Patient: “My Botox isn’t lasting!”
Provider: “I don’t understand that.”
I cannot tell you how many times I have heard this. It all started just about two months after we emerged from the March 17-June 5, 2020 lockdown here in PA. Patients who used to average four months per treatment were sometimes only getting three months, and rarely it was even less. And if they usually were benefitting from their botulinum toxin-A (BTA) procedure for three months, it could be the case that they only got two months out of it. Because most of my BTA treatments are done with the Botox brand name product, it was among those patients that I first observed this occurrence.
One of the ways that I tried to make up for the problem that my patients were having with their Botox was to next try one of the other BTA FDA-approved brands that are available to providers in this country. That is to say, I would choose either Dysport, Xeomin, or Jeuveau for their following treatment. I never doubted my patients’ observation of shorter duration of benefit from their Botox. I just did not understand it. This bothered me, and I was in search of an answer. Eventually, the lightbulb went off!
It’s Time for a Bit of Background
Many of us who have been doing BTA treatments for years (or for decades in the case of some of us), have come to recognize that the patients who have a high degree of facial animation tend to have shorter durations of benefit from their treatments. More specifically, if they are more of a natural smiler than a frowner then the wrinkles at the sides of their eyes return before the wrinkles between their eyebrows. Similarly, if they tend to frown more than smile, then the creases between their eyebrows (we call this region of the face the glabella) will recover from the effect of the BTA before their crow’s feet region creases will return.
So, what does all of this have to do with a shorter duration of benefit from Botox treatments since the pandemic started and the lockdown ended? And, by the way, did the other three FDA-approved BTA products last any longer than Botox when they were used? I’ll take the second and simpler question first. No, none of the other BTA brand products did any better than Botox after the lockdown ended! Clearly then it was not exclusively a Botox problem. I have been noticing that there has been a decided shortening of BTA treatment durations by an average of 1-4 weeks since our office reopened June 8, 2020.
And the reason for this is the general increase in stress and anxiety among almost all of us since the pandemic began! Stressed people have an overall increase in muscle tone. The increased tone occurs because the motor cortex of the brain sends stronger and more frequent nerve impulses to our muscles. This is part of the body’s sympathetic “fight or flight” response to danger and stress. As regards BTA treatments in the upper face, increased nerve stimulation to our muscles leads to a faster recovery from the effect of BTA and therefore a shorter duration of benefit from our Botox, Dysport, Xeomin, and Jeuveau treatments!
But this is not the only reason for the shorter BTA duration since the pandemic started and we were able to again give people treatments after the lockdown ended. And what is that you ask? Masks! Now I’m not arguing against masking. Masks are the single most important way we will escape the ongoing illness, deaths, and stress of COVID-19. Masks however block our lower faces from view when we are around others. How many of us have been frustrated trying to convey something to those around us while we were wearing a mask? How about all of us, right? So how do we try to compensate? We speak louder and we try to do more upper face animation in the attempt to convey emotion with just the exposed part of our face! That is to say, we put extra effort into trying to move our Botox weakened upper face muscles and this, in turn, leads to a shorter duration of beneficial effect from the BTA product.
No wonder our Botox, Dysport, Xeomin, and Jeuveau just isn’t lasting as long as it did in the pre-pandemic era. Let us all hope for continued high compliance with masking and other proven public health measures, as well as increased vaccine availability and acceptance in our country and around the globe. It is only in these ways that we will all again experience the prior longer duration of benefit from the BTA products that we enjoyed in pre-pandemic times.
William A. Carter, M.D. at Medical Cosmetics