Is 65+ units Botox each side of the masseters "too much"? (Photos)

Question

Is 65+ units to EACH SIDE OF THE MASSETERS considered "too much"? I'm needing an increase in Botox (resistance built up after 4 years) and I'm concerned that I'll need more than 65+ units on each side now. Is this abnormal and are there any risks? I have severe TMJ and have very large masseters that cause me a lot of pain. I also need touch ups within 1 month- which seems very odd since doctors advised that it should be spaced 3 months apart.

Kenneth D. Steinsapir, MD · Answer

You also indicated that you tested positive for botox antibodies.  Right now you are seeing someone who is making a lot of money selling you botox.  The question is with neutralizing antibodies, are you really getting anywhere with this treatment.  You are spending a fortune for these treatments but are they really making a difference.  Perhaps it is time to see a TMJ specialist for a night guard or other approach to helping your with your grinding. Your current approach is not working.

Milan Doshi, MS, MCh · Answer

Hi,thanks for the question.I personally feel injecting about 65+ units of botox in masseter area in a single session is excessive.We normally give about 25-30 units each side in a single session.We call the patient for a follow up visit after 2-3 weeks and decide for the touch up if required.Touch up in intervals of every  one month is not advisable.

Shaun Patel, MD · Answer

I typically start with 20-25 units of Botox per side in my patients. 65 + units per side is a high dose. You may want to try Dysport or Xeomin to see if you get a better response using a lower dose.

B. Edward O`Dell, MD · Answer

65+ plus units per side is pretty excessive.  There is likely antibody resistence to the Botox so I would ask your injector about trying Xeomin for one or two treatments.  It's possible that could help.  Thanks for your question.
Dr ODell

William Marshall Guy, MD · Answer

Hello mystlilith,65 units into each masseter muscle is a large dose of Botox.  If you are only having results for a month then that is also not to be expected.  At doses that high (130 units) it is possible you have developed antibodies.  You could try other neuromodulators like Dysport.  Another option is to use a neuromodulator based on a different molecule called Myobloc.  It is more expensive than the others, not usually used in cosmetic practices, but can be used in place of therapeutic Botox for medically indicated reasons.I hope this helps and good luck.

Alex Eshaghian, MD, PhD · Answer

Thank you for your question and for sharing your
photographs mystlilith. 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 a
formal exam in the office where I can view the skin in multiple angles, feel muscles on the face, and review a person's medical history. However I hope the information provided here is useful.Botox can be placed in the masseter muscle in
the lower face to contour the lower face and address pain associated with TMJ.
In this area 20-40 units of Botox are used per side. Depending on the reason
for the enlargement of the muscle, permanent results may be achieved. For
example, some people have a habit of grinding, clenching, or biting their teeth
subconsciously. Often times this happens in their sleep when they are not aware
of it. Botox placed in this muscle will relax the muscle and the grinding, clenching,
and/or biting will decrease. This will reduce the size of the muscle. If the
brain gets accustomed to this and the person stops grinding, clenching, or
biting, then the muscle will not become enlarged or as enlarged again. However,
if the habit starts again, the muscle will likely get larger. Some patients have stronger muscles and may require a higher dose.In rare cases, some people are resistant to a
certain neuromodulator such as Botox. In this case the treatment can be
repeated using a different neuromodulator such as Dysport or Xeomin.Botox (onabolutimun toxin) is what we call a
neuromodulator. This means that it controls nerves to relax the muscles by
preventing them from contracting. Botox is the most popular neuromodulator
available, has been the most studied, and is cleared for the most number of indications.
Other neuromodulators available in the United States include Dysport
(abobolutimun toxin), Xeomin (incobolutimun toxin), and Mybloc (rimabolutimun
toxin). Botox, Dysport, and Xeomin are type A toxins while Myobloc is a type B
toxin. This means the structure of the protein is slightly different. Overseas
many others are also available. Dysport is the most commonly used
neuromodulator other than Botox in the United States. The dosing for Dysport is
different than that for Botox. Approximately 2.5 to 3 units of Dysport are
required for every unit of Botox. For example, in the glabella 20 units of
Botox is most commonly used. If Dysport were to be used in this area 50 to 60
units of Dysport would be required. The investment per unit of Dysport is approximately
2.5 to 3 times less than that of Botox. While the manufacturer states that the
units of Xeomin are a one to one equivalent of Botox, many doctors find that a
higher dose of Xeomin is required to produce the same effects as Botox. Each
product has slight differences, but all of them work. Dysport, for example, is
known to spread more than Botox. This makes it useful in places like the
underarms where it can be used for excessive sweating. However, if it spreads
near the eyes it can lead to side effects such as a droopy eyelid. Xeomin is
also called a naked protein, because it does not contain the accessory proteins
that are included with Botox or Dysport. It is thought to have a slightly
faster onset (by one to two days faster) than Botox or Dysport. It is also
thought to have a decreased likelihood for allergic reactions, although
allergic reactions to Botox and Dysport are incredibly rare. In the United
States Myobloc is not FDA cleared for cosmetic use and is primarily used for
muscle pain in those with cervical dystonia. The majority of our patients find
that they like the results of Botox the best. Additionally, Allergan, the maker
of Botox, offers the Brilliant Distinctions Program. This is a rewards program
where patients receive points from their Botox treatments which can be used
toward discounts at subsequent treatments. Points are also received when
patients purchase other treatments in the Allergan portfolio including Juvederm
Ultra, Juvederm Ultra Plus, Voluma, Volbella, Vollure, and Kybella or products
such as Latisse or Skin Medica products.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 as described above. 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!

Jon A. Perlman, MD (retired) · Answer

I believe that doses over 100 units in one session are beyond FDA clearance and would personally avoid such a large dose.You might consider trying Xeomin to see if the result is any different.Jon A. Perlman, M.D., FACSBeverly Hills, Ca.  ABPS Bd Certified

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