Botox caused cheek ptosis- realistic timeline 6 units per eye/ 2 times in 7 weeks.

Question

Botox every 3-4 months for 8 years. On 12/1/23 had 38 units between crows 11 and forehead. Went back 7 weeks later and had 30 more units. Now I have cheek drop on both sides. cheek bone area is so flat and chipmunk when I smile (cheek is by nasolabial fold and not lifting). Derm confirmed it affected zygomaticus. Since I did the "double dose" within 7 weeks is my timeline for it to fade still 3-4 months? It's been 6.5 weeks and is not any better. Please advise! I'm panicked!

Anna Chacon, MD, FAAD · Answer

First, take a deep breath. What you’re describing is frightening and emotionally distressing, especially when you’ve been getting Botox successfully for 8 years and suddenly notice a dramatic change in your smile and cheek position. The good news is that Botox-related weakness of the zygomaticus muscles is almost always temporary.

Based on your timeline:

12/1/23: 38 units to the forehead, glabella, and crow’s feet
~7 weeks later: an additional 30 units
6.5 weeks after the second treatment: persistent flattening of the cheekbones and “chipmunk” fullness near the nasolabial folds when smiling

The fact that your dermatologist specifically felt the zygomaticus muscles were affected is actually helpful, because it provides a plausible explanation for the change in your smile.

Why this can happen

The zygomaticus major and minor muscles are responsible for lifting the cheeks upward when you smile. If botulinum toxin diffuses into these muscles—most commonly from injections placed too low in the crow’s-feet area or laterally near the upper cheek—the cheeks may appear:

flatter over the cheekbone,
less elevated when smiling,
and relatively fuller near the nasolabial fold, creating the “chipmunk” appearance you described.

This is a recognized, though uncommon, complication of periocular Botox.

Does the second treatment reset the clock?

Yes, to some extent.

The important thing is that the affected muscle weakness is related to the most recent exposure of those muscles to botulinum toxin, not the very first treatment in December. If the zygomaticus muscles were affected by the second session, the recovery timeline is usually counted from that session, not from the original 12/1 treatment.

What is a realistic timeline?

For unwanted facial muscle weakness, I usually counsel patients that:

6–8 weeks: often little or no obvious improvement yet
8–12 weeks: many patients begin to notice subtle return of cheek movement
3–4 months: significant improvement is common
4–6 months: near-complete recovery is typical for most cases

Because you are only 6.5 weeks out from the second treatment, I would not expect dramatic improvement yet, even though it feels like a long time when you are looking at your face every day.

Does getting Botox twice within 7 weeks make it last longer?

Not necessarily twice as long, but it can sometimes make the weakness feel more pronounced or more persistent because:

there was additional toxin exposure before the first treatment had fully worn off,
the muscles may have been further weakened, and
the cumulative effect can delay the point at which enough neuromuscular function returns for you to notice improvement.

However, this does not usually mean you are looking at a permanent problem.

The most reassuring sign

You mention that the issue is bilateral (both sides). When this happens from Botox diffusion, it is often symmetric, which fits the pattern of toxin-related zygomaticus weakness more than a structural facial problem.

What you can do

Unfortunately, there is no proven medication that can instantly reverse cosmetic Botox once it has bound to the nerve endings. The main treatment is time.

A few practical things that may help you cope during recovery:

Avoid additional Botox in the crow’s-feet or upper cheek area until you have fully recovered.
Take weekly photos in the same lighting and expression, because improvement is often so gradual that patients do not notice it day to day.
Gentle facial movement and normal smiling are fine; you do not need to immobilize the area.
My honest expectation

Given your history and the timing, I would tell a patient in your situation that:

6.5 weeks is still early for recovery from zygomaticus involvement.
I would expect the most meaningful improvement to occur between 8 and 16 weeks after the second treatment.
Complete normalization may take 3–5 months, and occasionally a bit longer in patients who received a relatively high cumulative dose in a short interval.

The encouraging part is that true permanent cheek ptosis from cosmetic Botox is extraordinarily unlikely. What you are describing is much more consistent with temporary zygomaticus weakness from toxin diffusion, and although it is understandably alarming, the overwhelming majority of patients experience progressive spontaneous recovery over the following few months.

So while I know it feels catastrophic right now, the fact that you are only 6.5 weeks from the second injection actually makes your current lack of improvement much less worrisome than it would be if you were 5–6 months out. I would be cautiously optimistic that you should begin to see **subtle return of cheek elevation and a more normal smile over the next several weeks rather than assuming this is a permanent change.

Lexie Wang, MD · Answer

Yes you will need to wait the full 3-4mo after your LAST injection to the crow's feet area (this is where it can migrate down into the zygomaticus). If you did not get a touchup in that area, then it will be 3-4mo from the first injection. If you did, then it will be 3-4mo from that 2nd injection 7wks later.

Jeffrey H. Spiegel, MD · Answer

Do you have difficulty moving your face?  Is smiling hard?
IF so, it is in the zygomaticus.  It will resolve.

Camille Cash, MD · Answer

I'm sorry to hear of the issue from your Botox treatment.  The effects are temporary and will gradually fade over three to four months from your most recent treatment.  Be sure to always use an expert injector.

Botox caused cheek ptosis- realistic timeline 6 units per eye/ 2 times in 7 weeks.

Answers (4)

More Botox Questions

Dents, lateral sweep and draping skin after facelift. Will Botox help? (Photo)

Difficulties producing saliva after Botox injections, will I experience the same problem?

Mesobotox procedure on cheeks for open pores - but my cheeks completely got flat - How long would it take to recover?

WE SEND PRETTY
EMAILS