Aesthetic Botulinum A Toxin in the Mid and Lower Face

and Neck
J EAN C ARRUTHERS , MD, n

AND

A LASTAIR C ARRUTHERS , MD w

Department of Ophthalmology and wDivision of Dermatology, University of British Columbia, Vancouver, British
Columbia, Canada

BACKGROUND. Botulinum toxin type A (BOTOX formulation)

is used extensively for smoothing hyperkinetic lines in the upper
face. The use of botulinum toxin for aesthetic indications in the
mid and lower face and neck is now becoming increasingly
popular.
OBJECTIVE. To review our current approaches to botulinum
toxin treatment for cosmetic indications in the mid and lower
face and neck.
METHODS. Procedures and outcomes are described for the
primary and adjunctive use of botulinum toxin.
RESULTS. Cosmetic treatment with botulinum toxin successfully
changes the contour of the palebral aperture; smoothes lines,

including bunny lines, perioral rhytides, and horizontal neck

lines; softens creases, including the mental crease and melomental folds; and alleviates facial asymmetry and nasal flare.
The doses of botulinum toxin used in the mid and lower face
are generally lower than those used in the upper face. Caution
must be used in injecting botulinum toxin in the perioral area to
avoid an incompetent mouth.
CONCLUSION. Botulinum toxin treatment is valuable for
aesthetic improvements in the mid and lower face and neck.
In some areas, particularly the perioral region, the use of
botulinum toxin in combination with other therapeutic
modalities provides optimal results.

THE CARRUTHERS ARE BOTH CONSULTANTS, STOCKHOLDERS, AND RESEARCHERS FOR ALLERGAN AND ELAN
PHARMACEUTICALS.

BOTULINUM A toxin (BTX-A) injections are now

commonly used in procedures to improve facial
aesthetics. They smooth hyperkinetic lines, including
glabellar lines, horizontal forehead lines, and crows
feet, in the upper face with outstanding success.1 The
cosmetic use of botulinum toxin is not limited to the
upper face, however. The use of botulinum toxin for
aesthetic indications in the mid and lower face and
neck has become increasingly popular, partly because
physicians feel confident in the outstanding efficacy
and safety profile demonstrated by the toxin since
1987 for indications in the upper face2,3 and partly
because physicians have come to realize that both
muscular hyperactivity and volume depletion are
important coexisting aesthetic determinants in the
mid and lower face.
This article presents our current approaches to
botulinum toxin cosmetic therapy for the mid and
lower face and neck. The information presented can
serve as a guideline for both the primary and the
adjunctive use of botulinum toxin. Our goal is to help
physicians to refine or expand their use of botulinum
Address correspondence and reprint requests to: Jean Carruthers, MD,
Department of Ophthalmology, University of British Columbia, 943
West Broadway, Suite 740, Vancouver, BC, Canada V5Z4E1, or e-mail:
drjean@carruthers.net.

toxin for cosmetic indications. For those who have not

previously used botulinum toxin for aesthetic procedures, however, it is important to note that the
techniques for injections should be acquired through
hands-on training with experienced clinicians. A
course of instruction is also advisable for aesthetic
physicians who have previously confined their use of
botulinum toxin to the upper face because the dosages
used in the mid and lower face and neck and the
underlying muscular anatomy and tissue relationships
are very different from those in the upper face.

Properties of Botulinum Toxins

Various strains of the bacterium Clostridium botulinum produce serologically distinct types of botulinum
toxins. In all, seven toxic serotypes of botulinum toxin
have been identified: A, B, C1, D, E, F, and G.4 These
serotypes share the ability to block neurotransmission
at the neuromuscular junction by blocking acetylcholine release. Thus, all of the botulinum toxins produce
denervation and atrophy of cholinergic skeletal muscles. However, because the neurotoxin serotypes differ
in their cellular mechanisms of action and in the size of
the neurotoxin complex, they are not interchangeable,
and their clinical profiles are known to vary.

r 2003 by the American Society for Dermatologic Surgery, Inc. ! Published by Blackwell Publishing, Inc.
ISSN: 1076-0512/03/$15.00/0 ! Dermatol Surg 2003;29:468476

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CARRUTHERS AND CARRUTHERS: AESTHETIC BOTULINUM TOXIN BELOW THE EYES

BTX-A is the most powerful and was the first to be

developed for clinical use. BTX-A is manufactured and
distributed by Allergan, Inc., under the brand name
BOTOX. Speywood Pharmaceuticals Ltd. also markets BTX-A under the brand name Dysport. Although
the active agent in each formulation is BTX-A, the two
preparations have different clinical properties that
might be due to differences in the vehicle, bacteria, or
manufacturing process. It is important to realize that
BOTOX and Dysport differ in potency; their units are
not interchangeable. For most procedures, 1 U of
BOTOX has an efficacy equivalent to 3 to 5 U of
Dysport.
Intramuscular injections of BTX-A have become the
treatment of choice for most forms of focal dystonia.
The ability of botulinum toxin to block acetylcholine
release from autonomic nerve endings innervating
glandular tissue or smooth muscle has led to investigation of its use for other indications, including
hyperhidrosis5,6 and gastrointestinal disorders.7,8
More recently, BTX-A has been reported to have
beneficial effects in relieving myofascial pain9,10 and
tension and migraine headache.1113
The only other serotype of botulinum toxin that is
currently commercially available is a formulation of
BTX-B (Myobloc, developed by Athena Neurosciences
and manufactured by Elan Pharmaceuticals) that was
recently approved in the United States for the
treatment of cervical dystonia.
Most of the information available on the cosmetic
uses of botulinum toxin, both from literature reports
and from our personal experience, pertains to the use
of the BOTOX formulation of BTX-A. Thus, the
following discussion focuses on the cosmetic use of the
BOTOX formulation of neurotoxin, and all unit doses
cited refer to BOTOX units.

469

and is ideal for injections.17 Injections for aesthetic

indications may be given intramuscularly, subcutaneously (just above the muscle), or intradermally. The
injections may be uncomfortable for some patients.
Any discomfort can be minimized by chilling the area
with ice before the injections or by using topical
anesthetic creams by using preserved saline.
Manual pressure is generally applied to the injection
site immediately after withdrawal of the needle to help
prevent bruising. Because there is evidence suggesting
that botulinum toxin concentrates in actively stimulated muscles, patients are also asked to contract and
relax the treated muscles for 30 to 60 minutes after the
injections.

Precautions and Anticipated Side Effects

Botulinum toxin is relatively contraindicated in
individuals with neuromuscular disease such as
myasthenia gravis and amyotrophic lateral sclerosis.
The prudent physician will discuss the neurologic
situation with the subjects neurologist before going
ahead. Experience with botulinum toxin in pregnant
and lactating women is extremely limited, and thus,
caution is warranted in these cases. We feel that use in
pregnancy is contraindicated. The possibility of drug
interactions exist, and subjects taking amino glycoside
antibiotics should receive lower doses of botulinum
toxin.
Most side effects result from undesired muscle
weakening caused by the diffusion of toxin to
nontargeted muscles in close proximity to the injection
site. These side effects can be avoided by carefully
targeting the injection and by using concentrated doses
of botulinum toxin to limit its diffusion. No long-term
adverse effects have been reported, and no other
systemic safety problems have been associated with
botulinum toxin treatment.

Handling of BTX-A (BOTOX)

Botulinum toxin is distributed in a crystalline form
with approximately 100 U per vial. The package insert
recommends reconstitution with sterile, nonpreserved
saline.14 The optimum concentration will depend on
the procedure. Among cosmetic users, the average
volume of diluent has been reported to be 2.5 mL,15
but we typically dilute the vial in 1 mL. Although the
package insert suggests that the reconstituted toxin
should be used within 4 hours, evidence now indicates
that the reconstituted product can be stored refrigerated for a week or longer.16 In our practice, the diluted
vial is stored capped in the refrigerator at 41C for
several days without an evident loss of efficacy.
The diluted toxin is transferred to a 0.3-mL insulin
syringe with a 30-g needle that has no dead volume

Dosing and Injection Schedules

The effects of botulinum toxin injections are usually
beginning to be apparent within 1 to 2 days, and they
typically last for 3 or 4 months or longer. There is a
tendency for repeated injections to show a longer
duration of effect. Although the reasons for this
priming effect are unexplained, it seems possible that
patients may alter their habitual use of muscles that
cause kinetic lines, and long-term remodeling of soft
tissue may occur.
Larger muscles require larger unit doses of botulinum toxin. The volume of the dose should be adjusted
according to the desired diffusion of toxin: More
concentrated doses will diffuse less and should be used

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CARRUTHERS AND CARRUTHERS: AESTHETIC BOTULINUM TOXIN BELOW THE EYES

to target small muscles. As a rule, the maximum dose

given in a procedure is 400 U of botulinum toxin,
divided among muscles at multiple injection sites as
needed. The recommendation to limit the dose to
400 U grew from the relatively high protein content of
the original BOTOX formulation in which there was
80% more protein content in each vial than with the
current formulation, in use since December 1997. The
clinical concern is that neutralizing antibodies to
botulinum toxin given in higher doses might potentially develop, thus limiting the therapeutic value of
future treatments.18 In fact, clinical resistance to
botulinum toxin effects in the treatment of dystonias
was attributed to immunologic resistance with the first
manufactured batch of BOTOX (7911). However,
antigenicity of a foreign protein is related to protein
load, and the batches of BOTOX currently available
contain 80% less protein than the original batch. With
this reduced protein load and the small doses (less than
100 U) used for most cosmetic procedures, the risk of
antibody development appears to be minimal. Nonetheless, it seems prudent to use the minimum effective
dose and to maintain an interval between procedures
of at least 3 months. In clinical practice, however,
booster injections are sometimes given when needed 2
weeks after the initial treatment.16

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29:5:May 2003

This procedure has opened up a new artistry in

using botulinum toxin for facial contouring and
sculpting: Botulinum toxin can be used for localized
facial sculpting of patients of every skin type as well as
for smoothing facial lines and rhytides. For example,
botulinum toxin treatment can delicately open the
palpebral aperture of Asian patients who desire a more
Eurasian eyelid aperture without losing their exotic
Oriental appearance17 (Figure 1).

Bunny Lines: Upper Nasalis

Contraction of the muscular fibers of the upper nasalis
across the bony dorsum of the nose causes fanning
rhytides (bunny lines) at the radix of the nose.
Weakening of the underlying mimetic musculature
with botulinum toxin effectively and dramatically
softens these lines.20 We inject 2 to 4 U of botulinum
toxin into the belly of the upper nasalis as it
transverses the nasal bone. The injection should be
given high on the lateral nasal wall, inferior to the
angular vein. Care must be taken to give the injection
well above the nasofacial groove to avoid relaxing the

Midface Indications for Cosmetic BTX-A

Hypertrophic Orbicularis
The orbicularis oculi muscle is divided into three parts:
the orbital portion, the preseptal portion, and the
pretarsal portion. Fine muscular fibers of the preseptal
and pretarsal orbicularis are involved in the blink
reflex. During smiling, the size of the palebral aperture
tends to be diminished partly due to the contraction of
the pretarsal orbicularis. Hypertrophy of the pretarsal
portion of the orbicularis oculi can give a jelly roll
appearance to the lower eyelid, enough that some
individuals may complain that they look overweight.
We have found that 2 u of botulinum toxin injected
into the lower pretarsal orbicularis will open the
palpebral aperture both at rest and when smiling.
Subcutaneous injections are given in the midpupillary
line, 3 mm below the ciliary margin. The dose is
limited to 2 U because higher doses of botulinum toxin
in this area can lead to symptomatic dry eye
(keratoconjunctivitis sicca). This procedure should be
used only for patients who respond well to a
preinjection snap test; treatment is contraindicated
for patients who have had previous lower eyelid
ablative resurfacing or infralash blepharoplasty without a coexisting canthopexy to support the normal
position of the lower eyelid.

Figure 1. Botulinum toxin treatment of the lower pretarsal orbicularis

opens the palebral aperture. (A) Subject before treatment and (B) after
treatment. Reprinted with permission.19

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levator labii superioris and causing upper lip ptosis.

Gentle massage should follow the injection to diffuse
the toxin.

Repeated Nasal Flare: Lower Nasalis

Some individuals repeatedly dilate their nostrils in
social situations. This repeated nasal flare can embarrass both the individuals and their associates. The sides
of the columella/septum become visible when the
nostrils are prominently flared. This undesired appearance is accentuated by contraction of the lower nasalis.
An injection of 5 to 10 U of botulinum toxin bilaterally
into the lower nasalis fibers draped over the lateral
nasal ala, at the most active area of muscle contraction, has led to a satisfactory decrease of involuntary
nostril flare in some patients for 3 to 4 months.21

Nasal Tip Droop: Depressor Septae

Nasal tip droop is common during aging. The
depressor septae, a small muscle located at the external
base of the nasal septae, contributes to the nasal tip
droop. An injection of 2 to 3 U of botulinum toxin at
the base of the columella slightly elevates the nasal
tip.22 Caution should be taken with individuals who
already have a long nonvermilion upper lip because
there is a significant risk of lip ptosis with the
procedure.

Vertical Lip Rhytides (Perioral Lines): Orbicularis

Oris
The lips are central to the appearance of the lower
face. During aging, the lateral portions of the lips
recede, resulting in a rosebud mouth. At the same
time, the distance between the columella and the
vermilion border of the upper lip increases and the
substance of the vermilion rolls inside, producing the
thin and disappointed lips that are characteristic of old
age. Dense vertical perioral rhytides are often associated with the lengthening of the cutaneous upper lip
during aging. These vertical lines are commonly
labeled as smokers lines but can also result from
heredity, photodamage, playing a musical instrument
that requires embouchure, or even whistling. Patients
often are disturbed by the increased vertical length of
the cutaneous lip and by the radial upper lip lines that
can cause lipstick to bleed upward from the lip and
blur the outline of the lip. Radial lip wrinkles are
exaggerated by the purse string-like action of the
orbicularis oris sphincter muscle of the lip. Although
multiple fine wrinkles of the upper lip can be
effectively treated with fillers such as collagen or with
ablative or nonablative resurfacing, deeper wrinkles

471

may be resistant to these treatments. Tiny doses of

botulinum toxin that produce localized microparesis
of the orbicularis oris can dramatically reduce radial
lip lines and improve the appearance of the lips,
particularly when the toxin is used in combination
with a soft tissue augmenting agent such as collagen,
hylaruronan, or Artecol.
Botulinum toxin treatment of the lip sphincter is
recommended for only deep lines. To maintain
competence of the mouth, it is important to be
conservative with dosing, and superficial injections
are recommended over deep injections.21 In our
practice, optimal results are achieved with doses not
exceeding 2 to 4 U of botulinum toxin per lip (with no
more than 2 U per lip quadrant). We typically inject
1 U per lip line at or above the vermilion border in the
area of muscle contraction adjacent to the creases.23
The corners of the lips are avoided because injection at
these sites causes undesirable weakness of the lateral
lip elevators, resulting in drooping of the lateral lip
and drooling. The midline is also avoided to prevent a
flattened cupids bow. These small doses of botulinum
toxin smooth the lines23 and also give a pleasing
pseudoeversion of the lip with enhancement of the
vermilion contour.3 Even with these low doses,
however, the use of botulinum toxin for radial lip
lines may result in lip sphincter weakening that affects
the ability of the individual to play musical instruments or whistle. Patients should be screened carefully;
musicians who play wind instruments, professional
singers or speakers, and patients with unrealistic
expectations are not ideal candidates for this procedure. Some patients have difficulty with lip proprioception after treatment, but eating, drinking, and
singing are typically not affected.1
Foster and Wulc24 have also described a detailed
technique for the use of botulinum toxin to soften
perioral lines. The patient is asked to pucker, and the
areas of muscle contraction adjacent to the lines are
marked. Low doses of botulinum toxin are injected:
the recommended concentration is 1.0 to 2.5 U/
0.1 mL, and volumes of 0.025 mL or less are injected
per site. The injection is made either intramuscularly
or subcutaneously, just above the muscle.
Botulinum toxin injections for radial lip lines may
be particularly useful in combination with perioral
laser and electrosurgical resurfacing. Resurfacing
treats the fabric of the skin, whereas botulinum toxin
relaxes the underlying mimetic musculature.20

Nasolabial Folds in Selected Patients

Nasolabial (melolabial) folds extend from the lateral
nasal ala to a point lateral to the external angle of the
mouth. Young adults have a shallow indentation there,

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but older individuals who have sustained photodamage or who smile excessively develop a permanent,
deep crevice. The lines typically appear in patients in
their 40 s and are more pronounced in smokers.
Ironically, the impression given by these lines is one
of bitterness or disapproval.
The most common treatment for these folds has
been soft tissue fillers and laser resurfacing. Because
muscle contraction contributes to the development of
the folds, it is tempting to try botulinum toxin
treatment for nasolabial folds. Unfortunately, injecting
toxin directly into the area of the fold is most likely to
produce an asymmetric smile and upper lip ptosis. The
midface flattens and the cutaneous upper lip elongates
vertically, an effect that is already perceived as a sign
of aging. However, in some individuals who have a
naturally shorter upper lip, very small doses of
botulinum toxin can be beneficial, particularly when
given concurrently with fillers or resurfacing.
In our practice, we have occasionally injected 2 to
3 U of botulinum toxin under electromyographic
(EMG) control into the levator labii superioris alaeque
nasi. Currently, we inject 1 U only of botulinum toxin
into each lip elevator complex in the nasofacial
groove. Injections result in some improvement in
collapsing the upper extent of the nasolabial fold but
also cause vertical lengthening of the upper lip.
Because the duration of effect of this procedure is
relatively long (76 months), it is important to be very
selective in patient selection and to be clear about the
potential results of the procedure.1 This treatment
should be considered a viable option for patients with
short upper lips, but for other patients, alternative
treatment procedures are preferred.

Facial Asymmetry: Functional Muscle Imbalance

Facial asymmetry is the norm in the adult face, but
generally it is not perceived by the patient unless
photographs are scrutinized. Mid facial asymmetry
may have bony tissue, soft tissue, or innervational/
muscular etiology. Botulinum toxin can be invaluable
in relieving asymmetry caused by neuromuscular
abnormalities. In hemifacial spasm, repeated clonic
and tonic facial movements draw the facial midline
over toward the hyperfunctional side. Botulinum toxin
relaxation of the hyperfunctional zygomaticus, risorius, and masseter allows the face to be centered at rest.
Hypofunctional asymmetry, such as after a unilateral seventh nerve paresis (Bells palsy), can be
alleviated by botulinum toxin treatment of muscles on
the normofunctional side.25 Injections of only 1 to 2 U
of botulinum toxin in the zygomaticus, risorius, and
orbicularis and 5 to 10 U in the masseter are required.

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29:5:May 2003

Some patients have asymmetric jaw movement. We

have found that an intraoral injection of 10 to 15 U of
botulinum toxin into the internal pterygoid on the
hyperfunctional side can relax the jaw and relieve
discomfort during masticating and elocution. For
physicians not thoroughly comfortable with facial
surface anatomy, we recommend injection through an
EMG system.
Surgical or traumatic lesion of the orbicularis oris or
the risorius muscle can result in the mouth being
pulled off center by the unopposed action of the
partner muscles in the normally innervated side.
Botulinum toxin chemodenervation of the risorius
immediately lateral to the corner of the mouth on the
normally innervated side will recenter the mouth when
the face is in repose. Moreover, some individuals have
congenital or acquired unilateral weakness of the
depressor anguli oris muscle, resulting in an inability
to depress the corner of one side of the mouth. In this
case as well, botulinum toxin treatment of the partner
muscle restores functional and aesthetic balance.

Lower Face Indications for Cosmetic BTX-A

Botulinum toxin should be used with caution for
cosmetic indications in the area of the mouth. Dosages
are much reduced compared with those used for the
upper face, and the underlying muscular anatomy is
very individualized.

Mouth Frown and Melomental Folds (Marionette

Lines): Depressor Anguli Oris
The frowning expression created when the lateral
corners of the mouth are permanently angled downward can create an impression of disapproval and
unpleasantness, even in the absence of a discrete
melomental fold or drool groove. The depressor
anguli oris pulls down the corner of the mouth in
opposition to the zygomaticus major and minor
muscles. Botulinum toxin can be used to weaken the
depressor anguli oris and reset the muscular balance,
allowing the zygomaticus to elevate the corners of the
mouth and return them to a horizontal position21
(Figure 2).
In our practice, patients are asked to pull down the
corners of their mouths to aid in the location of the
muscle, and 2 to 3 U of botulinum toxin are injected
directly into the depressor anguli oris on each side of
the mouth. As has been found with several other
botulinum toxin procedures, the effects may be
potentiated with repeated treatment.
Caution must be used when injecting toxin close to
the mouth. Possible complications of a misplaced

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473

Figure 2. Mouth frown in subject (A) before and (B) after botulinum toxin treatment of the depressor angulioris. Reprinted with permission.19

injection include flaccid cheek, incompetent mouth,

difficulty with elocution, and asymmetric smile. The
treatment is not recommended for singers or musicians
or for patients who use their perioral muscles with
intensity. The most satisfactory results may be
obtained with botulinum toxin injections in combination with laser resurfacing.
Melomental folds (drool grooves or marionette
lines) extending from the down-turned corner of
the mouth to the lateral mentum involuntarily produce
a sad expression and reinforce the negative impression
produced by the inverted smile. They also give
the appearance of advancing age and decrepitude.
Traditionally, soft tissue augmentation has been
used alone to rebuild the soft tissue support of
the lateral mouth corner and the melomental fold.
Agents such as collagen, Hylaform, Restalyn, and
Gore-Tex implants have been used. Although soft
tissue augmentation is successful in softening the
melomental fold, the effects are not long lasting
because the filling agents do not endure in this highly
mobile and expressive region of the face. Conversely,
they last longer when the muscles are relaxed with
botulinum toxin.
Botulinum toxin treatment is a useful adjunct to soft
tissue augmentation because the depressor anguli oris
muscle contributes to the manifestation of melomental
folds. In our practice, 2 to 5 U of botulinum toxin
(depending on the size of the muscle) are injected into
each depressor anguli oris immediately above the angle
of the mandible and 1 cm lateral to the lateral oral
commissure.24 It is critical to inject low at the junction
of the depressor labii and the inferior margin of the
mandibleinjection too medial can cause an ipsilateral weakness of the depressor labii and flattening of
the lower lip contour when the mouth attempts to
form an O, and an injection too high can
compromise the sphincter function of the orbicularis
oris leading to difficulties with speech and suction
movements.

One helpful approach is to use botulinum toxin

chemodenervation of the depressor anguli oris in
combination with the soft tissue augmenting agent
most suitable for the individual. Zyplast, Hylaform,
Restylane, Perlane, and Artecol have performed well in
combination with botulinum toxin treatment. Expanded polytetrafluoroethylene is also a good agent,
but it is difficult to achieve discrete placement with no
subsequent implant movement in this region of the
face. We have also successfully used autologous fat
(both fresh and thawed from storage). With all soft
tissue augmenting agents, the enhanced appearance of
the melomental folds appears to last longer when
botulinum toxin treatment prevents the repeated
molding and contortion of the implant.23

Mental Crease and Peau DOrange Chin

(Apple Dumpling): Mentalis
The convexity between the lower lip and the prominence of the chin is called the mental crease. A deep
groove is produced by the contraction of the mentalis
muscle. Because this region is closely tethered to the
bony mentum, filling the groove with soft tissue
augmenting agents can create visible beading of the
reagent and unsatisfactory results. Botulinum toxin
injections at the level of the crease will weaken the
orbicularis oris and may produce an incompetent
mouth. However, we have found that injection of the
mentalis at the bony mentum gives a satisfactory
aesthetic softening of the crease while avoiding
complications from weakening of the orbicularis oris.
We usually inject 3 to 5 U of botulinum toxin per
mentalis band.
The loss of dermal collagen and subcutaneous fat at
the mentum results in an orange peel appearance of
the chin. The appearance is worsened when the
mentalis and depressor labii are used together with
the orbicularis oris muscle during speech or chewing.
Peau dorange chin is frequently seen asymmetrically

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on recovery of Bells palsy. Previous treatment options

included soft tissue augmentation to fill in the soft
tissue gaps and ablative and nonablative laser resurfacing. Depending on the patients aesthetic need for
chin augmentation, botulinum toxin and soft tissue
augmentation can be used together, or botulinum toxin
can be used alone to soften the apple dumpling
appearance of the chin. In our practice, 5 to 10 U of
botulinum toxin are injected in the mentalis at the
most distal point from the orbicularis oristhe
prominence of the chin. This injection site is chosen to
avoid complications from oris orbicularis weakening.
After the injection, massage of the chin is recommended to aid in the diffusion of toxin.

Smile lines: Zygomaticus

Deep smile lines produced by contraction of the
zygomaticus are often connected to lower crows feet
lines. Treatment of crows feet can worsen these lines
because the redundant cheek skin gravitates downward. Carbon dioxide laser resurfacing of the lower
face is the preferred treatment for tightening the skin
texture and smoothing smile lines. We find that the
results are enhanced when botulinum toxin injections
are used to weaken the zygomaticus muscle prior to
resurfacing.20 We inject 1 to 2 U of botulinum toxin
per side only.

Upper Gum Show

Retraction of the upper lip during smiling results in
excessive exposure of the upper gum in some
individuals. The gum line, upper incisors, and canines
are fully revealed. The levator labii superioris alaeque
nasi muscle retracts the upper lip and produces the
upper gum exposure. Weakening of the muscle with
botulinum toxin results in a moderate drop in the
upper lip sufficient to cover the upper gum. We inject 1
to 2 U of botulinum toxin into the levator labii
superioris muscle on each side of the bony nasal
prominence.23 Small concentrated doses of botulinum
toxin are used, often in conjunction with an EMG
placement system, to target the muscle accurately.23
Vertical elongation of the cutaneous lip is a side effect
of this treatment. Because the procedure can exacerbate the vertical elongation of the lip that normally
occurs during aging, it produces less satisfactory
results in patients who are middle aged and older,
and treatment is generally recommended for only
younger patients. For most patients, the best results are
obtained when this procedure is used in combination
with the injection of a soft tissue filler into the lip
margins. This soft tissue augmentation also softens the
effect of the contraction of the lip elevators.

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Cervical Indications for Cosmetic BTX-A

Horizontal Neck Lines

Two or three horizontal necklace lines of skin
indentation often grace the slightly younger, chubbier
neck. These lines are caused by the superficial
musculoaponeurotic system attachments in the neck.26
We feel that the simplest approach is to dance along
the lines injecting small doses of botulinum toxin
over multiple sites. Aliquots of 1 to 2 U are injected
in the deep intradermal plane at approximately 1-cm
intervals along the horizontal neck lines to soften
and erase them. If the neck is gently massaged
afterward, the skin usually does not bruise. The
physician is cautioned to do deep dermal rather than
subcutaneous injections for two reasons: (1) There are
deeper venous perforators that can bleed, especially
lateral in the neck, and (2) the underlying muscles of
deglutition are cholinergic and could potentially be
affected. We usually inject no more than 15 to 20 U of
botulinum toxin for horizontal lines per treatment
session.

Vertical Platysmal Bands

The platysma muscle wraps around the thoracic inlet
from the sternomastoid, interdigitating with the
inferior muscles of facial expression including the
depressor labii, depressor anguli oris, and mentalis.
The larynx and the muscles of deglutition are located
deep to the platysma in the neck. Banding and
separation of the platysma occur as the anatomy
of the submental space changes during aging. Cervical
skin loses its elasticity. More submental fat becomes
visible, and the platysma separates anteriorly to
become two diverging vertical bands.27 The anterior
borders of these bands often tighten and become
visible when the neck is animated; the bands may
become particularly prominent when the subject
speaks, exercises, or plays a musical instrument.
Botulinum toxin has been used for many years
to attempt to ameliorate this complex problem.28
Botulinum toxin denervation of the anterior part of
the platysma muscle can produce a gentle anterior
neck lift with softening of vertical platysmal bands,
similar to the contour produced by a rhytidectomy.21
However, senescent changes in the neck musculature
may be accompanied by jowl formation and bone
resorption; in necks with these senescent characteristics, botulinum toxin chemodenervation of the
platysma may emphasize the muscle cords rather than
softening them.29 Careful selection for patients who
have obvious platysmal bands, good cervical skin
elasticity, and minimal fat descent is necessary for this
treatment.

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475

Figure 3. Platysmal bands (A) before and (B) after botulinum toxin treatment. Photographs courtesy of M. Carney. Reprinted with permission.19

In a series of 44 subjects, Kane described good

results but cautioned that the gold standard treatment
for most aging necks remains traditional rhytidectomy
surgery.29 Kane suggested that botulinum toxin be
used for those too young and too old to undergo
rhytidectomy surgery. Rhytidectomy may be required
for patients with softening and descent of cervical skin
and fat. However, botulinum toxin can be a very useful
adjunct to traditional face-lift surgerythe residual
muscular banding that becomes apparent in the
postoperative phase can be simply treated with
botulinum toxin chemodenervation rather than by an
inconvenient second surgical procedure. Botulinum
toxin treatment can also be used as a rehearsal so
that individuals who are not ready to undergo
traditional face-lift surgery can have aesthetic enhancement similar to the effects that will be achieved
with a later surgical neck lift.
Brandt and Bellman30 introduced the concept that
some lower facial problems may be a result of
platysma contraction enhancing depressor activity in
the lower face. When large doses of botulinum toxin
are used to paralyze the platysma, the elevators of the
lower face are allowed to be more effective and lift the
neck and jowls. These authors have reported injecting
up to 200 U of botulinum toxin per neck with
improvement in the appearance of the lower face and
neck.28
We have concerns about this dosage. Large doses of
botulinum toxin must be used cautiously because the
platysma is external to the muscles of deglutition and
neck flexion. Doses from 75 to 100 U can produce

weakness in the neck flexors and dysphagia.21 We have

previously reported one patient treated with only 60 U
in her neck who developed such profound dysphagia
that she had to use a nasogastric tube for 6 weeks until
she could again swallow.22 Therefore, we recommend
that the physician proceed with caution and inject no
more than 25 to 30 U of botulinum toxin over multiple
sites per cervical treatment session. Retreatment for
undercorrection is a safer approach.
In the procedure we use, the patient is asked to
contract the platysma. The offending platysmal band is
grasped and botulinum toxin is injected in three sites
at 1.0- to 1.5-cm intervals with 5 U per site (for a total
of 15 U per band). A single treatment typically involves
injection of two bands with a total dose of 30 U of
botulinum toxin. This dose is safe and effective and
has not been associated with any significant adverse
events. More botulinum toxin can always be given if
needed at a subsequent treatment session (Figure 3).

Conclusions
BTX-A has proven to be effective in cosmetic
procedures in the midface, lower face, and neck.
Understanding the resting and dynamic muscular
anatomy of the face as well as the location of the
neurovascular bundles will facilitate the achievement
of aesthetic and functional outcomes. Dosage of
BOTOX in the mid and lower face and neck is much
more conservative than in the brow and crows feet
regions because of the apparent increased responsive-

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CARRUTHERS AND CARRUTHERS: AESTHETIC BOTULINUM TOXIN BELOW THE EYES

ness of the musculature of this region. In some areas,

particularly in the perioral region, the use of botulinum toxin in combination with soft tissue augmentation gives the most harmonious results.

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