Aarti Narayan-Denning, MBBS

Dear yesenias1990,

I see exactly what you mean.

And I can see what has happened here as well. You are very perceptive. 

First thing is, do not worry, your smile will look happy and not "starey" in about 12 - 16 weeks after injection. Second thing, and more important, don't have "crows feet" botox again for many years, keep those laughter lines. They are beautiful.

When we say treat "crow's feet" with botox, what we mean is that we are injecting botox into the orbicularis oculi, the drawstring muscle around the eye, very thin muscle, to make it more difficult to scrunch it - something one needs to to be able to do when protecting the eyes by squinting, squeezing eyes tight shut, etc.


On the surface (and for btx injectors) it may seem the right thing to do to remove those smile lines that pop up at the corners of our eyes when we smile, especially since drug companies decided to call them by the ugly term "crow's feet" - I call them smilies.
But is it really the right thing in terms of facial expression as a whole?
Probably not. There is a popular psychology term the "Pan Am Smile" named after the friendly but forced smile that was trained into the Pan Am flight crews when greeting people as part of their "great customer service" image.
Today, some may refer to it as the courtesy smile which is polite but superficial.

What your photo shows is a "Botox smile". French physician Guillaume Duchenne (1806-1875) described this "courtesy smile", as "the smile that plays upon just the lips when our soul is sad."
Duchenne researched the smile in great detail in 1862.
His findings revealed that an artificial smile used only the large muscles on each side of the face, the zygomaticus major. 

But a genuine smile, induced by a joke, involved the obicularis oculi, as well. The resulting effect is a visible wrinkling around the corners of the eyes that lies outside voluntary control. You really can't help a happy smile smile - it just bursts upon your face!
Remember, these lines appear with smiling, but don't leave creases unless your skin is deteriorating due to pile-up of dead cells or photo-aging (sun-damage).

In research circles, a genuine smile is still known as a ‘Duchenne Smile’ while a fake smile is a ‘Pan Am Smile’ after the air hostesses in the defunct airline’s adverts.

Hope my philosophical/ medical ramblings would both reassure and inform you! Good luck!


Focus not just on the lines, but on the face and person as a whole!

Great question texaswildflower - in fact a bit of philosophy goes into it - you do seem to think quite deeply.


On the surface it may seem the right thing to do to remove those smile lines that pop up at the corners of our eyes when we smile, especially since drug companies decided to call them by the ugly term "crow's feet" - I call them smilies.
But is it really the right thing in terms of facial expression as a whole?
Probably not. A term in popular psychology is the "Pan Am Smile" named after the friendly but forced smile that was trained into the Pan Am flight crews when greeting people as part of their "great customer service" image.
Today, some may refer to it as the courtesy smile which is polite but superficial.
French physician Guillaume Duchenne (1806-1875) researched the smile in great detail in 1862.
His findings revealed that an artificial smile used only the large muscles on each side of the face, the zygomatic major, while a genuine smile, induced by a joke, involved the muscles running through the eyes, obicularis oculi, as well. The resulting effect is a visible wrinkling around the corners of the eyes that lies outside voluntary control. You really can't help a happy smile smile - it just bursts upon your face!
Remember, these lines appear with smiling, but don't leave creases unless your skin is deteriorating due to pile-up of dead cells or photo-aging (sun-damage).

In research circles, a genuine smile is still known as a ‘Duchenne Smile’ while a fake smile is a ‘Pan Am Smile’ after the air hostesses in the defunct airline’s adverts.
Duchenne described this "courtesy smile", as "the smile that plays upon just the lips when our soul is sad."
Science has actually proven this to be true - In the late 1950s, 141 female students at Mills College in California agreed to a long-term psychological study. Over the next 50 years they provided reports on their health, marriage, family life, careers and happiness. In 2001 two psychologists at Berkeley examined their college yearbook photos and noticed a rough 50/50 split between those showing a Duchenne or Pan Am smile. On revisiting the data it was found that those with a Duchenne smile were significantly more likely to have married and stayed married, and to have been both happier and healthier throughout their lives.
We now know the "Pan am smile" as the "Botox smile" because the rest of the face smiles but nothing happens around the eyes.
When we say treat "crow's feet" with botox, what we mean is that we are injecting botox into the orbicularis oculi to make it more difficult to scrunch it - something one needs to to be able to do when protecting the eyes by squinting, squeezing eyes tight shut, etc.
So your expressions do affect your emotions, and vice versa - another reason not to focus just on the lines, but on the face and person as a whole! 

Good Luck!

Dear Nicosia, 

That is a very interesting question! And, you will be pleased to know, has been a sort of "holy grail" for good non-surgical treatment. I can answer your question simply and more elaborately. 

The simple answer would be "No, larger amounts of hyaluronic acid are Not always required for subsequent treatments, If the other factors affecting skin aging are controlled." - that is a big If!

To elaborate on this, here are some basic principles, which I use very successfully in full-face non-surgical lifts to get a bespoke and very natural result that lasts. 

1. Skin aging is a cumulative process, and after age 35, sometimes called "dermopause" the skin declines faster than it restores itself.
2. Hyaluronic acid replacement, if done in the correct facial regions where we lose volume with age, has been shown to substantially slow down the rate of skin aging, by improving the collagen content, and in some cases even helping the skin heal from photo-aging
3. Sun damage (photo-aging) has been shown to cause depletion of collagen below the skin surface, and speed up skin aging. 
4. Sun exposure, nutrition, emotional factors - all impact the rate of skin aging, and happily we can take steps to optimise all these. 
5. Unfortunately some patients may have had fillers in less ideal places, for example all along the nasolabial fold, which is rather unnatural and can look distorted in the long term. It can be difficult to sustain this, so they will end up needing more if they wish to persist in the same technique. 
6. However if you get assessed and treated by an appropriate doctor and have an aesthetic correction, you will actually need the same or less amount of correction later for maintenance. 
7. A good treatment using a full-face approach will give you a most satisfying result and need less filler to maintain, as long as you are ensuring good sun protection all year round, letting your skin breathe, keeping your exercise moderate (you don't want a "gym-face"), keeping nutrition optimum (no yoyo diets) and hydrating yourself by drinking plenty of water.

Dear AbbyLucy123, I can see from the partial picture that the Right side of the upper lip is not moving as much, causing the "pulling away" of the left side of the mouth. 

To better understand the nature of the problem, and to avoid it recurring in future, could you tell me the following:

- the treatment which led up to this situation, was it botox treatment for "crow's feet" or was it injections anywhere near the upper or lower lips?

- at this point, do you have any problems with squeezing shut your eye on the affected side?

- where you trying to smile in this picture?

- and lastly, which side does not move when you try to smile?

The reason I am asking these questions is that depending on where the initial botox injection was, muscles involved with shutting the eyes, puffing out the cheeks, and smiling are present very close to each other in different layers in the face. 

The experience and anatomical knowledge of your injector is key in selecting the injection points and depth. 

For example, if one injects the lowest line running down from thecorner of the eye, over the cheekbone, and into the cheek, with botox, assuming this to be just another "crows feet" line, or if one injects close to the inner corner of the eye, they could end up paralyzing (temporarily of course):

- the zygomaticus major (pulls the upper lip outwards and upwards during natural smile), or 

- the levator labii superioris (lifts the upper lip to expose the the upper row of teeth/ gums during a smile).

So if you got this result following an upper face treatment, the reasons will be quite different from those results following migration from a lower face treatment. 

Best regards,

The evidence base showing improvement in patient-reported well-being scores following non-surgical treatments (such as botulinum toxin, fillers, etc) is now fairly well-established (I hear you heaving a sigh of relief at this, being the analytical academic you are!). 

I will list a couple of "on-the-nose" academic works below, and when you look up those citations on PubMed you will see the related research alongside, and appreciate how the research has evolved with the prevalence of treatment. 

Jandhyala R, J Clin Aesthet Dermatol. 2013 Sep; 6(9): 41–45. PMCID: PMC3780803


Davan SH, Dermatol Surg. 2010 Dec;36 Suppl 4:2088-97. doi: 10.1111/j.1524-4725.2010.01795.x.

There are many more, especially when taken in conjunction with the various aging and wrinkle-scoring systems that have developed. 


In the 2010 study - which was published in Dermatologic Surgery, interestingly, the emphasis was on the benefit to self-esteem in first-time patients, which was then sustained when treatments were repeated.

The 2013 work - note that it is in Clinical Aesthetic Dermatology - is more explorative, and the author has utilised standardised quality of life measures to show how it is not just the appearance that improves, or how they feel about themself, but that it improves other aspects of quality of life, the "intangibles".


One difficulty with getting data and evidence in this area is that there many of us who still see this as the "dark side" may be a bit reluctant to share! The take-home message is essentially that if done right, the benefits far outweigh the risks.

But do not worry, the prevalence of these treatments is reassuringly high. I am certain that you will look up a well qualified medical professional to perform your assessment and treatment, because you have to do it right the first time, get your questions answered, remember that taking control of aging and appearance is an ongoing process. Choose the right doctor, and you will be happy ever after! Good luck.