Significant Indentations from Botox Migraine Treatment?

Question

I received botox 3 months ago for treatment of migraines. 3 weeks later I noticed a dime size depression over my eyebrow which has gotten worse so that that now it covers an area 1 inch wide & 1.5 inches high, with a spoon-shaped strip next to the nerve that is particularly depressed. That whole area is so sunken that the other side of my forehead looks puffy in comparison. I'm 27. I'm worried because it is getting worse. Is this from the Botox? Can I reverse it? Thank you!

Kenneth D. Steinsapir, MD · Answer

The effects of BOTOX are not permanent. If the BOTOX was effective in controlling the migraines, you may just have to put up with this appearance. BOTOX for migraines is chosen when other treatments have not been effective. If you elect not to have more BOTOX treatment, I would expect this muscle atrophy change to be resolved 6 to 8 months after your last BOTOX treatment. I would recommend discussing this issue with your injecting neurologist to decide if this side effect is so objectionable that you will not be retreated with BOTOX.

Ron Shelton, MD · Answer

The temporal issue of noting your linear depression three weeks after Botox should not allow us to quickly dismiss the Botox treatment as a cause, but the Botox itself is not known to cause a depression.  So if not the Botox, what could this be?

	1. Was there steroid in the injection which got carried off in a vein and caused subcutaneous atrophy so quickly? That has been observed by doctors.

	2. Had there been a large vein in the area that had normally provided subcutaneous volume and support to those tissues but the vein somehow went into spasm and is now clotted off leaving a void? I have never seen, nor heard of a botox injection causing this but sclerosants of leg veins can.

	3. Would you have developed such a fast onset of localized morphea, "en coup de Sabre" ( the slash of a saber), I doubt it, but a work up by a rheumatologist or dermatologist would be worthwhile.

	You should speak to your doctor to see exactly what was injected. Possibly a scan such as a CT with enhancement or MRA may help, but discuss the risks and costs in detail with your doctors before having such.

Mark Taylor, MD · Answer

The spot you have developed may be linear Morphea and not related to the Botox at all.  Go see a good Dermatologist who can help you make the correct diagnosis and get the right treatment.

Steven Wallach, MD · Answer

Botox should not cause a depression of this sort. It looks like a progressive fat wasting condition called coup de sabre. Like a knife scar to the face. If this is the case it can sometimes this can be treated with fat injection.

Khaled El-Hoshy, MD · Answer

Dear wikit626, the type of marked atrophy of the full thickness of the skin, shown in the picture, is extremely unlikely to be caused by botox. Your dermatologist can best diagnose the exact cause. To me, it looks like either localized scleroderma, or "post-steroid atrophy". There are a few cases in the medical literature , where the simple act of a needle stick in the muscle was followed by localized scleroderma. No cases have been reported following Botox injections , as far as I know.

Jacqueline Calkin, MD · Answer

Thank you for posting the pictures as they are quite helpful in this case. While Botox can occasionally cause muscle atrophy, this does NOT look like what you are experiencing. This looks like a case of "en coup de sabre" which needs to be treated by a dermatologist. Occasionally, you can also see dramatic depressions like this caused from steroid injections. Please see a trusted dermatologist who can help you with either of these conditions. Best to you.

Karyn Grossman, MD · Answer

It would be highly unlikely that Botox could cause an indentation similar to the one in the photo you provided. Occasionally other types of injections - like steroids for an acne cyst - can cause an indentation. I would see your local dermatologist promptly to help determine the cause of your problems.

Sandy Martin, MD (retired) · Answer

Thank you for the photographs.  They are very helpful.  The first thing that came to my mind was what is called the En Coup de Sabre type of Scleroderma.  This is a linear type of scleroderma that one sees on the forehead or scalp.  This condition is not related to Botox or to underlying muscle atrophy but rather is a condition that may be associated with certain serologic changes.

	The cause is unknown, but I would suggest you discuss this with a dermatologist who I suspect may want to take a skin biopsy.

Francis R. Palmer, III, MD (retired) · Answer

I have used Botox for over 20 years and have never seen this type of muscle atrophy. I would ask the MD that did your Botox injections if steroid was used as well. This may explain the tissue indentation. IMHO, this is unlikely to resolve or reverse on its own.

Michael Elam, MD (retired) · Answer

The depression or indentation shown in the above photograph would be highly unlikely from Botox.  I would see your injecting physician immediately. This atrophy is more apparent in a steroid type injection used for scar tissue or acne and not from Botox. I would discuss with your physician what dilution was used in the injection and if there was any steroid injection used. Did your migraines go away? This looks like steroid atrophy not post Botox injection site!

Significant Indentations from Botox Migraine Treatment?

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