Escolar Documentos
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FACIAL PLASTIC
SURGERY CLINICS
OF NORTH AMERICA
Facial Plast Surg Clin N Am 15 (2007) 1–9
Treatment of facial and neck wrinkles with botu- (frown) lines; however, any muscle of the face can
linum toxin type A (Botox, Allergan, Irvine, Califor- be treated ‘‘off-label’’ as long as one uses the same
nia) remains by far the most common aesthetic principles used to treat the glabellar lines.
procedure performed in the United States. More Common facial wrinkles and lines are the result
than 3.2 million of these procedures were per- of other hyperfunctional muscles (Box 1). There-
formed in 2005, compared with 2.8 million in fore, an understanding of facial and neck muscle
2004 and only 65,000 in 1997 [1]. During 2005, anatomy is essential for optimal results and ad-
botulinum toxin type A injections accounted for vanced applications. It is important to keep in
28.8% of all cosmetic procedures (surgical and mind that this anatomy varies slightly from one in-
nonsurgical). Botox acts by inhibiting the release dividual to another, among genders, and among
of acetylcholine (neurotransmitter) at the neuro- races. Adding to the complexity is the significant
muscular junction, thereby producing partial chem- amount of misinformation that exists in the medi-
ical denervation of the muscle and a resultant cal literature. Many texts and academic papers use
localized reduction in muscle activity [2]. This arti- inconsistent or incorrect nomenclature, incorrect
cle reviews the anatomic basis for the treatment of descriptions of muscle action, and incorrect ana-
facial and neck rhytids caused by hyperfunctional tomic diagrams. The intent of this article is to cor-
muscle activity. The sole U.S. Food and Drug Ad- rectly describe facial and neck anatomy as it
ministration–approved indication for the cosmetic pertains to cosmetic Botox treatments and point
use of Botox is the treatment of hyperfunctional out some of the misconceptions that are present
procerus and corrugator supercili muscles, which in the literature. This information should help to
are the muscles responsible for creating glabellar improve results while avoiding pitfalls.
a
504 McCain Boulevard, Suite 114, North Little Rock, AR 72116-7624, USA
b
The Maas Clinic, 2400 Clay Street, San Francisco, CA 94109, USA
* Corresponding author.
E-mail address: lewisd03@hotmail.com (D. Lewis).
1064-7406/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2006.12.003
facialplastic.theclinics.com
2 Petrus et al
Box 1: Common cosmetic Botox treatments: intimately associated with one another. When in-
treatment site, muscles targeted jecting botulinum toxin A, it is helpful to visualize
the underlying muscle anatomy and attempt to in-
Upper face ject the actual muscle belly. Typically, the glabellar
Forehead, frontalis
region is treated with several injections targeted at
Glabella, procerus and corrugator supercili
Crow’s feet, orbicularis oculi the hyperkinetic procerus and corrugator supercili
Chemical browlift, orbicularis oculi muscles (Fig. 1). The procerus muscle is a single,
Lower lid lines, orbicularis oculi flat, midline muscle that is oriented vertically and
Bunny lines, nasalis originates from the nasal bones to insert into the
Lateral recruitment lines, orbicularis oculi subcutaneous tissues between the medial brows
Lower face
and slightly more superiorly. Contraction of this
Lip lines, orbicularis oris muscle produces one or more transverse (horizon-
Downturned oral commissure, depressor anguli tal) wrinkles in the region of the nasion (root of
oris the nose). Therefore, one or more Botox injections
Chin dimpling, mentalis targeted at the belly of this muscle improve trans-
Masseter hypertrophy, masseter verse nasal lines and other horizontal glabellar
Neck lines, if present. In some individuals, however,
Platysmal bands, platysma these transverse lines may not be present. Careful
Necklace lines, platysma evaluation of the glabellar region is required to as-
sess whether procerus treatment is indicated.
The vertical glabellar lines are often paired and
Basic treatment may be symmetric or asymmetric. These lines are
primarily the result of action of the paired corruga-
Frown lines/glabellar lines (procerus
tor supercili muscles. The inferior aspect of these
and corrugator supercili muscles)
vertical rhytids may have an oblique or horizontal
The muscles of facial expression are all cutaneous portion caused by the procerus muscle. The corru-
muscles that are innervated by the facial nerve (cra- gator supercili muscles originate from the procerus
nial nerve VII). These muscles lie within the super- muscle medially and insert, laterally, into the orbi-
ficial fascia, originate from fascia or bone, and cularis oculi muscle (by interdigitation) and the
insert into the skin [3]. Many of these muscles are soft tissues just at and slightly above the medial
Fig. 1. Fronto-orbital anatomy. (From Maas CS. Botulinum neurotoxins and injectable fillers: minimally invasive
management of the aging upper face. Facial Plast Surg Clin North Am 2006;14(3):242; with permission.)
Treatment with Botulinum Toxin 3
eyebrow. In most individuals, this muscle orienta- dehiscent in the midline of the forehead. In some
tion is nearly horizontal. Therefore, contraction of individuals, especially men, the frontalis muscle
this muscle produces a vertical wrinkle. In a few in- may be larger and have a greater thickness. Contrac-
dividuals, however, the corrugator supercili muscle tion of the frontalis muscle raises the brows, as in
is oriented more vertically, and contraction may the surprised patient, and creates horizontal creases
cause an oblique wrinkle orientation. It is crucial in the forehead that are curvilinear at their outer as-
that Botox injections be placed properly in the cor- pect. This anatomy is variable depending upon the
rugator supercili muscle to create a smoothing ef- forehead height, frontal bossing, forehead slope,
fect, and, more importantly, avoid any unnatural and hairline position. As a result, forehead rhytids
facial appearances. In many textbooks and dia- may be minimal or several rows of lines may be
grams, the corrugator supercili muscle is depicted present.
as a long, vertically oriented muscle that inserts Frequently, botulinum toxin A is used off-label to
into the frontalis muscle in the mid-forehead. relax the frontalis muscle and improve the appear-
This is rarely the case. As a result, a common mis- ance of forehead lines. The most important points
take with Botox treatment is to inject the corrugator in the cosmetic treatment of the frontalis muscle
supercili muscle too far superiorly, actually treating with neuromodulation are avoiding or minimizing
the frontalis muscle. This frontalis muscle relaxa- brow ptosis and symmetric placement of Botox
tion may cause an unnatural result: splaying of injections.
the medial eyebrows or medial eyebrow ptosis To avoid brow ptosis, botulinum toxin A injec-
(Fig. 2). The correct placement of Botox into the tions should not be placed within 1.5 cm above
corrugator supercili muscles of most individuals is the upper margin of the brows lateral to the midpu-
more inferior, just at or slightly above the medial pillary line. Severe preexisting brow ptosis can be
clubhead of the eyebrow. A second, small dose of a relative contraindication to treatment of the fron-
Botox also is given approximately 3 to 5 mm lateral talis muscle; however, this is an uncommon find-
to the initial injection to treat the entire length of ing. For most patients, however, brow position is
the corrugator supercili muscle (Fig. 3). With adequate, allowing frontalis muscle treatment. The
proper placement into the muscle, 10 units to goal is to strike a balance between frontalis muscle
each side are typically all that is necessary. relaxation and adequate brow position. Some pa-
tients, especially the elderly, compensate for under-
lying brow ptosis by partially contracting the
Advanced treatment frontalis muscle. The provider should be aware
and recognize the patients who give themselves
Forehead wrinkles (frontalis muscle) a ‘‘browlift’’ by compensatory frontalis contraction,
The frontalis muscle is a wide, flat muscle that actu- especially when looking in a mirror or being photo-
ally represents the frontal belly of the occipitofron- graphed. Careful physical examination and physi-
talis muscle. The frontalis muscle originates as an cian–patient discussion before treatment should
extension of the galea aponeurotica superiorly, in- help to minimize any problems.
serts inferiorly, and interdigitates with the procerus Asymmetric placement of botulinum toxin A in-
muscle, the corrugator supercili muscles, and por- jections by the injector is another pitfall associated
tions of the orbicularis oculi muscle [4]. The fronta- with treating forehead wrinkles. Asymmetric injec-
lis muscle may present as a single, continuous tions could result in noticeably asymmetric brows.
muscle without dehiscence, but more commonly Again, it is important to diagnose any preexisting
consists of two separate bellies that are variably asymmetry in eyebrow position and discuss this
finding with the patient. Some brow asymmetries
may be compensated for and corrected, in experi-
enced hands, with Botox injections. Typically, Bo-
tox is administered in a series of four to six
injections spaced evenly along the forehead at inter-
vals of approximately 1 cm (Fig. 4). The most lat-
eral injection along the forehead line is placed
approximately 1 cm medial to the lateral end of
the wrinkle. If these lateral-most forehead injec-
tions are not performed, the result may appear un-
Fig. 2. Medial brow ptosis. (From Maas CS. Botulinum natural, causing a laterally arched eyebrow (the
neurotoxins and injectable fillers: minimally invasive ‘‘Joker’’ or ‘‘Jack Nicholson’’ look) (Fig. 5). Soften-
management of the aging upper face. Facial Plast ing forehead lines with a small dose of Botox (eg,
Surg Clin North Am 2006;14(3):244; with permission.) 2–10 units) produces a natural result for most
4 Petrus et al
Fig. 3. Standard Botox glabellar therapy. (Adapted from Facial Plast Surg Clin North Am 2006;14(3); with
permission.)
Fig. 4. Standard injection sites in the upper face. (From Maas CS. Botulinum neurotoxins and injectable fillers:
minimally invasive management of the aging upper face. Facial Plast Surg Clin North Am 2006;14(3):243; with
permission.)
Treatment with Botulinum Toxin 5
use. A pretreatment snap test should be performed to inserts on the maxilla just superior to the canine,
evaluate the lower eyelid laxity. Abnormal laxity of whereas the lower lip portion originates on the man-
the lower lid signifies the chance for the develop- dible just lateral to the mentalis muscle. The orbicu-
ment of lower eyelid retraction (not ectropion). Small laris oris muscle inserts and fuses with the depressor
doses of Botox (1–2 units) are given in these loca- anguli oris muscle and risorius muscle at the oral
tions to minimize the chance of intraorbital drift or commissure in the region known as the modeolus
weakening of the inferior oblique extraocular mus- [11]. Movement of the lips and mouth is a complex
cle (see Fig. 4). Bruising is common in this location, interaction between the circular contraction of the
so injections should be given with minimal trauma. orbicularis oris muscle and the radial contraction
of the lip elevators and depressors (Fig. 6).
Lateral recruitment lines (orbicularis oculi Patients develop radial lip lines as a result of skin
muscle) aging, photodamage, and the repetitive action of the
Some facial lines may occur just above the brow in orbicularis oris muscle (eg, chewing, smoking).
the midpupillary region following glabellar Botox These lines are especially problematic for women
treatment. These lines, termed ‘‘lateral recruitment because lipstick tends to run or ‘‘bleed’’ into them.
lines,’’ often are related to horizontal fibers of the or- The upper lip lines may be treated with a small
bicularis oculi muscle at the 12 o’clock position. Be- amount of Botox to relax the superior portion of
cause the procerus muscle and corrugator supercili the orbicularis oris muscle slightly. The total dose
muscle have already been treated, the orbicularis oc- for treating upper lip lines is small to maintain
uli fibers are ‘‘recruited’’ to provide animation in the oral competence. For example, four separate 1-unit
area. A small dose of botulinum toxin A is used of- injections are spaced evenly and administered just
ten to soften the lateral recruitment lines; it is in- above the vermillion border. The same principles
jected at the level of, or just slightly above, the brow. apply as described previously: conservative dosing
with careful and symmetric placement of injections.
Bunny lines (nasalis muscle) Often, relaxing upper lip lines with Botox is com-
When wrinkling the nose, several ‘‘bunny lines’’ bined with other lip procedures, such as fillers, to
may appear on each side of the nose extending in- help expand and, therefore, minimize the lip lines.
feriorly. These lines are treated effectively with The lower lip portion of the orbicularis oris muscle
Botox and result from contraction of the nasalis is not treated with botulinum toxin A for fear of cre-
muscle, particularly the transverse portion. The ating asymmetry, incompetence, and drooling.
levator labii superioris alaeque nasi muscle also
may contribute to the appearance of ‘‘bunny lines.’’ Downturned oral commissure (depressor
The nasalis muscle is a paired, fan-shaped, trans- anguli oris muscle)
versely oriented muscle that originates from the The bilateral depressor anguli oris muscle inserts at
maxilla at the inferior nasal aperture; it crosses the the modeolus of each oral commissure from its
nasal dorsum to insert into the aponeuroses of origination inferiorly at the oblique line of the
the procerus muscle and contralateral nasalis mus- mandible. This muscle may become hyperkinetic
cle [9]. A small amount of Botox injected into these with time, resulting in downturned oral commis-
muscles causes a smoothing effect that can be dra- sures. The individual with downturned corners of
matic with low risk. The muscles should be targeted the mouth takes on a sad face appearance or an ex-
directly while the patient demonstrates the ‘‘bunny pression of disapproval. A few units of Botox in-
lines’’ for the practitioner. Botulinum toxin A injec- jected into the depressor anguli oris muscle relax
tions are aimed at the more superior portion of the this downward pull vector and allow the risorius
nasalis muscle to avoid inadvertent injection of the muscle, zygomaticus major muscle, and other ele-
levator anguli oris muscle or the levator labii supe- vators to act unopposed. The corners of the mouth
rioris alaeque nasi muscle. The concern for acciden- return to a neutral or even upturned position. This
tal injection of these levator muscles is drooping of positioning also can be assisted with filler material
the upper lip and other lip asymmetries [10]. placed inferior to the commissures. Despite often-
beneficial effects, treatment of this muscle occasion-
Lip lines (orbicularis oris muscle) ally can have inconsistent results.
The orbicularis oris muscle consists of two layers: su-
perficial and deep. This complex muscle primarily is Chin dimpling (mentalis muscle)
a sphincter muscle necessary for oral competence, Peau d’orange (orange peel) and golf ball dimpling
speech, and social expression. It functions to close describe this cosmetic deformity of the chin. The
the lips, protrude the lips (superficial portion), dimpled appearance is the result of the actions of
and to press the lips against the teeth (deep portion). the mentalis muscle coupled with the loss of colla-
The upper lip portion of the orbicularis oculi muscle gen and subcutaneous fat in the chin [12]. The
Treatment with Botulinum Toxin 7
Fig. 6. The orbicularis oris muscle anatomy, superficial and deep, indicating (A) circular contraction of the orbi-
cularis oris muscle and (B) the radial contraction of the lip elevators and depressors. m., muscle.
mentalis muscle originates from the incisor fossa of muscle elevates the mandible for chewing. With re-
the mandible inferiorly and inserts into the orbicu- petitive chewing, such as with gum, the muscle may
laris oris muscle and skin of the lower lip superiorly become hypertrophic and result in a mild cosmetic
[13]. Mentalis muscle contraction raises and pro- deformity, or slight bulge. Cosmetic improvement
trudes the lower lip. Low-dose Botox injections results from injecting each hyperactive masseter
are aimed at the inferior aspect of the mentalis mus- muscle with just 1 to 3 units of botulinum toxin
cle to avoid injection of the orbicularis oris muscle. A. Aggressive masseter muscle treatment should be
A deep transverse mental crease also may be treated avoided because of the adverse effects of weakened
similarly in affected individuals. mastication and the potential for malocclusion.
Fig. 7. Vertical neck bands or platysmal bands. (A) Patient in upright position, accentuating the bands.
(B) Patient after treatment.
fascia of the pectoralis muscle and subclavicular sternocleidomastoid muscles. These rhytids occur
and acromial regions. The muscle travels superome- perpendicular to the vector of contraction of the un-
dially in the neck to insert in the (1) midline, form- derlying platysma muscle. These lines may be
ing an inverted V below the chin, (2) orbicularis treated with Botox because it is the only option of
oris muscle, depressor anguli oris muscle, risorius treatment for this area; however, the results are vari-
muscle, and mentalis muscle, and (3) anterior one able. Patients should be informed that the treat-
third of the oblique line of the mandibular ramus ment may result in minimal improvement in this
[14]. area. Botulinum toxin A is administered in the pla-
Vertical neck bands, or platysmal bands, occur tysma muscle at evenly spaced intervals to provide
with aging and the loss of skin elasticity. Dehiscence relaxation. Again, deeper injections must be
of the platysma muscle in the midline also contrib- avoided because of the risk for weakening strap
utes to the formation of neck bands and can accen- muscles or cricothyroid muscle.
tuate submandibular gland ptosis. Botox treatment
of these platysmal bands may be successful in se-
lected individuals. In general, patients with reason- Summary
able skin elasticity and without significant The best results of treatment with Botulinum toxin
submental fat or submandibular gland herniation A are obtained from a careful history and physical
are good candidates. The technique is similar to examination of the patient combined with a de-
other Botox treatments, with even spacing of injec- tailed understanding of facial and neck anatomy.
tions along the band. The neck band may be Fully understanding the dynamic anatomic rela-
grasped with the fingers for treatment. The patient- tionships in the face is key to providing the patient
should be treated while in the upright position and with an excellent outcome.
can assist with accentuating the bands during treat-
ment (Fig. 7). It is important to inject botulinum
toxin A exactly intramuscularly. Deeper injections References
could result in complications, such as dysphagia,
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Treatment with Botulinum Toxin 9
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