Botox to Fix Crooked Smile Goes Wrong

Question

I had a very mildly crooked smile (right side rising higher than the other) which was not limited to my smile, but also when I talked.  I was informed that a little bit of Botox could make this even and had success the first time so I got a second treatment (but with another doctor) while on travel. Since my right side was rising too much, the doctor decided to inject my side only.  After 3 days I could see that there was too much injected on my right side, making my right side immobile. The left side seemed to over-compensate by moving much more than it used to, and also feels tired after talking even for a little bit. I returned to the doctor so that he could make the face somewhat symmetric by injecting a little to the left and he did so, but it has been over a week and no improvement can be seen. I have since left the country where I had it done, so I will have to search for another doctor. Looking at the appearance of my face, what would you recommend? Any advice that would help me get through the next 3 months would be helpful.

Brent Moelleken, MD · Answer

You have had several injections over varying periods of time.  Therefore, Botox in each area has a certain lifespan.  Even if you continue to try to balance the asymmetry, and can by some miracle achieve symmetry without further paralysis of the periorbital muscles, as each of the injections goes away, the asymmetry will return in a bizarre fashion.
We have seen your problem often.  The best solution is to allow all the Botox to go away, then retreat with a top notch doctor.  Also stick to one doctor who can know your facial expression intimately, including all its quirks and asymmetries, rather than go to several doctors.  Your doctor should have an intimate knowledge of the anatomy of facial nerves and their target muscles.  From your description there are several branches that have already been affected.  The separate durations of action of each injection (3 months each) will just prolong your asymmetry problem as they go away.

Harold J. Kaplan, MD · Answer

We're sorry that you have had to experience a bad Botox outcome. Unfortunately, we think your best bet is to live with it as it is until the Botox wears off. Chasing perfect symmetry after several injections is a recipe for disappointment. Your second practitioner probably underdosed you the second time for fear of relaxing both sides and making it impossible to smile!
Our suggestion would be to wait a couple months until the Botox wears off and start from scratch with your original injector. The good news is that Botox wears off faster around the mouth than anywhere else on the face because of the constant movement. Good luck.

Otto Joseph Placik, MD · Answer

As all my colleagues have stated the good thing is that Botox is not permanent.
As stated, the best is to wait it out.
The alternative is to undergo more injection on the left to drop the lip which most people would consider undesireable but would give you symmetry. You risk having a weak smile with little movement. Another downside is that you risk having the weakness last beyond the time that the right returns. It is difficult to tell the time of your right sided injection but if that is over two months I would wait it out.
I know this is difficult for you to appreciate but injecting botox even by the same physician in the same area with the same dose can have differing effects each time you inject it. It is not too dissimilar to laying down an ink spot and predicting it will be the same each time. With botox the diffusion is even more complex because it is 3 dimensional.

Steven H. Williams, MD · Answer

Dr. Moelleken captures the real issue well.
While you may be able to get good symmetry with Botox injection on the other side the real problem is the staggering of the treatments.
Botox works by blocking acetylcholine release, causing a chemical denervation. Meaning that the muscle is paralyzed.  Over time (4-6 months) that paralysis wears off.
If you get an injection now to balance out an injection you received a month previous you will likely have a period of symmetry followed by imbalance as the initial injection wears off.
You should wait for all the Botox to wear off.
I hope this helps.
Steven Williams, MD

David Shafer, MD, FACS · Answer

Blindlee,
The bad news is that you may have to wait several months for the Botox to wear off.  The good news is that Botox always wears off.  In the mean time, you may be able to partially correct the asymmetry at rest by having a very small amount of Botox injected under the right side of your lower lip.  The depressor muscle in this area pulls the corner of the lips down.  So, if you inject the depressor muscle, you may see some improvement.  However, with animation, only the left side of your face will continue to move until the Botox wears off.  Good Luck.
David Shafer, MD
Shafer Plastic Surgery
New York City

Botox to Fix Crooked Smile Goes Wrong

Answers (9)

Answer: Time is your friend

Answer: Time is your friend

Answer: The bright side is that Botox always goes away.

Answer: The bright side is that Botox always goes away.

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Everything you need to know about Botox

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Botox to Fix Crooked Smile Goes Wrong

Answers (9)

Answer: Time is your friend

Answer: Time is your friend

Answer: The bright side is that Botox always goes away.

Answer: The bright side is that Botox always goes away.

Browse related questions

Recommended reading

Everything you need to know about Botox

Our mission is to create a world where every investment in modern beauty is Worth It.