Is this possible zygomaticus/lip elevator Botox migration? (Photos)

Question

I was injected under brows (5 units mid brow each side) and 3 units under each brow tail to lift (16 units total). Now my smile stops short and weird and cheeks are also restricted and bunching - not a natural wide smile . I seem to also have sagging skin at jaw and under cheeks now and a feeling of unsupported muscle around mouth. I hate it! What happened? Heavy feeling in cheeks. How long can this dosing take to wear off??

Kenneth D. Steinsapir, MD · Answer

It is important to understand that this type of "side effect" can be emotionally difficult to manage. Even if the weakness is not that visible to others, you will be very aware of it. I have seen an number of individual who feel relatively emotionally dysphoric due to this type of weakness. Unfortunately there is no way to speed the resolution of this issue. There is no medication or exercise to make this go away.  Time is what is helpful. In some cases, the amount of treatment is relatively small and these small dose effects do tend to resolve faster than larger dose treatments.

Jason Emer, MD · Answer

This may be due to placement. Botox results last up to 3-4 months and can be softened with venus legacy and thermage treatments. I recommend getting a formal evaluation with a cosmetic dermatologist. Best, Dr. Emer

Monika Soni, MD · Answer

Thank you for your question! Botox lasts 2.5-4months typically. In the mouth area it may not last as long. Typically you need very little Botox in these areas for results. It is recommended to wait 4 hrs after injections before doing exercise, in theory, to prevent migration. I’ve not seen it in my practice. Best of luck!

Carey Campbell, MD · Answer

The Zygomaticus Major muscle inserts along the deep surface of the Orbicularis Oris muscle below/inferior to the orbit. I have seen a patient whose Botox was injected too medial (closer to the nose) and deeper than just under the skin (where the orbicularis lives). Her Botox did affect the elevation of her lip corners and resulted in a flatter smile.  This happened when attempting to eliminate all of her crows feet, even the low ones. When I treat a patient’s crows feet, I don’t aggressively treat those lower lines as a result. It doesn’t sound like you received too many units and I wouldn’t expect that much diffusion if it really was just at the tail of your brow. I’ve only seen it with low crows feet injection.

Leslie Pickens, MD · Answer

Unless the Botox was extremely dilute with saline it would be unusual for the small amount of product infection in the frown (glabellar) area or lateral brow to cause weakness of your smile.  It may be more likely if injections were also administered nearer to the cheeks.  Sometimes in order to achieve a desired result in one area it compromises other areas.  An example of this is relaxation of the forehead lines causing eyebrow drooping.  Return to your injector who can take comparison photos and discuss your results.  This will help him or her with subsequent treatments.  It is often best to return to the same injector who can now gain further knowledge of your particular muscle activity.

Marek Kacki, MD · Answer

Although it would be almost impossible to prove at this time any correlation between injections for brow lift and lower face, we can not disregard this possibility. It is well know that injection of Botox into a muscle may provoke a distant response that shows clearly an interdependence of many muscles in the area. For example, injecting the "frown" muscle (corrugator) may cause a "paradoxical" brow elevation. Injecting the orbicular oculi muscle ( as in your case) very low, with high dose and/or diluted Botox could weaken its part that normally elevates the cheek during smile. It is quite logical to consider that the surrounding muscles that also participate in the act of smile could respond in a "paradoxical" way as a compensatory effect. If that is the case you must be patient since nothing is know to shorten the effect of Botox predictably. If the problem resolves with time you will be a half way into proving this point. I would not suggest to have it repeated and observe the same effect but to use much smaller doses. Good luck!

Alex Eshaghian, MD, PhD · Answer

Thank you for your question and for sharing your photographs daynamiller12. 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 in the absence of consistent photographs before and after in the same lighting and angles for comparison. However, I hope the information provided here is useful.The pivotal studies used 24 units of Botox (12 units per side) to address the crow’s feet. 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.In the mid face, the zygomaticus muscles sit just below the orbicularis oculi muscle which is treated to address the crow’s feet. When smiling, the zygomaticus muscles pull the corners of the mouth upward. If Botox spreads from the orbicularis oculi muscle downward toward the zygomaticus muscles, these muscles can also become relaxed, leading to the appearance of an asymmetric smile. This side effect resolves on its own in 2 weeks to 4 months, depending on the severity.If I had a patient with the concern described here I would recommend that she return to her provider for an assessment and recommendations. I would also reassure her that such effects are temporary.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!

Leonard Grossman, MD · Answer

It is possible that Botox was inadvertently injected a little bit too deep when your crow's feet were being treated. This would result in a weak smile and some lack of balance in the facial expressions. The good news is that this may wear off over the next few weeks but can last lastbas long as three to four months. Good luck from New York City

Francis R. Palmer, III, MD (retired) · Answer

Hi, I've used neurotoxins for almost 30 years.  The dose is usually several units for each of those areas which is quite small.  This would not be expected to migrate to the point of affecting the peri-oral muscles.  There are post-injection techniques that can prevent Botox from migrating. However, if you're concerned you should discuss this with the expert Botox surgeon that performed your treatment.  All neurotoxins begin to wear off initially at 1 month and are the effects are gone at the end of the 3rd month.  Longer duration can be achieved by decreasing muscle size (and function) through serial treatments.Hope this helps.

Kristine Brecht, MD (license suspended) · Answer

Botox lasts 2.5-4months typically.In the mouth area it may not last as long.Typically you need very little Botox in these areas for results.It is recommended to wait 4 hrs after injections before doing exercise, in theory, to prevent migration.I’ve not seen it in my practice.Best. Dr Brecht

Is this possible zygomaticus/lip elevator Botox migration? (Photos)

Answers (10)

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