Treating Orbicularis Oculi with Botox: What can go wrong?

In this blog, Dr Tim Pearce explores why the orbicularis oculi is a complex muscle, which, if over treated with botulinum toxin or Botox® can cause some unfortunate side effects for your patients.

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What is the orbicularis oculi muscle?

Orbicularis oculi is the circular muscle that runs underneath the skin, very close to the surface, around your eye. It is quite a complex muscle because there are multiple different vectors involved, due to its circular nature. As the muscle runs around the eye, it is pulling in different directions at different points around its circular course.

For example, in a small proportion of patients, if you relax the lateral canthal lines (the crow’s feet) with botulinum toxin, you will start to see a medial pull. This occurs because the vector was neutralised – there was a relatively neutral vector where you are squeezing just laterally, but as you relax that, you start to squeeze medially. If you chase those lines, it can get even worse, to the point where every time the patient tries to make a small smile, it results in a strong pull medially. This does not happen in all patients, but for those where it does occur, it is one of the signs that can make them appear unnatural, because they have this medial vector having tried so hard to treat everything with botulinum toxin.

Dr Tim warns that sometimes you need to put less in, and find another way of treating the face, for example, with dermal filler or other modalities.

What are the vectors around the eyes?

As it circulates the eye, the orbicularis oculi muscle has different effects in different places.

The muscle is in a tug of war with the eyebrow and the frontalis muscle – the frontalis is pulling up and orbicularis oculi is pulling down. If you relax orbicularis oculi with botulinum toxin, it can result in a lift in the eyebrow, making it one of the ways of creating a subtle eyebrow lift. This can also be used as a treatment option for a brow ptosis. If you have over treated the frontalis muscle and caused this eyebrow drop complication, you can relax the orbicularis oculi muscle, that is essentially winning the tug of war, thus relieving the brow ptosis somewhat with a small lift.

In the cheek, the orbicularis oculi muscle is an accessory to cheek elevation. If you over treat it, the smile can look less genuine, or less like a Duchenne smile. This is the type of smile that our brains know is a real smile with real emotion, as distinct from a pretend or forced smile when we pose for a photograph.

For most patients, there is enough movement to still achieve a Duchenne smile, but if you have over treated the orbicularis oculi muscle, then the downside is that it can look a bit flat because the cheek is moving less than it should. It is important to note that the last 20% of a smile is your cheek being elevated by orbicularis oculi.

In older patients, it can also cause the cheek to appeared sagged, moving medially, and making them look older. Dr Tim highlights that this is one of the reasons why you must be careful when treating older patients with botulinum toxin because it can make the lower face drop, or descend a little, due to minimal support remaining in the muscles. Treating or over treating them with Botox to address lines and wrinkles can have the adverse effect of undermining the remaining support, thus, the face heads south.

Read more from Dr Tim on upper face muscle anatomy and how to avoid Botox side effects and advanced anatomy for Botox treatments: vectors, biomechanics & myomodulation.

Get your hands on this free helpful guide by downloading 26 essential injection patterns for botulinum toxin by Dr Tim Pearce. You can also purchase a beautiful anatomy poster of all the muscles within the face.

If you have any further questions about muscle anatomy and botulinum toxin treatments, Dr Tim would love to hear them, you can find Dr Tim Pearce on Instagram.

Botox® is a registered trademark of Allergan Aesthetics plc.

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Aesthetics Mastery Show

Orbicularis Oculi – What Can Go Wrong?

In this episode, Dr Tim looks further at the orbicularis oculi – a complex muscle with some unfortunate side effects if not carefully injected… Watch the full Aesthetics Mastery Show here.

Filler Complications eLearning Courses

If you want to increase your confidence by learning how to handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

• Botulinum Toxin Complications Mastery
• Dermal Filler Complications Mastery

Both give CPD and certificates on completion.

In addition, browse our FREE downloadable resources on complications.

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

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