion profile reduces the risk of spread into the levator muscle (causing ptosis) compared to Dysport. Precision matters most around the eyes.

For Longer Duration

Daxxify has demonstrated the longest median duration in glabellar clinical trials (~6 months), though individual results vary. It may appeal to patients who want less frequent treatment visits.

For Large Surface Areas

Dysport’s wider diffusion makes it efficient for the forehead and broad platysmal bands, where even spread is desirable. Its faster onset (2–3 days vs. 3–5) can also be convenient for patients with tight timelines.

For Patients with Antibody Concerns

Xeomin’s “naked toxin” formulation (no accessory proteins) may be preferred for high-dose therapeutic use or patients with a history of secondary non-response — where antibodies to complexing proteins may be contributing.

Treatment Details

In-clinic procedure — no anesthesia required; topical ice or numbing cream optional
Fine needle (30–32G); multiple small injections at anatomically precise points
Onset: 2–5 days depending on product; peak effect: 7–14 days
Duration: 3–4 months for most products; up to 6 months with Daxxify
Maintenance: Retreatment every 3–6 months to sustain results
Touch-up: A 2-week follow-up allows refinement of asymmetry or undertreated areas
Reconstitution: Toxin is lyophilized (freeze-dried) and reconstituted with sterile saline before use; concentration varies by practice. Xeomin is room-temperature stable before reconstitution.

Side Effects & Risks

Bruising — common; resolves in 5–10 days. Avoiding non-essential blood thinners (e.g., aspirin, NSAIDs, fish oil) about 1 week prior may reduce risk — but never stop a prescribed anticoagulant or antiplatelet medication without first consulting the prescribing physician.
Eyelid ptosis — the most clinically significant complication; from toxin diffusion into the levator palpebrae superioris. Most common with glabellar injections placed too close to or below the orbital rim. Produces a drooped upper eyelid. Treated with apraclonidine 0.5% drops (alpha-adrenergic agonist stimulating Müller’s muscle), which provides 1–2 mm elevation. Typically resolves as the toxin effect wears off (usually within 6–12 weeks). Risk is lowest with products with limited diffusion (Botox, Xeomin).
Brow ptosis — from excess frontalis weakening; heavy brows drop further. Prevented by conservative dosing and sparing the inferior-central frontalis.
Asymmetry — muscle strength varies between sides; may require touch-up injection at the 2-week visit.
Headache — transient; occasionally reported following first treatments, resolves within 24–48 hours.
Secondary non-response — reduced efficacy with long-term use due to neutralizing antibody formation. More common with frequent high-dose injections. Mitigated by maximizing injection intervals and minimizing dose. Switching products or using Xeomin (no complexing proteins) may help.
Dysphagia (neck/cervical injections) — relevant for blepharospasm patients receiving high-dose injections; transient swallowing difficulty is the most common serious adverse effect at high therapeutic doses.

Therapeutic Uses

Beyond cosmetic applications, oculoplastic surgeons use botulinum toxin therapeutically for:

Essential blepharospasm — injections into the orbicularis oculi provide 10–16 weeks of relief from involuntary eyelid closure. Botox and Xeomin have FDA approval for blepharospasm. See the Blepharospasm page for full details.
Hemifacial spasm — unilateral facial muscle spasms most often from vascular compression of the facial nerve; treated with injections targeting the affected orbicularis, zygomaticus, and frontalis on the involved side
Hyperhidrosis — excessive sweating of the palms, axillae, forehead, or scalp; injections reduce sweating by blocking sudomotor nerve terminals
Migraine prevention — fixed-site PREEMPT protocol (31 injection sites, 155 units) for chronic migraine (typically administered by neurology); Botox is the only FDA-approved toxin for this indication
Cervical dystonia — abnormal neck posturing from involuntary sternocleidomastoid and trapezius contraction; Botox, Dysport, Xeomin, and Daxxify are FDA approved

Botulinum Toxin Before & After

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Age 50Patients are from a national database. Individual results may vary.

Frequently Asked Questions

What is the difference between Botox, Dysport, Xeomin, and Daxxify?: All are botulinum toxin type A products that temporarily relax muscles by blocking acetylcholine release. Botox (onabotulinumtoxinA) and Dysport (abobotulinumtoxinA) have albumin as a carrier protein; Xeomin (incobotulinumtoxinA) does not (making it the 'naked' toxin, potentially reducing antibody formation). Daxxify (daxibotulinumtoxinA-lanm) uses a novel peptide stabilizer and has a longer duration (up to 6 months). Units are not interchangeable between products.
How long does botulinum toxin last?: Most botulinum toxin products last 3–4 months for cosmetic wrinkle treatment. Daxxify may last up to 6 months. Therapeutic uses (blepharospasm, hemifacial spasm) may have shorter duration due to higher metabolic activity in the treatment area.
Can botulinum toxin lift the brow?: Yes — strategic injection of botulinum toxin into the depressor muscles of the brow (orbicularis oculi, corrugator, procerus) can produce a subtle brow lift of 1–2 mm. This 'chemical brow lift' complements upper eyelid blepharoplasty and is often performed in combination with it.
What should I expect during a botulinum toxin consultation?: During your consultation, Dr. Kristan will evaluate your facial anatomy, discuss your cosmetic goals, and assess which areas would benefit most from treatment. They will review the different botulinum toxin products available, explain the expected results, and address any concerns about side effects or contraindications. This is an excellent time to ask questions and ensure you have realistic expectations about the outcome.
What are the common side effects and risks of botulinum toxin?: Most side effects are mild and temporary, including bruising, swelling, or redness at injection sites that typically resolve within a few days. Rare but more serious complications can include asymmetrical results, drooping of the eyelid or eyebrow, or difficulty with facial expressions if too much product is used. Choosing an experienced oculoplastic surgeon who understands facial anatomy significantly reduces the risk of adverse outcomes.

Your Surgeon

Ronald W. Kristan, MD, FACS

Atlantic Eye

📞 (732) 222-7373

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