Tag Archives: botulinum toxin

Facial Nerve Injury without Face lift Surgery

My facial nerve injury

In the previous blog I wrote about the anatomy of the facial nerve. Here is the link in case you missed it.



facial nerve photo

Botox or botulinum toxin injections can also lead to facial nerve paralysis in specific areas. See below.




Effects of facial nerve injury

Facial nerve injury has many causes, including:

  1. Trauma – getting the facial skin cut
  2. Surgery – facelift surgery or skin cancer surgery
  3. Tumors – brain or Parotid gland tumors or cysts putting pressure on a nerve
  4. TMJ – tempro-mandibular joint inflammation
  5. Bell’s palsy – unknown cause for loss of facial nerve function


Why a sudden interest in facelift nerve injuries?

Well, I just woke up with an acute partial facial nerve paralysis. It happens relatively commonly, and in most cases has an unknown cause called Bell’s palsy. In my case, I think it may be due to a TMJ problem that causes swelling around the facial nerve and decreases its function.

Damage to facial nerve functions and results respectively lead to:
  • Chorda tympani – inability to taste with one side of the tongue

  – Decrease in amount of saliva production leads to dry mouth

  • Temporal – inability to wrinkle brow; brow will droop
  • Zygomatic – inability to tightly close eye; eye will tear up

     – Unable to blink reflexively

  • Buccal – inability to puff out cheeks and purse lips
  • Marginal mandibular – inability to show lower teeth


Symptoms of facial nerve injury?


  • Inability to close my right eye and tearing

I have patched my eye to prevent damage to my cornea


  • Unable to chew or drink properly

Just like when you have come back from the dentist after anesthesia, I cannot purse my lips and drinking from a cup; it is… messy.


  • Unable to smile

I look grumpy and when I do try to smile I look like a pirate


  • Mouth feels dry

Only some of my salivary glands are working


  • Lack of taste

Perhaps the most interesting of the symptoms is an almost total lack of taste on one side of the tongue. Technically, it’s the front two thirds that have no sensation, but it feels like the whole side. Of course, the ability to sense a bitter taste is intact in the whole tongue.

Surprisingly I can feel all foods. All food feels alike, from a piece of bread to salami to an olive. They all feel slimy like an oyster! None have any taste at all! This is the worst sensation of all, in my opinion, since I have long suffered from the vice of gluttony, which I am now denied.


Since I am someone who usually has a very animated face and uses many facial expressions when talking, the lack of muscle function on one side is even more noticeable.


Treatment of facial nerve trauma (nerve palsy)

If the facial nerve is damaged during facelift surgery, it should be repaired immediately by the cosmetic plastic surgeon.

Facelift surgery that has damaged a facial nerve but is discovered later may need complicated cross-face nerve grafts in the future.

If palsy is due to known causes like tumors or cancers, these causes must obviously be addressed and treated first.

Facial nerve injury due to other causes requires treatment with steroids to decrease the swelling around the nerve, exercises to keep the muscles of the face working and taught and… a lot of prayer.

Facial nerve palsy usually improves within three weeks to six months, but some may be left with a remnant decrease in function.

Morad Tavallali, M.D., FACS

Face lift and Facial Nerve Surgery

Face lift and facial nerve; Botox of the entire face


Face lift surgery has few serious complications, but one of them is injury to the underlying facial nerve. The facial nerve is the primary nerve for facial expressions and innervates face muscles. Plastic surgeons must know about face lift and facial nerve surgery .

Here are some articles about facelift surgery.



The facial nerve has a long and convoluted course.  It may seem boring to read this anatomy lesson, but you will need to have an idea of the subject so my next blog makes sense—that one is going to be unnerving (could not resist). Your cosmetic plastic surgeon is intimately aware of this anatomy.


First, as our facial nerve comes out of our brains, it gives off a few branches (chroda tympani) and stapedial (ear) and travels by the tragus cartilage in front of the ear to a higher level. Our facial nerve then splits into five main branches just in front of the ear but still under the facial muscles and gives a combination of sensation and movement to our faces. The nerve comes out to a superficial level past the pupil area. If a branch is damaged during facelift or facial surgery, it may take days or months before function returns.


Branches of the facial nerve

facial nerve


facial nerve photo

Deep Facial nerve branches

  • Chorda tympani – taste to front (anterior) 2/3rd of the tongue
  • Submandibular/sublingual gland
  • Stapedial branch – to middle ear stapes muscle


Superficial Facial nerve branches

  • Temporal – helps to elevate the eyebrow  
  • Zygomatic – helps the cheek to elevate

          – helps eye closure

         – reflex blinking of lids

  • Buccal – helps the corner of the mouth/cheeks to elevate
  • Marginal mandibular – depresses lower lip muscles
  • Cervical – tightens neck muscles


Facelift surgery

During facelift surgery, the skin of the face is elevated above the fat and muscles of the face. The fat and muscles are elevated and held in place with sutures. The skin is then pulled tight. All facelift surgery occurs in a level above the face muscles. The facial nerve runs below the muscles. Injury to the facial nerve during facelift surgery is hence rare if the surgeon stays above the facial muscles. The facial nerve does become more superficial, piercing the facial muscles as it gets closer to the nose. Injury can occur in the central part of the face.

More commonly there is a temporary lack of function of the facial nerve due to the local anesthesia that is placed in the skin of the face for facelift surgery. The anesthesia gives the same results as paralysis of the superficial branches of the facial nerve.


Botox and botulinum toxin and facial nerve

Botox treatments give very similar results in some cases to facial nerve injury or decreased function. The botulinum toxin will actually stop some of these facial nerve branches from working. If the botulinum toxin is put in the wrong areas, Botox can lead to serious side effects that will require therapy. This is why Botox is only recommended for specific areas of the face, such as the area between the eyebrows, the crow’s feet and the forehead.

So much for the anatomy lesson—stray tuned for the next blog, which shows someone with facial nerve paralysis!


Morad Tavallali, M.D., FACS

Cosmetic Botox Injections from FDA-approved Pharmacies

The FDA and Botox injections

As with many things in life, this situation is more complicated than it seems.

I have been purchasing Botox Cosmetic (Allergan), the neurotoxin that paralyzes facial muscles temporarily to remove wrinkles, from a pharmaceutical company based in the US for years. Last year I received a call from another pharmacy, this one in Canada, and was offered a chance to buy the same Botox Cosmetic manufactured by Allergan at a cheaper price, which meant I could lower the cost for my patients to under that charged by even the nail salons that inject patients in the back room!

Canadian pharmacies approved by the FDA

Last week I received a letter from the FDA telling me that the Canadian company that was selling the Botox Cosmetic was not FDA-approved. This was news to me. I had no idea that the US FDA approved other countries’ pharmacies. Every day, millions of Americans have prescriptions filled by Canadian pharmacies, as they offer the same drugs cheaper than in the US for reasons that are unfathomable.

Recently, there has been evidence that a number of fraudulent drugs are being manufactured in various countries and have found their way into the US market. A patient’s getting a fraudulent cancer drug is an abomination of decency, but the Botox coming from Canada was not fraudulent. What was going on?

All Botox made in Ireland

  • It turns out that all Botox Cosmetic in the world is made in one Allergan factory in Ireland! 
  • The Botox Cosmetic is then shipped from there to other countries. 
  • The Botox Cosmetic destined for the US is also made there, but an FDA agent has to be present at the time of packaging (or at some point in the packaging process). 

But some pharmacies in Canada are approved by the FDA to sell Botox destined for the US. The problem arises when other pharmacies, properly licensed and controlled by the Canadian government but not approved by the FDA, sell the same Botox to the US!

Confused?  It gets even worse. The FDA does not have clear regulations about which Canadian pharmacies are allowed to sell which drugs! Apparently, some pharmacies can sell some drugs but not others! Nobody seems to know the whole story or have a grasp of what the laws are. Given the recent problems the FDA has had with internal corruption cases while dealing with pharmaceuticals in this country, can we really be surprised?

It would make sense to me that if a product, like Botox Cosmetic, is made in a particular factory, like the Allergan factory in Ireland, it should be accepted by all countries as being legitimate and there should be no trade barriers or fictitious pretenses about quality control by the FDA. If a particular drug is made in different factories, then each factory needs to be monitored and approved, or the FDA should only approve a particular factory or two to provide the drug to the US market to minimize fraudulent drugs entering the country.

The current system is ineffective, self-serving, costly and an incomprehensible bureaucracy run amok.

Morad Tavallali, M.D., FACS

Plastic Surgery on the Body Affects the Mind for the Better

Botox, cosmetic plastic surgery and body language


I have written in the past about plastic surgery and how muscle action affects our mood. Early experiments of this type involved measuring brain endorphins (happy-feeling brain hormones) after patients were asked to hold a pencil in their mouths to simulate grinning. We know that then we are happy, our mouths turn into a grin. The experiment showed that when we force a grin by using the same muscles, we become happy!


Botox (botulinum toxin) useful against depression and headaches

Last year, a study showed that Botox, a medication that blocks muscle action, has beneficial effects in patients who suffer from migraines. Patients with migraine headaches suffer a tightening of the muscles of the scalp as one of the sequels to migraine attacks. Injecting Botox or any other Botulinum toxin effectively knocks out the muscles, relaxing them and improving migraine symptoms.


tummy tucks for men photo

Body positioning affects body hormones




Recent research has shown that body position affects our hormonal levels within two minutes! Specifically, taking on a dominant or “powerful” stance for two minutes,  such as placing your hands on your hips with your legs apart or holding your arms up in a “victory” stance, such as that of Rocky Balboa above, will decrease your cortisol (stress) hormone levels and increase your testosterone levels, which are associated with feeling in control, being more outgoing and being more self-confident. In contrast, sitting quietly in a chair with hunched over shoulders and crossed arms and legs will increase your stress levels and decrease your testosterone levels.  Here is a link to a TED talk by the researcher who discovered this fact: http://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are.html


Plastic surgery affects mood?

The study that begs to be performed next concerns whether patients who have had plastic surgery also benefit from an increase in self-confidence and empowerment and whether they have decreased stress hormone levels and an increase in testosterone.

Any cosmetic plastic surgeon will tell you that they have seen a change in their patients’ body posture after surgery, be it a breast augmentation or a facelift. Plastic surgery patients hold themselves straighter, walk more confidently and even dress in a more extravagant way after cosmetic surgery. They typically also smile more.

In fact, one of the main reasons patients go to a plastic surgeon seeking cosmetic surgery is to “feel” better about themselves, and they will often voice that.  If you think about it, all of us have the same feelings on a daily basis when we look at ourselves in the mirror. On good days, when you wake up looking better, you will tend to enhance that by dressing up and thereby reinforcing your “on top of the world” look—which makes you feel even better! On a bad hair day or when you get up on the “wrong side of the bed,” you will look less attractive and may even dress down, thereby reinforcing the image of the “depressed and less attractive” you.

Why does all this matter, anyway?

Simply put, more attractive people have been shown in multiple studies to make more money. That’s one reason. See how I said attractive people and not beautiful people. There is a difference, as few of us are beautiful but many are attractive. The French even have a saying for “attractive ugly women”: une jolie laide!

Tall people tend to dominate us shorter folk, and it seems we pay them more for it. Thin people feel more confident than chubbier ones, and we also pay them more. This means that physical shape will affect financial earning potential. Some of our physical shape is determined by our genes, and there is little we can about that other than having plastic surgery to enlarge breasts, reduce nose size or remove excess skin and fat. The other part of our physical appearance is determined by aspects of posture, which you can control much more easily by keeping  your head held up high and standing tall! Plastic Surgery on the Body Affects the Mind!

Morad Tavallali, M.D., FACS

Information about Botox Injections

Information about Botox Injections

Botulinum toxin


Botulinum toxin injections, also known as Botox Cosmetic, Botulinum toxin, Myobloc and Dysport, are some of the most popular cosmetic and plastic surgery procedures performed around the world. All for a simple reason: they work!

Cosmetic uses of Botox toxin

Small wrinkles between the eyes, the crow’s feet, and in the forehead can be “removed” with a few small injections. Botox toxin’s effects last about three months, and the injections can be repeated safely. Technically, Botulinum toxin is only approved for injection into the glabella (the area between the eyes), but it has been used extensively and safely in other areas.

Other uses of Botulinum toxin

– treatment of migraines

– treatment of muscle spasms and spacticity

– treatment of hyperhidrosis, excessive sweating

– treatment of eye muscle disorders, strabismus

Limitations of Botox

Botulinum toxin has some limitations, like any other medication:

– takes 7-10 days to work

– works in all but works well only in 8 out 10 patients

– used with caution in patients with muscle diseases like ALS

– can cause allergies to itself, resulting in itchiness, redness, asthma

– effects on pregnancy and breast feeding are unknown

– rarely has effects away from the site of injection if injected in too high a concentration and by untrained individuals; this can cause double vision, trouble speaking, loss of bladder control and trouble breathing

More common side effects of Botox Cosmetic

– dry mouth

– pain at injection site

– tiredness or muscle weakness

– blurry or double vision

– headaches

– droopy eyelids

Biggest problem I see with Botulinum toxin injections

– Patient expectation – some patients have bigger and stronger muscles that cause deeper lines on the skin. Obviously, they will need more toxin to get the same result; but you will forget that when you see them! All you need is some more injected!

– Patient impatience – cosmetic patients are increasingly impatient for their surgical or procedure results. Medications need time to work! Botox needs 7-10 days for full effects, though you may see effects earlier!

More Botox info can be found here: https://www.tavmd.com/skin_filler.html