Q&A: Saami Khalifian, MD, FAAD, on Integrating BOTOX Cosmetic into Lower Face and Neck Rejuvenation

In October 2024, BOTOX Cosmetic (onabotulinumtoxinA) received FDA approval for the temporary improvement of moderate to severe platysma bands. The indication filled a long-standing therapeutic gap in lower face and neck rejuvenation by introducing a non-surgical way to address the dynamic muscular forces that drive visible banding and jawline blunting, an area that energy-based devices, fillers, and even surgery have struggled to address consistently.

Over a year later, Saami Khalifian, MD, FAAD, double board-certified dermatologist, Medical Director of the Allergan Aesthetics’ Medical Institute Training Centers, and founder of SOM Aesthetics in Encinitas, California, is reflecting on how the approval has reshaped the standard of care, offering practical insights into patient selection and technique and discussing why dermatologists are uniquely positioned to lead in this evolving treatment space.

Dermatology Times: Prior to the approval of BOTOX Cosmetic for platysma bands, how were clinicians addressing lower face and neck aging, and why were those methods often insufficient?

Khalifian: Lower face and neck changes are driven by simultaneous degradation across multiple tissue planes: mandibular bone resorption, compartmentalized fat atrophy and descent, and dermal collagen and elastin deterioration. Our traditional toolkit, which includes energy-based devices for skin tightening and hyaluronic acid for volumetric restoration, addressed only the static components. The critical gap was the dynamic component. The platysma’s continuous downward pulling vector, particularly during animation, creates what I call “antagonistic tension.” Radiofrequency and ultrasound devices can’t counteract muscular forces. Fillers provide structural scaffolding, but without controlling the hyperkinetic platysma, we’re fighting an uphill battle. Surgical platysma interventions and neck lifts are viable treatments, but they exclude many patients due to cost, downtime, and risk. This left a substantial treatment void for treating the neck.

Dermatology Times: How has the new BOTOX Cosmetic indication changed the standard of care?

Khalifian: This FDA approval of BOTOX Cosmetic to temporarily improve the appearance of moderate to severe platysma bands represents the first evidence-based, non-surgical neurotoxin intervention available in the US. The pivotal trials demonstrated significant improvements in the appearance of moderate to severe platysma bands. Allergan Aesthetics’ consumer research shows that most treated patients are satisfied with their platysma results. To note, there are risks with its use. The effects of BOTOX Cosmetic and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects.

Dermatology Times: How should dermatology clinicians approach this treatment? What patients are best suited for this?

Khalifian: My most effective technique is teaching patients to self-identify the dynamic component. Have patients perform maximal smile animation in the mirror while palpating their jawline. For patients with moderate to severe platysma bands, they’ll immediately appreciate how the platysma band is evident and blunts jawline definition. Once patients see this muscular contribution, it’s time to talk to a provider. I adhere to the FDA protocol: 8 units per side along the jawline (4 injection points, 1-2 cm apart) and 5 units per visible band (5 points, 1-2 cm apart, 1-2 bands per side).

Dermatology Times: Is there anything else you’d like to share with our audience today?

Khalifian: Not incorporating neurotoxin treatment for platysma bands may represent a missed opportunity. While neurotoxin treatment for moderate to severe frown lines, crow’s feet lines, and forehead lines remains foundational, platysma bands are where we differentiate our expertise. Dermatologists are uniquely positioned to excel here with our anatomic expertise, multimodal experience, and long-term patient relationships. The approval in moderate to severe platysma bands provides another tool in aesthetics medicine for appropriate patients. However, success requires thorough anatomic knowledge, appropriate patient selection, and mastery of technique. This isn’t just adding injection points; it’s elevating your entire approach. The lower face and neck have become an area we can address with neurotoxin treatment in appropriate patients.