Treating the lower face with botulinum toxin

August 1, 2006

Physicians must be very cautious not to overtreat their patients. If physicians perform an overly zealous treatment, simple motions like eating or drinking, gargling, the phoneticizing of certain words or letters, the playing of wind instruments and even whistling may become arduous motions to the patient.

Paris - In aesthetic practices worldwide, botulinum toxin type A has become a mainstay in the treatment of wrinkles and fine lines occurring in the aging skin of patients, effectively replacing, or at least postponing, an eventual surgical lifting procedure.

Phillip Levy, M.D., a dermatologist from Geneva, Switzerland, offers his vast experiences, speaking of his special techniques when administering botulinum toxin type A in the lower face of the aging facial skin of his patients, at the Anti-Aging Medicine World Congress, here.

Managing the mentalis

He injects 2 to 3 units into the tip of the chin and into each mentalis muscle. Then he proceeds to massage the injection site in a downward fashion, spreading the toxin evenly in the immediate area, achieving remarkable aesthetic results.

Lip service: use caution

Perioral wrinkling around the lips is due to the contraction of the orbicularis muscle as well as dermal actinic elastosis.

Here, the physician likes to either inject 1 unit of botulinum toxin per wrinkle site, or a maximum of 2 units per lip quarter per treatment session.

In order to achieve a better aesthetic result, Dr. Levy likes to sometimes combine this treatment with other cosmetic interventions like soft tissue augmentation, laser resurfacing or nonablative remodeling lasers. He stresses that physicians must be very cautious not to overtreat their patients.

If physicians perform an overly zealous treatment, simple motions like eating or drinking, gargling, the phoneticizing of certain words or letters, the playing of wind instruments and even whistling may become arduous motions to the patient.

Managing marionette lines

When treating the marionette lines or the "sad corners" of the mouth, the goal is to uplift the corners.

Here, Dr. Levy likes to use a couple of different techniques. In the first, he administers 1 to 2 units of botulinum toxin type A into each depressor anguli oris muscle, injecting precisely 7 mm laterally and 8 mm caudally to the corners of the mouth, achieving very positive aesthetic results.

In the second technique, he administers 2 to 3 units of botulinum toxin type A at two different sites, injecting at the mandibular border.

Approaching the neck

In the aging skin of the neck, the platysma bands become very prominent due to hypertrophy (anteriorly), as well as due to the contraction of the platysma borders.

Here, Dr. Levy uses a special trick when administering his injections and usually opts for Vistabel (Botox, Allergan, as marketed in France).

"I like to combine a treatment of a prominent platysma and marionette lines in my patients. I administer 3 units of botulinum toxin type A per two injection sites, into the depressor anguli, near the mandibular border and then follow down with superficial injections into the posterior platysma band with 3 units of botulinum toxin type A at three injection sites at intervals of 2 to 3 cm, ultimately effecting a 'cheek and mouth lift.' When treating the neck, I gently grasp the platysma bands and usually inject 2 to 3 units at intervals of 2 to 3 cm. Using this method of a total of 10 injections per side, I have experienced excellent results in my patients.

"When treating this area though, it is of paramount importance that a maximum dose of 30 units per session per side is administered to the patient, so as to avoid the potentially serious side effects, namely dysphonia and dysphagia," Dr. Levy explains.

Lifting the nose

If the physician needs to lift the nose a bit in his patients, he commonly administers 3 to 6 units of botulinum toxin type A in the center of the lip, just under the nasal septum at its base.

He stresses that one must be careful when injecting paranasally at the lower corners of the nose though, and terms these areas as "danger zones," due to potential lip drop.