Paradoxical masseter bulging Botox. What do I need to do to fix this? (Photo)

Thank you for your question. It sounds like your masseter was not treated entirely and you may need additional units. 

Thank you for your question and for sharing your photograph akgettingbetter. 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 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. 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.
To determine if someone is a good candidate for this treatment it is necessary to look at a person’s lower face when biting and comparing it to when the person is not biting. If a bulge is seen on the outer portion of the jawline, then the person is likely a candidate. It can also be felt with the fingers when biting.
A phenomenon seen with Botox is called muscle recruitment and compensation. When a muscle has been relaxed with Botox, sometimes other muscles or a different part of the same muscle are recruited and contract when one attempts to make the facial expression. This serves to compensate for the inability of the primary muscle to contract. Sometimes a bulge can appear in a muscle that was untreated or a part of a muscle that was not treated. A common example is the bunny lines (caused by contraction of the nasalis muscle) that are seen on the sides of the upper nose after treatment with Botox in the glabella or for the crow's feet. Since the muscles in the treated area are relaxed, the nasalis muscle contracts in an attempt to compensate for this loss when one frowns or smiles. In such a situation, the bunny lines can be treated with a small amount of Botox (2-4 units per side). In the upper face, sometimes a portion of the frontalis muscle in the upper forehead which was previously not active becomes active once the muscle is relaxed with Botox. In these case, new wrinkles may be seen, often near the hairline. This can be treated with a small dose of Botox in that area. This can also be seen in the lower face when not enough product has been used in an area such as the chin. Sometimes another part of the muscle begins to contract in order to compensate for the relaxation of the muscle from Botox. This can also be treated with a small dose of Botox in that area. Compensatory recruitment can also occur when the platysma muscle in the neck contracts after muscles in the lower face have been relaxed with Botox. Similarly, this muscle can be relaxed with Botox as well. For my patients, I usually use approximately 10 units per band. If placed properly it does not affect other muscles. Relaxing the platysma muscle may also lead to an improvement of jowls and jawline definition. When such recruitment occurs, I recommend prophylactic (preventive) treatment of the recruited muscles at the next treatment.If I had a patient with the concern described here I would say that there is a recruitment phenomenon occurring here. It is possible that the entire muscle was not treated. So it appears that the part that was not treated is still contracting and is responsible for the appearance of the bulge. Simply placing additional units in the bulge at the two week point should correct the appearance of the bulge.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!