What Is ‘Trap Tox’ and Why Is It So Popular?

Those who seek Botox (botulinum toxin injections) to reduce tension in the muscles along the jawline know how effective the treatment can be for headache and TMJ relief. In the past couple of years, a similar off-label treatment, dubbed “trap tox,” has gained traction among those looking to release tension in the trapezius muscles too. It has become popular as a way to reduce tension in the back, shoulders, and head, and create a slimming effect as a result.

Then there’s the Kardashian effect: In a teaser for season 3 of The Kardashians, Kim Kardashian indicated that she had received Botox in her neck area (something that may explain the slimming effect in her shoulders and neck that some fans had attributed to Photoshop). Unsurprisingly, interest in the treatment surged on social media, with videos related to “Kim K Trap Tox” having since racked up some 9.7 million views on TikTok.

But is “trap tox” really an effective way of relieving back and shoulder pain, and slimming the neckline, to boot? To get answers, we talked to a plastic surgeon and master injector.

What Is ‘Trap Tox’?

So-called “trap tox” is the treatment of injecting botulinum toxin (such as Botox, Xeomin, or Daxxify) into the trapezius muscle, the large superficial muscle on the back and base of the neck that resembles a trapezoid in shape, in order to relax the muscle. The treatment serves two purposes: Functionally, it can alleviate tightness and pain in the head, shoulders, and/or neck, while cosmetically, the treatment can slim the appearance of the neck and shoulders (in this context, it’s sometimes referred to as “Barbie Botox”).

Though the treatment became wider known after Kardashian mentioned having undergone it, the medical professionals we spoke to for this story report that most of their patients seek the treatment to alleviate pain and tightness in the back and shoulders and/or to minimize headaches. 

How Does ‘Trap Tox’ Work?

Like with other botulinum toxin injection treatments, the injection used for “trap tox” works to weaken the muscle’s ability to contract and block pain-relaying nerve signals. “It’s certainly not paralyzing the muscle, because with a paralyzed trapezius you’d lose the very important functionality of being able to hold the head up,” says Dr. Alexander Rivkin, M.D., a Los Angeles-based plastic surgeon and assistant clinical professor at the UCLA School of Medicine.

When botulinum toxin is administered for cosmetic purposes, the muscle is atrophied and shrinks over about four months’ time, creating a more elongated look in the neck or shoulder area.

Who Are the Best Candidates for Treatment?

Those looking to relieve tension in the shoulders, neck, or head, or those looking to slim the neck or shoulders may be good candidates for functional and cosmetic “trap tox,” respectively. These patients often have hypertrophy, an enlargement of the tissue due to an increase in the size of its cells. But there are a few caveats to consider before you jump into the trend.

Though patients may request “trap tox” to reduce headaches and neck and shoulder pain, a different treatment area sometimes proves to be a more effective way to achieve results. “A lot of times, a patient’s tension doesn’t originate in the neck or shoulders, but as teeth grinding,” Dr. Rivkin explains. “Because teeth grinding can trigger headaches and neck pain, I will first look to the masseter muscles to confirm whether that may be the root of the pain and/or the best first point of injection.”

Who Shouldn’t Get ‘Trap Tox’?

Dr. Rivkin also notes that not all patients seeking “trap tox” for cosmetic reasons (lengthening or slimming the appearance of the neck and/or shoulders) make good candidates. “Not everyone seeking this treatment for cosmetic reasons has hypertrophy of the trapezius muscles, so the practitioner must be able to identify whether this is the case,” he says. “Just because you want a neckline that looks like Audrey Hepburn’s from the back, doesn't mean it’s possible to achieve with botulinum toxin. You need to have actual hypertrophy. For every patient who is a good candidate for this treatment cosmetically, there are a lot who are not and who the practitioner will need to reject.”

Those seeking the treatment for cosmetic purposes should also consider whether they truly want to weaken the large set of back muscles in the first place. Olivia Salmen, R.N., C.P.S.N., an advanced aesthetic nurse injector based in Brentwood, Tennessee, says those with an intense workout regimen may not want to change the functionality of their traps to achieve a slimmer look. “This treatment does affect certain exercise motions because you’re weakening the muscle,” she says. “For example, when you shrink the traps, you’re less likely to be able to lift as heavy of objects as before having the treatment done. Most people don’t really think about that outcome until they feel the difference in the strength of the muscle three or more months after treatment.”

What Does a Typical Treatment Entail?

Because the trapezius is a large, strong muscle, treatment typically involves dozens of injection points. “I try to cover as much of the muscle as possible, going up into the neck, into the post into the back of the neck, and then down onto the shoulders,” Dr. Rivkin says. “It’s a large surface area, so you need a lot of units of botulinum toxin in order to treat it effectively.”

In fact, he says at least 50 units of botulinum toxin per side are commonly required, though he frequently treats with 70 to 75 units of botulinum toxin per side. 

Is ‘Trap Tox’ Painful?

Though receiving dozens of needle pricks doesn’t sound especially fun, Dr. Rivkin says his patients liken the treatment to a painless acupuncture session. “I use very small needles and very small syringes to inject small amounts of product into each injection point,” he says. “This allows me to be very precise in how I inject and it also makes it so pain isn’t much of an issue.”

How Long Does Treatment Last?

As with other botulinum toxin treatments, results vary from person to person and can depend on factors such as the number of units used. However, unlike botulinum toxin injections for treatment of facial wrinkles (and for which subsequent treatments are commonly expected every three to six months after the first treatment), ongoing “trap tox” treatment to address headaches and muscle tension in the neck and back typically requires far less maintenance.

“Treatment for the traps is a little different than botulinum toxin injections for the face because of the stress response involved,” Dr. Rivkin explains. “When you weaken the muscle for a prolonged period of time, such as when doing these injections a few times in a row, you’re cutting the muscle’s ability to signal to the brain, ‘I’m contracting,’ as a response to stress. You can degrade that reflex after a few treatments, so there’s a chance you won’t need to go in for additional treatments to maintain the functional benefits of less tension and/or fewer headaches.”

The cosmetic surgeon says that for the majority of his patients seeking tension or pain relief from “trap tox,” pain and headache relief is achieved for “quite a long time” after two treatments. He typically requests patients return for a second dose three months after the initial treatment.

Those seeking tension or pain relief from the treatment will likely notice maximum results two weeks after the treatment, while those seeking cosmetic results are likely to see optimum slimming three or more months after treatment.

What Are the Potential Risks?

Botulinum toxin is one of the most studied drugs in the field, Dr. Rivkin points out, with an enormous amount of medical data and studies proving its safety. “Even considering the large quantities needed to treat a big muscle like the trapezius, the margin of safety is so very, very large,” he says. “We know it’s quite safe because we treat [conditions such as] cerebral palsy and those kinds of indications using much, much more of the toxin.”

Even so, “trap tox” is considered “off-label” because the upper trap/neck area is not an FDA-approved treatment, even though the drug used is approved. Off-label treatments are legal and common and up to the physician's discretion. 

Dr. Rivkin notes, however, that overtreatment can pose a risk. “If you inject 100 units per side of the trapezius in a slender patient with small traps, then the patient can potentially have some trouble with head support,” he says. “But it's pretty rare to overdose if you're treating within the [physician-]recommended dosage amounts.” Rivkin considers himself a conservative injector who errs on the side of undertreatment. For this reason, he schedules patients for a follow-up appointment two weeks after treatment to confirm whether additional units of toxin are needed for optimal results. 

How Much Does ‘Trap Tox’ Cost?

Costs vary by location and the amount of units used per treatment, but Dr. Rivkin notes that as a general rule of thumb, one can expect to pay about $1,200 to $1,700 or more per treatment. “Ultimately, the cost for treatment depends on where you go, but I think that if you're paying under $10 per unit, then I would be very suspicious of the place and from where the provider is getting their toxin,” he says. Certifications for who can legally administer such injections vary from state to state, so be sure to check with your state’s medical board to confirm which types of providers can safely administer botulinum toxin. Medical insurance may cover treatment for those seeking functional benefits, such as tension relief, but not all aesthetic providers accept insurance, so check with your insurer and the medical provider to ensure qualifying insurance plans are accepted when making your appointment.