Can't Fully Smile or Raise Cheeks after Jaw Reduction with Botox, Options?

off-label use of Botox for facial thinning by treating the chewing muscles (masseter hypertrophy) can diffuse or inadvertently be injected into a different muscle than one that is desired, and there can be loss of function of the mouth elevators. Not only could there be difficulty smiling, but if one side is done differently than the other, there can be significant cosmetic asymmetry and it will take four months to go away.

All good feedback from the panel members.  Unfortunatey, only time will improve this negative outcome as the effects of the Botox gradually wears off.  Also, being that it has been only one week, your effects may continue to improve.

Most importantly, we encourage all patients to report their concerns to the one that did the treatment. 

It will wear off.  Don't save money this way.  Remember the expression: you get what you pay for.  There is no way to speed this process up.  I would recommend returning to your original injecting physician when this treatment resolves.

Thank you for your question MIssybee. 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.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.Botox is a prescription strength medication that is injected into the skin or other areas. Therefore, it is important that the treatment is performed by a trained medical professional. This can be a physician, physician’s assistant, nurse practitioner, or nurse. Laws vary from jurisdiction to jurisdiction on who is allowed to provide the treatment. In California, for example, any of these aforementioned medical professional is permitted to provide a treatment. With the recent explosion of cosmetic medicine, there are more and more people offering such services. This includes core physicians such as plastic surgeons and dermatologists as well as other physicians who are trained in cosmetic treatments such as general physicians, gynecologists, or other specialists. It is important to understand that just because a doctor is a plastic surgeon or dermatologist does not necessarily make them an expert on Botox. General doctors who routinely perform Botox treatments multiple times per day likely have more experience and expertise than a plastic surgeon who spends most of his time performing surgeries and performs perhaps only a single Botox treatment per month. Similarly, there are many outstanding nurse injectors who spend their entire days performing cosmetic treatments, as they are often delegated to nurses. Their experience can at times be great than that of many doctors. This understandably makes it difficult to find a good provider. I recommend looking for experience (specifically in Botox and other minimally invasive cosmetic treatments such as fillers and lasers), before and after photographs, and testimonials. Looking for an office who offers the most competitive price is often a recipe for disaster. We have had many patients come to our office to correct various issues they have had when they selected an injector based on price alone.
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!

I am sorry for your situation which by now I hope is much better. Obviously you did not save much by having a "cheaper" doctor inject your Masseter (the chewing) muscle with Botox to make it less prominent. It appears that in addition to injecting the muscle Botox was injected near the nerves and muscles involved in smiling causing a facial weakness (much like a mild stroke).

I can only hope the Botox given you was also cheaper because it was old and overly watered down resulting in a shorter duration of this complication.

I hope you are doing well and this rather expensive lesson stays with you and some of our readers.

I agree with much of the aforementioned responses. I would encourage direct communication with the injector to let them know this occurred. Dr. Krauss is pointing out a very important anatomical point to avoid deep placement of neurotoxin.

The good and the bad about Botox is that it goes away so you will regain your normal function in a few months.  It sounds as if too many units were used, and the placement was a bit off.  This is a tricky area to inject.  If you liked the results from your first injector, it is well worth the extra expense to get a great result!

It sounds like too much Botox was injected, and/or it spread beyond the jaw angle portion of the masseter muscle. Unfortunately it will probably take 1-3 months to improve, there is no effective way to speed this up

When Botox is injected to far forward (anteriorly) and high (superiorly) in the masseter muscle, it can weaken the muscles that lift the corners of the mouth that attach to the cheek bone.  This can happen when the procedure is done for cosmetic purposes or for teeth clenching/grinding.  Fortunately it sounds like you are symmetrical, but unfortunately it will improve only with time.

Botox injections are very effective at narrowing the lower face and thinning the jaw muscle. The condition where this muscle has thickened is called masseter hypertrophy.  Not only can injections in this muscle improve cosmesis, it can reduce jaw pain, TMJ pain and headaches from grinding your teeth at night.

It is important to inject deeply into the muscle, otherwise the Botox will get into the superficial facial muscles and cause a problem with smiling.  Unfortunately, you have to wait until it wears off and there is nothing that you can do to speed up the process.  I would go back to the injector and show him what you are dealing with. I suspect that it was not worth the cost savings.