How to correct facial asymmetry with botulinum toxin (Botox) treatment

Using botulinum toxin or Botox® to correct facial asymmetry in patients is both underused and overused because there are times when it achieves amazing results but other times when it is just not the right thing to do. Many patients will request treatment to restore symmetry and balance, and Botox injections can be a great fix for facial asymmetry in the right circumstances like Bell’s Palsy, an Elvis lip, or brow asymmetry, but it can be tricky to achieve a good result.

In this blog, Dr Tim Pearce will explore how to use botulinum toxin to correct facial asymmetry and the areas where it is most beneficial, with cautionary notes on how to avoid causing new asymmetries.

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Where can you use botulinum toxin to improve facial symmetry?

The most common area for patients to seek neuromodulator treatment for asymmetry is with the eyebrows. If an individual has one eyebrow that is slightly lower than the other, people will notice because eyebrows frame the face. A request to even them out, so they look the same, is quite commonplace, but can sometimes work very well or sometimes very badly, depending on the individual and their underlying anatomy.

Dr Tim highlights this problem with a case study of his own. He treated a patient with an asymmetrical eyebrow who had experienced trauma to her forehead. The injury resulted in no forehead movement on one side and caused the patient a lot of distress because she had one eyebrow that was quite raised, and the other was completely dropped. She sought to look more symmetrical, and Dr Tim delivered her desire by relaxing the muscle on the side that was too elevated. She then looked symmetrical but hated the result. Why? Well, because she went from looking alert and interested, even though she was asymmetrical, to looking exhausted and uninterested.

The take-home message from this case is to think about the face as a 3D tool for interacting with other people and not something that needs to become beautiful in a still 2D image or photograph. What the patient realised from this experience was that she preferred the function of her face over the form, in other words, it was better to be able to communicate non-verbally, looking interested and engaged with other people even though she looked very asymmetrical. Facial symmetry is not the be-all and end-all for many patients.

Adjusting eyebrow asymmetry with Botox treatment

As with the complex case highlighted by Dr Tim, the result you can achieve to correct eyebrow asymmetry will depend on the patient’s presentation. If there is more elevation, i.e., the frontalis is more active, there is something you can do to adjust the eyebrows, but there is very little you can do that does not risk increasing asymmetry elsewhere. He suggests that there are three injection points that you can target with confidence, but the rest must be more carefully considered.

Assuming knowledge of how to lift an eyebrow, the first and easiest way is to place approximately four Botox units at the tail of the eyebrow. This will release the strongest part of the orbicularis oculi muscles where it is pulling down the eyebrow and will allow for a small lift. This is the simplest solution if the patient wants nothing except correction of brow asymmetry. It is very unlikely they will spot any other deficits because the orbicular oculi muscle is still working everywhere else, but just at this point it is weaker, and that allows a little bit of lift in the eyebrow.

Read up on the best Botox brow lift injection patterns to avoid ptosis and Spock brow and Treating orbicularis oculi with Botox: what can go wrong?

The second, more complex option is to treat underneath the eyebrow. You are still treating orbicularis oculi and are very superficial to keep the eyelid safe. Similarly, you are over the periosteum, over the bone of the orbit, but you can treat with approximately two to three Botox units underneath the tail of the eyebrow. This releases even more of the muscle, allowing the eyebrow to lift more laterally. Learn more about this technique in How to inject Botox under the eyebrow for a brow lift.

A third, and yet more considered option relates to adjusting the amount of the frontalis muscle that is untreated on one side versus the other. However, this treatment can cause different asymmetries resulting in visible lines on the side that you are trying to lift and no lines on the side that you are not trying to lift; this will require a different treatment to resolve. Therefore, patients may not be content with this solution for eyebrow asymmetry correction due to the associated issues especially because it is very difficult to execute accurately and avoid them. The method involves adjusting the ‘triangle area’ on the frontalis that is left untreated to give you more lift on one side and less lift on the other, meaning you have less treated muscle on the side you want to lift. With small adjustments, you can sometimes get this right explains Dr Tim, but the downsides of an unequal lift and causal lines may not be worth the risk. Get further insight on injecting Botox into the frontalis muscle, safety advice.

Using botulinum toxin to improve facial asymmetry caused by Bell’s Palsy

Patients who suffer from the rare condition Bell’s Palsy also commonly seek help to treat an asymmetrical face. If Bell’s Palsy persists in a patient long-term, it will manifest as a weakening and a decrease in tone on one half of the face, with an increase in tone on the other half of the face.

Treatment is targeted at the side of the face which is unaffected by the palsy to restore a symmetrical result, i.e., where the face is hyperactive and the tone is high, you can use a small amount of botulinum toxin strategically to balance the tone across the whole face. The results can be quite astounding in such cases, but it is an advanced treatment with careful consideration given to which muscles are hyperdynamic.

If you have a patient with Bell’s Palsy, Dr Tim’s advice is to film them moving their face so you can see where the additional activity is happening due to the hyperdynamic muscles. You may note that perhaps one eye is more active, or you will see an increased downturn in the DAO (Depressor Anguli Oris) which pulls their mouth down on one side when they smile, for example. These are the muscles where a small amount of botulinum toxin is beneficial to increase symmetry and balance. The key consideration is starting with lower doses than you would usually employ when treating a normal DAO, (e.g., 1-2 Botox units) and observing the results, to reduce the resting tone and hyperactivity.

Correcting masseter asymmetry with Botox

Patients often present with the masseter muscle on one side of their face seeming to be bigger than the other, which can be quite tricky to correct exactly, notes Dr Tim.

His treatment approach depends on the relative size of the muscle, starting with a lower dose than typically used for treating the masseter. The aim is not to shrink it to its maximum relaxed state, but to cause enough atrophy to make it symmetrical. A normal dose may be 24 to 50 Botox units, but it would be wise to consider 15 to 20 and review the patient after 6 weeks to document the response so you can adjust accordingly for future treatments to achieve the symmetry.

If you believe that both masseters are hypertrophied, but one side is particularly strong, you can neutralise both sides because they should return to a similar size when both are completely relaxed in the lower third.

Dr Tim explains that you do not always have to perform asymmetrical treatments to increase symmetry and correct asymmetry; if you take both sides back to a neutral state where the muscles are effectively atrophied as much as they can be the result will be more symmetrical. The only caveat is if the underlying asymmetry is bone-related, which can occur in rare cases.

Correcting an Elvis lip with Botox

The so-called Elvis lip is very familiar and is an overactivity of the levator labii alaeque nasi muscle on one side of the mouth resulting in a snarl. Treatment with one unit of Botox on the affected side should achieve a reduction in the snarl. Read more with a muscle anatomy lesson: levator labii alaeque nasi muscle.

For additional guidance on botulinum toxin treatments:

• Download – Dr Tim Pearce’s 26 essential injection patterns for botulinum toxin
• Further reading – Best tried and tested BOTOX® injection patterns and mistakes to avoid

Dr Tim is always keen to hear about the experiences of his followers. So, if you have any questions, case studies, or discussion points for him, you can find Dr Tim Pearce on Instagram.>

Aesthetics Mastery Show

How to fix facial asymmetry with Botox

Dr Tim says:

“Many patients will often come to you asking for Botox to fix facial asymmetry. Botox injections can be a great fix for facial asymmetry in the right circumstances such as Bell’s Palsy and brow asymmetry. In this episode I discuss how to use Botox to fix asymmetry and the areas in which it will make a beneficial difference.”

Watch the full Aesthetics Mastery Show here.

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BOTOX (Botulinum Toxin) eLearning Courses

If you want to increase your confidence in botulinum toxin injections, or learn how to avoid and handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

• BOTOX® Foundation Course
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Both give CPD and certificates on completion.

In addition, browse our FREE downloadable resources on complications.

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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.

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