Is it possible my injector missed the muscle when injecting Botox?

Thank you for your question Gregarious3581. 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 and without knowing the dose used and the exact placement of the product. 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, 24 units of Botox (12 units per side) to address the crow’s feet, and 20 units of Botox in the forehead area above the brows to address the horizontal lines seen when one raises the brows. 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.
Despite having a natural appearance when performed correctly, many people are afraid of the results of their Botox treatment, in particular before their first treatment, which is natural. In these cases, a lower dose can be used. For example, sometimes I use 10 units in the glabella region instead of the recommended 20 units. In these cases, I advise my patients that the full results will be seen approximately two weeks after the treatment and have them return at that time to take after photographs. At this point, more Botox can be added if further enhancement is desired. I find that when lower doses are used, patients do not enjoy their results for as long; six to eight weeks as compared to three to four months. Therefore maintenance treatments must be performed more frequently.
Bruising is a risk with any injection. To prevent the risk of bruising I recommend that my patients avoid heat exposure, alcohol consumption, and strenuous exercise for 24 hours after a treatment because these activities bring blood to the skin and can increase the risk of bruising. I also recommend that they avoid medications that thin the blood such as aspirin as well as natural blood thinners like turmeric, ginger, cinnamon, cayenne peppers, and vitamin E for a few days before and after and injectable treatment. Tell your doctor if you are taking prescription-strength blood thinners such as coumadin or Plavix. I recommend that my patients avoid injectable treatments within two weeks of special events where they want to look their best.



After fillers we apply the Cearna OccuMend pad. The Cearna OccuMend pad is a new and innovative technology that is simple to use and significantly reduces the risk of bruising after injectable treatments and after surgery. It also makes bruises resolve more quickly and reduces swelling in the skin. The patch is clear and sticks to the skin. For most treatments two patches are used, one per side of the face. They are applied on the skin immediately after a treatment and left on for six hours. Then the patches are removed and replaced with another set of patches for another six hours; this can be done at bedtime and left on overnight while asleep. Ensure that the skin is clean and dry when applying the patches because any dirt or products on the skin will decrease the anti-bruising effects.

The Cearna OccuMend pad contains very high doses of arnica and ledum, natural ingredients that have been used for years. These ingredients reduce swelling, bruising, pain, and inflammation. Arnica is available over-the-counter in both topical and oral forms. However, the concentration of arnica in the anti-bruise patch is 50 times stronger than that available over-the-counter. Each pair of pads comes in a sterile sleeve that can be kept at room temperature without the need for refrigeration.

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.
If I had a patient with the concern described here I would want to know the dose and placement of the product and I would recommend waiting at least two weeks before assessing the results. Patience is important. Sometimes one area kicks in faster than another area. I have even seen patients at 10 days without results, but full results at 14 days. And sometimes the results are seen faster than others, even in the same person.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!

Botox locks the release of a chemical called acetylcholine, which triggers the muscle contractions that create wrinkles. Botox essentially paralyze the muscles and stops them from contracting. Results from these treatments are visible within 3-14 days with results that can last anywhere from 3-4 months. It is best to wait the full 2 weeks because you can possibly still see some changes up until then. Follow up with your injector at that time as well to discuss any questions or concerns that you may have. Hope this helps.