Can You Still Make a Sad Face?

Botulinum toxin does make changes not only to the resting face but also how your face will appear to others . This is also known as "non-verbal communication". Anyone having this popular treatment needs to make sure that they can still express the feelings, without causing any inappropriate feelings in others. Hence, I ask if you can still make a sad face?

Botulinum toxin injections are a popular cosmetic treatment for smoothing wrinkles. Recent trends emphasise not just wrinkle reduction but also the correction of facial expressions that convey emotions. Among these, the sad face expression, associated with the omega pattern, is often overlooked despite its significant role in emotional expression.

The relationship between botulinum toxin and emotional expression is gaining increasing attention, as studies suggest that altering facial expressions through these injections can influence emotional well-being. Emotions such as anger, surprise, happiness, and sadness are often expressed through five distinct glabellar (the region between the eyebrows and above the nose as well as any features in that area) contraction patterns, each leading to different wrinkle formations. These patterns, identified as “U,” “V,” “Omega,” “Inverted Omega,” and “Converging Arrows,” have been widely recognized in the evaluation of facial wrinkles in aesthetic medicine.

Despite the importance of these patterns, the sad face expression, associated with the omega pattern, has been largely overlooked in clinical assessments, even though it plays a significant role in emotional expression. In botulinum toxin treatments, assessments typically focus on the surprise, happy, and angry gestures, often neglecting the expression of sadness.

Behavioural research has long identified six universal facial expressions: disgust, anger, sadness, happiness, surprise, and fear. Each expression correlates with distinct muscle activities and emotional states. Despite its universal significance, the sad face expression has frequently been overlooked in aesthetic medicine, even though it is well-recognised in other fields such as behavioural science. This gesture involves complex muscle interactions it is important to note that the sad face and fear expressions are similar, both characterised by the omega sign, but they differ in the lower third of the face

To improve the precision of botulinum toxin treatments in the upper third of the face, it is suggested that pre-treatment assessments and photographic documentation include a series of frontal view photographs capturing a full range of facial expressions: neutral, angry, surprised, happy, disgusted, and sad. This comprehensive approach enables a detailed evaluation of muscle dynamics and emotional expressions, resulting in more accurate and effective treatment outcomes.

Findings indicate that while all individuals have the musculature necessary to produce universal facial expressions, such as surprise or happiness, the same holds true for the sad face in facial mimics. The visibility and intensity of these expressions vary depending on muscle strength and control, which is particularly evident in the sad face. As has been professionally noted, sadness is the hardest emotion to fake, and it is less frequently practiced or observed in daily life, making it more challenging to identify and replicate.

By understanding the muscle dynamics of this expression, clinicians can improve treatment outcomes, balancing cosmetic and emotional considerations. Future research will focus on refining injection techniques to prevent omega lines, ensure natural expressions, and maintain ideal eyebrow positioning.

NOT MY OWN WORK. For further information, please refer to the full article whence the above was derived:

Muñoz-Gonzalez, C., Zarate, J.M. and Fakih-Gomez, N. (2025), The Overlooked Sad Face Expression: Understanding the Omega Sign in Botulinum Toxin Treatment. J Cosmet Dermatol, 24: e70200. https://doi.org/10.1111/jocd.70200