Skin Botox is often thought of as a treatment that smooths skin texture and makes pores look smaller: something that looks good for a few months and then wears off. But there is another way to look at what it does. If a spot on the face that folds countless times a day were made to fold a little less, what would happen to the line in that spot a few years later? Dr. Jeong, a board-certified dermatologist, sees skin Botox as anti-aging care that gently holds back the folding of the skin caused by expressions, which can help delay fine lines setting into deep wrinkles. This article sets out the research behind that view, what has not yet been confirmed, and how the effects differ depending on where and how it is placed.
Summary in Three Lines
- Skin Botox places diluted botulinum toxin in small amounts across many points in the shallow layer of the skin. Rather than stopping a whole muscle, it eases the pull of the shallowest muscle fibers attached to the skin, so the same spot folds less often.
- In studies of regular Botox repeated between the brows, lines visible at rest tended to improve with each cycle, more clearly in people whose lines were mild at the start. There are no studies yet of skin Botox repeated over years, so the view that skin Botox can work in the same direction is Dr. Jeong's judgment based on how it works.
- Even with the same drug, what you gain and what to watch for differ by depth and area, and how long the effects lasted varied from one measure to another. Skin Botox is therefore closer to ongoing care adjusted to your skin than to a one-off procedure, and if you have it regularly, it is a good idea to keep track of your total toxin use, including Botox in other areas.
What Skin Botox Is — Gently Holding Back the Shallow Muscle Fibers Attached to the Skin
When people think of Botox, they usually picture regular Botox: injected into the middle of a muscle to reduce that muscle's strength substantially. Keeping the brows from frowning, or reducing the bulk of the jaw muscle that gives the face a square look, are typical examples.
Skin Botox uses the same drug in diluted form, placed in very small amounts over many points in the shallow layer of the skin. Papers call it intradermal injection, microbotox or mesobotox; these are different names for the same family of techniques.
Most facial expression muscles start at the bone and end attached to the skin. When the muscle moves, the skin is pulled along and folds, which is why lines appear when we make expressions. Skin Botox is described as acting on the shallowest of these fibers, just beneath the skin where they attach to it. Rather than stopping the whole muscle, it is closer to easing some of the force that drags the skin.
On top of this, it can act on the sebaceous and sweat glands and reduce shine. Being able to look after skin texture while leaving expressions relatively natural is a feature of skin Botox. Pores and oil are covered separately in our article on how skin Botox improves pores; this article is about wrinkles and anti-aging.
How Expression Lines Set In — What Happens When the Same Spot Folds Again and Again
Wrinkles can be divided broadly into two kinds.
- Dynamic wrinkles (lines that show only with movement) — they appear when you smile or frown and disappear when your face relaxes.
- Static wrinkles (lines that show even at rest) — they stay in place after the expression is gone.
Lines at the corners of the eyes that at first appeared only when smiling are, one day, found to linger faintly even at rest. When the same spot folds again and again over the years, the mark stays in the skin as if etched into it, much as a sheet of paper folded repeatedly along the same line keeps a crease even after it is smoothed out.
As we age and the skin thins and loses elasticity, these marks are left more easily. And once a static line has deepened, it often does not smooth out well with Botox alone. That is why Dr. Jeong considers it important to manage lines while they are still at the folding stage, before they set deeply. In Dr. Jeong's judgment, once lines that showed only when you smiled or frowned start to remain at rest, it may be time to consider care before they set in.
Repeated Treatment and Static Lines — Studies of Regular Botox and a Twin Case Report
If repeated folding is reduced, do static lines actually change? The evidence that offers a hint comes not from skin Botox but from studies of regular Botox repeated in the muscles between the brows.
An analysis of three rounds of Botox between the brows
In an analysis published in 2016 (Carruthers 2016), 225 people received Botox in the muscles between the brows three times, 4 months apart, and at each cycle the researchers checked whether the lines between the brows had disappeared completely at rest. After one treatment, these lines at rest disappeared in most participants, and in a little under half they disappeared in all three cycles. The likelihood of a response tended to rise with each cycle, and this trend was clearer in people whose lines were mild at the start, and among them in women aged 55 and older.
This can be read as meaning that lines respond more readily when they are managed before they set deeply, which fits the process described above. However, these results come from a year of continued treatment, so whether the effect lasts after stopping is not known.
A case report of identical twins
For a longer time frame, there is a case report of identical twin sisters (Binder 2006). One had Botox in the forehead and between the brows 2–3 times a year for 13 years, while the other had it only twice; fewer forehead and frown lines visible at rest were seen in the twin treated regularly. There is also a follow-up report on the same twins at 19 years (Rivkin 2015). As the case of a single pair of twins, it should be read as reference material only.
What about skin Botox?
There are no long-term studies yet of skin Botox repeated over years. But if reducing repeated folding with regular Botox led lines at rest to improve with each cycle, Dr. Jeong's view is that skin Botox, which eases some of the pull on the skin a little at a time, can work in the same direction. We want to be clear that this is a judgment based on how it works, not a result confirmed by research.
Because skin Botox manages the spots that fold without taking away much strength, leaving expressions relatively intact, Dr. Jeong considers it meaningful as care that continues over time, and tends to recommend skin Botox not as a procedure that smooths lines all at once, but as anti-aging care that manages them before they deepen.
Studies of Skin Botox Itself — Fine Lines at Rest and Skin Texture
Fine lines around the eyes
The most direct evidence is a randomized study from 2018 (Cao 2018), in which 30 women with crow's feet were divided into three groups, including a muscle-injection group and an intradermal (skin Botox) group, treated once, and assessed at weeks 1, 4 and 12. The score for crow's feet at rest fell from 1.90 to 0.65 at week 4 in the intradermal group. In other words, change was seen not only in lines when smiling but also in fine lines at rest, with intradermal injection.
By week 12, however, the intradermal group had also come back close to its starting level, at 1.60. This is why we see skin Botox as care to be continued periodically rather than a one-time treatment. The study also reported improvements in skin elasticity and collagen content, but the collagen figures were measured from device imaging, so they should be read as reference only.
A small study of 9 people (Chang 2008) also reported that fine lines on the side treated with toxin became softer than before treatment.
Skin texture
There is a little more research on skin texture. In a randomized split-face study of 10 women (Sapra 2017), skin texture improved after intradermal injection, and a mild lift of the midface was also reported. Changes in pores and oil were not clear, however, and the design added muscle injections, so we treat it as reference only.
In a randomized, double-blind split-face study carried out in Korea (Shin 2022, 15 people analyzed), more participants reported improved skin texture on the toxin side than on the saline side at week 4, and nasolabial fold scores also improved on the toxin side. In a placebo-controlled study (Roessle 2025, 33 women completed), skin roughness also improved more than with placebo through day 112. That study enrolled women with skin problems related to wearing face masks.
Both studies were supported by the manufacturer. The changes in oil and pores seen in the same studies are covered in the pore article mentioned above.
Same Drug, Different Depth and Area — Forehead and Eyes, the Edges of the Face, the Jawline
Even with the same Botox, what you gain and what to watch for differ depending on whether it goes into the muscle or the skin, and which area it is placed in.
The forehead — where brow height matters too
A double-blind split-face study (Jun 2018) compared the two methods directly on the forehead. In 3 women aged 52, 56 and 71, one side of the forehead was injected intradermally and the other into the muscle, and they were followed for 24 weeks. The degree of smoothing and the time of peak effect (2 weeks) were similar for both methods. On the muscle-injected side, however, the brow drooped in all three women throughout follow-up, and a heavy feeling in the brow and discomfort with expressions were also reported on that side.
The forehead muscle (frontalis) is the muscle that raises the brows, so when its strength is reduced substantially, the brows can drop and the upper eyelids can feel heavy. The researchers proposed that because forehead skin is thin, intradermal injection still reaches the shallow fibers, while the deeper muscle that supports the brows is less affected. It is a pilot study of only three people, but it shows why the choice of method matters in areas like the forehead, where a drooping brow is a concern.
In the eye-area study above (Cao 2018), intradermal injection also improved lines both when smiling and at rest. The Jun team also noted the hypothesis that in areas other than the forehead, where the skin is thicker, intradermal injection may not reach the shallow muscle fibers. Even with the same intradermal injection, where it is placed can change the result considerably.
The edges of the face — easing the downward pull to tidy the contour
Placing toxin intradermally along the edges of the face to tidy the contour slightly has also been studied. In a randomized split-face study of 22 people (Wanitphakdeedecha 2016), toxin was injected intradermally on one side and saline on the other, and in photographic assessment 2 weeks later, lifting was observed more often on the toxin side than on the saline side. The degree of improvement was mostly mild, and asymmetry of the brows or smile was reported in some participants, which shows that design matters even when the injections are shallow.
A study of 25 women (Atwa 2020) placed injections together below the hairline on the forehead, at the temples, around the eyes, in front of the ears and along the jawline. Lifting was observed in more than half of the participants on the toxin side and in none on the saline side, and the effect was reported to last 16 weeks. Because several areas were injected together, the effect of each area cannot be separated.
Rather than pulling the face upward, this approach is closer to easing the downward pull, so that as the skin texture becomes smoother, the contour looks tidier.
The jawline and neck — two approaches aimed at the platysma
For the jawline, the muscle that pulls down from below, the platysma, matters. This thin muscle covers the neck up to the lower face; when it pulls the jawline down, the jawline blurs and vertical bands stand out on the neck. Reducing this pull makes the jawline look less dragged down. There are two approaches here.
- Nefertiti lift — injected into the muscle along the jawline and the upper part of the platysma
- Lower-face and neck microbotox — placed densely in the shallow layer of the skin over the same area
The Nefertiti technique was first described in 2007 (Levy 2007) in a report of experience with 130 patients, without a control group. In a study that compared the two approaches by giving microbotox to 25 people previously treated with the Nefertiti technique (Awaida 2018), the main changes differed by approach: jowls and neck volume after microbotox, and platysmal bands on the neck after the Nefertiti technique. The result suggests that the suitable approach may differ depending on what you want to address, but because the same people received the two approaches one after the other, the level of evidence is not high.
In a retrospective study without a control group (Park 2021, 20 people), after intradermal injection in several areas including the jawline, jawline measurements improved from week 1, peaked at week 4 and were maintained through week 12.
If the jawline looks saggy mainly because of the muscle, these approaches can be meaningful; if fat or loose skin is the main cause, the effect may be small. Cases with a different cause, such as a double chin, are discussed cause by cause in our article on double chin causes and treatment.
What to expect and what to watch for, by approach
We have not found studies that compared effects by changing only the dilution, the injection depth or the spacing between points. So we plan these details at the consultation, based on the area and the goal. Gathering what studies have reported, approach by approach, gives the following.
| Approach | Main target | What studies reported | Points to watch | Level of evidence |
|---|---|---|---|---|
| Intradermal — forehead and eye area | Fine lines from repeated folding | Eye area: lines at rest improved for several weeks. Forehead: in a comparison with muscle injection, lines smoothed with both methods; brow drooping and heaviness were reported on the muscle-injected side | The effect fades over roughly three months. The forehead comparison was a pilot study of 3 people | Low (small randomized and pilot studies) |
| Intradermal — cheeks and lower face | Skin texture and roughness | Improvement in texture and roughness lasting weeks to months | Some measures showed no clear effect, depending on the study. Some studies were manufacturer-supported | Low to moderate (includes placebo-controlled randomized studies) |
| Intradermal — edges of the face | Tidying the contour by easing the downward pull | Mild lifting seen on photographic assessment (more often than with saline) | Asymmetry (a drooping brow, a tilted smile) reported. Several areas were injected at once, so effects by area cannot be separated | Low |
| Lower-face and neck microbotox | Jowls and neck volume | In a comparison with the Nefertiti technique, changes seen mainly in jowls and neck volume | Not a randomized trial. May have little effect if the sagging is due to fat or skin | Low (level of evidence IV) |
| Nefertiti (injection into the platysma) | Platysmal bands on the neck, jawline | In the same comparison, changes seen mainly in platysmal bands; a technique report on recontouring the jawline | Mostly technique reports without a control group. Injected into the neck muscle, so the points to watch differ | Low |
| Muscle injection — between the brows (regular Botox) | The frowning force itself | With repeated treatment, lines at rest between the brows tended to improve (1 year, while treatment continued) | Not a study of skin Botox. Whether results last after stopping is unknown | Moderate (post hoc analysis of large trial data) |
How Long the Effect Lasts — It Varies by Measure, and the Next Session Depends on Your Skin
How many months skin Botox lasts is hard to answer with a single number, because even within the same study, the effect lasted for different lengths of time depending on what was measured.
| Study | Participants and design | Measure | Period over which the effect was seen | Notes |
|---|---|---|---|---|
| Cao 2018 | 30 women with crow's feet, randomized into 3 groups | Crow's feet at rest (intradermal group) | Peaked at week 4; close to the starting level by week 12 | No difference between groups at week 12 |
| Shin 2022 | 15 people analyzed, split-face vs saline | Skin texture | 8 weeks (no significant difference at week 12) | Manufacturer-supported |
| Shin 2022 | Same study | Nasolabial folds | Improvement maintained through week 12 | — |
| Roessle 2025 | 33 women completed, placebo-controlled randomized | Skin roughness | 112 days | Mask-related skin problems; manufacturer-supported |
| Park 2021 | 20 people, retrospective | Jawline measurements | Peaked at week 4, maintained through week 12 | No control group |
| Wanitphakdeedecha 2020 | 28 women completed, uncontrolled | Nasolabial and jawline contour | 3 months (followed for 6 months) | — |
| Atwa 2020 | 25 women, split-face vs saline (the same side treated in everyone) | Photographic assessment of lifting | 16 weeks | Several areas injected at once |
Lines at rest in the eye-area study (Cao 2018) had come back close to their starting level by week 12; skin texture in the Korean study (Shin 2022) lasted to week 8; and skin roughness in the placebo-controlled study (Roessle 2025) differed from placebo up to day 112. For lifting, a study in which 28 women completed follow-up (Wanitphakdeedecha 2020) looked at duration directly: over 6 months of observation, changes in the contour of the nasolabial area and the jawline were significantly maintained up to 3 months. It helps to keep the observation period (6 months) separate from the period over which the effect lasted (3 months).
All of these periods are results after a single treatment. As a general guide based on Dr. Jeong's blog, skin Botox is usually continued at intervals of around 3–4 months while checking the skin's condition. Even so, rather than fixing the next session like a date on a calendar, we decide it based on when the lines or texture you want to manage start to return, and how much toxin you have had in the meantime, including in other areas.
What to Keep in Mind with Regular Treatment — Unwanted Muscle Effects and Resistance
Unwanted muscle effects
Shallow placement is a way to keep the toxin from reaching the muscle as much; it does not mean that no muscle effect will occur. There are reports of temporary muscle weakness or asymmetry on the side that received a larger dose. In most cases this improves over time, but keeping to the right dose and depth for each area is key.
Resistance — neutralizing antibodies
If neutralizing antibodies (antibodies that inactivate the drug) form against the toxin, the same dose can become less effective. This is not common: in an analysis pooling 33 clinical trials (Jankovic 2023), 27 of 5,876 people developed neutralizing antibodies. These figures include treatment for medical conditions, however, so they are not specific to skin Botox.
Diluting the toxin and placing it shallowly does not remove this possibility, because a weaker concentration and a smaller total amount entering the body are two different things. If you also have Botox in the forehead, between the brows or in the jaw, it is a good idea to keep track of the total amount and the dates rather than going by procedure name. The principles of avoiding frequent touch-ups and leaving intervals are set out in our article on Botox resistance.
At your consultation, letting us know where and when you have had Botox so far, and whether your expressions have ever felt unnatural afterward, helps us plan.
Precautions and Limits of the Evidence
This article is general information based on research published to date and does not replace individual medical care. The effect of skin Botox and how long it lasts can vary with skin thickness, the depth of the lines, expression habits and the cause of any sagging.
After skin Botox, bruising, pain and swelling can occur at the injection sites, and, rarely, unwanted muscle effects such as a drooping brow, an asymmetric smile or facial muscle weakness. With repeated treatment, there is also a possibility that neutralizing antibodies reduce the effect. Before treatment, we check for infection at the treatment site, hypersensitivity to the toxin, neuromuscular disease, and pregnancy or breastfeeding.
The studies on repeated treatment and static lines are data on regular Botox injected into the muscle. The results of repeating skin Botox over the long term have not yet been confirmed, so we have marked this as a judgment based on how it works. Most of the skin Botox studies cited had few participants and followed a single treatment for weeks to months, and some were supported by the manufacturer.
References
- Carruthers A, Carruthers J, Fagien S, Lei X, Kolodziejczyk J, Brin MF. Repeated OnabotulinumtoxinA Treatment of Glabellar Lines at Rest Over Three Treatment Cycles. Dermatol Surg. 2016;42(9):1094-1101. doi:10.1097/DSS.0000000000000704
- Binder WJ. Long-term effects of botulinum toxin type A (Botox) on facial lines: a comparison in identical twins. Arch Facial Plast Surg. 2006;8(6):426-431. doi:10.1001/archfaci.8.6.426
- Rivkin A, Binder WJ. Long-term effects of onabotulinumtoxinA on facial lines: a 19-year experience of identical twins. Dermatol Surg. 2015;41(Suppl 1):S64-S66. doi:10.1097/DSS.0000000000000193
- Cao Y, Yang JP, Zhu XG, et al. A Comparative In Vivo Study on Three Treatment Approaches to Applying Topical Botulinum Toxin A for Crow's Feet. Biomed Res Int. 2018;2018:6235742. doi:10.1155/2018/6235742
- Chang SP, Tsai HH, Chen WY, et al. The wrinkles soothing effect on the middle and lower face by intradermal injection of botulinum toxin type A. Int J Dermatol. 2008;47(12):1287-1294. doi:10.1111/j.1365-4632.2008.03895.x
- Sapra P, Demay S, Sapra S, et al. A Single-blind, Split-face, Randomized, Pilot Study Comparing the Effects of Intradermal and Intramuscular Injection of Two Commercially Available Botulinum Toxin A Formulas to Reduce Signs of Facial Aging. J Clin Aesthet Dermatol. 2017;10(2):34-44.
- Shin DM, Lee J, Noh H, et al. A double-blind, split-face, randomized study on the effects and safety of intradermal injection of botulinum toxin A (incobotulinum toxin A) in the cheek. Ann Dermatol. 2022;34(6):442-450. doi:10.5021/ad.21.316. Corrigendum in: Ann Dermatol. 2023;35(1):88.
- Roessle A, Gluecklich S, Kerscher M, Buntrock H. Efficacy of Incobotulinumtoxin A on Maskne: Evaluation in a Prospective, Single-Center, Placebo-Controlled, Double-Blind Study. J Cosmet Dermatol. 2025;24(Suppl 4):e70391. doi:10.1111/jocd.70391
- Jun JY, Park JH, Youn CS, Lee JH. Intradermal Injection of Botulinum Toxin: A Safer Treatment Modality for Forehead Wrinkles. Ann Dermatol. 2018;30(4):458-461. doi:10.5021/ad.2018.30.4.458
- Wanitphakdeedecha R, Ungaksornpairote C, Kaewkes A, et al. The comparison between intradermal injection of abobotulinumtoxinA and normal saline for face-lifting: a split-face randomized controlled trial. J Cosmet Dermatol. 2016;15(4):452-457. doi:10.1111/jocd.12289
- Atwa EM, Nasr MM, Ebrahim HM. Evaluation of Intradermal Injection of Botulinum Toxin A for Facial Lifting. J Clin Aesthet Dermatol. 2020;13(12):22-26. Erratum in: J Clin Aesthet Dermatol. 2022;15(10):14.
- Levy PM. The 'Nefertiti lift': a new technique for specific re-contouring of the jawline. J Cosmet Laser Ther. 2007;9(4):249-252. doi:10.1080/14764170701545657
- Awaida CJ, Jabbour SF, Rayess YA, et al. Evaluation of the Microbotox Technique: An Algorithmic Approach for Lower Face and Neck Rejuvenation and a Crossover Clinical Trial. Plast Reconstr Surg. 2018;142(3):640-649. doi:10.1097/PRS.0000000000004695
- Park JY, Cho SI, Hur K, Lee DH. Intradermal Microdroplet Injection of Diluted Incobotulinumtoxin-A for Sebum Control, Face Lifting, and Pore Size Improvement. J Drugs Dermatol. 2021;20(1):49-54. doi:10.36849/JDD.5616
- Wanitphakdeedecha R, Yan C, Apinuntham C, et al. Intradermal Micro-Dosing of AbobotulinumtoxinA for Face-Lifting: How Long Does It Last? Dermatol Ther (Heidelb). 2020;10(4):779-789. doi:10.1007/s13555-020-00414-7
- Jankovic J, Carruthers J, Naumann M, et al. Neutralizing Antibody Formation with OnabotulinumtoxinA (BOTOX®) Treatment from Global Registration Studies across Multiple Indications: A Meta-Analysis. Toxins (Basel). 2023;15(5):342. doi:10.3390/toxins15050342
This column is adapted from Dr. Jeong's blog post (2026-11-02, in Korean). Read the original (Korean)
From Consultation Through Treatment
A board-certified dermatologist examines you directly, identifies which layer the cause sits in, sets the device and the parameters, and then carries out the procedure as the same physician. This is not a structure in which a consultant sells the treatment.
The number of sessions, the intervals, the maintenance point and the cost are agreed together before the first session.
Frequently Asked Questions
- If I have skin Botox regularly, will my wrinkles get less deep?
- In studies of repeated Botox between the brows, lines visible at rest tended to improve with each cycle. Because skin Botox also works by easing the force that folds the skin, Dr. Jeong believes it may help keep fine lines from setting into deep wrinkles. There are no long-term studies of repeated skin Botox yet, so this is a judgment based on how it works rather than a research finding.
- Should I get regular Botox or skin Botox?
- It depends on what you want to address. For areas where the frowning force itself needs to be reduced substantially, such as between the brows or the jaw muscle, injection into the muscle is considered; for the forehead, where fine lines, texture or a drooping brow are a concern, intradermal injection is considered. The choice is made area by area.
- Will skin Botox in the forehead make my brows feel less heavy?
- In a small study comparing the two methods on the forehead, the degree of smoothing was similar, and brow drooping and a heavy feeling were reported on the side injected into the muscle. It was a pilot study of three people and individual responses vary, but if a heavy forehead concerns you, this can be considered together at your consultation.
- Can skin Botox lift the jawline too?
- Approaches that reduce the downward pull of the platysma so that the jawline looks less dragged down have been studied. If the sagging is caused by fat or loose skin, however, the effect may be small, so we check the cause first.
- Won't I build up resistance if I keep having it?
- Neutralizing antibodies can form, but this is uncommon, and placing the toxin shallowly does not eliminate the possibility. It is a good idea to space treatments based on your total use, including Botox in other areas, and to avoid frequent top-up injections.