Botox® in lower third of face – Part 2

Dr Singh who runs his botox clinic in Stevenage, Hertfordshire, in his latest blog shares his thoughts on botox in the lower third of the face.

Corners of the mouth

Some patients have a reverse smile where the corners of the mouth are going downwards. This is the result of an over active Depressor Anguli Oris (DAO) which is responsible for lowering the corners of the lips and subsequently Marionette lines. The DAO is a triangularly shaped muscle. The easiest way to locate this muscle is to get the patient to do a sad face and you will see the muscle contracting just above the jaw line. It can also normally be found by drawing a line from the corner of the nose down to the corner of the mouth and continue this line just above the jaw. I inject 10 botox units per side, perpendicular to the muscle and superficially.

Complications can occur if you inject too medially. The toxin can potentially diffuse into the Depressor labii inferiors and cause a protrusion of the lower lip, known as a Gomer Pyle appearance. if you inject too laterally, the toxin can diffuse into the Buccinator, causing the patient to bite and traumatise the buccal mucosa.

Gummy smile

This is the result of an over active Levator Labii Superioris Alaeque nasi (LLSAN) muscle. By administration toxin into the LLSAN you can lengthen the upper lip. You are looking to inject in the naso facial groove which is adjacent to the Ala. I inject at 45 degrees, deep and 5 botox units per side.

It is worth being in mind Rubin’s 3 classifications of smile patterns:
Mona Lisa smile – dominated by the Zygomaticus Major which elevates the oral commissures as the highest point of the smile. Do not treat with botox as this will exaggerate the Mona Lisa smile pattern.
Canine smile pattern – dominated by the Levator Labii Superioris where the highest part of the smile is the central upper lip.
Gummy smile – excessive display of the upper gingival when smiling

I will sit the patient down and will get them to look at a mirror at eye level. then i will push the upper lip down by 3/4mm to show then the expected result and if agreeable, then will carry out the procedure.

Masseter

Over activity of this muscle can cause a square jaw look and potentially bruxism. I would get my patient to clench their teeth and observe where the bulk of the muscle contracting and bulging. I normally give 3 injection sites per side and would start of with 15 botox units per injection site and then review in 2 weeks for any top ups. Over dosing can reduce their biting force. I would inject deep into the belly of the muscle at 30 degrees to the muscle.
Chin

The Mentalis is responsible for pushing out the lower lip and contributes to chin wrinkles, also known as ‘orange peel’. This appearance is more common amongst gummy smilers and in anterior open bites. Even though the Mentalis is a pair of muscles, my preferred injection technique is for one injection site in the midline, very deep at 90 degrees. I would normally inject 10 botoxunits.
Neck

Contraction of the Platysma can lead to bands and premature ageing of the neck region. Toxin is rarely used in isolation in this area and normally treatments to improve the skin complexion such as mesotherapy will yield the optimal results for the patient. Ask the patient to contract their neck via clenching their teeth and then mark along the bands. I would normally inject between 4/5 sites per band and 10 botox units per site very superficially whilst the non injecting hand is pulling out and squeezing the band.
In conclusion,I would rather under dose and get the patient back for any necessary top ups than be over optimistic on the first visit and over dose causing complications. By baby stepping in the lower third of the face you will greatly reduce the risks and have a happier patient and less sleepless nights.

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