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Related Experiment Video

Updated: May 29, 2026

Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer
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The Pre-DIT Technique: A Fascicle-Specific Dual-Plane Approach for Correcting and Preventing Paradoxical Masseteric

Borja Gallardo Peydro1, Balma Gallardo Peydro2, Mariano Marqués Mateo3

  • 1Maxillofacial Service, Clinic University Hospital of Valencia, INCLIVA Biomedical Research Institute, Valencia, Spain.

Journal of Oral and Maxillofacial Surgery : Official Journal of the American Association of Oral and Maxillofacial Surgeons
|May 27, 2026
PubMed
Summary

Paradoxical masseteric bulging (PMB) after botulinum toxin injections can be effectively treated and prevented. A novel technique targeting superficial muscle fascicles resolves PMB and prevents recurrence, challenging previous assumptions about its cause.

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Published on: November 9, 2016

Area of Science:

  • Plastic Surgery
  • Neurology
  • Anatomy

Background:

  • Paradoxical masseteric bulging (PMB) is a rare complication of botulinum toxin type A injections.
  • PMB typically manifests within a week post-injection.
  • Existing theories suggest PMB arises from inadequate diffusion across the deep inferior tendon.

Purpose of the Study:

  • To investigate the underlying mechanism of PMB.
  • To introduce and evaluate a novel treatment and prevention strategy for PMB.
  • To describe a fascicle-specific dual-plane approach for masseteric botulinum toxin injections.

Main Methods:

  • Case identification and analysis of PMB occurrences.
  • Dynamic ultrasonography to assess masseter muscle fascicle activity.
  • Implementation and evaluation of a corrective superficial plane injection technique.
  • Introduction of a preventive "Pre-deep inferior tendon" technique.

Main Results:

  • Dynamic ultrasonography revealed persistent superficial fascicle contraction with deep fascicle inhibition in PMB cases.
  • Corrective treatment with targeted superficial injections led to rapid improvement within 48 hours and near-complete resolution within a week.
  • The preventive technique successfully avoided PMB recurrence in subsequent treatment cycles.

Conclusions:

  • PMB may result from isolated superficial fascicle hyperactivity rather than insufficient deep-plane diffusion.
  • A fascicle-specific dual-plane injection technique offers an effective method for both treating and preventing PMB.
  • This approach refines masseter botulinum toxin injection protocols for improved patient outcomes.