My question concerns the so called Mephisto effect from an injection with Botox.

Is there a risk that the skin of the upper eyelid and under the brow gets stretched (from being pulled up and sideways) that it gets wrinkled and saggy?

Doctor Answers 10

Long term effects of Botox

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Botox is a neuromodulator that is selectively injected into areas of the central brow and eyelids which helps to relax the muscles that cause wrinkles and lines, as well as reflexively lifting the outer brow. There are numerous positive effects of Botox, including lessening deep static lines with serial injections. Stretching the skin and causing bagginess is not a typical result with proper injection techniques. Try an experienced injector and start with a conservative amount.

Austin Plastic Surgeon
4.9 out of 5 stars 50 reviews

Botox and Results

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Botox lasts 2-4 months and the results dissolve after.  you can get a pulled look if not injected properly.  Best, Dr. Emer.

Jason Emer, MD
Los Angeles Dermatologic Surgeon
4.8 out of 5 stars 204 reviews

Can Mephisto sign stretch the skin of the eyelids?

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In a word - no. Mephisto sign occurs when the Botox is clustered in the middle of the forehead, and the muscle just above the eyebrows, on the outside edges of the forehead is left alone. Injectors use this technique to keep the eyebrows from becoming too heavy. However, in some patients this leads to "spocking" where the edges of the forehead move up and down, about the middle stays in place - also called the Mephisto sign. 
This will not damage the skin of the eyelids or forehead, because your forehead is not actually moving any more than it normally would, you simply notice it more because the center of your forehead is not moving - making normal movement look greater by comparison. On another note, this is incredibly simple to correct. See your provider - usually 1 or 2 units in the area of the brow which is moving is enough to fix this problem.

Flora Waples, MD
Denver Physician

Complications from Botox injections

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Botox, Dysport do not stretch the skin. Their only effect that Botox and Dysport has is to relax the muscles they are injected into. People have a lot of variation in the strength and positioning of their facial muscles due to genetics, positioning of facial features they copy from those around them and their own habitual expressions. An experienced injector should be able to anticipated and adjust for these factors in most cases. Occasionally a slight adjustment injection is needed. People should know that if they go to an injector who doesn't understand what they are doing and just gives everyone the same "cookbook" injection occasionally patients are going to end up with weird expressions which will subside in 2 to 3 months.

Curtis Perry, MD
Downey Facial Plastic Surgeon
4.8 out of 5 stars 19 reviews

Mephisto effect and Botox

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Great question. The Mephisto effect is related to misplacement of Botox into the frontalis muscle resulting in "flairing up" of the lateral brow. It is a temporary effect and can be corrected with a small amount of Botox injected into the lateral frontalis muscle. I would not worry about long term skin changes related to Mephisto effect. If you have Mephisto effect from a recent Botox injection, I would follow up with your injector as it can be easily corrected.

Mephisto Sign

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The Mephisto sign occurs when Botox is injected I the forehead centrally, allowing the lateral portions of the frontalis muscle to raise the eyebrows unopposed. The eyelid skin you're referring to is not being "stretched" any more than when you simply raise your eyebrows. And if that skin is wrinkly and saggy with the eye brows down, then that means you may be needing a brow lift anyway. Seek a qualified plastic surgeon who can assess this for you in front of a mirror. I wish you the best!

Arnold Almonte, DO
Roseville Plastic Surgeon
4.9 out of 5 stars 34 reviews

Forehead Botox

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The Mephisto sign and its closely related cousins, the dreaded Spock and Jack Nicholson look, are related to placement of Botox within the large muscle on the forehead called the frontalis. With misplacement, a portion of this muscle is not immobilized properly, which allows different forces to be placed on the brow, altering the brow shape. This does not, however, change the overall amount of force that this muscle is able to put on the brow that would "stretch it out," and actually decreases the overall force, reducing wrinkles in the long term. If there is a shape change in the brow, it can be  corrected with a subsequent touch up treatment by a skilled injector. 
To ensure you are receiving the highest level of care, seek out a modernly trained, new-school dermatologic surgeon, oculoplastic surgeon, facial plastic surgeon or plastic surgeon who is board certified and fellowship trained in one of these "core four" cosmetic specialties.
Cameron Chesnut
#realself500 Physician

Cameron Chesnut, MD, FAAD, FACMS
Spokane Dermatologic Surgeon
4.9 out of 5 stars 114 reviews

My question concerns the so called Mephisto effect from an injection with Botox.

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The muscles of facial expression insert to the skin. When these muscles contract the overlying skin moves with them (in a direction that is perpendicular to the action of the muscle). Skin laxity happens from aging, decrease of elastin fibers, effects of smoking, sun exposure etc. Botox relaxes the muscles so they do not stretch the overlying skin. The Mefisto effect as described is elevation of lateral brows with lowering of medial brows. The frontalis muscle elevates the brows (especially the lower portion of the muscle). Targeting the corrugators and depressors with preservation of the lower medial frontalis will allow elevation of the medial brow and a more even brow shape without a lateral peak. Targeting the lateral lower frontalis will decrease the lateral brow elevation and contribute to an even brow shape. Most men prefer an even brow shape but many women prefer a laterally peaked brow. Balancing the areas of injection (target muscles) will help avoid this effect.

Mephisto effect after Botox

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Thank you for your question gondan. Botox is a purified protein used to address wrinkles associated with facial expression. Sometimes when treating the frown lines the brows go up and give a peaked effect, giving an appearance that looks surprised or evil, sometimes called the Mephisto effect. This can be easily corrected by placing a small amount of Botox on the upper forehead. This does not likely cause sagginess and wrinkles in the upper eyelid or under the brow. Loose skin in this area is usually caused by a lack of collagen which occurs with age, sun damage, smoking, etc. Please consult with a doctor for specific recommendations. Good luck!

Avoid the "fullness" effect

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Good question. Botox does not stretch skin. However, when giving Botox for migraines, the eyebrow can drop, giving more upper eyelid fullness. This should be discussed as a consequence of migraine relief with Botox. Frequently, we perform upper blepharoplasty to eliminate the fullness.

Michael A. Burnstine, MD
Los Angeles Oculoplastic Surgeon

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.