Uneven glabella results. Is there a fix for this? (Photo)

Question

11 days ago I got Botox in the glabella, 15 units total 5 in between brows and 5 by each inner brow. The results are uneven, one brow is completely frozen and the other I can still move slightly in.Is there a fix for this? Picture is me trying to frown.

Danielle Shanley, MD · Answer

Hi,
I recommend waiting a full two weeks for the Botox to completely settle. If you still have uneven brows, please reach out to your injector for an in person assessment. Usually this can be easily corrected with a few extra units of Botox.

Michael A. Zadeh, MD, FACS · Answer

Your issue can be improved with some more expertly placed Botox. However, you need an in-person examination in different states of muscle expression to determine how much additional Botox needs to be given and where it should be injected. Make sure you are under the care of an experienced physician. Best wishes.

Camille Cash, MD · Answer

It can take up to two weeks to see final results from your treatment.  If after that time you still have uneven results return to your injector for a touch up.  It may be that the muscle on one side is a bit stronger than the other and requires a little more product.

New You Medical Spa - Chandler · Answer

Thank you for your question. This is not an abnormal occurrence. Many people have uneven muscles in their face that are not seen until Botox injections are received. 
As you are 11 days post injection I would recommend calling your Injector and scheduling a follow up appointment for after 14 days post injection as that will be when the Botox has fully kicked in. They should easily be able to add a couple more units to stop that remaining muscle movement. 
Take care!

Carmen A. Traywick, MD, FAAD · Answer

This is not uncommon and can happen. Follow up with your injector at 2 weeks to discuss your concerns. A small touch-up maybe needed to adjust/correct an asymmetry. Hope this helps.

Maria Milone, MBBS · Answer

Nobodies muscles are perfectly even and although a small difference is usually not noticeable in some cases a little extra on one side may be required however I normally wait 2 weeks before making this decision .

Michele S. Green, MD · Answer

It appears from your photos that you would benefit from a small amount of Botox to make this area even. Some “baby Botox” will fix this area. Best, Dr. Green

Alex Eshaghian, MD, PhD · Answer

Thank you for your question and for sharing your photograph Real34. 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 appearance of frown lines is variable from person to person. Usually they are in a vertical orientation but sometimes they can be oblique and sometimes a horizontal line is seen across the upper portion of the nasal bridge. The most common variation is to have two parallel lines, hence the common term "11's" to describe them. But some people have one, three, or more lines. Some people also will see a bulge in the area when contracting the muscle. This bulge is smoothened out after a Botox treatment.
The pivotal studies used 20 units of Botox in the glabella area between the brow to address the frown lines. These 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. 
When patients present with concerns about specific wrinkles in the upper face such as the frown lines, I always assess and usually treat the other wrinkles in the upper face including the horizontal forehead wrinkles and crow’s feet. The reason is to maintain a harmonious and natural balance to the appearance of the upper face. The muscles in the glabella which are responsible for the formation of the frown lines serve to pull down on the inner brows when a person frowns. Similarly, the muscles around the eyes which are responsible for the formation of the crow’s feet seen when smiling (orbicularis oculi) are also responsible for pulling down on the brows, but in this case the outer brows. On the other hand, the muscle in the upper forehead which is responsible for the formation of the horizontal forehead wrinkles when a person raises the brows (frontalis) serves to pull the brows upward. If one of these muscles is relaxed with Botox and the others are not, the other muscles will still be active. This will lead to an unbalanced and unnatural appearance of the upper face where the brow can be elevated, depressed, or uneven in shape or position. Therefore, I recommend that my patients take a global approach to the upper face when receiving Botox treatments and treat all three of these areas. Sometimes bunny lines on the bridge of the nose are also treated.
If I had a patient who looked like the person in this photograph I would want to see the entire face and examine before and after pictures. But his patient would likely be a good candidate for additional units on her right side (left side of the picture).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!

Dean P. Kane, MD, FACS · Answer

Dear Real34: Thanks for sharing your photo.  From this picture, I do notice an uneven distribution of Botox from the ripples along the middle right brow. Botox is an injectable muscle weakener. Botox injection is art and science. The production of the medication is the science. The rebalancing of muscles of expression, injection amount, injection sites and technique are the art.
The 2 frontalis muscles directly above the brows elevate them upwardly and create lateral forehead wrinkling.  The 1 round muscle around the eyes called the orbicularis oculi muscle pulls the medial brows down and in as it pulls the lateral brow down and out.4 muscles in the glabella: corregator, depressor supercilis, procerus and orbicularis pull the brows down and inward and crease the upper nose.The desired effects of Botox on the forehead expression lines are to:
Reduce glabella wrinklingReduce central forehead wrinklingIndividualize elevation of the medial, middle and lateral browWeaken the upper, outer “crow’s feet” active wrinklesWeaken the vertical upper eyelid fan-like active wrinklesI am sure you can appreciate the artistic and skillful talent required to achieve these desired effects when individuals have such a spectrum of muscle pull, skin texture and wrinkles, sun-damage and weathering, short and long foreheads, different presentations of expression, anatomy and unique muscles weaving and skin insertion.You have described a very basic FDA approved technique of Botox injection. Please consider a more talented and skilled injector to understand the tremendous variability in muscle "design" work required to properly inject Botox and Dysport.   
I cannot anticipate your results so please consult with a talented, Board Certified Plastic Surgeon with proper skills for this artful technique. I wish you the best.

Lindsay Sturm, DO · Answer

Great question, thank you!  It is common for Botox to take up to 2 weeks for final results to be apparent, I would give this a few more days to see if the eyebrows don't even out.  If after the two weeks you are still noticing the uneven brows, I would return to your provider to discuss this with him/her.  Often times, a few more units of Botox may need to be injected to help make things more symmetric.  Thank you for your question and take care!!

Uneven glabella results. Is there a fix for this? (Photo)

Answers (14)

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