When neuromodulators—Botox Cosmetic, Dysport, Jeuveau, Xeomin and newcomer DAXI—are done right by the right person, they are fabulous; when done wrong, well, it’s kind of no-brainer that it’s not the best look. “‘Bad Botox’ or overdone Botox is a HUGE concern these days,” says Santa Monica, CA, dermatologist Karyn Grossman, MD. “Many people look at overfilled and overfrozen people in the media and are terrified that they are going to get that look as well. Neuromodulators have become very popular because of their ease of injection. However, just because it is easy to inject, doesn’t mean it is easy to inject well.”
Sign 1: You didn’t get the real deal.
For starters—and we can’t stress this enough—you should only go to a board-certified plastic surgeon, facial plastic surgeon or dermatologist to get any kind of injectable done. Beyond that, Troy, MI, plastic surgeon Anthony Youn, MD, says he recommends asking your provider where the neuromodulator is from or doing a quick search online if you have doubts. “Ask whether the Botox was purchased directly from Allergan in the United States. This is really the most important question. You can also go online to see if the provider is listed under the Allergan website of official Botox providers.”
Sign 2: Or you went for too “good of a deal.”
Dr. Grossman advises to be wary of “specials” that seem too good to be true, because they probably aren’t legit. “Maybe that practitioner isn’t using branded products—remember the chiropractor in Florida who sent people to the ICU injecting boot-leg product imported from China? Discounts are typically a sign that the injectors are using a blanket treatment protocol for everyone.” Likewise, New York dermatologist Jody A. Levine, MD stresses to beware of bargains. “There are so many people who inject these days who do not fully understand facial musculature and the science behind how Botox works. Botox should not be treated like a product you are purchasing, for which you are trying to get the best price, but rather like a procedure you are having done, for which you want the best result.”
Sign 3: Your doctor went with a “template.”
This one is a little tricky, but there are ways to avoid it. “Neuromodulators, fillers, lasers and surgery, have a science and an art,” Dr. Grossman says. “Unfortunately, many people go to afternoon training courses where they are given a template and learn how to inject to match the template. It works, but it freezes/paralyzes the muscles and doesn’t take into account an individual’s unique features or muscle patterns. Thus, everyone comes out looking frozen and mask-like.” So how can you avoid it? “The best thing to do prior to getting injections is to look at people who have been treated by that practitioner. Do they have the look you are going for? Are they more natural or more frozen?”
Sign 4: Your doctor didn’t take YOU into account.
Another nod to there isn’t a “one-size-all” when it comes to neuromodulators, Dr. Grossman says your injector should be looking at your face, analyzing your muscle movements and strengths. “Is he/she asking you about how you want to look? Is he/she asking the effects/results that you desire? Those are all important questions.” Encino, CA plastic surgeon George Sanders, MD also advise that good old “go with who you know” route. “Have your Botox done in an office where you’ve had other procedures. They value you as a patient and would never do anything to harm that relationship, like giving you dilute Botox, etc.”
Sign 5: You don’t look natural while resting—or while moving.
“Not looking natural” is a vague term, but Scottsdale, AZ, facial plastic surgeon Kelly Bomer, MD, breaks it down in regards to neuromodulators: “My definition of ‘Bad Botox’ is a result that looks unnatural at rest or while moving. It is important to ask about retaining natural movement of brow elevation when actively raising the brow and normal cheek elevation when smiling. A common ‘Bad Botox’ result is the ‘Spock Brow,’ where the tail of the brow is unnaturally high and spiked and the medial brow is unnaturally low. And for the crow’s-feet area, if Botox is injected in a pattern that lowers cheek elevation, one can get a look of hollow eyes and chipmunk cheeks.”
Sign 6: There’s something REALLY different about your brows.
In another nod to the brow equation, Dr. Bomer points out that if your lateral brow elevates upon brow raising naturally before Botox Cosmetic, and, if while the forehead is getting injected there are no injections in the forehead over the lateral brow, this will lead to the “Spock Brow.” “Not every brow naturally elevates laterally, so not every face requires lateral forehead injection to maintain a natural appearance. If your eyes look hollow before Botox, it is helpful not to have injections at the top of the cheek/side of the eye as this will hollow the eyes more and push the cheek out unnaturally when smiling. Best to keep the injection at the lateral eye and above to raise the tail of the brow without dropping the cheek.”
Sign 7: All of a sudden, you have a “mouth issue.”
Dr. Grossman agrees that brows can be a main area that showcase when something isn’t right, as can the mouth. “If your eyebrows have dropped into your eyelashes, you look like you are auditioning for the next Star Trek, or your mouth is drooping, you’ve had ‘Bad Botox.’ These are miserable things that can happen from incorrect or overdosage of neuromodulators. They are not permanent, but can be debilitating while you have them.”
Sign 8: You’re having an adverse reaction.
Dr. Youn says that any adverse event or concerning side effect—vision changes, increasing pain, increasing swelling, etc.—should prompt you to call your doctor to make sure everything is OK.
Sign 9: You’re not seeing a difference.
“There are bad side effects, like the ones listed above, or the Botox just isn’t working [the wrinkles are unchanged a week later] are also signs that what you got may not be what you thought,” Dr. Youn adds, but it is important to remember that you may not see a result right away. “Botox takes about 7 to 14 days for most people to have the full effect after a Botox injection. In some patients, it can take up to three weeks,” Dr. Bomer says. “Because there is a time period in the body for the action of Botox to relax the muscles, it is required to wait until the Botox has taken its full effect to understand if there had been a heavy hand. It is difficult to know immediately after an injection if there is going to be an unnatural-looking result.”
Sign 10: You actually have new lines forming.
Yes, Dr. Grossman says this one can happen. “When one area is frozen too hard, you can see new lines forming.” The good news: “If your provider has been heavy handed, it will eventually go away. Unfortunately, the heavier the hand, the longer it will take. Also, long-term usage of large amounts of neuromodulators—especially in the upper face—can lead to atrophy of the muscles over time. You might say that’s ‘good’ and that you will need less Botox in the future, but it’s not. The atrophy actually causes your face to age because of the loss of volume of the muscles. We are now seeing women with smooth shiny thin-skinned foreheads with lower faces that are full of wrinkles.”
Sign 11: You got too much.
“I always advise my patients that you can always add to Botox but you can’t take away,” Dr. Levine says. “It is better to inject less and return in two weeks for more than put too much to begin with and then need to wait a full three months for the effects to wear off.”
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