If too much Botox is injected,would that lead to muscle wasting away or leaving dents and contour irregularities?

Question

I have been having Botox treatments for 4 years now. Originally my nurse suggested more units. Over the years I have noticed my forehead has a massive vertical line in the middle. I have also noticed dents on my forehead. Is this asymmetry permanent and can it be reversed maybe with less units injected in the future. Thank you

Aric Aghayan, MD · Answer

Dear caci5,Thank you for your question. It is difficult to evaluate your concerns without photos before you started Botox as well as current photos demonstrating the areas of concern. It would be very unusual to have permanent contour irregularities from Botox. I would recommend seeking a consultation with an experienced plastic surgeon or facial plastic surgeon that can exam you and address your concerns. Best of luck.

Monika Soni, MD · Answer

Botox can cause wasting in a thick muscle such as the master cheek muscle but you would not expect this to have occurred from Botox to the forehead.

Alex Eshaghian, MD, PhD · Answer

Thank you for your question caci5. I understand your concern. Botox is a purified protein used to address wrinkles associated with facial expression. When injected into the skin Botox will relax the muscles and smoothen out the overlying wrinkles. The most common areas of treatment are in the upper face. These include the horizontal lines seen on the upper forehead when one raises the brows, the vertical lines seen between the brows when one frowns (frown lines), and the crow's feet seen around the eyes when one smiles.It is difficult to make an assessment without knowing the dose used and the exact placement of the product. However, I hope the information provided here is useful.The appearance of frown lines is variable from person to person. Usually they are in a vertical orientation but sometimes they can be oblique and sometimes a horizontal line is seen across the upper portion of the nasal bridge. The most common variation is to have two parallel lines, hence the common term "11's" to describe them. But some people have one, three, or more lines. Some people also will see a bulge in the area when contracting the muscle. This bulge is smoothened out after a Botox treatment.The pivotal studies used 20 units of Botox in the glabella area between the brow to address the frown lines. These studies demonstrated that the peak results are seen 14 days after the treatment and most people enjoy their results for 3-4 months. At that point, a maintenance treatment is recommended. While some people start to see results as early as the next day, it can take two weeks for full results so patience is important. We have our patients return two weeks after their treatment to assess their results via photographs. At that time additional units may be added if necessary.Although 20 units is a good standard dose to start with, some people require a higher dose because of higher muscle volume. This is common in mature patients, in those with large bulges from expressive faces, and in men. I find that Botox still works in these cases, just a higher dose is required. I have used up to 40 units in the glabella.When patients present with concerns about specific wrinkles in the upper face such as the frown lines, I always assess and usually treat the other wrinkles in the upper face including the horizontal forehead wrinkles and crow’s feet. The reason is to maintain a harmonious and natural balance to the appearance of the upper face. The muscles in the glabella which are responsible for the formation of the frown lines serve to pull down on the inner brows when a person frowns. Similarly, the muscles around the eyes which are responsible for the formation of the crow’s feet seen when smiling (orbicularis oculi) are also responsible for pulling down on the brows, but in this case the outer brows. On the other hand, the muscle in the upper forehead which is responsible for the formation of the horizontal forehead wrinkles when a person raises the brows (frontalis) serves to pull the brows upward. If one of these muscles is relaxed with Botox and the others are not, the other muscles will still be active. This will lead to an unbalanced and unnatural appearance of the upper face where the brow can be elevated, depressed, or uneven in shape or position. Therefore, I recommend that my patients take a global approach to the upper face when receiving Botox treatments and treat all three of these areas. Sometimes bunny lines on the bridge of the nose are also treated.The dose used is not indicated here. If wrinkles get deeper over time with continued regular use of Botox, I would suspect that the dosing is low. If I had a patient with the concern described here I would want to know the dose and placement of the product and how frequent the treatments are. I may recommend using a higher dose. I suspect new wrinkles (dents) may be due to not taking a global approach as described above.With any injection, there are risks such as pain, bleeding, bruising, redness, swelling, tenderness, and infection. We take special precautions to minimize these risks such as using a painless technique. We also treat bruises with a laser as early as the next day. Bruises usually resolve within two weeks if untreated. After a laser treatment bruises usually resolve in 1-3 days, but may still take two weeks for full resolution. In addition to these risks, with Botox there is also a risk that the product spreads or diffuses to nearby structures. Spread to nearby muscles can lead to side effects such as the temporary appearance of droopy eyelids or a temporary asymmetric smile.
  
After a Botox treatment, I recommend that my patients avoid heat exposure, alcohol consumption, and strenuous exercise for 24 hours and not lie down flat for four hours. This is because all of these activities may possibly lead to the movement of the product and consequent side effects such as droopy eyelids. Although there have been no definitive studies shown that these actually occur and some physicians do not provide such aftercare instructions, in the absence of data I err on the side of caution and recommend that my patients avoid such activities.
  
Please consult with a doctor for specific recommendations. Good luck!

Damon Thomas, FRACS · Answer

Botox can cause wasting in a thick muscle such as the master cheek muscle but you would not expect this to have occurred from Botox to the forehead.
You are best to consult your injector.

Amy Miller, MD · Answer

This is a great question!  The way I explain it to patients is that over time you actually "train" the muscles-so as some weaken over time others may get stronger to make up for it.  if you have been treating the frontalis (forehead) muscle, the procerus and corrugators (the ones that cause the "11's" between the eyebrows) may start overcompensating and get stronger and bigger and can cause a central vertical line.   If only part of the muscle is treated consistently the surrounding muscles fibers can hypertrophy, or get bigger, to compensate.  This would cause the appearance of a dent that gets more noticeable with contraction of the muscle in question.  
The good news is it is reversible, though it may take some time for "retraining".  The human body is an amazing piece of machinery! If you stop treating the frontalis, the muscle will slowly build back up and then the other muscles will stop overreacting. Things will go back to equilibrium.  
It can be hard to go "cold turkey" so I often try to change the placement of injections and do lower doses. It works but it can take some time to figure out.  I recommend staying with the same injector so they can get to know your muscles and their reactions.  It is harder when a different person treats you each time.
I hope that all makes some sort of sense!  Best of luck to you.
Dr. Amy

If too much Botox is injected,would that lead to muscle wasting away or leaving dents and contour irregularities?

Answers (5)

Answer: Botox muscle wasting

Answer: Botox muscle wasting

Answer: Long term use of botox

Answer: Long term use of botox

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If too much Botox is injected,would that lead to muscle wasting away or leaving dents and contour irregularities?

Answers (5)

Answer: Botox muscle wasting

Answer: Botox muscle wasting

Answer: Long term use of botox

Answer: Long term use of botox

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.