Botox in DAO muscle did not work. Why might this have happened?

Question

I am a 29 year old female who received 3 units of botox a side in my DAO muscle which worked beautifully. I had a baby, and had my first treatment in 1.5 yrs. 3 units on either side did absolutely nothing. I followed up with the nurse 12 days later, and she injected another 3 units per side. Why might this have happened? I had other areas done that were successful, but didn't notice if product all came from one vial.

Jason Emer, MD · Answer

This may be due to Botox placement. Sometimes a combination approach is needed with fillers, lasers and microneedling/prp.  I recommend getting a formal evaluation with a cosmetic dermatologist. Best, Dr. Emer

Philip Solomon, MD, FRCS · Answer

Hello and thank you for your question. Often times injectors can miss the DAO muscle entirely. This may have happened in your case. Experienced injectors know the anatomy very well and should not have an issue locating and treating the DAO. However, in some cases it's not always effective and you may need to consider using dermal fillers to help fill in the marionette lines and possibly adding structure to the chin area.  If you are questioning the possibility that the injector may have used a different product/ vial for that area, I think the bigger concern is that you don't seem to trust your provider and should consider finding a specialist that you trust.

Peter N. Butler, MD, FACS · Answer

Did you visit the same injector each time? Injection technique does vary, and it sounds like the target muscle may have been missed with your most recent treatment. The DAO muscle is an area many injectors are more cautious with, because it can cause an asymmetric smile.

Tim Sayed, MD, MBA, FACS · Answer

Thanks for the question.Injecting Botox to the lower face is of course "off-label" use but many of us safely offer it in selected patients. It is important to be conservative in injecting the area around the mouth to avoid migration of the Botox/Dysport/Xeomin to muscles that are not the targets for the treatment. A couple of things may explain the apparent lack of effect of the Botox you had injected to the DAO:1. Inexperienced or just plain not a great injector. Is this the same person who injected you in the past?2. Conservative use of product - the injector may have been taking extra precautions in injecting the area for the reasons above and perhaps you need more product3. Habituation to Botox - your body may require slightly more units than you previously required even with identical injection technique, though I am not sure I truly believe this as a phenomenon 4. (most likely) The issue you are trying to correct is not correctable anymore with Botox but may instead require fillers. As we age, the corners of the mouth turn down and our jowls and nasolabial folds become more prominent. This is a combination of gravitational changes and skin laxity. You may have too much "overhang" or "etching of the creases" around the corner of the mouth to be fully corrected with Botox in the first place. In person exam with a board-certified plastic surgeon, facial plastic ENT surgeon or dermatologist would be preferable to a nurse injector in most cases, in my opinion. At minimum, you should at least get a second opinion from another experienced injector as to what your options are in person.

Alex Eshaghian, MD, PhD · Answer

Thank you for your question pompbeauty. I understand
your concern. Congratulations on the birth of your baby. Botox is a purified protein used to address wrinkles associated
with facial expression.In the lower face Botox can be placed in the DAO muscle which pulls down the corners of the mouth. This will lead to a slight elevation of the corners of a downturned mouth and improve a sad face appearance. It is important to use low doses in the lower face because there are many muscles nearby that are required for eating, speaking, smiling, and general lip movement. If the product spreads to nearby muscle side effects may occur. The most common side effect when Botox is placed in the DAO is spread to the nearby DLI, the muscle that is responsible for pulling down on the lower lip. When this happens it may lead to the temporary appearance of an asymmetric smile. This can also occur when treating the cobblestone appearance on the chin from the mentalis muscle.It is difficult to make an assessment without before and after photographs. Also, you did not state the results after the second treatment. Was there improvement? Also was this the same injector as before? Every injector has a slightly different technique and some work better for certain people than others.
Please consult with a doctor for specific
recommendations. Good luck!

Melvin Elson, MD · Answer

It is possible that she missed the muscle or that the Botox was more dilute or old. It would be best to see a dermatologist who will inject you

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