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Botox Alternatives

What to Do if Botox Just Isn't For You


Updated April 22, 2014

Whether you’re one of those rare people who has developed an “immunity” to Botox, or you’re getting tired of facing the needle every three months to maintain your results, or if you just don’t like the idea of regularly injecting poison into your face, you may wonder what alternatives you have for keeping your face youthfully smooth. So just what is a Botox-resistant person with stubborn frown lines to do?

Topical Preparations: Safer Alternatives or Snake Oil?

We’ve all seen the ads announcing the newest miracle serum that is supposed to be “Better Than Botox”. Often, there is a side-by-side before and after picture accompanying the ad, and the results depicted are nothing less than astonishing. If you were to believe your eyes, you would think that these magical elixirs could erase twenty years in a matter of minutes. But don’t be fooled. In the corner, in tiny, light-colored print, appear the words “photo dramatization”. Even more insidious are some of the “real” photos -- the ones that show only a close-up of an eye. What they don’t show is that in the before photo, the person is smiling (which makes the crows feet show up). In the after photo, no smile means no crinkling around the eyes. If you look really closely, you’ll notice the difference.

Though some of these products do seem to deliver a certain measure of very temporary results, they can in no way be compared to the results achieved with Botox injections or with surgery. If they could, wouldn’t we all be using them? The real kicker is that most of these products cost almost as much as the real thing. If it sounds too good to be true, it probably is. Most doctors worth their salt will tell you to save your money and skip the lotions and potions.

Myobloc (Botulinum Toxin Type B)

It seems that some doctors who are aware of the problem are offering Botox-resistant patients another option in the form of botulinum toxin type B (which is sold under the brand name Myobloc). This form of the botulism toxin has proven effective in patients suffering from cervical dystonia (a painful neuromuscular condition affecting the head and neck), pediatric urinary incontinence, migraine headaches, and other medical problems –- even in patients who have developed resistance to botulinum type A (Botox). Although it is not approved for cosmetic use, some doctors do offer this off-label use as an alternative for Botox-resistant patients.

Besides its non-approved status, one concern is this: For Botox-resistant patients, what’s the likelihood that they will develop antibodies to other types of the toxin? The same type of toxin-blocking antibodies which are responsible for Botox-resistance have shown up in patients participating in clinical studies with Myobloc. However, no studies have been done on the off-label cosmetic use, which uses much smaller doses than are used to treat patients with cervical dystonia (the only condition for which the use of Myobloc is currently approved). The only answer anyone seems to have at this point is that it could certainly happen, but the use of careful (minimal) dosing may be able to prolong its usefulness in cosmetic patients.

Snip The Muscle

One more invasive (surgical) option is available for those who would use Botox solely for the vertical frown lines which appear between the brows. The procedure is called a corrugator myectomy or corrugator excision. The basic idea is to surgically disable (either by cutting or completely removing) the muscle that draws the eyebrows down and together, rendering it unable to create those pesky lines in the first place. In a less extreme approach, corrugator myotomy, the muscle is merely cut into, not removed (which results in a decrease in furrowing of the brow, as opposed to total elimination of furrowing).

Of course, some risks come with this procedure, including a decrease in sensation in a small area of the forehead, and a cosmetically undesirable depression in between the brows which may need to be filled with some sort of dermal filler. In addition, some doctors warn against this procedure, saying that it can result in the face taking on an exaggerated, artificial, perpetually “surprised” look. Patients should also be aware that unless the corrugator muscle is completely removed during the procedure, the results may not be permanent.

The Standards

If none of the above options appeal to you, you could consider a face lift, brow lift, eye lift, and/or laser resurfacing combined with injectable dermal fillers. Although these procedures will not address the repeated facial movements that cause expression lines to appear, they can help significantly with their appearance.

On the Horizon

A newer treatment which shows promise as a Botox alternative is the use of a technology called REX (short for "Relaxed Expressions", formerly known as GFX or NoTox). REX uses targeted radiofrequency energy to weaken (via heat-induced injury) the motor nerves which connect to the forehead muscles responsible for frowning. This is similar in principle to Botox injections, although quite different in practice.

There aren’t yet a lot of doctors using this new technology, and no long-term studies support its safety and effectiveness over time. However, it is FDA-approved for medical use, and is currently undergoing clinical trials for cosmetic purposes. REX’s proponents have a lot of good things to say, and the before and after pictures are impressive. I’d say it’s a development worth keeping an eye on.


Endoscopic Frontal Branch Neurectomy, Corrugator Myectomy, and Brow Lift for Forehead Asymmetry After Facial Nerve Palsy; Moody FP, Losken A, Bostwick J III, Trinei FA, Eaves FF III; Journal of Plastic and Reconstructive Surgery, Volume 108, pp 218-224, 2001.

Interview with Adam Tattelbaum, MD, Rockville, MD; conducted on December 17, 2007.

Interview with Min S. Ahn, MD, Westborough, MA; conducted on September 11, 2008.

Interview with Timothy R. Jones, MD, St Louis, MO; conducted on September 11, 2008.

Myobloc Physician Prescribing Information Sheet, Solstice Neurosciences, Inc., South San Francisco, CA.

Press Release, Bioform Medical, Inc., San Mateo, Calif., April 30, 2008.

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