Immune to Botox? This Could Be The Fix

Last time I saw Dr Sophie Shotter for toxin, she tried something new – and injected my masseters (the jaw muscles that get over-tight from clenching my teeth) with a mixture of toxin and hyaluronidase. Unless you’re an avid follower of all things aesthetics, that might sound insane. Isn’t hyaluronidase the stuff that’s used to dissolve fillers? Yes it is. So why on earth? Bear with me…

Why mix toxin with hyaluronidase?

Dr Shotter takes up the story: ‘There’s an interesting theory proposed by Dr Steven Weiner  and Dr Peter Velthius about toxin resistance and the fact that maybe it isn’t so much resistance, but it’s actually the fact that after people have been having toxin for a while there’s some fibrosis or almost like scar tissue that develops from the injections. So, the toxin doesn’t spread in the muscles in the way it should – and that’s been demonstrated using ultrasound in the masseter muscles.

‘Dr Steven Weiner then put forward the idea of using a little bit of the enzyme hyaluronidase mixed in with the toxin to improve the way it spreads through the tissues. And he’s had some remarkable results.’

I’m not immune to toxin, but…

Now, before you jump to the obvious assumption, I’m not resistant to toxin, but there’s a second part to this theory of Dr Weiner’s, which is that using this tox/ hyaluronidase mix, you can use much less toxin – and still get the same muscle-relaxing results. Now that interested me greatly.

I’m well aware that the recognised risk factors for developing toxin resistance include having large doses of the stuff, and having them too often. I have toxin every three or four months, which isn’t ‘too’ often, but the doses I have, have increased greatly over the past decade, from around 40 units per treatment 10 years ago, to the best part of 200 now  – largely because Dr Shotter treats not just my forehead and crow’s feet lines, but my lower face, too. I have buckets of the stuff (well, 50 units) in my masseters, and a fair bit in the platysma muscles that run down my neck from my chin. Oh, and also in my chin, to stop it ‘cobbling’ up, and in the ‘grumpy face’ muscles that pull the corners of my mouth down. So I can see I may well be on my way to the point of overload.

What is toxin resistance? 

Botulinum toxin resistance is a hot topic in aesthetics. Loads of people think they’ve become immune to toxin, and loads of practitioners see patients they believe to be immune. While some people do develop actual antibodies to botulinum toxin, so it doesn’t work any more, most of the top experts argue that true toxin resistance is extremely rare, and that most so-called ‘immunity’ to toxin is the result of a lack of expertise from practitioners who don’t quite hit the right muscles in the right way to get the effect they’re after.

But because it is a thing, even if it’s a fairly niche thing, and even if, as Drs Weiner and Velthius suggest, it’s more a question of fibrosis than antibodies that’s stopping the tox from working, you can see the appeal of Dr Weiner’s new technique. Using a a toxin/ hyaluronidase mix that spreads more quickly through the muscles gets the drug past the fibrosis and also seems to enable the toxin to, for want of a better phrase, beat the antibodies to the receptor sites on the muscles where it is needed.

Testing the theory: half the dose, same results?

Back to Dr Shotter, and my treatment: ‘When you look at Alice’s movement from toxin, she always takes more than I would expect. So we use quite a high dose,’ she continues. ‘We decided as an experiment to try this hyaluronidase theory just in the masseter muscle, which is a very safe area in which to have a little bit more spread of the toxin, and I halved the dose and lo and behold…’

Two weeks later, she reviewed the results, and they were great. On one side, the reduction in muscle-strength from the tox/ hyaluronidase mix was as strong as usual—despite the reduced dose. On the other, I needed a slight top-up, which Dr Shotter says is normal given that muscle strength varies slightly from side to side. Overall, though, we reckon this experiment was a success: I achieved the same muscle relaxation with significantly less toxin.

And what if you have antibodies to toxin?

I’m not a relevant guinea-pig to try this for toxin resistance, but if you are genuinely resistant to toxin, this new approach could just help. To understand the detail of this better, take a look at this Instagram Live where Dr Weiner and practitioner April Harrison discuss how well this technique worked on a patient of hers who had suddenly stopped seeing results from toxin.

I dropped Dr Weiner a line to let him know about this little experiment and how well it worked, and he came back to let me know one new finding: ‘Hyaluronic acid bathes the neuromuscular junction, so adding hyaluronidase allows for better access for the active toxin to bind.’

Thanks Dr Weiner! I’m sure we’ll be hearing a lot more about all this in future.

• For more detail on this topic, listen to this episode of the Inside Aesthetics podcast with Dr Steven Weiner from September 2024.
• And if you want the real fine detail, it’s all there in part 2 of that podcast. For that, you need to subscribe to the Inside Aesthetics patreon. Worth every penny for practitioners and aesthetics junkies IMHO.
• Here’s a quick video on toxin resistance from ‘King of Tox’ Dr Michael Kane, filmed at a meeting in Miami in 2023 too.