One of the most common side effects for using Botox® for chronic migraine is the cosmetic appearance. From eyebrow droopiness, to immobile forehead, to the infamous "caught-in-the-headlight" surprised look, all can happen when Botox used to alleviate chronic migraine.
It is important to understand that the cosmetic side effects of Botox are the result of it paralyzing the injected muscles. There are numerous facial muscles that can be injected, but the typical migraine protocol involves injecting these three muscles in the forehead:
1. Procerus: This is the muscle above the nose. When it contracts, it gives a horizontal crease between eyebrows
2. Corrugator: This is the eyebrow muscle. When it contracts, it furs the brows. It is a downward pulling muscle of the forehead
3. Frontalis: This occupies most of the forehead, and it pulls the eyebrows up, causing the forehead wrinkles. It is an upward pulling muscle of the forehead.
Migraine Botox protocol has pre-determined quantities and locations of injections; which are outlined in the picture below:
While this ensures some standardization between headache providers, it also ignores the salient differences in the individual's anatomy and their specific muscle' needs for Botox. As a result, some patients may experience migraine relief, but at the unfortunate expense of appearance.
Here we will go through some of the most common "unwanted" looks after administering Botox for headache purposes. The red dot indicates the faulty injection location.
Eyebrow sagging:
This is the most reported one, and it happens more frequently that it should to in headache patients, as the reason is counterintuitive to the providers new to these injections.
Eyebrow sagging happens when providers try to avoid injecting too close to the eye (paradoxically due to their fear of eyebrow sagging), and hence inject the botox a little bit higher, as in the image below. As a result, more botox ends up in the frontalis than needed, and the muscle becomes very weak, unable to lift the eyebrow above, so it sags.
Unfortunately, when the patient complain about this to their physician, they become more fearful and inject even a bit higher than the time before, and hence complicating the problem and making it worse.
Eyelid droop:
This frequently gets confused with the one above. However, it is important for the difference to be appreciated, as this is one of the complications that I consider should rarely, if ever, happen. It is the most severe one as well, since the result is not only cosmetic appearance, but also obscuring the ability to see out of the affect eye.
Eyelid droopiness happens when Botox spreads into the eyelid muscle itself, rather than to the eyebrow.
This is not supposed to happen in experienced hands. It is more common when the injection is given more toward the center of the eyebrow, rather than above the midline endge of the eyebrow.
Lateral Eyebrow Lift:
The good news about this one is that it is not always "unwanted". Patients frequently do like the lateral eyebrow lift and they consider it aesthetically pleasing.
The other interesting thing about this lateral lift is that it is unbelievably common in patients receiving their Botox from a headache provider and not from a cosmetic one (a.k.a a plastic surgeon or a dermatologist). At this point of my carrier, I can spot patients receiving botox from neurologists a mile away as they almost all have this appearance.
Lateral eyebrow lift most commonly occurs when the provider injects the two frontalis spots too close to each other, and hence paralyzing the portion of the muscle close to the midline, and yet not affecting the portion close to the temple. Hence, the eyebrow begins to droop toward the midline, while gets "lifted" from the side.
The Surprised Look
Usually a telltale sign of receiving Botox as it is the most "portrayed" image in the minds of the public.
This surprised look tends to happen when the downward pulling muscles (corrugators) are paralyzed, but not the upward pulling ones (frontalis). The most common reason for this mistake that I observed is due to injecting frontalis muscles way too high in the forehead, and not close to the belly of the muscle (upper third of the forehead) where the wrinkle lines are. It is also quite easy to fix as one can always place few more units in the right location and the appearance will correct within few days.
Final word:
Always remember that no matter what the unwanted appearance is after Botox, they are always transient, usually disappearing within 4-6 weeks. More over, it is important to avoid rubbing the face in the first 24 hours after the injections, to lessen the chance of spreading to a nearby muscle, and hence developing these unwanted appearances.
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