Botox Aftercare Instruction Sheets - Why We Stopped Using Them

Why our Botox post-treatment instructions are in the bin.

Most clinics hand patients a list of things to do and avoid after botulinum toxin treatment. Here is the science behind why ours got considerably simpler — and what a toxin scientist had to do with it.

This post is an extract from the extended version on our Perspectives Blog.

The A4 Botox Instruction Sheet

For a number of years after starting in aesthetic practice, we gave every patient who had botulinum toxin treatment a printed A4 sheet of detailed aftercare instructions. It was thorough. It covered what to do, and what to avoid, for how long, and why.

It felt responsible and professional; the kind of thing a careful medical practice does.

Then over a decade ago, Dr Forrester attended a lecture by Professor Andy Pickett.
And the A4 sheet was quietly consigned to the waste bin and never seen again..

Why our Botox post-treatment instructions are in the bin.

Who is Dr Andy Pickett?

Professor Pickett is not a clinician. He has probably never injected a patient. He is an eminent scientist who has spent over thirty years working specifically on botulinum toxin; its structure, its mechanism of action, and the gap between what the science says and what the aesthetic industry teaches. He has delivered over five hundred lectures worldwide and published extensively in prestigious medical and scientific journals. When he talks about botulinum toxin, it is worth listening very carefully.

What he said about aftercare instructions was simultaneously obvious in retrospect and genuinely surprising in the moment.

What happens after a Botox injection — the science

Botulinum toxin works by attaching selectively to receptors at the junction where the nerve attaches to the muscle. It then enters nerve-ending cells where it disrupts the signals responsible for muscle activity. Once that ‘internalisation’ has occurred, the toxin's fate is determined. It is inside the cell, working at a molecular level, and nothing that happens at the skin surface or in the surrounding tissue is going to change that.

The critical detail is the timing. Most of the toxin is internalised within 5~10 minutes of binding. By the time a patient has put on their coat, paid, and walked out, the biological process that will determine their clinical outcome is essentially complete. The question of whether they then lie down, exercise, or have a hot shower is, from the toxin's perspective, largely irrelevant.

What the evidence says about specific instructions

Lying flat and head elevation

There is no clinical evidence that keeping the head elevated after treatment reduces complications. And if you think about the specific complication practitioners most want to avoid, that of upper eyelid droop (ptosis), caused by downward diffusion of toxin towards the muscle that lifts the eyelid — keeping the head upright theoretically increases rather than reduces the hydrostatic pressure driving any unbound toxin downwards. The instruction makes no mechanical sense and has no evidential basis. We stopped giving it years ago. However, not lying flat is still widely advised. Even the prestigious Cleveland Clinic still advocates keeping your head elevated.

Massaging the area

There is no demonstrated clinical effect from massaging or not massaging the treated area after treatment. We ask patients not to rub or massage for a couple of hours simply as a sensible precaution while any minor swelling settles. It is not going to affect the toxin.

Exercise and hot baths

This is where we do give advice, but with an important distinction. Strenuous exercise and hot showers increase blood flow to the face, which is why they make you red in the face. Increased blood flow in an area that has just been injected may worsen bruising. So we advise against both for the rest of that day. Not because they will affect the botulinum toxin, but because they may make a bruise worse. That is a meaningful and honest distinction that most aftercare sheets do not make.

The 7~14 day rule

A number of our patients have mentioned that their beautician has told them not to come in for a facial for one, or sometimes two weeks after a botox treatment. It is a precaution taught in beauty training and repeated in good faith by practitioners who do not have the scientific background to question it.

Our advice to patients is simple: the one/two week rule has no scientific basis, and a facial a day or two after well-delivered botulinum toxin treatment is entirely safe. If your beautician asks whether you have recently had a Botox treatment, you are of course free to tell them but that risks them refusing to perform your facial treatment. The restriction they would impose is not clinically necessary. Or you could quite safely tell a white lie and say you haven’t had one.

What our aftercare advice now looks like

Don't massage or rub the treated area for a couple of hours. Avoid strenuous exercise and hot baths or showers for the rest of the day, not because of the Botox, but because of potential bruising. That is it.

No A4 sheet. No list of restrictions. No instruction to stay upright or keep your head elevated. Just two sensible, evidence-based pieces of advice — and the honest explanation of why each one exists.

Why this matters

It matters because patients deserve accurate information rather than inherited caution. And it matters because the gap between what the science supports and what clinical culture teaches is wider than most practitioners acknowledge, not just in aftercare instructions, but across a range of botulinum toxin practice. Professor Pickett has spent thirty years pointing that out. We think he is right. But unfortunately this seems to largely have fallen on deaf ears.

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