Can You Be Too Old for Neurotoxin Injections?


Most of the conversation surrounding neurotoxins and age revolve around the younger end of the spectrum and prejuvenation: Questions like “How young is too young?” and “If I start young, will I look better when I’m older?” flood doctors’ offices and Google searches. But there’s a whole other group of patients—those ages 70 and up—who benefit from a bit of muscle freezing, if you will, and this particular conversation focuses on them.

“I do think older people get concerned thinking they’re past an age where they can do anything, or they have to have surgery at this point, but there is a lot we can do that is nonsurgical and still get good results,” says Campbell, CA dermatologist Amelia K. Hausauer, MD. “We often end up skewing toward talking more about millennials and younger people, but there’s a whole other end of the spectrum. We don’t end up talking about some of the older patients and what they may or may not be good candidates for.” Here, we are.

Is there a recommended “age limit” for neurotoxins?

Dover, OH facial plastic surgeon David Hartman, MD says neurotoxins “work” on older people by the same mechanism that they work on younger people: by decreasing the contraction of the underlying facial muscles, which lead to the “bunching” of the overlying skin. “‘Dynamic lines’ from bunching skin comprise the majority of lines found on a younger person’s face,” he explains. “By contrast, ‘static lines’—primarily caused by decades of sun exposure—are far more prevalent in an aging face.  Static lines are wrinkles that are present all the time, not just when underlying muscles are contracting. Neurotoxins only work on dynamic lines. Because many of the lines on an aging face are static lines (wrinkles), neurotoxins are not as effective at smoothing an aging face overall. However, in the appropriate aging face, neurotoxins can still be highly effective.”

Dr. Hausauer agrees, saying neurotoxins work for any age group when they’re done appropriately and with respect to the patient’s anatomy. “The difference with age is that as we get older, our muscle strength changes and the way the muscles balance one another may change, which a board-certified doctor will be aware of when using neurotoxins. I had a patient who came in last month and she said she didn’t like the lines between her eyebrows and she wanted a little lift here and there, but she wasn’t interested in surgery and didn’t think she was a candidate. I told her there were plenty of nonsurgical things we could do, and she looked great. Then I looked at her chart and she was in her 90s!”

Do neurotoxins last just as long in patients ages 75 and up as they do in younger patients?

“Neurotoxins disable the thousands of microscopic nerve endings (neuromuscular endplates), which trigger muscle contraction,” says Dr. Hartman. “The duration of the effect of neurotoxins depends on how long it takes a person to regenerate new ‘neuromuscular endplates.’ Endplates disabled by neurotoxin injections take three to five months to re-sprout and become active again. Arguably, neurotoxins last longer in seniors simply because seniors ‘regenerate’ nerve endings somewhat slower than younger people do.”

However, this is not always the case across the board. Dr. Hausauer says the reason some older patients are able to go longer between dosing is because they’ve been getting neurotoxin injections for a long time, and as a result, they’ve kind of retrained their muscles, so they don’t make those same expressions. “Sometimes as you get older and you’ve done the procedure for longer and longer, you can get a bit of an extended duration out of your treatment. But I don’t think age in and of itself makes you metabolize the neurotoxin faster,” she explains.

Do older age groups need more units of neurotoxin to achieve the same result as younger patients?

Contrary to what we may think, the doctors agree older patients often actually need fewer units. “Sometimes as we get older, our muscles become thinner and weaker, and in fact we may need a little bit of a lower dose in those muscles,” says Dr. Hausauer. “The one place I think the dosage definitely goes down as people age is the forehead. They become more reliant on their forehead muscle to hold up their eyebrows, so especially as they lose volume on the orbital rim (the bone above the eye) and actually in the forehead itself, they become very dependent on the muscle to hold their eyebrows up. We may sacrifice some lines here, but if I put too much in there, your eyebrows are going to be sitting on your eyelids and you’re going to be really unhappy with me.”

However, patients at these ages may also want to treat more areas, so the overall amount used may go up. “We may end up treating their glabella, their crow’s-feet and some off-label areas to try to counteract any areas where muscles are depressors, meaning they pull down,” Dr. Hausauer adds.

How often are doctors administering neurotoxin injections on patients ages 75 and up?

Dr. Hausauer does them frequently—she has a wide age range of patients, from millennials to those in their 70s, 80s and beyond—and most often in conjunction with fillers. “As we age, because of the loss of collagen and the changes in the fat pads, we’re often restoring volume,” she explains. “And then we’re using neurotoxins to minimize some of the more dynamic areas like around the eyes and between the eyebrows. And neurotoxin also helps with the longevity of the filler: If you can not have the muscle contracting against it continuously, the filler will tend to last longer.”

Another important point to keep in mind, according to Dr. Hartman: “Aging faces tend to have thinner, more fragile skin, which increases the risk of bleeding and bruising,” he says. “All medication use in aging persons must be done with extra care, as they tend to have more complex medical issues and take more medicines—especially blood thinners—which can complicate neurotoxin injections by causing bruising. However, there are many very healthy older people who live extremely active lives, who benefit greatly from the more rested and more youthful appearance of a face treated with neurotoxins.”

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