Botox in masseter deformed my smile. Need help! (Photo)

Question

Botox in massetter caused my smile limitation. I did enject 20 units per side and two weeks after I noticed droopy cheek and horrible smile. It’s been 7 months and it got much better but corner of my mouth still not going up and stretch out like before. I got my money back and complained to my doctor about this procedure.Meanwhile can someone tell me how much longer I need to wait or what facial exercises can help to speed the recovery?

Alex Eshaghian, MD, PhD · Answer

Thank you for your question and for sharing your photograph moor22moor. 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 and observe wrinkles formed with facial expression. However, I hope the information provided here is useful.Although Botox is most commonly used in the upper face, it can also be used in the lower face. 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.Other areas where Botox is used in the lower face are as follows: The nasalis muscle on the bridge of the nose is responsible for the bunny lines that are sometimes seen there when one frowns or smiles. Usually 2-4 units of Botox are used per side for this area. Botox can be placed in the orbicularis oris muscle around the lips to provide a pout to the lips and reduce the appearance of vertical lines around the lips sometimes called smoker’s lines (although they are seen in people who do not smoke as well). In this area 2-4 units are used above the upper lip and 2 units are used on the lower lip. Botox can be placed in the depressor anguli oris (DAO) muscle to elevate downturned corners of the mouth which sometimes produce a sad face appearance. In this area 2-4 units are used per side. Botox can be placed in the mentalis muscle on the chin to address a cobblestone appearance or dimpling on the chin. In this area 2-8 units of Botox are used. Botox can be placed in the levator labii superioris alequae nasii (LLSAN) muscle located just beside the nose on either side to address what is called the gummy smile. The gummy smile is seen in some people whose upper lip elevates so high when they smile that the upper gums are seen in addition to their upper teeth. In this area 2-4 units are used per side. Botox can be placed in a vestigial muscle (seen in some people) called the depressor septi nasii to prevent the tip of the nose from moving downward when smiling. Here only 1-2 units is required. Botox can be placed just under the jawline in what is called the Nefertiti lift to relax the platysma muscle which pulls down on the lower face, thereby improving jawline definition. When placed lower in the neck Botox can address vertical neck bands. Approximately 10 units are used below each jaw and in each band.In the mid face, the zygomaticus muscles sit near the masseter muscle which is treated for TMJ pain or to contour the lower face. The masseter muscle is used to bite down when eating while the zygomaticus muscles pull the corners of the mouth upward when smiling. If Botox spreads from the masseter muscle to the zygomaticus muscles and relaxes these muscles it can lead to the appearance of an asymmetric smile. This side effect resolves on its own in 2 weeks to 4 months, depending on the severity.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!

Melvin Elson, MD · Answer

There are a number of different techniques to treat the masseter and the one most doctors are trained on have this side effect because one of the sites is too medial. discuss this with your doctor if you choose to do this again and see a board certified dermatologist

Shaun Patel, MD · Answer

It usually takes 3-4 months but in some cases can take up to 6 months for the Botox to completely wear off. At this point, 7 months after your treatment, your smile should have returned to baseline. I would followup with your injector to discuss your concerns and review your pretreatment photos.

Botox in masseter deformed my smile. Need help! (Photo)

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Botox in masseter deformed my smile. Need help! (Photo)

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