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What a Toxin Scientist Taught Us About Botulinum Toxin

What Professor Andy Pickett, Toxin Scientist, Taught Us About Botulinum Toxin

For thirty years, one scientist has been doing something the aesthetic industry rarely welcomes: applying rigorous evidence to its most widely used treatment and challenging the myths that have accumulated around it.

Professor Andy Pickett occupies an unusual position in aesthetic medicine. He is not a clinician. He probably has never injected a patient. His is pharmaceutical science, forty years working with biological products in the industry, the last thirty of them focused almost exclusively on botulinum toxin.

He is Director and Founder of Toxin Science Limited in Wrexham, and Adjunct Professor at the Research Center, Institute of Advanced Sciences, University of Massachusetts, and has delivered over 500 lectures on botulinum toxin and its uses to audiences worldwide.

What Dr Pickett brings to a field dominated by clinicians, industry representatives, and training organisations is something relatively rare: a deep understanding of what botulinum toxin actually is, how it actually behaves, and crucially, where the gap between the science and the received clinical wisdom is widest. That gap, it turns out, is considerable. And Pickett has spent much of his career pointing it out, sometimes to audiences who possibly would have preferred not to hear it.

most consistent and most publicly stated concern about botulinum toxin in aesthetic practice is the persistence of misconceptions that have no basis in the science. Over the years, certain misconceptions, errors, mistakes, and myths, notably about the different products used, have perpetuated. These have generally been linked to marketing efforts to one product from others.

The title of his 2019 paper in the Aesthetic Surgery Journal "Continuing Myths About Botulinum Toxin Use in Aesthetics Are Unhelpful and Unnecessary" is not a title chosen for diplomatic effect. It reflects the genuine frustration of a scientist who has watched marketing-driven claims as clinical fact across training courses, conference presentations, and product literature for decades.

The most commercially sensitive of Pickett's positions, and the one most likely to generate resistance from industry, concerns the meaningful equivalence of the different licensed botulinum toxin products available for aesthetic use.

The marketed between products are considerable. Manufacturers have invested significantly in positioning their products as distinct from competitors, claims about molecular size, diffusion characteristics, onset and duration profiles, and the presence or absence of complexing proteins. Pickett's analysis of the underlying science most of these distinctions directly.

The evidence suggests that experienced users should achieve equivalent results regardless of BoNT-A formulation, but additional, well-designed, adequately powered, controlled randomised studies should be performed.

The complexing proteins argument, which holds that Botox and Dysport, which contain accessory proteins surrounding the toxin core, behave differently from Bocouture (Xeomin), which does not, is one has specifically examined. His position, supported by the available evidence, is that the complexing proteins from the neurotoxin before injection and play no meaningful role in behaviour. The majority of differences between products seen clinically are, by far, due to simple dose differences used in studies, OnabotulinumtoxinAAbobotulinumtoxinAIncobotulinumtoxinAPrabotulinumtoxinALetibotulinumtoxinARimabotulinumtoxinBHyaluronic Acid FillersCalcium Hydroxylapatite FillersPoly-L-lactic Acid FillersPolymethylmethacrylate FillersAutologous Fat GraftingForehead Lines TreatmentGlabellar Frown Lines TreatmentCrow's Feet TreatmentBunny Lines TreatmentChemical Brow LiftLip FlipGummy Smile CorrectionMasseter ReductionJaw SlimmingDimpled Chin SmoothingCobblestone Chin SmoothingNefertiti Neck LiftMicro-BotoxMesotoxHyperhidrosis TreatmentChronic Migraine ReliefBruxism TreatmentTMJ TreatmentCervical Dystonia TreatmentNeck Spasm TreatmentBlepharospasm TreatmentLip AugmentationLip ContouringCheekbone EnhancementTear Trough FillersNasolabial Fold SofteningMarionette Line FillersLiquid RhinoplastyNon-Surgical Nose JobJawline ContouringJawline DefinitionChin AugmentationTemple VolumisingHand RejuvenationAcne Scar Subcision Filling especially when two or more products are being compared.

The practical implication is significant. Practitioners who report meaningfully different clinical behaviour brands, namely different onset, different spread, different duration are, in view, primarily observing the consequences of different dosing conventions and different reconstitution rather than genuinely different biological activity from the same active molecule.

The are not identical in formulation. In experienced hands, at appropriately calibrated doses, they are clinically equivalent.

It is worth acknowledging here, in the spirit of the evidence transparency we have about elsewhere in this blog, that Pickett has held a senior scientific role at Galderma, the manufacturer of and Azzalure. A position that brand differences are largely marketing-driven is not without commercial convenience for a manufacturer whose products have sometimes been perceived as lower potency per unit than a competitor. His science is sound, but the context is worth noting.

If Pickett's position on brand equivalence is the most commercially sensitive of his contributions, his analysis of post-treatment instructions is the most practically interesting for the clinical practitioner.

The standard aftercare instructions given to following botulinum toxin treatment e.g. do not lie down for four hours, do not exercise, do not massage the area, remain upright, avoid heat, are almost universally taught and almost universally given. They have the authority of established clinical practice behind them. What they do not have, according to Pickett's analysis, is meaningful scientific evidence.

The reason comes down to the biology of toxin binding. Most of the toxin is inside the neuromusclar synaptic vesicles within five to ten minutes after binding. Once the botulinum toxin has bound to the presynaptic nerve terminal at the neuromuscular junction and been internalised into the synaptic vesicle, it is effectively committed. The subsequent steps, translocation of the light chain into the cytoplasm, of the SNARE protein, occur inside the cell and are not influenced by what happens at the skin surface or in the surrounding tissue. There have been no demonstrated alterations of effect from massaging or not massaging the areas injected post-treatment.

A large Italian retrospective study published in 2025, which cited 2019 paper directly, provided clinical support for this position. A retrospective, multicentric study of 5,014 patients found that omitting extended post-injection instructions does not negatively impact patient satisfaction or rates. Given the toxin's rapid and localised effect, extended behavioural restrictions may be redundant.

There is no evidence that keeping the head elevated for six hours post-treatment reduces the chance of adverse events. The instruction persists not because the evidence supports it but because it has been taught, repeated, and institutionalised to the point where questioning it feels contrarian. This is precisely the kind of clinical myth that Pickett's 2019 paper title was aimed.

Dr Forrester heard a conference presentation on this topic by Dr Pickett, years ago and abandoned almost all advice at that point in time.

Given that one of the very few significant is upper lid ptosis, Dr Forrester has always believed that advising to keep the head elevated is completely counter-intuitive. This is because the eyelid elevator muscle (levator palpebrae superioris) lies immediately inferior to the lateral injection point of the corrugated muscle. So gravity would increase the likelihood of lid ptosis if the head were kept upright. If it weren’t for our knowledge of the rapid toxin binding, above, we should be advising patients to avoid keeping their head up and lie flat after treatment!

One of Pickett's less widely known but scientifically interesting positions concerns the use of ice or cooling before or after injection — a common practice for patient comfort and to reduce bruising. Cooling the treatment area might hinder BoNT-A and should probably be abandoned.

The basis is sound, reducing tissue temperature slows metabolic processes including the internalisation of the toxin into the nerve terminal. If the toxin is bound at the surface of the presynaptic membrane but not yet internalised, cooling could theoretically slow or reduce the efficiency of that internalisation step. The clinical evidence for this effect is limited, but the mechanistic plausibility is real and it stands as an example of a routine clinical practice that has never been properly examined against the underlying science.

The picture is not entirely one of abandoned . Pickett acknowledges one area where post-injection behaviour does appear to influence outcome and the direction of the effect is the opposite of what conventional caution would suggest. The only study showing that post-treatment muscle activity by a patient can be beneficial demonstrated that masseteric muscle atrophy was significantly higher in patients who clenched their chewing muscles for two hours per day after treatment. Recommending chewing gum after masseter toxin would be sound clinical advice — although this evidence is very preliminary.

The mechanistic basis is plausible: active muscle contraction may toxin uptake at the neuromuscular through increased recycling of synaptic vesicles. If confirmed in larger studies, it would represent a genuine evidence-based modification to post-injection practice — and a rather elegant inversion of the standard "rest the muscles" instruction.

Andy Pickett has done that the aesthetic medicine field needs more of: applied the standards of pharmaceutical science to the claims, practices, and received wisdom of a rapidly growing .

He has challenged brand differentiation claims that are more marketing than science.

He has examined post-treatment instructions that are more convention than evidence.

He has identified practices i.e. cooling and certain aftercare restrictions that may be unnecessary or counterproductive.

And he has done so consistently, across hundreds of lectures and multiple peer-reviewed publications, with the rigour of a scientist rather than the authority of a clinician.

Not all of his positions are uncontested. The brand equivalence argument in particular continues to generate debate, and his industry affiliations are relevant context when evaluating his conclusions. But the core of what he has argued, that botulinum toxin practice in aesthetics carries more myth than most practitioners acknowledge, and that the science deserves more respect than the marketing it has accumulated is both well-evidenced and worth heeding.

For those of us who attended his lectures a decade ago and came away with the unsettled feeling that much of what we had been taught was more tradition than science, the published record confirms that the feeling was justified.

The views expressed in Clinical Perspectives are the Dr Forrester’s own and reflect his personal and professional experience of 15 years in aesthetic medicine.

Pickett A. Continuing Myths About Botulinum Toxin Use in Aesthetics Are Unhelpful and Unnecessary. Aesthetic Surgery Journal. 2019;39(5):NP150–NP151. 

Dover JS, Monheit G, Greener M, Pickett A. Botulinum Toxin in Aesthetic Medicine: Myths and Realities. Dermatologic Surgery. 2018;44(2):249–260. 

Nestor MS, Kleinfelder RE, Pickett A. The Use of Botulinum Neurotoxin Type A in Aesthetics: Key Clinical Postulates.  Surgery. 2017;43 Suppl 3:S344–S362. 

Pickett A. Dysport: pharmacological properties and factors that toxin action. Toxicon. 2009;54:683–9.

Talarico S et al. Are Post-Care Recommendations Following Upper-Face Botulinum Toxin Treatment Scientifically Necessary? A Retrospective Study Based on 5000 Patients. Toxins. 2025;17(8):372. 

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