Are Other Muscles Creating a Lumpy Look After Botox? (Photo)

Question

I've successfully had Botox on the "11's" for several years. Recently, after injections, I've seen a strange thing when I smile. On either side of one of the 11's, there is a finger-width raised area that travels vertically all the way up the forehead. It gives my forehead a "corrugated" look that I find worse than the natural lines. Are muscles outside the 11's area acting to push up the skin?(The other 11 side is fine). The area is not sore and the bumpiness doesn't show unless I smile.

Ron Shelton, MD · Answer

An evaluation over the internet is no substitute for an examination in person, having the physcian observe your ridge while you are at rest with facial muscles, then during active expressions. Also it may help the physician to feel the ridge and adjacent muscles during contraction. Unlike all the panelists, I'm not convinced that there is an overcompensation of the corrugator muscle. If that were the case it wouldn't explain a vertical ridge extending the length of the forehead! Also I'm not aware that contraction of the levator muscles which make one smile would cause the corrugator muscle to become active. Possibly there is some venous congestion which is causing back pressure to build up when smiling making the vein distend? Veins in the forehead run vertically from the eyebrow up to the hairline. I have seen one patient who came to me to treat this condition,never having had botox, but had noticed forehead veins bulging.

Harold J. Kaplan, MD · Answer

Despite your consistent use of Botox over the years, it would appear that other muscles or areas are beginning to require attention.  

	Having your injector assess this movement when animating will help determine which muscles are being used and the best way to resolve this reaction.

Craig Vander Kolk, MD · Answer

Since we all want to use our facial muscles for expression, blocking one set of muscles can cause others to compensate. Think of it as trying to let someone know you are frowning and unhappy (your teenager late on Friday night). If you can frown, other muscles try to do the same thing but are not as strong. Therefore, you often need a small amount of botox in the other muscle(s). Occasionally I find that its best not to over treat the muscle, but that is something you need to work out with your doctor using photos and accurate follow up notes.

Khaled El-Hoshy, MD · Answer

Dear Jack Grace of California: Very easy to correct with a few units in the "over-active" muscle [ the corrugator] on the side of the lumpiness.Men usually need more units than the standard amount used for females. A touch up injection @ the right site will restore normality.

Sheri G. Feldman, MD · Answer

When certain muscles between the brows are " paralyzed " by Botox, others will try to compensate by overcontracting when you try to frown. You probably need a few more units of Botox in the lateral portion of the corrugator muscles to reduce this effect. Be sure your injector stays at least 1 centimeter above your brow and does not inject lateral to the mid pupillary line to avoid a droopy lid.

Emily Altman, MD · Answer

It's possible that the tails of the corrugators were not relaxed enough and are contracting when the central portion is relaxed, giving a folding look.

	I usually have my patients contract their corrugators as hard as they can and inject the botox into the muscle bulk.  That targets the entire contracting unit. 

	One has to be careful, however, injecting over the brow as Botox may cause lid ptosis as it drifts into the lid elevator muscle.

Eugene Mandrea, MD (retired) · Answer

It appears that you need a few more units of Botox in your Procerus and your left corrugator. How much, depends on how powerfully these muscles still perform upon forced frowning.

	Always make sure that you are being treated by an experienced, Board Certified Dermatologist or Plastic Surgeon.

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

Yes, they certainly can. This is called recruitment when other muscles try to accomplish the task of the weakened muscle where the Botox was injected. Most commonly, small doses of Botox to the recruitment muscles will soften this effect out. Botox or Dysport, which are basically the same in MHO.

Are Other Muscles Creating a Lumpy Look After Botox? (Photo)

Answers (8)