Third Botox injection in the DOA muscle, still no results (Photo)

Botox treatment for downturned corner of mouth and light marionette lines. 3 different "modest" attempts, but I'm assuming by now over 3 units on the stronger side. I see no result; I can still make the exact same frown, and no change in appearance. Is there a point/danger of getting a 4th touchup or should I just insist on the filler I originally wanted and asked for? so far paid 3k, which included Sculputra in the cheeks, and I'm yet to see ANY results from all the money I've spent.

Doctor Answers 10

Botox in the DOA's

Botox injection to the DOA muscles is best performed in a subtle fashion.  A heavy hand with Botox in the perioral region will lead to a 3-4 month problem which is best avoided.  Perhaps a filler to the marionette lines/ oral commissures will provide more benefit and higher satisfaction.  Sculptra in the cheeks is a separate issue, which requires time, patience, and multiple injection sessions.

Fort Myers Facial Plastic Surgeon
4.8 out of 5 stars 93 reviews

How lift your smile #marionettelines #juvederm

I do like like botox in the DAO, I usually used 2U at each injection session. But typically stop after a total of 4U(the DAO is not a very strong muscle. The other technique I like to use when improving downward turned corners of the mouth is filler injections. Typicall I used Juvederm Ultraplus XC into the corners of the mouth. I approach from a superior lateral to inferior medial direction as I pull the corner of the mouth up I inject into the corner of the lip at the vermillion border as well as perpendicular to the melolabial fold (corner of lip to jawline)  This acts as a kick stand and help to lift the corners of the mouth.  You may also want inject botox into your mentalis muscle. It appears that is is hyperactive in one of our photos and give a peau d'orange appearance or orange peel look when flexed. by injecting about 5 units it will relax that muscle and give a smoother appearance. I too like sculptra but for a better lifting effect of the cheek and corner of the mouth, I find that voluma works better in my hands

Manolis Manolakakis, DMD, FACS
Shrewsbury Oral & Maxillofacial Surgeon
5.0 out of 5 stars 12 reviews

3 treatments of Botox to DAO and still not responding

There are many ways to look at the frown muscle of the mouth and the DAO. From the photographs you submitted it looks like you have a combination of volume loss in the chin area (which is very common as we age) as well as the corners of the mouth turning down. Usually relaxing the DAO with up to six or seven units of Botox or other products such as Xeomin and Dysport, is one method. However, improving volume along the jawline and chin as well as relaxing the chin muscle may give far more improvement. If you continue to be unsatisfied and have waited for the Sculptra to work seek out a second opinion from an experienced injector. Sculptra is very effective not only in the cheek area but in the area around the chin and lower face to create volume and improve the corners of the mouth drooping. However it is very technique dependent and requires several treatments. That being said, it seems you would be an excellent candidate for both treatment of the DAO as well as Sculptra. Hope that is helpful. Best of luck.

Joseph A. Eviatar, MD, FACS
New York Oculoplastic Surgeon
4.7 out of 5 stars 66 reviews

After 3 attempts at Botox in the DAO without results, you need to see another doctor

It's evident that you still have movement in the DAO.  The doctor just doesn't know how to do the injection properly.  You need to get another doctor to do the injection.  As far as the Sculptra goes, I would wonder about the experience with it as well.  Remember though, it takes 6 weeks for the collagen to form the injection.  Also note that after one treatment, results are minimal, it takes a 2nd treatment to begin to see most Sculptra results.

Steven F. Weiner, MD
Panama City Facial Plastic Surgeon
4.7 out of 5 stars 41 reviews

Botox Treatment for Downturned Smile

Sorry to hear about your lack of results with Botox and Sculptra. If you have had 3 attempts without any results, then I would not attempt anymore as you are putting yourself at risk for complications. I would go ahead with filler to the area. It should help, and results are immediate.

Michael A. Zadeh, MD, FACS
Sherman Oaks General Surgeon
5.0 out of 5 stars 10 reviews

Filler vs. Botox for DAO

In addition to doing filler in the marionette lines, and filler in the hollows of your chin, I would suggest filler to the cheeks and temples which can help to lift when there is skin laxity in the jowls over the DAO.  Another point, if you have been using Botox for awhile, and not getting a good response with the typical dose (1-3 units only per side to DAO) it is possible you are immune to it, and could try Dysport or Xeomin.  

Karen Stolman, MD
Sandy Dermatologic Surgeon
5.0 out of 5 stars 7 reviews

Injectible filler is great for the marionette lines.

Hello NYCbee,
If you haven't gotten the results you need from DAO Botox alone, it may be helpful to add a little injectible filler into the marionette's lines to add volume into this area.  As far as being able to make a frown goes, there are more muscles than the DAO that contribute to frowning.  The problem is that trying to add Botox to all these muscles would cause oral incompetence which is functionally and socially disruptive.  
I think filler is the safest option.
Good luck,
Dr. Shah

Manish H. Shah, MD, FACS
Denver Plastic Surgeon
4.8 out of 5 stars 55 reviews

Careful with botox around the mouth

I just want to issue some caution with injections of botox around the mouth. Botox can take 72 hours to kick in. Even when injecting the DAOs, this can distort the normal movement and smile of the mouth. You may look a little different. 

My recommendation for marionette lines is filler.

Best of luck.

- Dr. Bryson Richards

Bryson G. Richards, MD
Las Vegas Plastic Surgeon
5.0 out of 5 stars 282 reviews

Using Botox to treat the DAO muscle

First, make sure your injector is an experienced and highly trained injector, especially since locating the DAO muscle requires a thorough knowledge of facial anatomy. Second, sometimes the amount and depth of injection plays a role, and in other cases, as I suspect with you, you're better off adding a filler for these Marionette/sad lines.

Benjamin Barankin, MD, FRCPC
Toronto Dermatologic Surgeon
4.9 out of 5 stars 49 reviews

DAO muscle not responding to botox


Based from your photos and your statement, you probably need a combination of filler to reduce the marionette lines and botox to relax the muscle. As for the botox, there are 2 main reasons shy it may not be working, the target muscle was not hit, or the dose may not be enough. 

Somyos Kunachak, MD
Thailand Facial Plastic Surgeon
4.7 out of 5 stars 17 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.