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Directly Acting Muscle Relaxants: Dantrolene and Botulinum Toxin01:26

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Skeletal muscle relaxants are used to relax muscle tone and alleviate painful muscle contractions. However, the choice of skeletal muscle relaxants depends on the duration of the surgical procedure in order to minimize potential side effects. Skeletal muscle relaxants like neuromuscular blocking agents [NMBAs] are commonly employed as adjuvants alongside general anesthetics in clinical settings. NMBAs are also used to maintain controlled ventilation during surgery of the larynx or pharynx...
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The craniofacial muscles are a collection of approximately 20 thin skeletal muscles situated beneath the skin of the face and scalp. These muscles, primarily responsible for the vast array of human facial expressions, originate from the bones or fibrous structures of the skull and extend outwards to connect with the skin. While most skeletal muscles in the body are enveloped in thick fascia, facial muscles generally have a more delicate fascial covering, with the buccinator muscle being a...
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Skeletal Muscle Relaxants: Adverse Effects01:21

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Updated: Apr 26, 2026

Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea
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Factors Associated With Paradoxical Masseteric Bulging After Botulinum Toxin Injection for Masseter Hypertrophy: A

Yi-Dan Sun1, Xiang-Wen Xu2, Lin Luo1

  • 1Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, P. R. China.

Journal of Cosmetic Dermatology
|April 25, 2026
PubMed
Summary

Preventing paradoxical masseteric bulging (PMB) after botulinum neurotoxin (BoNT) injections involves assessing masseter and deep inferior tendon (DIT) characteristics with ultrasound. Layered injections and tactile feedback significantly reduce PMB risk.

Keywords:
botulinum toxin type amasseter hypertrophyparadoxical masseteric bulging

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Area of Science:

  • Plastic Surgery
  • Medical Imaging
  • Aesthetics

Background:

  • Botulinum neurotoxin (BoNT) injections are a primary treatment for masseter hypertrophy.
  • Paradoxical masseteric bulging (PMB) is a significant complication of these injections.
  • Preventing PMB is a key concern for physicians performing these procedures.

Purpose of the Study:

  • To identify ultrasound and injection-related factors associated with paradoxical masseteric bulging (PMB).
  • To establish methods for preventing PMB in patients undergoing masseter hypertrophy treatment.

Main Methods:

  • Ultrasound and injection data were collected from 22 PMB and 66 non-PMB masseter muscles.
  • Univariate analysis compared masseter prominence, thickness, deep inferior tendon (DIT) type and thickness, tactile sensation, and injected agent between groups.

Main Results:

  • Significant differences were found in masseter prominence, DIT type, DIT thickness, masseter thickness, injection dosage, and tactile sensation (p < 0.05).
  • The PMB group exhibited greater masseter thickness (13.30 ± 0.171 mm vs. 10.32 ± 0.169 mm) and thicker DIT (0.85 [0.348] mm vs. 0.60 [0.208] mm).
  • Fascial penetration sensation was more common in the PMB group.

Conclusions:

  • Preoperative ultrasound assessment of masseter and DIT characteristics is crucial.
  • Individualized layered injections and intraoperative tactile feedback effectively mitigate PMB risk.
  • Ultrasound-guided precise supplementary injection is recommended for PMB management.