Cosmetic Botulinum Toxin: is it a Replacement for Invasive Facial Procedures?
The cosmetic use of Botulinum Toxin (BoNTA) has elevated the art of Facial Plastic Surgery. Since being approved in 2002 by the Food and Drug Administration for treatment of glabellar frown lines, inventive uses of Botulinum Toxin have enabled surgeons to shape the face non-invasively. By understanding the underlying facial anatomy and the push-pull connections between muscles that control facial expression, Cosmetic Facelift Surgeons have the ability to increase muscular pull in one direction by eliminating the opposing force with neuromodulators.
Non-surgical procedures are popular with today’s patients because there is virtually no down time, so they can return to work right away after a visit to the surgeon’s office. Some treatments with neurotoxis are so effective that they have replaced conventional surgical procedures.
When a Facial Cosmetic Plastic Surgeon has a deep understanding of the opposing pull of muscles that control facial expression, neurotoxin injections can be precisely placed to enhance specific facial features.
Administered either alone or in combination with filler agents, neurotoxin injections have the potential to replace open procedures for Elevation of the Brow or Oral Commissure, Hypertrophy of the Orbicularis Oculi Muscles, Gummy Smile improvement, as well as Lip Lift.
While severe brow ptosis requires surgery, mild ptosis or mild brow asymmetry misalignment can be carefully corrected with neurotoxin injection planned placement.
Neurotoxin injections should not be used as a state-of-the-art Necklift treatment; however, mild platysmal banding can be treated to postpone open surgery or improve a subpar surgical result.
Innovative methods such as Nefertiti Necklift may be used to replace or delay the need for open surgery.
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Facial rejuvenation that involves the upper third of the face has typically focused on attaining the ideal brow shape and position. When examining brow aesthetics, the supraorbital rim and the upper eyelid crease are key factors that must be considered.
The perfect position of the female brow is at the middle of the brow ridge, with the arc above this bony ridge laterally with gradual tapering. The desired position of the male brow is just above the brow ridge following a horizontal course along the rim. The male brow is thicker and does not taper. Lower brows are the result of aging and are often related to sadness, grief, anger and tiredness. In addition, eyebrow position can intensify the appearance of lax uppereyelids. Traditionally, Forehead Lifts have been employed to rejuvenate the upper third of the face and improve brow position. Recently, neuromodulation of brow depressions and elevators with BoNTA has been used to contour the brows to suit the patient’s preference.
Existing surgical procedures available for the forehead include coronal, pretrichial, midforehead, direct and endoscopic approaches. Typical methods achieve brow repositioning by removing scalp skin and weakening the muscular brow depressors. Endoscopic lifting typically relies on skin redraping within the forehead and brow suspension. Since the Endoscopic Browlift has been introduced, the procedure has become extremely popular, due to the smaller incisions hidden in the scalp. Browlifts are performed under general anesthesia and require 1 to 2 weeks of recovery. Possible Browlift complications include: hematomas, seromas, alopecia, poor scarring, forehead dysesthesias, and facial paralysis.
A new alternative to surgical approaches to brow rejuvenation known as the Chemical Browlift has debuted thanks to BoNTA. When using BoNTA, the following side effects are possible when treating hyperdynamic glabellar rhytides: increased interbrow distance and medial brow elevation. BoNTA works to purposely obtain a Browlift by weakening brow depressors while allowing brow elevators to lift the brow. Selectively weakening brow depressors and allowing the frontalis to apply brow elevation results in a moderate Bowlift.
Preoperative Chemical Browlift Planning
The injection sites medially and laterally are determined by examining the brow position during facial movement. Touching the orbital rim prevents injection into the orbit, which may cause eyelid drooping by affecting the elevating muscle of the upper eyelid. Asking a patient to frown and relax several times helps identify the belly length of the corrugator supercilii. Having a patient squint and smile reveals the crow’s feet. When planning the injections, it is imperative to preserve muscle function in the forehead by not overly relaxing/treating the frontalis muscle with Cosmetic Botulinum Toxin. If the frontalis muscle is not able to elevate the brow, brow drooping may occur. It is important to notice that patients with severe brow ptosis are less likely to get a significant lift from a neurotoxin and might be better candidates for Traditional or Endoscopic Browlifts.
Additional variations can be planned in cases where only certain portions of the brow requite treatment or in cases of brow asymmetries. Female patients often request injections for brow contouring and elevation of the lateral brow only. In such cases, weakening the medial frontalis lowers the medial brow accentuating the lateral brow and providing the desired brow contour. Brow asymmetries where one brow is higher than the other can be corrected by attempting to lower the higher brow and raise the lower brow.
Neurotoxin is placed into the procerus and corrugators muscles using approximately 5 to 7 injection sites.
In addition, the lateral orbicularis muscle can be treated to increase the lateral lift.
To treat the whole brow, a total of 20 to 25 BoNTA units (BU) or 60 to 75 abobotulinum- toxinA (Dysport) units (DU) may be necessary.
The frontalis muscle superior to the brows should not be weakened, since it is the only means to enable brow elevation.
Potential Chemical Browlift Complications
The treatment area is in close proximity to the muscles of the orbit and neurotoxin effect may spread to intraocular sites affecting the elevating muscle of the upper eyelid leading to unwanted drooping. Care should be taken to keep the injection close to the surface of the skin to avoid deeper spread. Apraclonidine (Iodipine) 0.5% eyedrops are an a-adrenergic agonist used to correct this problem. By causing Müller muscle contraction, apraclonidine raises the eyelid margin by 1 to 2 mms.
Not all patients achieve the same degree of brow elevation using this technique. Overtreatment of the frontalis muscle may negate any possible brow elevation achieved. The limitation of the degree of brow elevation is dictated by the unopposed action of frontalis muscle; after reaching the point of maximal weakening of brow depressors, further elevation will require surgical intervention.
Immediate Chemical Browlift Postprocedural Care and Recovery
While some Cosmetic Facelift Surgeons instruct their patients not to push on the injection sites, exercise, lay flat, or bend over for 4 hours, there are no statistics that demonstrate this prevents eyelid drooping. Similarly, there are no studies that show movement of the injected muscles increases neurotoxin uptake.
Oral Commissure Rejuvenation Treatment
Downward turn of the lips is a sign of an aging mouth that gives an appearance of being tired, sad, or even bitter. The Lateral Oral Commissure can extend, forming a groove, and contribute to the marionette appearance. In severe cases, especially in older patients, it can be a site for drooling and inflammatory lesions may develop at the corner of the mouth. This area can represent a problem even after successful rejuvenation with Facelift. During Facelift, correction of the corner of the mouth would require excessive pulling that would result in a Fish Mouth Deformity, an unnatural and obviously postsurgical look. Although patients can be bothered by this appearance, improvement of the corner of the mouth can be achieved by treating the Oral Commissure.
Preoperative Oral Commissure Rejuvenation Planning
Careful assessment of the perioral muscles should always be done at rest and with contraction. The DAO muscle may be touched while having patients actively frown from the origin in the mandible to its insertion into the corner of the mouth. Patients should be appropriately counseled that DAO injection does not improve severely depressed corner of the mouth where the lip borders the facial skin, which most likely require filler injection in addition to DAO injection, and does not elevate the marionette lines.
A single injection per muscle is suggested and well tolerated.
The DAO muscle should be palpated while having patients actively frown. If the belly of the muscle cannot be palpated, an approximate estimate of its location can be made by going1 cm lateral to the Oral Commissure and then 1 cm inferiorly.
Inject approximately 2-5 BU (or 6-15 DU) deeply into each muscle.
Alternatively, to avoid other perioral muscles, injections may be placed into the muscle along the jaw border.
Potential Oral Commissure Rejuvenation Complications
Overtreatment of this area can lead to oral incompetence. Using conservative doses of BoNTA, it is more likely that only a mild improvement in the downturned Oral Commissure is seen, especially in patients with heavy surrounding skin. The major risk of BoNTA is distribution of the product to perioral muscles, which may affect the smile or expression.
Oral Commissure Rejuvenation Clinical Results
Treatment by chemical neuromodulation of the DAO to improve the downward turn of the Oral Commissure is increasingly described in the literature, making evident a trend favoring this technique over open commissuroplasty. Injection technique and understanding of the facial musculature around the Oral Commissure as critical in adequately identifying the DAO to achieve corner of the mouth elevation without affecting the other muscles involved in lip movement. Injection along the mandibular border is recommended to avoid perioral muscles. There have been no reported problems with asymmetric smile after meticulous injection techniques. Predictable and replicable results are shown with few risks and minimal discomfort.
The smile is a facial expression that transmits happiness and is essential to establishing warmth and human connection. Extreme gum show above the dentate line when smiling is referred in the literature as Gummy Smile or even a Horse Smile. Patients with Gummy Smiles are often self-conscious and restrain themselves from a full smile, often seeking consultation for possible intervention.
Evaluation of this problem includes examining the dynamic contribution of the maxilla, the gingiva, and the lips. Excessive vertical height can affect the position of the lips, which may be corrected with orthognathic surgery, such as a Le Fort type I osteotomy. Delayed teeth eruption is an abnormality in which the gingiva covers the dental crown, allowing aesthetic crown lengthening as a possible intervention. Frequently, hyperfunction of the lip elevators muscles with excessive lip retraction or short lips can also cause this problem.
Levator labii superioris (LLS), LLS alaeque nasi (LLSAN), levator anguli oris, zygomaticus muscles, and risorius are the facial muscles that control lip elevation. Depressor septi nasi muscle can also contribute to elevation of the lip at the midline.28 LLS, LLSAN, and zygomaticus minor provide vertical elevation whereas levator anguli oris, zygomaticus major, and risorius also contribute to Oral Commissure elevation.
Lip-lengthening procedures that reposition and lengthen the upper lip have traditionally been used to address excessive gingival show during smile.29-32 The lip is approached transorally and an ellipse excision of the mucosa in the gingival labial sulcus is performed, allowing for inferior repo- sitioning and lengthening of the lip on closure. For additional lengthening, myotomies at the insertion of the lip elevator muscles can be performed through this incision. The main muscle targeted is the LLS, allowing for sparring of the Oral Commissure. The muscles can be divided through this approach without disrupting the orbicularis oris. The LLS originates along the orbital rim in the maxilla and inserts into the skin lateral to the nostril and on the upper lip, blending with the orbicularis oris. Lip lengthening can be used for cases of hyperfunctional lip elevation, short lips, or even in cases of excessive maxillary height when patients decline orthognathic surgery. The procedure can be performed under local anesthesia in the surgeon’s office. Potential wound healing complication as well as transient lip numbness can result from this procedure. More recently, BoNTA injection to lower the upper lip, in order to minimize gingival show, has become an alternative treatment option. Techniques aimed at reducing gingival show target the LLSAN muscles. The injection is well tolerated as an outpatient patient procedure that allows patients to return to their regular activities immediately after injection.
Gummy Smile Treatment Goals
- The main goal during this injection is to decrease gingival display during smile by injecting the lip elevators.
- A single injection per side is recommended and well tolerated.
- The LLSAN muscle is targeted by injecting 3 mm to 5 mm lateral to the nostril.
- Inject approximately 2-4 BU or 6-12 DU deeply to attain muscular injection.
Possible Gummy Smile Complications
BoNTA may affect the wrong perioral muscles and affect the smile or expression. Injecting into the lateral corner of the mouth can result in oral incompetence.
Gummy Smile Postprocedural Care
Patients may resume regular activities immediately following injection. Bruising in this area is unlikely; however, care must be taken to stay lateral to avoid the angular artery.
Gummy Smile Clinical Results
Treatment of excessive gingival show by neuromodulation of the lip elevators has been increasingly reported in the literature. Sucupira and Abramovitz published a case series evaluating 52 patients who underwent injection for treatment of Gummy Smile and photo documented response after injection. In the study, gingival display decreased from an average of 3.6 mm to 0.58 mm with an increase in lip length from 12.48 mm to 19 mm.
Average patient satisfaction was extremely high, at 9.75, from a 10-point scale, and up to 94% of the patients stated they would repeat the injection. Polo obtained similar results in a case series of 30 patients, which observed a decreased gingival show from 5.2 mm to 0.09 mm and a lip drop of 5.1 mm. No complications were reported in either study.
Full lips give a young, gorgeous look, while thin lips are usually considered unattractive and a sign of old age. Increasing vermilion height, improving lip contour definition, and enhancing general lip fullness is an extremely sought-after feature for women seeking a cosmetic consultation. During the aging process, the ratio of the red lips to white lips diminishes with reduction in the height of vermilion border and an increase in the dermal area of the upper lip in a condition described as vermilion lip hypoplasia. Vertical wrinkles and Cupid’s bow diminishment are other undesired changes that transpire as lips age.
Lip reshaping procedures are becoming very popular in cosmetic surgery and facial rejuvenation. Surgical options available to increase the ratio of red lips to white lips include Direct Vermilion Advancements, Subnasal Liplift, and VY Advancements. Direct Vermilion Advancements involve excision of the skin immediately above the vermilion border with advancement of the red lip superiorly. Subnasal Liplift increases the red lip through direct excision of skin under the nasal vestibule of the nose. Intraoral VY Advancements can be used to increase lip projection. The use of soft tissue augmentation with filler technology that avoids scarring while restoring volume has become more popular. Injectable hyaluronic acid can improve vermilion border definition, enhance lip contour, while increasing the red-to-white lip ratio. Although volume restoration has been the standard lip rejuvenating approach, a combination of fillers and BoNTA has emerged as a new option.
Treatment of the perioral region with BoNTA injections in the orbicularis oris can complement other rejuvenation strategies. The orbicularis oris muscle is a circular muscle that functions as a sphincter that surrounds the mouth. The deep fibers bring the lips together, whereas the more superficial fibers pucker the lips forward. The muscle fibers are naturally aligned so as to pull toward the center. Weakening this pull allows the upper lip elevators and the lower lip depressors to increase their displacement of the lips. The end result is a more visible pink lip with minimal lip eversion. This technique produces slight lip augmentation, a possible 1 mm to 2 mm increase in pink lip visibility. Patients should not expect the same results as fillers, but this procedure can be used in addition to fillers in patients with very thin lips. Additionally, minute vertical perioral rhytides, known as Lipstick Lines or Smokers’ Lines, are improved after patients receive these injections
Liplift Treatment Goals
Minor improvement in the visible pink lip can be attained by the use of neurotoxins. This can be used to enhance the upper and/or lower lips.
Preoperative Liplift Planning
- The lips and the perioral muscles should be evaluated. Asking the patient say the letters E and O is very useful.
- BoNTA is injected at the base of the philtrum at the vermillion border.
- Injections are superficial and symmetry is key.
- Both upper and lower lips can be injected.
- Two injection sites per lip, with one injection in each lip quadrant is recommended.
- The corresponding location of the lower lip can also be injected.
- Approximately 1-2 BU (or 3-6 DU) is used for each injection.
- Concentrate on avoiding the medial portion of the lip over Cupid’s bow and the corners of the lips.
Possible Liplift Complications
Reduce lip asymmetry by insuring the injections are placed precisely and symmetrically. Injection at the midline should be avoided because it can cause flattening of Cupid’s bow. When the corners of lips are avoided, weakness in the muscles that elevate the lips is prevented, thereby preventing difficulties with drooling or speech.
Postprocedural Liplift Care
Platysmal Banding Treatment
The platysma muscle is a thin superficial muscle that originates on the clavicle and upper chest and inserts onto the superficial muscular aponeurotic system, the skin of the lower face, the facial muscles, and the mandible. Although in young individuals it is smooth, in elderly patients, the muscle may splay centrally and create visible vertical bands.
Emphasis of these vertical fibrous platysma bands and herniation of underlying fat pads as the muscle separates, most commonly at the anterior edges, is characteristic of the aging neck. Platysmal bands can be pronounced in patients with thin necks, thin skin, and patients without abundant overlying fat. Facelift Surgery continues to be the chief treatment option. Folding the medial platysmal bands and lateral suspension of the posterior borders can improve their appearance. Corset plastymaplasty with submental suspension after midline fat removal reinforces the muscle sling and is advocated to prevent recurrent banding. Despite the success obtained with these procedures, residual or recurrent banding is a possible outcome.
Aging neck rejuvenation with BoNTA treatment of platysmal banding has emerged as a safe and minimally invasive approach. This technique is well-suited for younger patients in their mid-30s or early 40s who demonstrate good skin elasticity and for patients who already underwent Facelift and have remaining or recurrent banding.
- With the platysma muscle in full contraction, the edge of the muscle band is grasped with 2 fingers while the muscle is injected.
- The needle is placed deeply into the muscle, between the operator’s fingers and perpendicular to the muscle fibers.
- Approximately 3-5 BU (or 6-25 DU) is injected into each injection site, for a total of 15-20 BU (or 45-60 DU) per band.
- A series of approximately 3 injections is placed down the length of the band approximately 1.5 cm to 2 cm apart.
- If lateral bands are prominent on full contraction, then these can be injected in the same manner, although they often need fewer units.
Begin injections at the cervicomental angle and work inferiorly, staying approximately 2 cm to 2.5 cm below the mandibular border so as not to affect the upper facial muscles that control expression.
Possible Platysmal Banding Treatment Complications
Overinjection may affect the deeper musculature resulting in difficulty swallowing or vocal function disturbance. Bruising is not uncommon and has been reported in as high as 20% of patients. Patients with heavy necks may not be good candidates for this procedure because injection results may not be effective.
Postprocedural Platysmal Banding Treatment
Apply pressure to prevent bruising. Patients may resume normal activities immediately.
There have been high success rates and patient satisfaction when using BoNTA in platysmal bands. The dose used in the bands has varied between studies. Matarasso and colleagues published their experience in 1500 patients, where 50 to 100 BU were used per band, with a maximum of 250 BU per patient. In this study, reported complications included neck discomfort in 10% of patients, 1 patient with neck weakness, and 1 patient with dysphagia. Afterwards, Kane published experience with platysmal banding treatment at drastically lower doses. In that study, 44 patients were treated with a maximal dose of 40 BU per patient and 7.5 BU to 12.5 BU per band without any dysphagia or dysphonia.
The ancient Egyptian queen, Nefertiti, was revered as the most beautiful woman in the world. The hand-painted limestone bust of Nefertiti is one of the most copied images in ancient Egypt, and currently forms part of the collection of Neues Museum in Berlin. This famous art piece shows a graceful woman with a sculpted jawline.
Loss of jawline definition occurs with aging, because skin elasticity and volume gradually weaken. Facelift has been the surgical technique traditionally used to improve mandibular contour. The results obtained with the Nefertiti Necklift have been compared with the results obtained with a Minilift, which is often used in younger patients that require less dissection to achieve neck rejuvenation.
Most techniques that use BoNTA to rejuvenate the neck focus on treating platysma bands, whereas the Nefertiti technique uses BoNTA to emphasize mandible definition. The injections target the platysma muscle at the mandible level. The platysma muscle is a neck depressor that originates at the clavicle and fascia of the upper chest and inserts onto the mandible and skin of the chin and cheek. Weakening of the muscle allows facial elevators to elevate the sagging skin over the lower face and clearly define the mandibular border, achieving a slim and smooth jawline with a well-defined cervicomental angle.
Nefertiti Necklift Treatment Goals
Improve jawline definition while achieving neck rejuvenation.
Preoperative Nefertiti Necklift Planning
Patients who want a more defined mandibular contour should be evaluated for the extent of platysma pull on their lower face. It is suggested that patients be asked to contract the platysma muscles and, if the mandibular border becomes less visible, they are good candidates for this procedure.
- Injections of BoNTA are placed along the inferior aspect of the mandible and in the upper aspect of the strongest lateral platysma band.
- Injections are deep into the muscle.
- Approximately 15-20 BU (45-60 DU) are used per side in equal amounts.
- Sites lateral to the nasolabial fold are preferred for injection to avoid weakening the depressor labii inferioris muscle.
Possible Nefertiti Necklift Complications
Administering these injections too far medially can affect the depressor labii inferioris and cause an asymmetric smile. Do not inject medial to a line drawn down from the nasolabial fold to the mandible. Overinjection of this area can also cause dysphagia if the deeper neck muscles are affected. Excessive pull upwards on the lower face can result in irregular bunching of the tissue over the mandible.
Postprocedural Nefertiti Necklift Treatment
Apply pressure to prevent bruising. The Nefertiti Necklift offers patients immediate recovery. Minilifts are often chosen by patients because of the decreased downtime when compared to Traditional Facelifts, given their more limited dissection. The Nefertiti Necklift provides an option with no downtime, which appeals to patients.
Selected facial cosmetic surgical procedures have been rendered archaic with the innovative use of BoNTA. Mild brow ptosis can be treated with neurotoxin before patients must face a surgical procedure. Similarly, for patients who have mild platysmal banding or recurrent banding postoperatively, neurotoxin injection can improve band tension.