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COSMETIC Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers: Focus on the Lower Face Maurício de Maio, M.D. Woffles T. L. Wu, M.D. Summary: This third article of a three-part series addresses techniques and rec- ommendations for aesthetic treatment of the lower face. The lower face is con- Greg J. Goodman, M.D. sidered an advanced area for facial aesthetic treatment. In this region, soft-tissue Gary Monheit, M.D. fillers play a more important role than neuromodulators and should be used on behalf of the Alliance first to provide structure and support before neuromodulators are considered for the Future of Aesthetics for treatment of dynamic lines. Treatment of the lip, perioral region, and chin, Consensus Committee in addition to maintaining balance of the lower face with the face overall, is chal- São Paulo, Brazil; Singapore; South lenging. Procedures on the lip should avoid overcorrection while respecting the Yarra, Victoria, Australia; projection of the lips on the profile view and the ratio of lip size to chin. The and Birmingham, Ala. chin is often neglected, but reshaping the jawline can provide dramatic improve- ment in facial aesthetics. Both profile and anterior views are critical in assessment e and treatment of the lower face. Finally, rejuvenation of the neck region requires fillers for structural support of the chin and jawline and neuromodulators for treatment of the masseter and platysma. (Plast. Reconstr. Surg. 140: 393e, 2017.) T his is the final part of a three-part series on AESTHETICS OF THE PERIORAL AREA injection techniques for aesthetic procedures AND LIPS involving use of injectable fillers and/or neu- The perfect lip includes a visible transition romodulators. Recommended needles for each line or border between the vermillion and skin, a product are listed in Table 1 and recommended V-shaped Cupid's bow, a full medial tubercle and Allergan plc (Dublin, Ireland) portfolio products vermillion, an ascendant line in the oral commis- and volumes/doses for each area of the midface sures, and an upper-to-lower lip ratio of are illustrated in Table 2. Other filler and neuro- modulator options are available and can be used in the treatment areas described; good results are AGING OF THE PERIORAL AREA AND as much dependent on injector technique as on LIPS the product utilized. We provide detail specific to Intrinsic lip volume loss, photodamage, and Allergan products because of our extensive experi- lip muscle movement lead to static and dynamic ence with these products in clinical practice. This wrinkles, lip elongation and thinning, flatness article discusses techniques in the lower face, one of the vermillion border, loss of Cupid's bow, lip of the most challenging areas to treat. The lip is challenging to reshape with fillers; comprehensive assessment is necessary to avoid improper correc- Disclosure: Dr. de Maio and Dr. Goodman are tion. The chin is one of the most neglected areas, Allergan plc consultants for speaking events and mar- but reshaping the jawline can provide dramatic keting strategy. Dr. Wu is a consultant for Allergan improvement in facial aesthetics. Finally, the neck plc, Galderma, and Merz for speaking events and ad- is a challenging area, where both fillers and neuro- visory boards. Dr. Monheit has no conflicts to disclose. modulators may be necessary. From the Clinica Dr. de Maio; the Woffles Wu Supplemental digital content is available for Aesthetic Surgery and Laser Centre; the Dermatology Insti- this article. Direct URL citations appear in the tute of Victoria; and the Total Skin and Beauty Dermatology text; simply type the URL address into any Web Center. browser to access this content. Clickable links Received for publication April 2016; accepted February to the material are provided in the HTML text 10, 2017. of this article on the Journal's website (www. by the American Society of Plastic Surgeons PRSJournal.com). DOI: 10.1097/PRS.0000000000003646 www.PRSJournal.com 393e Copyright 2017 American Society of Plastic Unauthorized reproduction of this article isPlastic and Reconstructive Surgery September 2017 dryness, and downturned oral commissures. 1-3 In and radiating from the lip border, particularly the aging lip, the perioral tissues of the cutaneous in the area above the lips. 5 These lines develop lip also atrophy. Age-related deepening of the because of perioral soft-tissue volume loss, lip nasolabial fold may be caused by repeated con- atrophy, hyperdynamic contractions of the peri- traction of the levator labii superioris and levator oral musculature, and underlying resorption of labii superioris alaeque nasi muscles during wrin- mandibular kling of the nose and by ptosis of the superficial musculoaponeurotic system. With aging, perioral ASSESSMENT OF THE PERIORAL AREA lines become evident perpendicular to the lips AND LIPS Assessment should be made at rest and during Table 1. Recommended Needle Sizes for Delivery of animation (i.e., while smiling and while puckering), Soft-Tissue Fillers and OnabotulinumtoxinA including the projection of the lips on the profile Assess preservation of lip landmarks, including Product Needle Size the vermillion border, vermillion body, Cupid's bow, Injectable fillers philtrum, and oral commissures, and any loss of lip Ultra 30-gauge, 1/2-inch (13 mm) Ultra Plus 27-gauge, 1/2-inch (13 mm) and perioral volume. Also, assess the dental arcade Volbella 30-gauge, 1/2-inch for the presence of occlusions and the inclination Volift 30-gauge, 1/2-inch (13 mm) of the teeth. Evaluate for asymmetry at rest and dur- Voluma 1/2-inch 3 mm) ing animation, excessive inversion of the vermillion, OnabotulinumtoxinA 30-gauge, 1/2-inch (13 mm) and whether the gingiva are prominent. Assess the Table 2. Recommended Allergan plc Portfolio Product and Volume/Dose for Individual Areas Region Product Volume/Dose Range Hyaluronic acid filler Nasolabial fold Ultra Plus 0.5-1.0 ml per side Volift Voluma 0.1-0.3 ml per side Lip border Ultra Plus 0.1-0.2 ml per quadrant Ultra Volift Volbella Vermillion linear technique Ultra Plus 0.5-1.0 ml for both lips Ultra Volift Volbella Vermillion aliquot technique Ultra Plus 0.05 ml per bolus Ultra 0.5-1.0 ml for both lips Volift Commissures Ultra Plus 0.05-0.1 ml per side Volift Philtrum Ultra Plus 0.05-0.1 ml per side Ultra Volift Perioral lines UltraVolume 140, Number 3 Injection Guide for the Lower Face surrounding areas for perioral wrinkles, nasolabial folds; inject into the superficial subcutaneous space. folds, and marionette lines. Before treating the naso- For fanning technique (not shown), deliver a slow labial fold, the midface region should always be eval- and superficial subcutaneous injection medial to uated and treated. In rare cases, the nasolabial fold the fold, Use a may be treated only by a direct approach. slow, continuous-movement, low-volume, linear retrograde injection. Do not overinject, as overin- ANATOMY OF THE PERIORAL AREA jection may lead to irregularities. For injection on AND LIPS the medial aspect of the fold, position the needle more superficially and deliver a subcutaneous injec- The superior and inferior labial arteries found tion using a fanning technique. Inject more slowly as in the submucosal layer (wet part) are branches of the injection approaches the nose. Massage to shape the facial artery and supply the upper and lower after each injection; do not overfill. lips, The infraorbital nerve and Use of Voluma for nasolabial folds is indicated mental nerve provide sensory innervation of the in patients with severe volume loss to compensate upper and lower lips, respectively, whereas the for bone retrusion. Specific training for this area is buccal branch of the facial nerve provides motor advised. Voluma is injected very deeply at the canine innervation to these areas. 1 fossa (Fig. 2, left). Inspect the skin surface to deter- mine the vascular pattern, and avoid the facial artery FILLER INJECTION TECHNIQUE FOR and nose branches, the facial vein, and the inferior INDICATIONS IN THE PERIORAL AREA alar artery branch of the angular artery (Fig. 2, AND LIPS right). 6 Position the needle perpendicular to the skin surface. Touch the bone, and aspirate before injec- Nasolabial Fold tion. Inject very slowly with low pressure to deliver Injections of Ultra Plus or Volift are made at a supraperiosteal small bolus. (See Figure, Supple- two areas (Fig. 1, left). Injectors should be alert to mental Digital Content which shows the injection the facial artery and vein and exercise caution dur- technique for retruded canine fossa. Insert needle ing augmentation of the proximal nasolabial folds perpendicular to skin surface, and inject very slowly because of a risk of vascular compromise of the with low pressure, facial artery and nose branches (Fig. 1, 6 For Massage to shape and avoid overfilling. the retrograde linear injection (area 1), position the needle and aspirate before injection. Stretch the Lip Border skin using two fingers to better visualize the Reshaping the lip border (Fig. 3) is achieved Stay slightly medial to the fold, and insert the needle using Ultra Plus, Ultra, Volift, or (See Fig- angled upward parallel to the fold to deliver a super- ure, Supplemental Digital Content 3, which shows ficial subcutaneous injection. [See Figure, Supple- the injection technique for lip border. Inject very mental Digital Content 1, which shows the linear slowly and avoid inadvertent displacement of the retrograde technique for treatment of nasolabial filler, Assess any Angular a. & Infraorbital a. & Superior labial a. & V. Inferior labial a. & Facial a. & Mental a. & Fig. 1. Treatment of nasolabial folds using either Ultra Plus or Volift (left). Aspiration is mandatory before each injec- tion. Areas of caution (right). a., artery; V., vein. 395e Copyright 2017 American Society of Plastic Unauthorized reproduction of this article isPlastic and Reconstructive Surgery September 2017 Angular a. & Infraorbital a. & V. Superior labial & V. Inferior labial a. & V. Facial a. & V. Mental a. & Fig. 2. Treatment of the retruded canine fossa using Voluma (left). Inspect skin for vascular pattern to avoid areas of high caution, including facial artery and vein and the inferior alar artery branch of the angular artery (right). Aspiration is mandatory before injection. recommended (Fig. 4). With the first technique, the filler is administered at one site in each quad- rant of the lip body. Administer Ultra Plus, Ultra, and Volift by means of intramuscular anterograde linear threading and Volbella by means of retro- grade linear threading into the dry submucosa. [See Figure, Supplemental Digital Content 4, which shows the injection techniques for vermil- lion. Inject very slowly either linearly in the sub- mucosa (left, technique 1) or in small aliquots Fig.: Treatment of the lip border using Ultra Plus, Ultra, Volift, or Vol- intramuscularly (right, technique 2), http://links. bella. The product is injected along the lip border. Areas of caution: Avoid the labial artery and avoid the labial artery and vein in the intraoral submucosal plane. vein in the intraoral submucosal plane. Insert the needle into the lip mucosa at a 30-degree angle asymmetry before injection, and respect the propor- to the lip body.5 Enter through the skin and inject tions between the upper lip and the lower lip. When very slowly to avoid bleeding in this bruise-prone identifying injection sites, avoid the labial artery area. The second technique can be used with and vein in the intraoral submucosal plane (i.e., wet Ultra Plus, Ultra, and Volift. Filler is administered part of the lip). Position the needle at the vermil- at three injection sites per quadrant. To avoid pain lion border near the lateral edge of the mouth, and and bruising, insert the needle at points 2 mm insert the needle below the mucocutaneous junc- superior to the upper lip border and 2 mm infe- tion. Inject very slowly using an anterograde linear rior to the lower lip border, and place the filler technique with deposition of a linear thread as the inside the vermillion. Deliver very small intra- needle is being advanced into the skin. Avoid inad- muscular bolus injections very slowly. Massage is vertent displacement of the product outside of the mandatory to avoid irregularities and nodules. intended treatment area. Injection into the sensitive The precautions outlined for enhancing the lip Cupid's bow is performed very slowly. Administer border should also be followed for the vermillion. equal volumes of filler on both sides unless gross asymmetry is Avoid overcorrecting the lip Commissures border and producing excessive anterior projection Restoring the commissures may be achieved of the upper lip. with Ultra Plus or Volift. Before treating the com- missures, the lip border should be treated, if indi- Vermillion cated. Insert the needle superficially at the lateral Enhancing the shape or volume of the ver- edge of the mouth angle, and deliver a very small million can be achieved with Ultra Plus, Ultra, bolus injection intramuscularly and/or into the Volift, or Volbella. Two different techniques are mucosa (Fig. 5). Be alert to avoid the labial artery 396e Copyright © 2017 American Society of Plastic Unauthorized reproduction of this article isVolume 140, Number 3 Injection Guide for the Lower Face Ultra Plus, Ultra, or Volift Vobella Filler Labial Filler Labial Artery Artery Fig. 4. Treating the vermillion with Ultra Plus, Ultra, Volift, or Volbella. These fillers can be injected either linearly (above) or in small aliquots (below). Areas of caution: avoid the labial artery and vein in the intra- oral submucosal plane. Fig. 5. Treating the oral commissures with Ultra Plus or Volift. Fig. 6. Augmentation of the philtrum with Ultra Plus, Ultra, These fillers are injected at one site on each side. Areas of cau- Volift, or Volbella. These fillers are injected at one site on each tion: avoid the labial artery and vein. Inject very slowly. side. Areas of caution: avoid the columella branches of the upper labial artery near the nose. and vein. Inject very slowly. Avoid overcorrection because of the possibility of creating a bulging Ultra Plus, Ultra, Volift, or Volbella with one injec- area or displacement during animation. Overcor- tion site per side (Fig. 6). Avoid the columella rection may lead to an abnormal smile. branches of the upper labial artery near the nose. Pinch the philtral column using two fingers, and insert the needle at the base of the philtrum with Philtrum the needle pointed upward and the needle bevel The ridge between the nose and lips, known inward. (See Figure, Supplemental Digital Content as the nasal philtrum, tends to flatten with aging. 5, which shows the injection technique for phil- Reshaping of the philtrum can be achieved with trum. Pinch the philtral column, and insert thePlastic and Reconstructive Surgery September 2017 needle upward with the bevel facing inward; inject Injections of onabotulinumtoxinA for correction slowly, Administer of gummy smile are made at three sites if mod- a superficial subcutaneous injection using a linear erate and at five sites if severe (Fig. 8). The total retrograde technique. Ensure that the inverted-V dose is 6 to 10 U of onabotulinumtoxinA, depend- shape of the philtrum is preserved. Avoid widen- ing on severity and muscles involved. [See Figure, ing the philtral columns and avoid overcorrection Supplemental Digital Content 7, which shows the that may result in elongating the upper lip. injection technique for gummy smile. For each injection, insert the needle pointed upward to Perioral Lines one-half of its depth; inject into the depressor Correction of perioral lines can be achieved septi nasi (left) and levator labii superioris alaeque with Ultra or Volbella (Fig. 7). Be alert to the peri- nasi (right). Assess for asymmetry before and after oral vasculature, including branches of the upper injection, Exces- labial artery. Insert the needle perpendicular to sive doses lead to upper lip elongation and the wrinkles and administer a superficial subcuta- lip ptosis. Patients with a short upper lip are ideal neous injection using a linear technique. (See Fig- candidates, whereas care should be exercised in ure, Supplemental Digital Content 6, which shows patients with gummy lip and a long upper lip. the injection technique for perioral lines. Inject slowly and evenly perpendicular to the wrinkles; Upper Lip and Lower Lip Lines massage after the injection, Vertical lines on the upper and lower lips occur PRS/C316.) Inject slowly and evenly, and massage with aging and may remain after dermal filler treat- after each injection. Do not chase superficial lines. The orbicularis oris is the main muscle in Avoid elongation and flattening of the upper lip the lips, with superficial fibers responsible for lip because of overinjection and avoid overcorrec- 7 Upper lip lines are treated at one or tion.6 In many aged lips, judicious volumization two sites per side (Fig. 9), whereas lower lip lines are with Ultra or Volift will aid in treatment of lines. treated at one site per side. Insert only the needle bevel pointed upward. (See Figure, Supplemental ONABOTULINUMTOXINA INJECTION Digital Content 8, which shows the injection tech- nique for upper lip lines. For each injection, insert TECHNIQUE FOR INDICATIONS IN THE the needle to the depth of the bevel, with the bevel PERIORAL AREA AND LIPS Gummy Smile Gummy smile refers to the showing of exces- sive gum while smiling or laughing. In moderate gummy smile, the levator labii superioris alaeque nasi muscle elevates and everts the upper lip, and the depressor septi nasi muscle draws the nasal tip downward and lifts the medial In severe gummy smile, the levator labii superioris and zygomatic minor muscles also raise the upper Fig. 8. Treatment of gummy smile with Fig. 7. Correction of perioral lines with Ultra or Volbella. These Injections are made at three sites for moderate gummy smile fillers are injected at one site in each quadrant. Areas of caution: (yellow X) and at two additional sites for severe gummy smile perioral vascularization (branches of the upper labial artery). (blue X). The symbol X indicates one-half needle depth. 398e Copyright 2017 American Society of Plastic Unauthorized reproduction of this article isVolume 140, Number 3 Injection Guide for the Lower Face presence of marionette lines, including sagging skin or manifest lines. Finally, assess the platysma for the presence of neck lines and for active con- traction of the platysma bands when speaking. ANATOMY OF THE CHIN AND JAWLINE The mental and submental arteries, which are branches of the inferior alveolar artery and facial artery, respectively, supply the The mental nerve provides sensory innervation to the chin and lower lip; it exits the mental foramen below the second mandibular Particular attention should be paid to the facial artery and marginal mandibular facial nerve branch, as they cross superficially just anterior to the masseter muscle in the postjowl sulcus. FILLER INJECTION TECHNIQUE FOR INDICATIONS IN THE CHIN AND Fig. 9. Treatment of upper and lower lip lines with onabotu- JAWLINE linumtoxinA. Injections are made at one or two sites per side. Marionette Lines pointed upward. Assess for asymmetry before and Marionette lines give the face a sad or hard after injection, appearance. Treatment of marionette lines may Avoid administering excessive doses, which may be achieved with Ultra Plus or Volift. Injections lead to flattening of the lips and restrict lip purs- are made at two sites on each side (Fig. 10). Injec- tors should be alert to avoid the inferior labial ing, or injecting too close to the mouth, which may impact lip function and cause drooling. and sublabial arteries and veins. Using a linear retrograde technique, deliver a superficial sub- cutaneous injection. Inject slowly, and deliver AESTHETICS OF THE CHIN AND most of the volume to the top third of the fold JAWLINE while staying medial to the marionette line. The The chin should be oval and delicate in women, upper injection is made by inserting the needle with less fullness concentrated at its lateral part, inferior to the modiolus and injecting slowly using whereas it may have more square, heavier features a vertical column technique, in which the filler and a stronger appearance in men. For both men is injected as the needle is withdrawn from the and women, good chin projection and a youthful deeper tissue. [See Figure, Supplemental Digital jawline are considered the standards of 1,9 Content 9, which shows the injection technique ASSESSMENT OF THE CHIN AND JAWLINE The chin assessment should include evalu- ations of occlusion, skeletal and dental relation- ships, lateral fullness, and projection along the subnasal vertical The ratio of the upper lip to lower lip/chin should be one-third to two-thirds. The jawline assessment should consider the chin- neck angle (submental-neck line); 121 degrees is considered optimal in women. The jawline should be smooth from the angle of the jaw until the Fig. 10. Correction of marionette lines with Ultra Plus or Volift. chin, uninterrupted by the jowl or postjowl and Fillers are delivered by means of injections at two sites per side. prejowl sulcus. Viewing this area from the front Areas of caution: avoid the inferior labial and sublabial arteries and sides is critical in assessment. Evaluate for the and veins. 399e Copyright 2017 American Society of Plastic Unauthorized reproduction of this article isPlastic and Reconstructive Surgery September 2017 for marionette lines. The upper injection is made in the modiolus using a smaller volume. For the linear retrograde technique, deliver a superficial subcutaneous injection (not shown). Keep both injections medial to the marionette line, http:// Mental Crease The labiomental or mental crease is a horizon- tal line that develops during aging just above the chin.5 These lines develop because of soft-tissue volume loss, dermal atrophy, reduced skin elastic- Fig. 11. Treatment of a mental crease with Ultra Plus or Volift. ity, hyperdynamic contractions of the lower facial Fillers are delivered by means of linear retrograde or antero- muscles, and underlying resorption of mandibular grade injection. Areas of caution: avoid the sublabial artery and bone. A reduction in the depth of a mental crease vein. may be achieved with Ultra Plus or Volift. Filler is delivered to one injection site per side (Fig. 11). Injectors should be alert to avoid the sublabial artery and vein. Deliver a superficial subcutaneous injection through a linear retrograde technique. [See Figure, Supplemental Digital Content 10, which shows the injection technique for mental crease. Injections are made by means of linear ret- rograde technique. Alternatively, injection using a linear anterograde technique can be made if starting laterally (not shown). Injections should be made slowly, Mas- sage after each injection, and avoid overinjection, Fig. 12. Augmentation of the chin apex with Ultra Plus or as overinjection may lead to irregularities. Voluma. Both fillers are delivered by means of injections at two to three sites. Areas of caution: avoid the mental artery and vein. Chin Apex A recessed chin is aesthetically undesirable; augmentation increases the anterior projection and rounding of the chin.5 Augmentation of the chin apex can be achieved with Ultra Plus or Voluma. Each product is delivered to two to three injection sites (Fig. 12). Injectors should be alert to avoid the mental artery and vein. For the first injection, posi- tion the needle at the midline of the jawline, and aspirate before injection. (See Figure, Supplemen- tal Digital Content 11, which shows the injection technique for augmentation of chin apex. Aspirate before injection and inject slowly. Pinch the chin to Fig. 13. Filling of the prejowl area with Ultra Plus or Voluma. avoid unwanted displacement of the filler, http:// Both fillers are delivered by means of a deep subcutaneous Inject slowly and deliver injection using a fanning technique. Areas of caution: avoid the a supraperiosteal small bolus. Compare symmetry mental artery and vein and the mental nerve. before and after the injection by watching from the cephalic view. Maintain the injection in the mid- line and avoid chin deviation. Use two fingers to Prejowl Area pinch the chin to avoid unwanted displacement The prejowl area is the triangular area from of the filler. Do not inject the filler too low, as this the mental foramen to the midlateral zone of the can lead to formation of a "witch's chin," and do mandible (Fig. 13). Filling of jowls can be achieved not overfill. Massage after the injection. Deliver the with Ultra Plus or Voluma. Injectors should be alert other two injections in the same manner at supero- to avoid the mental artery and vein and the men- lateral sites on either side of the chin. tal nerve. Position the needle at the jawline of the 400e Copyright 2017 American Society of Plastic Unauthorized reproduction of this article isVolume 140, Number 3 Injection Guide for the Lower Face prejowl area, and aspirate before injection. (See Fig- ure, Supplemental Digital Content 12, which shows the injection technique for filling of the prejowl area. Inject very slowly and use fingers to control the placement of the product. Aspiration before injection is necessary, C322.) Make a deep subcutaneous injection using a fanning technique to deliver filler to the distal parts of the triangular prejowl area. Inject slowly, use fin- gers to control placement of the product, and exer- cise care with displacement of the filler over the mandibular ligament. Overcorrection lateral to the ligament may worsen the jowl area. Fig. 14. Treatment of the mandible body and angle with Ultra Mandible Body and Angle Plus or Voluma. Both fillers are delivered by means of a super- The injection of fillers in this area creates ficial subcutaneous injection over the mandible body and by a more defined jawline This may be supraperiosteal small-bolus injections over the mandible angle. achieved using Ultra Plus or Voluma, with injec- Areas of caution: palpate and avoid the facial artery and vein, tions at two to three sites per side (Fig. 14). Injec- and avoid the parotid gland. tors should be alert to palpate and avoid the facial artery, facial vein, and parotid gland. For the sub- cutaneous injection, pinch the skin above the man- dible body and position the needle superficially to avoid the facial artery. [See Figure, Supplemental Digital Content 13, which shows the injection tech- nique for the mandible body. For the subcutaneous injection, pinch the skin to avoid the facial artery. The supraperiosteal injections are delivered over the mandibular angle (not shown). Aspirate before each injection, inject slowly, and avoid scratching the periosteum, Do not inject deep at this level. Aspirate before injection, and inject slowly using a linear retro- grade technique. For the supraperiosteal injections, deliver one or two small boluses at the mandibular angle. This is ideal for male patients. A subcutane- ous approach is preferable for female patients. Aspi- rate before each injection, inject slowly, and avoid scratching the periosteum. The treatment area is prone to development of deep hematomas, espe- cially the site of the supraperiosteal injections. Fig. 15. Treatment of the depressor anguli oris muscle with ona- botulinumtoxinA. Injections are made at one site per side. The ONABOTULINUMTOXINA INJECTION symbol X indicates one-half needle depth. TECHNIQUE FOR INDICATIONS IN THE CHIN AND JAWLINE 4 U of onabotulinumtoxinA is injected at each site. Insert the needle near the jawline to one half of its Depressor Anguli Oris Muscle depth and at least 1 cm away from the corner of the The depressor anguli oris muscle draws the cor- mouth. (See Figure, Supplemental Digital Content ners of the mouth down, creating a crease descend- 14, which shows the injection technique for the ing from the corner of the mouth that imparts a depressor anguli oris muscle. For each injection, sullen or dissatisfied Treatment of insert the needle to one-half its depth. Assess for these lines, resulting from excessive contraction of asymmetry before and at 2 weeks after injection, the depressor anguli oris muscle, is made at one http://links.lww.com/PRS/C324.) Assess for asymme- site on each side of the face (Fig. 15). A dose of 2 to try before and at 2 weeks after injection, as this area 401e Copyright 2017 American Society of Plastic Unauthorized reproduction of this article isPlastic and Reconstructive Surgery September 2017 is at risk for asymmetrical results. Excessive dosing and medial injections may lead to paralysis of the depressor labii inferioris muscle, resulting in an asymmetrical smile. Mentalis Muscle Contraction of the mentalis muscle may lead to a cobblestone or dimpled chin, and may increase the mentolabial crease while pushing the lower lip forward. Treatment of a cobblestone chin may be achieved by injecting onabotulinumtoxinA at a midline point approximately 0.5 to 1 cm above the inferiormost point of the chin and no closer than 1.5 cm from the lower Some patients, however, may benefit from injections made at two additional lateral sites parallel to the midline and/ or from higher doses (Fig. 16). A dose of 4 to 8 Fig. 17. Treatment of masseteric hypertrophy with onabotu- U of onabotulinumtoxinA should be delivered. linumtoxinA. Injections are made at three sites on each side of (See Figure, Supplemental Digital Content 15, the face. Square symbols indicate full-needle depth. which shows the injection technique for the men- talis muscle. Insert the needle to its full depth and enlarged from repeated clenching of the jaw, maintain the injection in the midline, http://links. resulting in bulging of the lateral jawline, a con- Maintain the injection in the dition known as masseteric hypertrophy. 10 Treat- midline. Excessive lateral displacement of the nee- ment with onabotulinumtoxinA is made at three dle may lead to paralysis of the depressor labii infe- sites on each side of the face (Fig. 17). A dose of rioris muscle, resulting in an asymmetrical smile. 4 to 8 U of onabotulinumtoxinA at each point should be delivered with the needle inserted Masseter Muscle perpendicular to the skin to its full depth. (See The masseter muscle elevates the mandible Figure, Supplemental Digital Content 16, which and is important during chewing; it may become shows the injection technique for masseteric hypertrophy. For each injection, insert the needle perpendicular to the skin to its full depth. Shown is the injection at the apex point. Inject lateral to the anterior margin of the masseter muscle, Ask the patient to clench before marking the injection site, and Fig. 16. Treatment of the mentalis muscle with onabotulinum- toxinA. An injection is made at a midline point 0.5 to 1 cm above Fig. 18. Treatment of the platysma muscle/jawline with ona- the chin and symmetrically on either side. Square symbols indi- botulinumtoxinA. Injections are made at six sites on each side at cate full-needle depth. one-third needle depth. 402e Copyright © 2017 American Society of Plastic Unauthorized reproduction of this article isVolume 140, Number 3 Injection Guide for the Lower Face inject lateral to the anterior margin of the masse- which shows the injection technique for platysma ter muscle. Superficial and higher injections may bands. Asterisks indicate one-third needle depth. cause asymmetry during animation. This area is Pinch the band and insert the needle to one-third prone to deep hematomas. Asian patients with of its depth. Avoid injecting too deeply or with severe hypertrophy may require higher doses of excessive doses, as they impair swallowing, http:// 40 U or more of 11-16 This area is prone to bruising. Deep injections and excessive dosing Platysma Muscle/Jawline may lead to impaired swallowing. Patients with a The platysma muscle draws down the lower highly overactive platysma may benefit from two jaw and the corners of the Treatment of sessions to optimize the dosage of onabotulinum- lines resulting from excessive contraction of the toxinA. Consideration should be given to inject- platysma muscle at the jawline is made at six sites ing the lateral bands at the first session and then on each side (Fig. 18). (See Figure, Supplemen- reevaluating whether any medial bands need tal Digital Content 17, which shows the injection treatment. technique for the platysma muscle/jawline. For Injections in medial platysmal bands are more each injection, insert the needle to one-third of challenging than lateral bands; the overall dose its depth. Avoid injecting too deeply or with exces- of neurotoxin should be lower. Although these sive doses, as they impair swallowing, http://links. injections can reduce the hypertonicity of medial This area is prone to bruis- platysmal bands, they can also lead to skin lax- ing. Deep injections and excessive dosing may ity. Proper patient selection is important. Ideally, lead to impaired swallowing. Patients with a highly these injections should be considered in patients overactive platysma may benefit from two sessions without skin excess in this area. to optimize the dosage of The OnabotulinumtoxinA Microdroplet Platysma Bands Technique for Lower Face and Neck The caudal parts of the platysma muscle are This technique has been previously described thin muscle sheets that run down the lateral neck and is a useful adjunct for improving the appear- and insert into the fascia Contrac- ance of the skin and contours of the lower face tion of the platysma expands and extends the and neck. 17 The product is injected into the der- skin in vertical lines in the form of bands. Treat- mis or the junction between the dermis and the ment of lateral platysma bands is made at four superficial fibers of the platysma (which insert sites per band (Fig. 19, left), whereas treatment into the undersurface of the dermis) over an area of medial platysma bands is made at three sites starting three fingerbreadths above the mandibu- per band (Fig. 19, right). Pinch the band to help lar border, one fingerbreadth behind the mario- guide the injection into the contracted nette line, and over the entire neck anterior to the (See Figure, Supplemental Digital Content 18, sternocleidomastoids. This results in an improved Fig. 19. Treatment of the platysma bands with Injections are made at four sites on each lateral band (left) and at three sites on each medial band (right). 403e Copyright 2017 American Society of Plastic Unauthorized reproduction of this article isPlastic and Reconstructive Surgery September 2017 cervicomental angle, elevation and flattening of 2. Albert AM, Ricanek K Patterson E. A review of the literature the jowls, reduction of horizontal skin creases on the aging adult skull and face: Implications for forensic sci- and vertical platysmal banding, and an improved ence research and applications. Forensic Sci Int. 3. Ali MJ, Ende K, Maas CS. Perioral rejuvenation and lip aug- sheen and texture of the overlying skin. The even mentation. Facial Plast Surg Clin North Am. vii. distribution of these microdroplets at a superficial 4. Rohrich RJ, Pessa JE. The anatomy and clinical impli- plane reduces the risk of difficulty in swallowing cations of perioral submuscular fat. Plast Reconstr Surg. or weakness of the sternocleidomastoid muscles. 009;124:266-271. 5. Small R. Dermal Filler Procedures. New York: Wolters Kluwer 2012. CONCLUSIONS 6. Gassia Raspaldo H, Niforos FR, Michaud T. Global 3-dimen- sional approach to natural rejuvenation: Recommendations Soft-tissue fillers are more important than neu- for perioral, nose, and ear rejuvenation. Cosmet romodulators in the lower Fillers should be used first to provide structure and support, 7. de Maio M, Rzany B. Botulinum Toxin in Aesthetic and then assessment of dynamic lines should be Berlin/Heidelberg, Germany: Springer-Verlag; 2009. evaluated to determine whether neuromodulator 8. Carruthers JD. Glogau RG, Blitzer A; Facial Aesthetics treatment is required. The lip is one of the most Consensus Group Faculty. Advances in facial rejuvenation: Botulinum toxin type a, hyaluronic acid dermal fillers, and challenging areas to reshape with fillers. Compre- combination therapies. Consensus recommendations. Plast hensive assessment of dental arches and occlusion Reconstr Surg. 2008;121 quiz 31S. is important to avoid improper correction. When 9. Swift A, Remington K. BeautiPHIcation: A global approach volumizing the lips, respect the projection of the to facial beauty. Clin Plast Surg. V. lips on the profile view and respect the ratio of 10. P. Kumar Nayyar PV, Singh A. Botox: Broadening the horizon of dentistry. / Clin Diagn Res. lip size to chin. Rejuvenation of the neck region 11. Ahn BK, Kim YS, Kim HJ. Rho NK, Kim HS. Consensus rec- is also challenging, where fillers are needed for ommendations on the aesthetic usage of botulinum toxin structural support of the chin and jawline and type A in Asians. Dermatol Surg. 2013;39:1843-1860. neuromodulators are needed to treat the masse- 12. Goodman GJ. The masseters and their treatment with botu- ter and platysma. linum. In: Carruthers A, Carruthers eds. Botulinum Toxin: Procedures in Cosmetic Dermatology Series. 3rd ed. New York: Maurício de Maio, M.D. 2013:135-141. Clinica Dr. Maurício de Maio 13. Wu WTL. Facial and lower limb contouring. In: Benedetto Avenida Ibirapuera, 2907 cj 1202 AV, ed. Botulinum Toxins in Clinical Aesthetic Practice. 2nd ed. Moema EP 04029200 New York: Informa Healthcare; São Paulo-SP, Brazil 14. Wu Facial sculpting and facial slimming with neuro- toxins. In: Sundine M. Connell B, eds. Aesthetic Rejuvenation of the Face. 1st ed. New York: Thieme Publishers; 2015:39-44. 15. Wu WTL. Botulinum toxin Ainjections for facial rejuvenation ACKNOWLEDGMENTS and reshaping. In: Lee P. Chen Li et al., eds. Aesthetic Plastic Surgery in Asians: Principles and Techniques Volume I and This article was sponsored through an educational II. 1st ed. Boca Raton, Fla: CRC 2015:149-169. grant from Allergan plc, Dublin, Ireland. Medical writ- 16. Wu WT. Botox facial slimming/facial sculpting: The role ing assistance was provided by Barry Weichman, Ph.D., of botulinum toxin-A in the treatment of hypertrophic of Peloton Advantage, Parsippany, New Jersey, and masseteric muscle and parotid enlargement to narrow funded by Allergan plc. No honoraria or other forms of the lower facial width. Facial Plast Surg Clin North Am. 2010;18:133-140. payment were made for authorship. 17. Wu WT. Microbotox of the lower face and neck: Evolution of a personal technique and its clinical effects. Plast Reconstr REFERENCES 18. Wollina U. Perioral rejuvenation: Restoration of attractive- 1. de Maio Rzany B. Injectable Fillers in Aesthetic Medicine. 2nd ness in aging females by minimally invasive procedures. Clin ed. Germany: Springer-Verlag; 2014. Aging 2013;8:1149-1155. 404e Copyright 2017 American Society of Plastic Unauthorized reproduction of this article is