Is Botox most effective when injected directly INTO the muscle?

Question

I recently got Botox to treat my 11's. One side took, and I clearly noticed the "crunch" of the needle into the muscle. The side that did not "crunch," barely took and had to be redone a few weeks later. I was told it was because one side was "stronger." What gives??? Thank you for your time, PKR

J. Jason Wendel, MD, FACS · Answer

Thank you for your question.Not hearing a "crunch" does not mean that the Botox was not properly injected into the muscle. Some individuals have stronger muscles on one side verses the other, so it is very well possible you needed more Botox on one side. To be sure, see two or more board-certified providers in your area for a complete evaluation to make sure you are a good candidate and that it is safe for you to have treatment.I hope this helps.

Mariusz Sapijaszko, MD, FRCPC · Answer

Botox results depend on where it is injected (experience of the injecting doctor), patient's unique anatomy and the amount of Botox injected. Although, it is best if Botox is injected right into the muscle, even injection just close to the muscle can work as Botox moves slightly from the injection sites. Most peoples one side of the face is slightly different than the other side, so some variation in effect can occur. Experienced injectors can notice this and make these differences minimal. I hope that helps

Jason Emer, MD · Answer

There are many ways to get good results from Botox injections.  It is indicated for muscular injection but can be used on the forehead and eyes for example more superficially.  I suggest you go to a reputable physician for treatment.  Best, Dr. Emer.

Michael I. Echavez, MD · Answer

Botox can be injected directly into the muscle or just around the muscle.  The liquid should distribute enough so that the effect should be the same.  Feeling a crunch on one side versus the other would not necessarily mean that one side was injected into the muscle and one side was not.  Many times, people do have one side that is stronger than the other at the frown area and sometimes one side will need a bit more than the other.

Benjamin Barankin, MD, FRCPC · Answer

Botox efficacy, results and safety are based on a combination of factors, so make sure you have an expert injector such as a dermatologist or plastic surgeon treating you, not a nurse, "technician" or other. Generally speaking injecting into the muscle is optimal as that is the target (we're blocking communication between the nerve and muscle).

Dean P. Kane, MD, FACS · Answer

Dear pke:Botox is an injectible muscle relaxer with a science and an art. Those injectors who understand anatomy and muscle function / expression are best suited to achieve the results you desire.Yes, the best results for Botox placement are in the muscle desired to relax as the nerve/muscle connection where Botox works occurs within muscle fibers and not outside the muscle bundle. There are many factors in the art of injection. These include:understanding which muscle(s) to inject to achieve the balance or dynamic tone of expressionat what level to inject to achieve the best accuracy and limit diffusion of the liquid outside of the muscle fibers themselvesthe amount (number of units and amount of fluid) to inject at each sitethe angle of the needle and the orientation of the needle bevelAnatomically, the "crunch" you heard maybe the needle passing through the skin, fascia, muscle covering or bone covering. These are tougher tissues which create a  "crackle" or "crunch" as the needle pops through. It is possible that the fluid delivery was not directly into the muscle and held in place by the muscle covering but may have partially flowed outside the muscle delivering less units of Botox. Functionally, patients do show asymmetric variations in facial expression. This may be due to individual personality or variations in muscle size, attachments and bone position. As you see, there are many factors in the "not so simple" technique of injecting Botox and the resultant effects. It is best to be treated by a well experienced Board Certified "core" physician trained to inject this drug. These include: Plastic Surgeons, ENT Facial Surgeons, Occuloplastic Ophthalmologists and Dermatologists. I hope this was helpful. All the best!

Janie M. Leonhardt, MD · Answer

There are times when the needle placed into the muscle creates a sound that is sometimes understood as the "pop of the muscle sheath".  Not hearing this sound, however, does not mean that you are not in the right place.  Placement of Botox is critical to its success, and a thorough understanding of facial anatomy and variations on that anatomy are essential.  These complexities are typically best understood by physicians - specifically, physicians who have been trained in aesthetic specialties.

Steven F. Weiner, MD · Answer

I think it's unlikely that there is significant asymmetry in the glabellar area, but it does occur.  More likely the Botox was injected into the wrong area, or some of the Botox was injected into a vessel and carried away (which is harmless).  In the glabella, the muscle needs to be injected directly.  In the crows and forehead, injecting the skin is enough, because the Botox diffuses into the muscle (proven by studies).  It is frustrating to the experienced injectors when people think that all Botox is the same, and search only for the least expensive provider, not giving any credit to who is actually injecting.

Richard Ort, MD · Answer

Usually I prefer to inject Botox directly into the muscle using a tiny 32 gauge needle.  As long as the needle is sharp, there is very little resistance or "crunch."  With repeat injections, the needle can dull slightly and you can feel slight resistance.  I make sure to avoid going too deep and hitting the periosteum which is just above the bone and is sensitive.  Around the eyes, I prefer to inject more superficially, just below the skin, which helps to minimize the risk of bruising in this area which has many blue veins.  Botox will diffuse into the muscle when it is injected more superficially.

Harry V. Wright, MD · Answer

That "crunch" was likely the needle popping through some fascia, the tough thin layer that covers muscles. Most injectors prefer injecting Botox via multiple individual injection sites with a short needle. But every time the needle is advanced through the skin it gets a little more dull, and eventually a dull needle will make a crunching/popping sensation when pushing through a tough tissue like fascia.A recent study showed evidence that Botox works just as well when injected subcutaneously as when injected around the muscle, or directly into it. That said, I prefer to use a long, thin needle to inject along the length of the muscle through one or two injection sites per muscle. My patients almost universally prefer this technique because it results in fewer pokes, less pain, faster onset, and more efficient relaxation. Entering the muscle itself with the needle causes pain that I feel is unnecessary, and subcutaneous injection seems imprecise (study or no study). Hope that helps!  Harry V. Wright MD, Sarasota, Florida

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