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. Greg J. Goodman, M.D. Gary Monheit, M.D. on behalf of the Alliance for the Future of Aesthetics Consensus Committee São Paulo, Brazil; Singapore; South Yarra, Melbourne, Victoria, Australia; and Birmingham, Ala.
Summary: This third article of a three-part series addresses techniques and recommendations for aesthetic treatment of the lower face. The lower face is considered an advanced area for facial aesthetic treatment. In this region, soft-tissue fillers play a more important role than neuromodulators and should be used first to provide structure and support before neuromodulators are considered for treatment of dynamic lines. Treatment of the lip, perioral region, and chin, in addition to maintaining balance of the lower face with the face overall, is challenging. Procedures on the lip should avoid overcorrection while respecting the projection of the lips on the profile view and the ratio of lip size to chin. The chin is often neglected, but reshaping the jawline can provide dramatic improvement in facial aesthetics. Both profile and anterior views are critical in assessment 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 injection techniques for aesthetic procedures involving use of injectable fillers and/or neuromodulators. Recommended needles for each product are listed in Table 1 and recommended Allergan plc (Dublin, Ireland) portfolio products and volumes/doses for each area of the midface are illustrated in Table 2. Other filler and neuromodulator options are available and can be used in the treatment areas described; good results are as much dependent on injector technique as on the product utilized. We provide detail specific to Allergan products because of our extensive experience with these products in clinical practice. This article discusses techniques in the lower face, one of the most challenging areas to treat. The lip is challenging to reshape with fillers; comprehensive assessment is necessary to avoid improper correction. The chin is one of the most neglected areas, but reshaping the jawline can provide dramatic improvement in facial aesthetics. Finally, the neck is a challenging area, where both fillers and neuromodulators may be necessary. From the Clinica Dr. Maurício de Maio; the Woffles Wu Aesthetic Surgery and Laser Centre; the Dermatology Institute of Victoria; and the Total Skin and Beauty Dermatology Center. Received for publication April 13, 2016; accepted February 10, 2017. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003646
AESTHETICS OF THE PERIORAL AREA AND LIPS The perfect lip includes a visible transition line or border between the vermillion and skin, a V-shaped Cupid’s bow, a full medial tubercle and vermillion, an ascendant line in the oral commissures, and an upper-to-lower lip ratio of 1:1.618.1
AGING OF THE PERIORAL AREA AND LIPS Intrinsic lip volume loss, photodamage, and lip muscle movement lead to static and dynamic wrinkles, lip elongation and thinning, flatness of the vermillion border, loss of Cupid’s bow, lip Disclosure: Dr. de Maio and Dr. Goodman are Allergan plc consultants for speaking events and marketing strategy. Dr. Wu is a consultant for Allergan plc, Galderma, and Merz for speaking events and advisory boards. Dr. Monheit has no conflicts to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www. PRSJournal.com).
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393e
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Plastic and Reconstructive Surgery • September 2017 dryness, and downturned oral commissures.1–3 In the aging lip, the perioral tissues of the cutaneous lip also atrophy.4 Age-related deepening of the nasolabial fold may be caused by repeated contraction of the levator labii superioris and levator labii superioris alaeque nasi muscles during wrinkling of the nose and by ptosis of the superficial musculoaponeurotic system.1 With aging, perioral lines become evident perpendicular to the lips Table 1. Recommended Needle Sizes for Delivery of Soft-Tissue Fillers and OnabotulinumtoxinA Product Injectable fillers Ultra Ultra Plus Volbella Volift Voluma OnabotulinumtoxinA
Needle Size 30-gauge, ½-inch (13 mm) 27-gauge, ½-inch (13 mm) 30-gauge, ½-inch (13 mm) 30-gauge, ½-inch (13 mm) 27-gauge, ½-inch (13 mm) 30-gauge, ½-inch (13 mm)
and radiating from the lip border, particularly in the area above the lips.5 These lines develop because of perioral soft-tissue volume loss, lip atrophy, hyperdynamic contractions of the perioral musculature, and underlying resorption of mandibular bone.5
ASSESSMENT OF THE PERIORAL AREA AND LIPS Assessment should be made at rest and during animation (i.e., while smiling and while puckering), including the projection of the lips on the profile view.1 Assess preservation of lip landmarks, including the vermillion border, vermillion body, Cupid’s bow, philtrum, and oral commissures, and any loss of lip and perioral volume. Also, assess the dental arcade for the presence of occlusions and the inclination of the teeth. Evaluate for asymmetry at rest and during animation, excessive inversion of the vermillion, and whether the gingiva are prominent. Assess the
Table 2. Recommended Allergan plc Portfolio Product and Volume/Dose for Individual Areas Region Hyaluronic acid filler Nasolabial fold Lip border
Vermillion linear technique
Vermillion aliquot technique Commissures Philtrum Perioral lines Marionette lines Mental crease Chin apex Prejowl area Mandible body and angle Neurotoxin Gummy smile Upper lip and lower lip lines Depressor anguli oris muscle Mentalis muscle Masseter muscle Platysma muscle/jawline Platysma bands
Product
Volume/Dose Range
Ultra Plus Volift Voluma Ultra Plus Ultra Volift Volbella Ultra Plus Ultra Volift Volbella Ultra Plus Ultra Volift Ultra Plus Volift Ultra Plus Ultra Volift Ultra Volbella Ultra Plus Volift Ultra Plus Volift Ultra Plus Voluma Ultra Plus Voluma Ultra Plus Voluma
0.5–1.0 ml per side
OnabotulinumtoxinA OnabotulinumtoxinA OnabotulinumtoxinA OnabotulinumtoxinA OnabotulinumtoxinA OnabotulinumtoxinA OnabotulinumtoxinA
2.0 U per site; total dose: 6.0 U, moderate; 10.0 U, severe 1.0 U per site; total dose: upper lip, 2.0–4.0 U; lower lip, 2.0 U 2.0–4.0 U per site; total dose, 4.0–8.0 U 4.0–6.0 U per site; total dose, 6.0–24.0 U per side 4.0–8.0 U per site; total dose, 4.0–24.0 U 2.0–4.0 U per site; total dose, 12.0–24.0 U per side 2.0 U per site; total dose, 8.0 U per lateral band; 6.0 U per medial band
0.1–0.3 ml per side 0.1–0.2 ml per quadrant
0.5–1.0 ml for both lips
0.05 ml per bolus 0.5–1.0 ml for both lips 0.05–0.1 ml per side 0.05–0.1 ml per side ≤0.25 ml per quadrant 0.5–1.0 ml per side for lower injection 0.5–1.0 ml per side for upper injection 0.2–0.5 ml per side 0.2–0.3 ml per site 0.5–1.0 ml per side 0.5–1.0 ml for subcutaneous injection; 0.25 ml for bolus injections
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Volume 140, Number 3 • Injection Guide for the Lower Face surrounding areas for perioral wrinkles, nasolabial folds, and marionette lines. Before treating the nasolabial fold, the midface region should always be evaluated and treated. In rare cases, the nasolabial fold may be treated only by a direct approach.
ANATOMY OF THE PERIORAL AREA AND LIPS The superior and inferior labial arteries found in the submucosal layer (wet part) are branches of the facial artery and supply the upper and lower lips, respectively.1 The infraorbital nerve and mental nerve provide sensory innervation of the upper and lower lips, respectively, whereas the buccal branch of the facial nerve provides motor innervation to these areas.1
FILLER INJECTION TECHNIQUE FOR INDICATIONS IN THE PERIORAL AREA AND LIPS Nasolabial Fold Injections of Ultra Plus or Volift are made at two areas (Fig. 1, left). Injectors should be alert to the facial artery and vein and exercise caution during augmentation of the proximal nasolabial folds because of a risk of vascular compromise of the facial artery and nose branches (Fig. 1, right).6 For the retrograde linear injection (area 1), position the needle and aspirate before injection. Stretch the skin using two fingers to better visualize the fold.1 Stay slightly medial to the fold, and insert the needle angled upward parallel to the fold to deliver a superficial subcutaneous injection. [See Figure, Supplemental Digital Content 1, which shows the linear retrograde technique for treatment of nasolabial
folds; inject into the superficial subcutaneous space. For fanning technique (not shown), deliver a slow and superficial subcutaneous injection medial to the fold, http://links.lww.com/PRS/C311.] Use a slow, continuous-movement, low-volume, linear retrograde injection. Do not overinject, as overinjection may lead to irregularities. For injection on the medial aspect of the fold, position the needle more superficially and deliver a subcutaneous injection using a fanning technique. Inject more slowly as the injection approaches the nose. Massage to shape after each injection; do not overfill. Use of Voluma for nasolabial folds is indicated in patients with severe volume loss to compensate for bone retrusion. Specific training for this area is advised. Voluma is injected very deeply at the canine fossa (Fig. 2, left). Inspect the skin surface to determine the vascular pattern, and avoid the facial artery and nose branches, the facial vein, and the inferior alar artery branch of the angular artery (Fig. 2, right).6 Position the needle perpendicular to the skin surface. Touch the bone, and aspirate before injection. Inject very slowly with low pressure to deliver a supraperiosteal small bolus. (See Figure, Supplemental Digital Content 2, which shows the injection technique for retruded canine fossa. Insert needle perpendicular to skin surface, and inject very slowly with low pressure, http://links.lww.com/PRS/C312.) Massage to shape and avoid overfilling. Lip Border Reshaping the lip border (Fig. 3) is achieved using Ultra Plus, Ultra, Volift, or Volbella.5 (See Figure, Supplemental Digital Content 3, which shows the injection technique for lip border. Inject very slowly and avoid inadvertent displacement of the filler, http://links.lww.com/PRS/C313.) Assess any
Fig. 1. Treatment of nasolabial folds using either Ultra Plus or Volift (left). Aspiration is mandatory before each injection. Areas of caution (right). a., artery; v., vein.
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Plastic and Reconstructive Surgery • September 2017
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.
Fig. 3. Treatment of the lip border using Ultra Plus, Ultra, Volift, or Volbella. The product is injected along the lip border. Areas of caution: avoid the labial artery and vein in the intraoral submucosal plane.
asymmetry before injection, and respect the proportions between the upper lip and the lower lip. When identifying injection sites, avoid the labial artery and vein in the intraoral submucosal plane (i.e., wet part of the lip). Position the needle at the vermillion border near the lateral edge of the mouth, and insert the needle below the mucocutaneous junction. Inject very slowly using an anterograde linear technique with deposition of a linear thread as the needle is being advanced into the skin. Avoid inadvertent displacement of the product outside of the intended treatment area. Injection into the sensitive Cupid’s bow is performed very slowly. Administer equal volumes of filler on both sides unless gross asymmetry is evident.5 Avoid overcorrecting the lip border and producing excessive anterior projection of the upper lip. Vermillion Enhancing the shape or volume of the vermillion can be achieved with Ultra Plus, Ultra, Volift, or Volbella. Two different techniques are
recommended (Fig. 4). With the first technique, the filler is administered at one site in each quadrant of the lip body. Administer Ultra Plus, Ultra, and Volift by means of intramuscular anterograde linear threading and Volbella by means of retrograde linear threading into the dry submucosa. [See Figure, Supplemental Digital Content 4, which shows the injection techniques for vermillion. Inject very slowly either linearly in the submucosa (left, technique 1) or in small aliquots intramuscularly (right, technique 2), http://links. lww.com/PRS/C314.] Avoid the labial artery and vein in the intraoral submucosal plane. Insert the needle into the lip mucosa at a 30-degree angle to the lip body.5 Enter through the skin and inject very slowly to avoid bleeding in this bruise-prone area. The second technique can be used with Ultra Plus, Ultra, and Volift. Filler is administered at three injection sites per quadrant. To avoid pain and bruising, insert the needle at points 2 mm superior to the upper lip border and 2 mm inferior to the lower lip border, and place the filler inside the vermillion. Deliver very small intramuscular bolus injections very slowly. Massage is mandatory to avoid irregularities and nodules. The precautions outlined for enhancing the lip border should also be followed for the vermillion. Commissures Restoring the commissures may be achieved with Ultra Plus or Volift. Before treating the commissures, the lip border should be treated, if indicated. Insert the needle superficially at the lateral edge of the mouth angle, and deliver a very small bolus injection intramuscularly and/or into the mucosa (Fig. 5). Be alert to avoid the labial artery
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Volume 140, Number 3 • Injection Guide for the Lower Face
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 intraoral submucosal plane.
Fig. 5. Treating the oral commissures with Ultra Plus or Volift. These fillers are injected at one site on each side. Areas of caution: avoid the labial artery and vein. Inject very slowly.
and vein. Inject very slowly. Avoid overcorrection because of the possibility of creating a bulging area or displacement during animation. Overcorrection may lead to an abnormal smile. Philtrum The ridge between the nose and lips, known as the nasal philtrum, tends to flatten with aging. Reshaping of the philtrum can be achieved with
Fig. 6. Augmentation of the philtrum with Ultra Plus, Ultra, Volift, or Volbella. These fillers are injected at one site on each side. Areas of caution: avoid the columella branches of the upper labial artery near the nose.
Ultra Plus, Ultra, Volift, or Volbella with one injection site per side (Fig. 6). Avoid the columella 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 the needle pointed upward and the needle bevel inward. (See Figure, Supplemental Digital Content 5, which shows the injection technique for philtrum. Pinch the philtral column, and insert the
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Plastic and Reconstructive Surgery • September 2017 needle upward with the bevel facing inward; inject slowly, http://links.lww.com/PRS/C315.) Administer a superficial subcutaneous injection using a linear retrograde technique. Ensure that the inverted-V shape of the philtrum is preserved. Avoid widening the philtral columns and avoid overcorrection that may result in elongating the upper lip. Perioral Lines Correction of perioral lines can be achieved with Ultra or Volbella (Fig. 7). Be alert to the perioral vasculature, including branches of the upper labial artery. Insert the needle perpendicular to the wrinkles and administer a superficial subcutaneous injection using a linear technique. (See Figure, Supplemental Digital Content 6, which shows the injection technique for perioral lines. Inject slowly and evenly perpendicular to the wrinkles; massage after the injection, http://links.lww.com/ PRS/C316.) Inject slowly and evenly, and massage after each injection. Do not chase superficial lines. Avoid elongation and flattening of the upper lip because of overinjection and avoid overcorrection.6 In many aged lips, judicious volumization with Ultra or Volift will aid in treatment of lines.
ONABOTULINUMTOXINA INJECTION TECHNIQUE FOR INDICATIONS IN THE PERIORAL AREA AND LIPS
Injections of onabotulinumtoxinA for correction of gummy smile are made at three sites if moderate and at five sites if severe (Fig. 8). The total dose is 6 to 10 U of onabotulinumtoxinA, depending on severity and muscles involved. [See Figure, Supplemental Digital Content 7, which shows the injection technique for gummy smile. For each injection, insert the needle pointed upward to one-half of its depth; inject into the depressor septi nasi (left) and levator labii superioris alaeque nasi (right). Assess for asymmetry before and after injection, http://links.lww.com/PRS/C317.] Excessive doses may lead to upper lip elongation and lip ptosis. Patients with a short upper lip are ideal candidates, whereas care should be exercised in patients with gummy lip and a long upper lip. Upper Lip and Lower Lip Lines Vertical lines on the upper and lower lips occur with aging and may remain after dermal filler treatment.7 The orbicularis oris is the main muscle in the lips, with superficial fibers responsible for lip protrusion.7 Upper lip lines are treated at one or two sites per side (Fig. 9), whereas lower lip lines are treated at one site per side. Insert only the needle bevel pointed upward. (See Figure, Supplemental Digital Content 8, which shows the injection technique for upper lip lines. For each injection, insert the needle to the depth of the bevel, with the bevel
Gummy Smile Gummy smile refers to the showing of excessive 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 tubercle.7 In severe gummy smile, the levator labii superioris and zygomatic minor muscles also raise the upper lip.7
Fig. 7. Correction of perioral lines with Ultra or Volbella. These fillers are injected at one site in each quadrant. Areas of caution: perioral vascularization (branches of the upper labial artery).
Fig. 8. Treatment of gummy smile with onabotulinumtoxinA. Injections are made at three sites for moderate gummy smile (yellow X) and at two additional sites for severe gummy smile (blue X). The symbol X indicates one-half needle depth.
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Volume 140, Number 3 • Injection Guide for the Lower Face presence of marionette lines, including sagging skin or manifest lines.7 Finally, assess the platysma for the presence of neck lines and for active contraction of the platysma bands when speaking.7
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 chin.1 The mental nerve provides sensory innervation to the chin and lower lip; it exits the mental foramen below the second mandibular premolar.1 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.
Fig. 9. Treatment of upper and lower lip lines with onabotulinumtoxinA. Injections are made at one or two sites per side.
pointed upward. Assess for asymmetry before and after injection, http://links.lww.com/PRS/C318.) Avoid administering excessive doses, which may lead to flattening of the lips and restrict lip pursing, or injecting too close to the mouth, which may impact lip function and cause drooling.8
AESTHETICS OF THE CHIN AND JAWLINE The chin should be oval and delicate in women, with less fullness concentrated at its lateral part, whereas it may have more square, heavier features and a stronger appearance in men.1 For both men and women, good chin projection and a youthful jawline are considered the standards of beauty.1,9
FILLER INJECTION TECHNIQUE FOR INDICATIONS IN THE CHIN AND JAWLINE Marionette Lines Marionette lines give the face a sad or hard appearance. Treatment of marionette lines may be achieved with Ultra Plus or Volift. Injections are made at two sites on each side (Fig. 10). Injectors should be alert to avoid the inferior labial and sublabial arteries and veins. Using a linear retrograde technique, deliver a superficial subcutaneous injection. Inject slowly, and deliver most of the volume to the top third of the fold while staying medial to the marionette line. The upper injection is made by inserting the needle inferior to the modiolus and injecting slowly using a vertical column technique, in which the filler is injected as the needle is withdrawn from the deeper tissue. [See Figure, Supplemental Digital Content 9, which shows the injection technique
ASSESSMENT OF THE CHIN AND JAWLINE The chin assessment should include evaluations of occlusion, skeletal and dental relationships, lateral fullness, and projection along the subnasal vertical line.1 The ratio of the upper lip to lower lip/chin should be one-third to two-thirds.1 The jawline assessment should consider the chinneck angle (submental-neck line); 121 degrees is considered optimal in women. The jawline should be smooth from the angle of the jaw until the chin, uninterrupted by the jowl or postjowl and prejowl sulcus. Viewing this area from the front and sides is critical in assessment. Evaluate for the
Fig. 10. Correction of marionette lines with Ultra Plus or Volift. Fillers are delivered by means of injections at two sites per side. Areas of caution: avoid the inferior labial and sublabial arteries and veins.
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Plastic 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:// links.lww.com/PRS/C319.] Mental Crease The labiomental or mental crease is a horizontal line that develops during aging just above the chin.5 These lines develop because of soft-tissue volume loss, dermal atrophy, reduced skin elasticity, hyperdynamic contractions of the lower facial muscles, and underlying resorption of mandibular bone.5 A reduction in the depth of a mental crease 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 retrograde technique. Alternatively, injection using a linear anterograde technique can be made if starting laterally (not shown). Injections should be made slowly, http://links.lww.com/PRS/C320.] Massage after each injection, and avoid overinjection, as overinjection may lead to irregularities. 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, position the needle at the midline of the jawline, and aspirate before injection. (See Figure, Supplemental Digital Content 11, which shows the injection technique for augmentation of chin apex. Aspirate before injection and inject slowly. Pinch the chin to avoid unwanted displacement of the filler, http:// links.lww.com/PRS/C321.) Inject slowly and deliver a supraperiosteal small bolus. Compare symmetry before and after the injection by watching from the cephalic view. Maintain the injection in the midline and avoid chin deviation. Use two fingers to pinch the chin to avoid unwanted displacement of the filler. Do not inject the filler too low, as this can lead to formation of a “witch’s chin,” and do not overfill. Massage after the injection. Deliver the other two injections in the same manner at superolateral sites on either side of the chin.
Fig. 11. Treatment of a mental crease with Ultra Plus or Volift. Fillers are delivered by means of linear retrograde or anterograde injection. Areas of caution: avoid the sublabial artery and vein.
Fig. 12. Augmentation of the chin apex with Ultra Plus or Voluma. Both fillers are delivered by means of injections at two to three sites. Areas of caution: avoid the mental artery and vein.
Fig. 13. Filling of the prejowl area with Ultra Plus or Voluma. Both fillers are delivered by means of a deep subcutaneous injection using a fanning technique. Areas of caution: avoid the mental artery and vein and the mental nerve.
Prejowl Area The prejowl area is the triangular area from the mental foramen to the midlateral zone of the mandible (Fig. 13).1 Filling of jowls can be achieved with Ultra Plus or Voluma. Injectors should be alert to avoid the mental artery and vein and the mental nerve. Position the needle at the jawline of the
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Volume 140, Number 3 • Injection Guide for the Lower Face prejowl area, and aspirate before injection. (See Figure, 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, http://links.lww.com/PRS/ 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 fingers to control placement of the product, and exercise care with displacement of the filler over the mandibular ligament. Overcorrection lateral to the ligament may worsen the jowl area. Mandible Body and Angle The injection of fillers in this area creates a more defined jawline contour.1 This may be achieved using Ultra Plus or Voluma, with injections at two to three sites per side (Fig. 14). Injectors should be alert to palpate and avoid the facial artery, facial vein, and parotid gland. For the subcutaneous injection, pinch the skin above the mandible body and position the needle superficially to avoid the facial artery. [See Figure, Supplemental Digital Content 13, which shows the injection technique 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, http://links.lww.com/PRS/C323.] Do not inject deep at this level. Aspirate before injection, and inject slowly using a linear retrograde technique. For the supraperiosteal injections, deliver one or two small boluses at the mandibular angle. This is ideal for male patients. A subcutaneous approach is preferable for female patients. Aspirate before each injection, inject slowly, and avoid scratching the periosteum. The treatment area is prone to development of deep hematomas, especially the site of the supraperiosteal injections.
ONABOTULINUMTOXINA INJECTION TECHNIQUE FOR INDICATIONS IN THE CHIN AND JAWLINE Depressor Anguli Oris Muscle The depressor anguli oris muscle draws the corners of the mouth down, creating a crease descending from the corner of the mouth that imparts a sullen or dissatisfied appearance.7 Treatment of these lines, resulting from excessive contraction of the depressor anguli oris muscle, is made at one site on each side of the face (Fig. 15). A dose of 2 to
Fig. 14. Treatment of the mandible body and angle with Ultra Plus or Voluma. Both fillers are delivered by means of a superficial subcutaneous injection over the mandible body and by supraperiosteal small-bolus injections over the mandible angle. Areas of caution: palpate and avoid the facial artery and vein, and avoid the parotid gland.
Fig. 15. Treatment of the depressor anguli oris muscle with onabotulinumtoxinA. Injections are made at one site per side. The symbol X indicates one-half needle depth.
4 U of onabotulinumtoxinA is injected at each site. Insert the needle near the jawline to one half of its depth and at least 1 cm away from the corner of the mouth.7 (See Figure, Supplemental Digital Content 14, which shows the injection technique for the depressor anguli oris muscle. For each injection, insert the needle to one-half its depth. Assess for asymmetry before and at 2 weeks after injection, http://links.lww.com/PRS/C324.) Assess for asymmetry before and at 2 weeks after injection, as this area
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Plastic 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.7 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 lip.7 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 U of onabotulinumtoxinA should be delivered. (See Figure, Supplemental Digital Content 15, which shows the injection technique for the mentalis muscle. Insert the needle to its full depth and maintain the injection in the midline, http://links. lww.com/PRS/C325.) Maintain the injection in the midline. Excessive lateral displacement of the needle may lead to paralysis of the depressor labii inferioris muscle, resulting in an asymmetrical smile. Masseter Muscle The masseter muscle elevates the mandible and is important during chewing; it may become
Fig. 16. Treatment of the mentalis muscle with onabotulinumtoxinA. An injection is made at a midline point 0.5 to 1 cm above the chin and symmetrically on either side. Square symbols indicate full-needle depth.
Fig. 17. Treatment of masseteric hypertrophy with onabotulinumtoxinA. Injections are made at three sites on each side of the face. Square symbols indicate full-needle depth.
enlarged from repeated clenching of the jaw, resulting in bulging of the lateral jawline, a condition known as masseteric hypertrophy.10 Treatment with onabotulinumtoxinA is made at three sites on each side of the face (Fig. 17). A dose of 4 to 8 U of onabotulinumtoxinA at each point should be delivered with the needle inserted perpendicular to the skin to its full depth. (See Figure, Supplemental Digital Content 16, which 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, http://links.lww.com/PRS/C326.) Ask the patient to clench before marking the injection site, and
Fig. 18. Treatment of the platysma muscle/jawline with onabotulinumtoxinA. Injections are made at six sites on each side at one-third needle depth.
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Volume 140, Number 3 • Injection Guide for the Lower Face inject lateral to the anterior margin of the masseter muscle. Superficial and higher injections may cause asymmetry during animation. This area is prone to deep hematomas. Asian patients with severe hypertrophy may require higher doses of 40 U or more of onabotulinumtoxinA.11–16 Platysma Muscle/Jawline The platysma muscle draws down the lower jaw and the corners of the mouth.7 Treatment of lines resulting from excessive contraction of the platysma muscle at the jawline is made at six sites on each side (Fig. 18). (See Figure, Supplemental Digital Content 17, which shows the injection technique for the platysma muscle/jawline. For each injection, insert the needle to one-third of its depth. Avoid injecting too deeply or with excessive doses, as they impair swallowing, http://links. lww.com/PRS/C327.) This area is prone to bruising. Deep injections and excessive dosing may lead to impaired swallowing. Patients with a highly overactive platysma may benefit from two sessions to optimize the dosage of onabotulinumtoxinA. Platysma Bands The caudal parts of the platysma muscle are thin muscle sheets that run down the lateral neck and insert into the fascia pectoralis.7 Contraction of the platysma expands and extends the skin in vertical lines in the form of bands. Treatment of lateral platysma bands is made at four sites per band (Fig. 19, left), whereas treatment of medial platysma bands is made at three sites per band (Fig. 19, right). Pinch the band to help guide the injection into the contracted muscle.7 (See Figure, Supplemental Digital Content 18,
which shows the injection technique for platysma bands. Asterisks indicate one-third needle depth. Pinch the band and insert the needle to one-third of its depth. Avoid injecting too deeply or with excessive doses, as they impair swallowing, http:// links.lww.com/PRS/C328.) This area is prone to bruising. Deep injections and excessive dosing may lead to impaired swallowing. Patients with a highly overactive platysma may benefit from two sessions to optimize the dosage of onabotulinumtoxinA. Consideration should be given to injecting the lateral bands at the first session and then reevaluating whether any medial bands need treatment. Injections in medial platysmal bands are more challenging than lateral bands; the overall dose of neurotoxin should be lower. Although these injections can reduce the hypertonicity of medial platysmal bands, they can also lead to skin laxity. Proper patient selection is important. Ideally, these injections should be considered in patients without skin excess in this area. The OnabotulinumtoxinA Microdroplet Technique for Lower Face and Neck This technique has been previously described and is a useful adjunct for improving the appearance of the skin and contours of the lower face and neck.17 The product is injected into the dermis or the junction between the dermis and the superficial fibers of the platysma (which insert into the undersurface of the dermis) over an area starting three fingerbreadths above the mandibular border, one fingerbreadth behind the marionette line, and over the entire neck anterior to the sternocleidomastoids. This results in an improved
Fig. 19. Treatment of the platysma bands with onabotulinumtoxinA. Injections are made at four sites on each lateral band (left) and at three sites on each medial band (right).
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Plastic and Reconstructive Surgery • September 2017 cervicomental angle, elevation and flattening of the jowls, reduction of horizontal skin creases and vertical platysmal banding, and an improved sheen and texture of the overlying skin. The even distribution of these microdroplets at a superficial plane reduces the risk of difficulty in swallowing or weakness of the sternocleidomastoid muscles.
CONCLUSIONS Soft-tissue fillers are more important than neuromodulators in the lower face.18 Fillers should be used first to provide structure and support, and then assessment of dynamic lines should be evaluated to determine whether neuromodulator treatment is required. The lip is one of the most challenging areas to reshape with fillers. Comprehensive assessment of dental arches and occlusion is important to avoid improper correction. When volumizing the lips, respect the projection of the lips on the profile view and respect the ratio of lip size to chin. Rejuvenation of the neck region is also challenging, where fillers are needed for structural support of the chin and jawline and neuromodulators are needed to treat the masseter and platysma. Maurício de Maio, M.D. Clinica Dr. Maurício de Maio Avenida Ibirapuera, 2907 cj 1202 Moema EP 04029200 São Paulo-SP, Brazil [email protected]
ACKNOWLEDGMENTS
This article was sponsored through an educational grant from Allergan plc, Dublin, Ireland. Medical writing assistance was provided by Barry Weichman, Ph.D., of Peloton Advantage, Parsippany, New Jersey, and funded by Allergan plc. No honoraria or other forms of payment were made for authorship. REFERENCES 1. de Maio M, Rzany B. Injectable Fillers in Aesthetic Medicine. 2nd ed. Berlin/Heidelberg, Germany: Springer-Verlag; 2014.
2. Albert AM, Ricanek K Jr, Patterson E. A review of the literature on the aging adult skull and face: Implications for forensic science research and applications. Forensic Sci Int. 2007;172:1–9. 3. Ali MJ, Ende K, Maas CS. Perioral rejuvenation and lip augmentation. Facial Plast Surg Clin North Am. 2007;15:491–500, vii. 4. Rohrich RJ, Pessa JE. The anatomy and clinical implications of perioral submuscular fat. Plast Reconstr Surg. 2009;124:266–271. 5. Small R. Dermal Filler Procedures. New York: Wolters Kluwer Health; 2012. 6. Gassia V, Raspaldo H, Niforos FR, Michaud T. Global 3-dimensional approach to natural rejuvenation: Recommendations for perioral, nose, and ear rejuvenation. J Cosmet Dermatol. 2013;12:123–136. 7. de Maio M, Rzany B. Botulinum Toxin in Aesthetic Medicine. Berlin/Heidelberg, Germany: Springer-Verlag; 2009. 8. Carruthers JD, Glogau RG, Blitzer A; Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: Botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies. Consensus recommendations. Plast Reconstr Surg. 2008;121(5 Suppl):5S–30S; quiz 31S. 9. Swift A, Remington K. BeautiPHIcation: A global approach to facial beauty. Clin Plast Surg. 2011;38:347–377, v. 10. Nayyar P, Kumar P, Nayyar PV, Singh A. Botox: Broadening the horizon of dentistry. J Clin Diagn Res. 2014;8:ZE25–ZE29. 11. Ahn BK, Kim YS, Kim HJ, Rho NK, Kim HS. Consensus recommendations on the aesthetic usage of botulinum toxin type A in Asians. Dermatol Surg. 2013;39:1843–1860. 12. Goodman GJ. The masseters and their treatment with botulinum. In: Carruthers A, Carruthers J, eds. Botulinum Toxin: Procedures in Cosmetic Dermatology Series. 3rd ed. New York: Saunders; 2013:135–141. 13. Wu WTL. Facial and lower limb contouring. In: Benedetto AV, ed. Botulinum Toxins in Clinical Aesthetic Practice. 2nd ed. New York: Informa Healthcare; 2011:206–222. 14. Wu WTL. Facial sculpting and facial slimming with neurotoxins. 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 A injections for facial rejuvenation and reshaping. In: Lee P, Chen YR, Li QF, et al., eds. Aesthetic Plastic Surgery in Asians: Principles and Techniques Volume I and II. 1st ed. Boca Raton, Fla: CRC Press; 2015:149–169. 16. Wu WT. Botox facial slimming/facial sculpting: The role of botulinum toxin-A in the treatment of hypertrophic masseteric muscle and parotid enlargement to narrow the lower facial width. Facial Plast Surg Clin North Am. 2010;18:133–140. 17. Wu WT. Microbotox of the lower face and neck: Evolution of a personal technique and its clinical effects. Plast Reconstr Surg. 2015;136(5 Suppl):92S–100S. 18. Wollina U. Perioral rejuvenation: Restoration of attractiveness in aging females by minimally invasive procedures. Clin Interv Aging 2013;8:1149–1155.
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Summary: This third article of a three-part series addresses techniques and recommendations for aesthetic treatment of the lower face. The lower face is considered an advanced area for facial aesthetic treatment. In this region, soft-tissue fillers play a more important role than neuromodulators and should be used first to provide structure and support before neuromodulators are considered for treatment of dynamic lines. Treatment of the lip, perioral region, and chin, in addition to maintaining balance of the lower face with the face overall, is challenging. Procedures on the lip should avoid overcorrection while respecting the projection of the lips on the profile view and the ratio of lip size to chin. The chin is often neglected, but reshaping the jawline can provide dramatic improvement in facial aesthetics. Both profile and anterior views are critical in assessment 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 injection techniques for aesthetic procedures involving use of injectable fillers and/or neuromodulators. Recommended needles for each product are listed in Table 1 and recommended Allergan plc (Dublin, Ireland) portfolio products and volumes/doses for each area of the midface are illustrated in Table 2. Other filler and neuromodulator options are available and can be used in the treatment areas described; good results are as much dependent on injector technique as on the product utilized. We provide detail specific to Allergan products because of our extensive experience with these products in clinical practice. This article discusses techniques in the lower face, one of the most challenging areas to treat. The lip is challenging to reshape with fillers; comprehensive assessment is necessary to avoid improper correction. The chin is one of the most neglected areas, but reshaping the jawline can provide dramatic improvement in facial aesthetics. Finally, the neck is a challenging area, where both fillers and neuromodulators may be necessary. From the Clinica Dr. Maurício de Maio; the Woffles Wu Aesthetic Surgery and Laser Centre; the Dermatology Institute of Victoria; and the Total Skin and Beauty Dermatology Center. Received for publication April 13, 2016; accepted February 10, 2017. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003646
AESTHETICS OF THE PERIORAL AREA AND LIPS The perfect lip includes a visible transition line or border between the vermillion and skin, a V-shaped Cupid’s bow, a full medial tubercle and vermillion, an ascendant line in the oral commissures, and an upper-to-lower lip ratio of 1:1.618.1
AGING OF THE PERIORAL AREA AND LIPS Intrinsic lip volume loss, photodamage, and lip muscle movement lead to static and dynamic wrinkles, lip elongation and thinning, flatness of the vermillion border, loss of Cupid’s bow, lip Disclosure: Dr. de Maio and Dr. Goodman are Allergan plc consultants for speaking events and marketing strategy. Dr. Wu is a consultant for Allergan plc, Galderma, and Merz for speaking events and advisory boards. Dr. Monheit has no conflicts to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www. PRSJournal.com).
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393e
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Plastic and Reconstructive Surgery • September 2017 dryness, and downturned oral commissures.1–3 In the aging lip, the perioral tissues of the cutaneous lip also atrophy.4 Age-related deepening of the nasolabial fold may be caused by repeated contraction of the levator labii superioris and levator labii superioris alaeque nasi muscles during wrinkling of the nose and by ptosis of the superficial musculoaponeurotic system.1 With aging, perioral lines become evident perpendicular to the lips Table 1. Recommended Needle Sizes for Delivery of Soft-Tissue Fillers and OnabotulinumtoxinA Product Injectable fillers Ultra Ultra Plus Volbella Volift Voluma OnabotulinumtoxinA
Needle Size 30-gauge, ½-inch (13 mm) 27-gauge, ½-inch (13 mm) 30-gauge, ½-inch (13 mm) 30-gauge, ½-inch (13 mm) 27-gauge, ½-inch (13 mm) 30-gauge, ½-inch (13 mm)
and radiating from the lip border, particularly in the area above the lips.5 These lines develop because of perioral soft-tissue volume loss, lip atrophy, hyperdynamic contractions of the perioral musculature, and underlying resorption of mandibular bone.5
ASSESSMENT OF THE PERIORAL AREA AND LIPS Assessment should be made at rest and during animation (i.e., while smiling and while puckering), including the projection of the lips on the profile view.1 Assess preservation of lip landmarks, including the vermillion border, vermillion body, Cupid’s bow, philtrum, and oral commissures, and any loss of lip and perioral volume. Also, assess the dental arcade for the presence of occlusions and the inclination of the teeth. Evaluate for asymmetry at rest and during animation, excessive inversion of the vermillion, and whether the gingiva are prominent. Assess the
Table 2. Recommended Allergan plc Portfolio Product and Volume/Dose for Individual Areas Region Hyaluronic acid filler Nasolabial fold Lip border
Vermillion linear technique
Vermillion aliquot technique Commissures Philtrum Perioral lines Marionette lines Mental crease Chin apex Prejowl area Mandible body and angle Neurotoxin Gummy smile Upper lip and lower lip lines Depressor anguli oris muscle Mentalis muscle Masseter muscle Platysma muscle/jawline Platysma bands
Product
Volume/Dose Range
Ultra Plus Volift Voluma Ultra Plus Ultra Volift Volbella Ultra Plus Ultra Volift Volbella Ultra Plus Ultra Volift Ultra Plus Volift Ultra Plus Ultra Volift Ultra Volbella Ultra Plus Volift Ultra Plus Volift Ultra Plus Voluma Ultra Plus Voluma Ultra Plus Voluma
0.5–1.0 ml per side
OnabotulinumtoxinA OnabotulinumtoxinA OnabotulinumtoxinA OnabotulinumtoxinA OnabotulinumtoxinA OnabotulinumtoxinA OnabotulinumtoxinA
2.0 U per site; total dose: 6.0 U, moderate; 10.0 U, severe 1.0 U per site; total dose: upper lip, 2.0–4.0 U; lower lip, 2.0 U 2.0–4.0 U per site; total dose, 4.0–8.0 U 4.0–6.0 U per site; total dose, 6.0–24.0 U per side 4.0–8.0 U per site; total dose, 4.0–24.0 U 2.0–4.0 U per site; total dose, 12.0–24.0 U per side 2.0 U per site; total dose, 8.0 U per lateral band; 6.0 U per medial band
0.1–0.3 ml per side 0.1–0.2 ml per quadrant
0.5–1.0 ml for both lips
0.05 ml per bolus 0.5–1.0 ml for both lips 0.05–0.1 ml per side 0.05–0.1 ml per side ≤0.25 ml per quadrant 0.5–1.0 ml per side for lower injection 0.5–1.0 ml per side for upper injection 0.2–0.5 ml per side 0.2–0.3 ml per site 0.5–1.0 ml per side 0.5–1.0 ml for subcutaneous injection; 0.25 ml for bolus injections
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Volume 140, Number 3 • Injection Guide for the Lower Face surrounding areas for perioral wrinkles, nasolabial folds, and marionette lines. Before treating the nasolabial fold, the midface region should always be evaluated and treated. In rare cases, the nasolabial fold may be treated only by a direct approach.
ANATOMY OF THE PERIORAL AREA AND LIPS The superior and inferior labial arteries found in the submucosal layer (wet part) are branches of the facial artery and supply the upper and lower lips, respectively.1 The infraorbital nerve and mental nerve provide sensory innervation of the upper and lower lips, respectively, whereas the buccal branch of the facial nerve provides motor innervation to these areas.1
FILLER INJECTION TECHNIQUE FOR INDICATIONS IN THE PERIORAL AREA AND LIPS Nasolabial Fold Injections of Ultra Plus or Volift are made at two areas (Fig. 1, left). Injectors should be alert to the facial artery and vein and exercise caution during augmentation of the proximal nasolabial folds because of a risk of vascular compromise of the facial artery and nose branches (Fig. 1, right).6 For the retrograde linear injection (area 1), position the needle and aspirate before injection. Stretch the skin using two fingers to better visualize the fold.1 Stay slightly medial to the fold, and insert the needle angled upward parallel to the fold to deliver a superficial subcutaneous injection. [See Figure, Supplemental Digital Content 1, which shows the linear retrograde technique for treatment of nasolabial
folds; inject into the superficial subcutaneous space. For fanning technique (not shown), deliver a slow and superficial subcutaneous injection medial to the fold, http://links.lww.com/PRS/C311.] Use a slow, continuous-movement, low-volume, linear retrograde injection. Do not overinject, as overinjection may lead to irregularities. For injection on the medial aspect of the fold, position the needle more superficially and deliver a subcutaneous injection using a fanning technique. Inject more slowly as the injection approaches the nose. Massage to shape after each injection; do not overfill. Use of Voluma for nasolabial folds is indicated in patients with severe volume loss to compensate for bone retrusion. Specific training for this area is advised. Voluma is injected very deeply at the canine fossa (Fig. 2, left). Inspect the skin surface to determine the vascular pattern, and avoid the facial artery and nose branches, the facial vein, and the inferior alar artery branch of the angular artery (Fig. 2, right).6 Position the needle perpendicular to the skin surface. Touch the bone, and aspirate before injection. Inject very slowly with low pressure to deliver a supraperiosteal small bolus. (See Figure, Supplemental Digital Content 2, which shows the injection technique for retruded canine fossa. Insert needle perpendicular to skin surface, and inject very slowly with low pressure, http://links.lww.com/PRS/C312.) Massage to shape and avoid overfilling. Lip Border Reshaping the lip border (Fig. 3) is achieved using Ultra Plus, Ultra, Volift, or Volbella.5 (See Figure, Supplemental Digital Content 3, which shows the injection technique for lip border. Inject very slowly and avoid inadvertent displacement of the filler, http://links.lww.com/PRS/C313.) Assess any
Fig. 1. Treatment of nasolabial folds using either Ultra Plus or Volift (left). Aspiration is mandatory before each injection. Areas of caution (right). a., artery; v., vein.
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Plastic and Reconstructive Surgery • September 2017
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.
Fig. 3. Treatment of the lip border using Ultra Plus, Ultra, Volift, or Volbella. The product is injected along the lip border. Areas of caution: avoid the labial artery and vein in the intraoral submucosal plane.
asymmetry before injection, and respect the proportions between the upper lip and the lower lip. When identifying injection sites, avoid the labial artery and vein in the intraoral submucosal plane (i.e., wet part of the lip). Position the needle at the vermillion border near the lateral edge of the mouth, and insert the needle below the mucocutaneous junction. Inject very slowly using an anterograde linear technique with deposition of a linear thread as the needle is being advanced into the skin. Avoid inadvertent displacement of the product outside of the intended treatment area. Injection into the sensitive Cupid’s bow is performed very slowly. Administer equal volumes of filler on both sides unless gross asymmetry is evident.5 Avoid overcorrecting the lip border and producing excessive anterior projection of the upper lip. Vermillion Enhancing the shape or volume of the vermillion can be achieved with Ultra Plus, Ultra, Volift, or Volbella. Two different techniques are
recommended (Fig. 4). With the first technique, the filler is administered at one site in each quadrant of the lip body. Administer Ultra Plus, Ultra, and Volift by means of intramuscular anterograde linear threading and Volbella by means of retrograde linear threading into the dry submucosa. [See Figure, Supplemental Digital Content 4, which shows the injection techniques for vermillion. Inject very slowly either linearly in the submucosa (left, technique 1) or in small aliquots intramuscularly (right, technique 2), http://links. lww.com/PRS/C314.] Avoid the labial artery and vein in the intraoral submucosal plane. Insert the needle into the lip mucosa at a 30-degree angle to the lip body.5 Enter through the skin and inject very slowly to avoid bleeding in this bruise-prone area. The second technique can be used with Ultra Plus, Ultra, and Volift. Filler is administered at three injection sites per quadrant. To avoid pain and bruising, insert the needle at points 2 mm superior to the upper lip border and 2 mm inferior to the lower lip border, and place the filler inside the vermillion. Deliver very small intramuscular bolus injections very slowly. Massage is mandatory to avoid irregularities and nodules. The precautions outlined for enhancing the lip border should also be followed for the vermillion. Commissures Restoring the commissures may be achieved with Ultra Plus or Volift. Before treating the commissures, the lip border should be treated, if indicated. Insert the needle superficially at the lateral edge of the mouth angle, and deliver a very small bolus injection intramuscularly and/or into the mucosa (Fig. 5). Be alert to avoid the labial artery
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Volume 140, Number 3 • Injection Guide for the Lower Face
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 intraoral submucosal plane.
Fig. 5. Treating the oral commissures with Ultra Plus or Volift. These fillers are injected at one site on each side. Areas of caution: avoid the labial artery and vein. Inject very slowly.
and vein. Inject very slowly. Avoid overcorrection because of the possibility of creating a bulging area or displacement during animation. Overcorrection may lead to an abnormal smile. Philtrum The ridge between the nose and lips, known as the nasal philtrum, tends to flatten with aging. Reshaping of the philtrum can be achieved with
Fig. 6. Augmentation of the philtrum with Ultra Plus, Ultra, Volift, or Volbella. These fillers are injected at one site on each side. Areas of caution: avoid the columella branches of the upper labial artery near the nose.
Ultra Plus, Ultra, Volift, or Volbella with one injection site per side (Fig. 6). Avoid the columella 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 the needle pointed upward and the needle bevel inward. (See Figure, Supplemental Digital Content 5, which shows the injection technique for philtrum. Pinch the philtral column, and insert the
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Plastic and Reconstructive Surgery • September 2017 needle upward with the bevel facing inward; inject slowly, http://links.lww.com/PRS/C315.) Administer a superficial subcutaneous injection using a linear retrograde technique. Ensure that the inverted-V shape of the philtrum is preserved. Avoid widening the philtral columns and avoid overcorrection that may result in elongating the upper lip. Perioral Lines Correction of perioral lines can be achieved with Ultra or Volbella (Fig. 7). Be alert to the perioral vasculature, including branches of the upper labial artery. Insert the needle perpendicular to the wrinkles and administer a superficial subcutaneous injection using a linear technique. (See Figure, Supplemental Digital Content 6, which shows the injection technique for perioral lines. Inject slowly and evenly perpendicular to the wrinkles; massage after the injection, http://links.lww.com/ PRS/C316.) Inject slowly and evenly, and massage after each injection. Do not chase superficial lines. Avoid elongation and flattening of the upper lip because of overinjection and avoid overcorrection.6 In many aged lips, judicious volumization with Ultra or Volift will aid in treatment of lines.
ONABOTULINUMTOXINA INJECTION TECHNIQUE FOR INDICATIONS IN THE PERIORAL AREA AND LIPS
Injections of onabotulinumtoxinA for correction of gummy smile are made at three sites if moderate and at five sites if severe (Fig. 8). The total dose is 6 to 10 U of onabotulinumtoxinA, depending on severity and muscles involved. [See Figure, Supplemental Digital Content 7, which shows the injection technique for gummy smile. For each injection, insert the needle pointed upward to one-half of its depth; inject into the depressor septi nasi (left) and levator labii superioris alaeque nasi (right). Assess for asymmetry before and after injection, http://links.lww.com/PRS/C317.] Excessive doses may lead to upper lip elongation and lip ptosis. Patients with a short upper lip are ideal candidates, whereas care should be exercised in patients with gummy lip and a long upper lip. Upper Lip and Lower Lip Lines Vertical lines on the upper and lower lips occur with aging and may remain after dermal filler treatment.7 The orbicularis oris is the main muscle in the lips, with superficial fibers responsible for lip protrusion.7 Upper lip lines are treated at one or two sites per side (Fig. 9), whereas lower lip lines are treated at one site per side. Insert only the needle bevel pointed upward. (See Figure, Supplemental Digital Content 8, which shows the injection technique for upper lip lines. For each injection, insert the needle to the depth of the bevel, with the bevel
Gummy Smile Gummy smile refers to the showing of excessive 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 tubercle.7 In severe gummy smile, the levator labii superioris and zygomatic minor muscles also raise the upper lip.7
Fig. 7. Correction of perioral lines with Ultra or Volbella. These fillers are injected at one site in each quadrant. Areas of caution: perioral vascularization (branches of the upper labial artery).
Fig. 8. Treatment of gummy smile with onabotulinumtoxinA. Injections are made at three sites for moderate gummy smile (yellow X) and at two additional sites for severe gummy smile (blue X). The symbol X indicates one-half needle depth.
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Volume 140, Number 3 • Injection Guide for the Lower Face presence of marionette lines, including sagging skin or manifest lines.7 Finally, assess the platysma for the presence of neck lines and for active contraction of the platysma bands when speaking.7
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 chin.1 The mental nerve provides sensory innervation to the chin and lower lip; it exits the mental foramen below the second mandibular premolar.1 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.
Fig. 9. Treatment of upper and lower lip lines with onabotulinumtoxinA. Injections are made at one or two sites per side.
pointed upward. Assess for asymmetry before and after injection, http://links.lww.com/PRS/C318.) Avoid administering excessive doses, which may lead to flattening of the lips and restrict lip pursing, or injecting too close to the mouth, which may impact lip function and cause drooling.8
AESTHETICS OF THE CHIN AND JAWLINE The chin should be oval and delicate in women, with less fullness concentrated at its lateral part, whereas it may have more square, heavier features and a stronger appearance in men.1 For both men and women, good chin projection and a youthful jawline are considered the standards of beauty.1,9
FILLER INJECTION TECHNIQUE FOR INDICATIONS IN THE CHIN AND JAWLINE Marionette Lines Marionette lines give the face a sad or hard appearance. Treatment of marionette lines may be achieved with Ultra Plus or Volift. Injections are made at two sites on each side (Fig. 10). Injectors should be alert to avoid the inferior labial and sublabial arteries and veins. Using a linear retrograde technique, deliver a superficial subcutaneous injection. Inject slowly, and deliver most of the volume to the top third of the fold while staying medial to the marionette line. The upper injection is made by inserting the needle inferior to the modiolus and injecting slowly using a vertical column technique, in which the filler is injected as the needle is withdrawn from the deeper tissue. [See Figure, Supplemental Digital Content 9, which shows the injection technique
ASSESSMENT OF THE CHIN AND JAWLINE The chin assessment should include evaluations of occlusion, skeletal and dental relationships, lateral fullness, and projection along the subnasal vertical line.1 The ratio of the upper lip to lower lip/chin should be one-third to two-thirds.1 The jawline assessment should consider the chinneck angle (submental-neck line); 121 degrees is considered optimal in women. The jawline should be smooth from the angle of the jaw until the chin, uninterrupted by the jowl or postjowl and prejowl sulcus. Viewing this area from the front and sides is critical in assessment. Evaluate for the
Fig. 10. Correction of marionette lines with Ultra Plus or Volift. Fillers are delivered by means of injections at two sites per side. Areas of caution: avoid the inferior labial and sublabial arteries and veins.
399e Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic 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:// links.lww.com/PRS/C319.] Mental Crease The labiomental or mental crease is a horizontal line that develops during aging just above the chin.5 These lines develop because of soft-tissue volume loss, dermal atrophy, reduced skin elasticity, hyperdynamic contractions of the lower facial muscles, and underlying resorption of mandibular bone.5 A reduction in the depth of a mental crease 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 retrograde technique. Alternatively, injection using a linear anterograde technique can be made if starting laterally (not shown). Injections should be made slowly, http://links.lww.com/PRS/C320.] Massage after each injection, and avoid overinjection, as overinjection may lead to irregularities. 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, position the needle at the midline of the jawline, and aspirate before injection. (See Figure, Supplemental Digital Content 11, which shows the injection technique for augmentation of chin apex. Aspirate before injection and inject slowly. Pinch the chin to avoid unwanted displacement of the filler, http:// links.lww.com/PRS/C321.) Inject slowly and deliver a supraperiosteal small bolus. Compare symmetry before and after the injection by watching from the cephalic view. Maintain the injection in the midline and avoid chin deviation. Use two fingers to pinch the chin to avoid unwanted displacement of the filler. Do not inject the filler too low, as this can lead to formation of a “witch’s chin,” and do not overfill. Massage after the injection. Deliver the other two injections in the same manner at superolateral sites on either side of the chin.
Fig. 11. Treatment of a mental crease with Ultra Plus or Volift. Fillers are delivered by means of linear retrograde or anterograde injection. Areas of caution: avoid the sublabial artery and vein.
Fig. 12. Augmentation of the chin apex with Ultra Plus or Voluma. Both fillers are delivered by means of injections at two to three sites. Areas of caution: avoid the mental artery and vein.
Fig. 13. Filling of the prejowl area with Ultra Plus or Voluma. Both fillers are delivered by means of a deep subcutaneous injection using a fanning technique. Areas of caution: avoid the mental artery and vein and the mental nerve.
Prejowl Area The prejowl area is the triangular area from the mental foramen to the midlateral zone of the mandible (Fig. 13).1 Filling of jowls can be achieved with Ultra Plus or Voluma. Injectors should be alert to avoid the mental artery and vein and the mental nerve. Position the needle at the jawline of the
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Volume 140, Number 3 • Injection Guide for the Lower Face prejowl area, and aspirate before injection. (See Figure, 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, http://links.lww.com/PRS/ 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 fingers to control placement of the product, and exercise care with displacement of the filler over the mandibular ligament. Overcorrection lateral to the ligament may worsen the jowl area. Mandible Body and Angle The injection of fillers in this area creates a more defined jawline contour.1 This may be achieved using Ultra Plus or Voluma, with injections at two to three sites per side (Fig. 14). Injectors should be alert to palpate and avoid the facial artery, facial vein, and parotid gland. For the subcutaneous injection, pinch the skin above the mandible body and position the needle superficially to avoid the facial artery. [See Figure, Supplemental Digital Content 13, which shows the injection technique 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, http://links.lww.com/PRS/C323.] Do not inject deep at this level. Aspirate before injection, and inject slowly using a linear retrograde technique. For the supraperiosteal injections, deliver one or two small boluses at the mandibular angle. This is ideal for male patients. A subcutaneous approach is preferable for female patients. Aspirate before each injection, inject slowly, and avoid scratching the periosteum. The treatment area is prone to development of deep hematomas, especially the site of the supraperiosteal injections.
ONABOTULINUMTOXINA INJECTION TECHNIQUE FOR INDICATIONS IN THE CHIN AND JAWLINE Depressor Anguli Oris Muscle The depressor anguli oris muscle draws the corners of the mouth down, creating a crease descending from the corner of the mouth that imparts a sullen or dissatisfied appearance.7 Treatment of these lines, resulting from excessive contraction of the depressor anguli oris muscle, is made at one site on each side of the face (Fig. 15). A dose of 2 to
Fig. 14. Treatment of the mandible body and angle with Ultra Plus or Voluma. Both fillers are delivered by means of a superficial subcutaneous injection over the mandible body and by supraperiosteal small-bolus injections over the mandible angle. Areas of caution: palpate and avoid the facial artery and vein, and avoid the parotid gland.
Fig. 15. Treatment of the depressor anguli oris muscle with onabotulinumtoxinA. Injections are made at one site per side. The symbol X indicates one-half needle depth.
4 U of onabotulinumtoxinA is injected at each site. Insert the needle near the jawline to one half of its depth and at least 1 cm away from the corner of the mouth.7 (See Figure, Supplemental Digital Content 14, which shows the injection technique for the depressor anguli oris muscle. For each injection, insert the needle to one-half its depth. Assess for asymmetry before and at 2 weeks after injection, http://links.lww.com/PRS/C324.) Assess for asymmetry before and at 2 weeks after injection, as this area
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Plastic 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.7 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 lip.7 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 U of onabotulinumtoxinA should be delivered. (See Figure, Supplemental Digital Content 15, which shows the injection technique for the mentalis muscle. Insert the needle to its full depth and maintain the injection in the midline, http://links. lww.com/PRS/C325.) Maintain the injection in the midline. Excessive lateral displacement of the needle may lead to paralysis of the depressor labii inferioris muscle, resulting in an asymmetrical smile. Masseter Muscle The masseter muscle elevates the mandible and is important during chewing; it may become
Fig. 16. Treatment of the mentalis muscle with onabotulinumtoxinA. An injection is made at a midline point 0.5 to 1 cm above the chin and symmetrically on either side. Square symbols indicate full-needle depth.
Fig. 17. Treatment of masseteric hypertrophy with onabotulinumtoxinA. Injections are made at three sites on each side of the face. Square symbols indicate full-needle depth.
enlarged from repeated clenching of the jaw, resulting in bulging of the lateral jawline, a condition known as masseteric hypertrophy.10 Treatment with onabotulinumtoxinA is made at three sites on each side of the face (Fig. 17). A dose of 4 to 8 U of onabotulinumtoxinA at each point should be delivered with the needle inserted perpendicular to the skin to its full depth. (See Figure, Supplemental Digital Content 16, which 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, http://links.lww.com/PRS/C326.) Ask the patient to clench before marking the injection site, and
Fig. 18. Treatment of the platysma muscle/jawline with onabotulinumtoxinA. Injections are made at six sites on each side at one-third needle depth.
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Volume 140, Number 3 • Injection Guide for the Lower Face inject lateral to the anterior margin of the masseter muscle. Superficial and higher injections may cause asymmetry during animation. This area is prone to deep hematomas. Asian patients with severe hypertrophy may require higher doses of 40 U or more of onabotulinumtoxinA.11–16 Platysma Muscle/Jawline The platysma muscle draws down the lower jaw and the corners of the mouth.7 Treatment of lines resulting from excessive contraction of the platysma muscle at the jawline is made at six sites on each side (Fig. 18). (See Figure, Supplemental Digital Content 17, which shows the injection technique for the platysma muscle/jawline. For each injection, insert the needle to one-third of its depth. Avoid injecting too deeply or with excessive doses, as they impair swallowing, http://links. lww.com/PRS/C327.) This area is prone to bruising. Deep injections and excessive dosing may lead to impaired swallowing. Patients with a highly overactive platysma may benefit from two sessions to optimize the dosage of onabotulinumtoxinA. Platysma Bands The caudal parts of the platysma muscle are thin muscle sheets that run down the lateral neck and insert into the fascia pectoralis.7 Contraction of the platysma expands and extends the skin in vertical lines in the form of bands. Treatment of lateral platysma bands is made at four sites per band (Fig. 19, left), whereas treatment of medial platysma bands is made at three sites per band (Fig. 19, right). Pinch the band to help guide the injection into the contracted muscle.7 (See Figure, Supplemental Digital Content 18,
which shows the injection technique for platysma bands. Asterisks indicate one-third needle depth. Pinch the band and insert the needle to one-third of its depth. Avoid injecting too deeply or with excessive doses, as they impair swallowing, http:// links.lww.com/PRS/C328.) This area is prone to bruising. Deep injections and excessive dosing may lead to impaired swallowing. Patients with a highly overactive platysma may benefit from two sessions to optimize the dosage of onabotulinumtoxinA. Consideration should be given to injecting the lateral bands at the first session and then reevaluating whether any medial bands need treatment. Injections in medial platysmal bands are more challenging than lateral bands; the overall dose of neurotoxin should be lower. Although these injections can reduce the hypertonicity of medial platysmal bands, they can also lead to skin laxity. Proper patient selection is important. Ideally, these injections should be considered in patients without skin excess in this area. The OnabotulinumtoxinA Microdroplet Technique for Lower Face and Neck This technique has been previously described and is a useful adjunct for improving the appearance of the skin and contours of the lower face and neck.17 The product is injected into the dermis or the junction between the dermis and the superficial fibers of the platysma (which insert into the undersurface of the dermis) over an area starting three fingerbreadths above the mandibular border, one fingerbreadth behind the marionette line, and over the entire neck anterior to the sternocleidomastoids. This results in an improved
Fig. 19. Treatment of the platysma bands with onabotulinumtoxinA. Injections are made at four sites on each lateral band (left) and at three sites on each medial band (right).
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Plastic and Reconstructive Surgery • September 2017 cervicomental angle, elevation and flattening of the jowls, reduction of horizontal skin creases and vertical platysmal banding, and an improved sheen and texture of the overlying skin. The even distribution of these microdroplets at a superficial plane reduces the risk of difficulty in swallowing or weakness of the sternocleidomastoid muscles.
CONCLUSIONS Soft-tissue fillers are more important than neuromodulators in the lower face.18 Fillers should be used first to provide structure and support, and then assessment of dynamic lines should be evaluated to determine whether neuromodulator treatment is required. The lip is one of the most challenging areas to reshape with fillers. Comprehensive assessment of dental arches and occlusion is important to avoid improper correction. When volumizing the lips, respect the projection of the lips on the profile view and respect the ratio of lip size to chin. Rejuvenation of the neck region is also challenging, where fillers are needed for structural support of the chin and jawline and neuromodulators are needed to treat the masseter and platysma. Maurício de Maio, M.D. Clinica Dr. Maurício de Maio Avenida Ibirapuera, 2907 cj 1202 Moema EP 04029200 São Paulo-SP, Brazil [email protected]
ACKNOWLEDGMENTS
This article was sponsored through an educational grant from Allergan plc, Dublin, Ireland. Medical writing assistance was provided by Barry Weichman, Ph.D., of Peloton Advantage, Parsippany, New Jersey, and funded by Allergan plc. No honoraria or other forms of payment were made for authorship. REFERENCES 1. de Maio M, Rzany B. Injectable Fillers in Aesthetic Medicine. 2nd ed. Berlin/Heidelberg, Germany: Springer-Verlag; 2014.
2. Albert AM, Ricanek K Jr, Patterson E. A review of the literature on the aging adult skull and face: Implications for forensic science research and applications. Forensic Sci Int. 2007;172:1–9. 3. Ali MJ, Ende K, Maas CS. Perioral rejuvenation and lip augmentation. Facial Plast Surg Clin North Am. 2007;15:491–500, vii. 4. Rohrich RJ, Pessa JE. The anatomy and clinical implications of perioral submuscular fat. Plast Reconstr Surg. 2009;124:266–271. 5. Small R. Dermal Filler Procedures. New York: Wolters Kluwer Health; 2012. 6. Gassia V, Raspaldo H, Niforos FR, Michaud T. Global 3-dimensional approach to natural rejuvenation: Recommendations for perioral, nose, and ear rejuvenation. J Cosmet Dermatol. 2013;12:123–136. 7. de Maio M, Rzany B. Botulinum Toxin in Aesthetic Medicine. Berlin/Heidelberg, Germany: Springer-Verlag; 2009. 8. Carruthers JD, Glogau RG, Blitzer A; Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: Botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies. Consensus recommendations. Plast Reconstr Surg. 2008;121(5 Suppl):5S–30S; quiz 31S. 9. Swift A, Remington K. BeautiPHIcation: A global approach to facial beauty. Clin Plast Surg. 2011;38:347–377, v. 10. Nayyar P, Kumar P, Nayyar PV, Singh A. Botox: Broadening the horizon of dentistry. J Clin Diagn Res. 2014;8:ZE25–ZE29. 11. Ahn BK, Kim YS, Kim HJ, Rho NK, Kim HS. Consensus recommendations on the aesthetic usage of botulinum toxin type A in Asians. Dermatol Surg. 2013;39:1843–1860. 12. Goodman GJ. The masseters and their treatment with botulinum. In: Carruthers A, Carruthers J, eds. Botulinum Toxin: Procedures in Cosmetic Dermatology Series. 3rd ed. New York: Saunders; 2013:135–141. 13. Wu WTL. Facial and lower limb contouring. In: Benedetto AV, ed. Botulinum Toxins in Clinical Aesthetic Practice. 2nd ed. New York: Informa Healthcare; 2011:206–222. 14. Wu WTL. Facial sculpting and facial slimming with neurotoxins. 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 A injections for facial rejuvenation and reshaping. In: Lee P, Chen YR, Li QF, et al., eds. Aesthetic Plastic Surgery in Asians: Principles and Techniques Volume I and II. 1st ed. Boca Raton, Fla: CRC Press; 2015:149–169. 16. Wu WT. Botox facial slimming/facial sculpting: The role of botulinum toxin-A in the treatment of hypertrophic masseteric muscle and parotid enlargement to narrow the lower facial width. Facial Plast Surg Clin North Am. 2010;18:133–140. 17. Wu WT. Microbotox of the lower face and neck: Evolution of a personal technique and its clinical effects. Plast Reconstr Surg. 2015;136(5 Suppl):92S–100S. 18. Wollina U. Perioral rejuvenation: Restoration of attractiveness in aging females by minimally invasive procedures. Clin Interv Aging 2013;8:1149–1155.
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