Cannot smile properly 1 and half months after masseter Botox. Advise? (photos)

Question

I had masseter Botox done about a month and a half ago. And although I really like the results, I cannot smile like I used to. My smile now does not turn upwards and is very contrived and restricted. I also had small amounts of fillers on the marionette area just below my lip corners, and along the nasolabial folds. Can you please advise if a DOA Botox injection will help or on the corner of the lips area? The last picture is when I did not get anything done for reference and comparison. Thank you.

Philip Solomon, MD, FRCS · Answer

Hi there,Your injector may have accidentally injected a muscle called the risorious which is very close to the masseter muscle and works to pull the corner of the mouth laterally. As a result, one’s smile becomes narrower. Botox typically lasts 3-4 months, you should start to see improvement in your smile within that timeframe. Injecting the DAOs will not help unfortunately.

Michael I. Echavez, MD · Answer

It is possible for a Botox treatment to the masseter muscles to affect the smile.  Normally, the points of injection can be altered to avoid this side effect.  Your smile should return completely after the effects from your treatment have worn off.  I would discuss your issue with the physician who treated you so that your treatment can be altered next time.  I would not recommend adding more Botox anywhere to try and improve your smile at this point.

Alex Eshaghian, MD, PhD · Answer

Thank you for your question and for sharing your photographs loveandhappiness2018. 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.Although Botox is most commonly used in the upper face, it can also be used in various areas in the lower face. 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 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.
To determine if someone is a good candidate for this treatment it is necessary to look at a person’s lower face when biting and comparing it to when the person is not biting. If a bulge is seen on the outer portion of the jawline, then the person is likely a candidate. It can also be felt with the fingers when biting.
In the mid face, the risorius muscle and zygomaticus muscles sit near the masseter muscle which is treated for TMJ pain or to contour the lower face. When smiling, the risorius muscle pulls the corners of the mouth outward towards the ears and the zygomaticus muscles pull the corners of the mouth upward. The masseter muscle is used to bite down when eating. If Botox spreads from the masseter muscle forward toward the risorius muscle or upward toward the zygomaticus muscles, these muscles can also become relaxed, leading to the appearance of an asymmetric smile. This side effect resolves on its own in 2 weeks to 4 months, depending on the severity. Some find that laser skin tightening treatments using infrared light or radiofrequency may speed up the resolution process.If I had a patient with the concern described here I would reassure her that the asymmetric smile is temporary and that treatment of the DAO muscle would unlikely affect or improve the smile. I would also consider dissolving some of the filler in the lips.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!

Michelle Ellern, DO · Answer

I would wait for the remaining botox effect to wear off in the next 2 months. If your smile is corrected by this then adjust the injection plan for the next time.  I don't think adding more areas injected to the mix is the right decision at this point. Good luck with getting your original smile back.

Melvin Elson, MD · Answer

there are 2 methods of injecting the masseter and one is close to lip area and if it is done this is the result/. next time have your doctor use the 3 point method instead of the 5 point and see a board certified dermatologist

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