Quy Trình Tiêm Botulinum Toxin Trong Da Liễu Thẩm Mỹ (Cosmetic Dermatology Series)

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12 
Glabella
cycles. Interestingly, acne, injection site pruritus, oral
herpes, rash, lower respiratory tract infection, dental
caries, and eye pain were significantly more common in
placebo controls than in the onabotulinumtoxinA-treated
patients.
Botulinum toxin-induced lid ptosis can manifest within
48 hours or as late as a week after injection, and can last
for weeks. Vartanian & Dayan found that it typically
resolves within 2–6 weeks.
Apraclonidine 0.5% (Iopidine®, Alcon Labs, Fort
Worth, Texas), naphazoline (Naphcon-A®, Alcon Labs)
and phenylephrine 2.5% (Mydfrin® 2.5%, Alcon Labs) are
alpha-adrenergic agonist ophthalmic eye drops that may
be used to correct eyelid ptosis as a result of botulinum
toxin injection. The alpha-adrenergic agonist effect stimu­
lates Müller’s muscle to help elevate the ptotic eyelid.
Typical dosage is 2 drops, 2–3 times a day, until the ptosis
is resolved. GaAs laser was also reported by Majlesi to
improve upper eyelid ptosis as a result of botulinum toxin
injection.
Conclusion
Botulinum toxin injection of the glabella is a safe and
proven treatment for glabellar rhytides and may also
provide eyebrow elevation. Patient satisfaction with botu­
linum toxin type A treatment is consistently high and a
review by Fagien & Carruthers of patient-reported out­
comes indicated significant improvement, demonstrating
that treatment significantly improves patient self-
perceptions and reduced perceived age relative to current
age by approximately 5 years.
Further reading
Alster TS, Lupton JR 2003 Botulinum toxin type B for dynamic
glabellar rhytides refractory to botulinum toxin type A.
Dermatologic Surgery 29(5):516–518
Beer KR, Boyd C, Patel RK, et al 2011 Rapid onset of response and
patient-reported outcomes after onabotulinumtoxina treatment
of moderate-to-severe glabellar lines. Journal of Drugs in
Dermatology 10(1):39–44
Borodic GE 1992 Botulinum A toxin for (expressionistic) ptosis
overcorrection after frontalis sling. Ophthalmic Plastic and
Reconstructive Surgery 8(2):137–142
Brin MF, Boodhoo TI, Pogoda JM, et al 2009 Safety and
tolerability of onabotulinumtoxinA in the treatment of
facial lines: a meta-analysis of individual patient data from
global clinical registration studies in 1678 participants. Journal
of the American Academy of Dermatology 61(6):961–970;
e1–11
Carli L, Montecucco C, Rossetto O 2009 Assay of diffusion of
different botulinum neurotoxin type a formulations injected in
the mouse leg. Muscle and Nerve 40(3):374–380
Carruthers A, Carruthers J 1998 Clinical indications and injection
technique for the cosmetic use of botulinum A exotoxin.
Dermatologic Surgery 24(11):1189–1194
Carruthers A, Carruthers J 2005 Prospective, double-blind,
randomized, parallel-group, dose-ranging study of botulinum
toxin type A in men with glabellar rhytids. Dermatologic
Surgery 31(10):1297–1303
Ethnic variation
Asian patients have been shown in a study by Brin and
co-workers to have an increased incidence of eyelid
sensory disorder and eyelid edema after glabellar injection
on onabotulinumtoxinA. However, double-blind, random­
ized, placebo controlled trials by Yan Wu et al of botuli­
num toxin A for the treatment of glabellar lines in 227
Chinese patients demonstrated the treatment was safe
and effective. No ethnic difference in the efficacy of botu­
linum toxin for glabellar rhytides has been noted.
Potential adverse events
The most common adverse events from botulinum toxin
injection of the glabella are mild, and include temporary
pain at the injection sites, edema, bruise, headache,
eyebrow ptosis, and upper eyelid ptosis.
In the first multicenter, double-blind, randomized,
placebo-controlled trials of the safety of botulinum toxin
type A in the treatment of glabellar lines, performed by
Carruthers and colleagues in 2002, out of the 264 patients
studied (BoNT-A 203, placebo 61), 5.4% (11/203) had
mild blepharoptosis in the BoNT-A group, which had
resolved by day 120. The group’s second multicenter ran­
domized trial for safety and efficacy, published 1 year
later, showed that in 273 patients (BoNT-A 202, placebo
71) the most common adverse event was headache
(BoNT-A 11%, placebo 20%). In this study the incidence
of blepharoptosis was 1% (2/202) for the botulinum toxin
group. The incidence of blepharoptosis decreased with
subsequent treatments in a 1-year follow-up study of the
two trials where botulinum toxin was administered to
glabellar rhytides at day one and then at two subsequent
treatments 4 months apart.
A meta-analysis by Brin et al of the safety and tolerabil­
ity of onabotulinumtoxinA, from global clinical studies in
1678 participants, demonstrated that the only adverse
events with significantly greater incidence in the onabotu­
linumtoxinA group compared with placebo were eyelid
sensory disorder (2.5% versus 0.3%, p = 0.004; verbatim
phrases ‘tight’, ‘pressured’, ‘heavy’, ‘drooping feeling’,
‘feeling of droopiness’), and eyelid ptosis (1.8% versus 0%,
p = 0.02), both present only in glabellar studies. Eyelid
sensory disorder was more common in Asian patients.
Both adverse events decreased with subsequent treatment
Pearl 4 
Eyelid ptosis is caused by diffusion of botulinum toxin into
the levator palpebrae muscle, typically from the injection
point into the corrugator supercilli at the mid-pupillary line.
Holding on to the muscle during injection and injecting 1 cm
above the orbital rim while resting the thumb of the non-
injecting hand on the superior orbital rim helps to avoid this
potential complication. This is particularly important in the
area of the mid-pupillary line.

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Kane M, Glogau R, Caulkins C, et al n.d. Pooled analysis of
duration of efficacy of onabotulinumtoxinA in glabellar lines
(poster presented first at the Winter Clinical Dermatology
meeting, Hawaii, Jan 14-19 Jan 2011)
Kranz G, Haubenberger D, Voller B, et al 2009 Respective
potencies of Botox and Dysport in a human skin model:
a randomized, double-blind study. Movement Disorders
24(2):231–236
Lewis T, Jacobsen G, Ozog D 2008 Intrafollicular orifice injection
technique for botulinum toxin type A. Archives of Dermatology
144(12):1657–1658
Lowe P, Patnaik R, Lowe N 2006 Comparison of two formulations
of botulinum toxin type A for the treatment of glabellar lines:
a double-blind, randomized study. Journal of the American
Academy of Dermatology 55(6):975–980
Majlesi G 2008 GaAs laser treatment of bilateral eyelid ptosis due
to complication of botulinum toxin type A injection.
Photomedicine and Laser Surgery 26(5):507–509
Moers-Carpi M, Tan K, Fulford-Smith A 2011 A multicentre,
randomized, double-blind study to evaluate the efficacy of
onabotulinumtoxinA (20 units) in the treatment of glabellar
lines, when compared to incobotulinumtoxinA (30 units)
(poster presented at the 7th European masters in aesthetic and
anti-aging medicine, September 30-October 1, Paris, France)
Monheit G, Carruthers A, Brandt F, et al 2007 A randomized,
double-blind, placebo-controlled study of botulinum toxin type
A for the treatment of glabellar lines: determination of optimal
dose. Dermatologic Surgery 33(1 spec. no.):S51–S59
Nestor MS, Ablon GR 2011 Comparing the clinical attributes of
abobotulinumtoxina and onabotulinumtoxina utilizing a novel
contralateral frontalis model and the frontalis activity
measurement standard. Journal of Drugs in Dermatology
10(10):1148–1157
Roche N, Schnitzler A, Genêt FF, et al 2008 Undesirable distant
effects following botulinum toxin type a injection. Clinical
Neuropharmacology 31(5):272–280
Sattler G, Callander MJ, Grablowitz D, et al 2010 Noninferiority
of incobotulinumtoxinA, free from complexing proteins,
compared with another botulinum toxin type A in the treatment
of glabellar frown lines. Dermatologic Surgery 36(suppl
4):2146–2154
Trindade de Almeida AR, Marques E, de Almeida J, et al 2007
Pilot study comparing the diffusion of two formulations of
botulinum toxin type A in patients with forehead hyperhidrosis.
Dermatologic Surgery 33(1 spec. no.):S37–S43
Vartanian AJ, Dayan SH 2005 Complications of botulinum toxin A
use in facial rejuvenation. Facial Plastic Surgery Clinics of North
America 13(1):1–10
Wu Y, Zhao G, Li H, et al 2010 Botulinum toxin type A for the
treatment of glabellar lines in Chinese: a double-blind,
randomized, placebo-controlled study. Dermatologic Surgery
36(1):102–108
Carruthers A, Carruthers J 2007 Eyebrow height after botulinum
toxin type A to the glabella. Dermatologic Surgery 33(1 spec.
no.):S26–S31
Carruthers A, Carruthers J, Lei X, et al 2010 OnabotulinumtoxinA
treatment of mild glabellar lines in repose. Dermatologic
Surgery 36(suppl 4):2168–2171
Carruthers A, Carruthers J, Lowe NJ, et al 2004 One-year,
randomized, multicenter, two-period study of the safety and
efficacy of repeated treatments with botulinum toxin type A in
patients with glabellar lines. Journal of Clinical Research 7:1–20
Carruthers A, Carruthers J, Said S 2005 Dose-ranging study of
botulinum toxin type A in the treatment of glabellar rhytids in
females. Dermatologic Surgery 31(4):414–422; discussion 422
Carruthers JA, Lowe NJ, Menter MA, et al 2002 Glabellar Lines I
Study Group. A multicenter, double-blind, randomized,
placebo-controlled study of the efficacy and safety of botulinum
toxin type A in the treatment of glabellar lines. Journal of the
American Academy of Dermatology 46(6):840–849
Carruthers JD, Carruthers JA 1992 Treatment of glabellar frown
lines with C. botulinum-A exotoxin. Journal of Dermatologic
Surgery and Oncology 18(1):17–21
Carruthers JD, Lowe NJ, Menter MA, et al 2003 Botox Glabellar
Lines II Study Group. Double-blind, placebo-controlled study
of the safety and efficacy of botulinum toxin type A for patients
with glabellar lines. Plastic and Reconstructive Surgery
112(4):1089–1098
Dailey RA, Philip A, Tardie G 2011 Long-term treatment of
glabellar rhytides using onabotulinumtoxina. Dermatologic
Surgery 37(7):918–928
Dressler D, Mander GJ, Fink K 2008 Equivalent potency of
Xeomin and Botox. Movement Disorders 23(suppl 1):S20–S21
Dressler D, Mander G, Fink K 2012 Measuring the potency
labelling of onabotulinumtoxinA (Botox(r)) and
incobotulinumtoxinA (Xeomin(r)) in an LD50 assay. Journal of
Neural Transmission 119(1):13–15
Dysport® (package insert)
Fagien S, Carruthers JD 2008 A comprehensive review of
patient-reported satisfaction with botulinum toxin type a for
aesthetic procedures. Plastic and Reconstructive Surgery
122(6):1915–1925
Flynn TC 2010 Botulinum toxin: examining duration of effect in
facial aesthetic applications. American Journal of Clinical
Dermatology 11(3):183–199
Huang W, Rogachefsky AS, Foster JA 2000 Browlift with botulinum
toxin. Dermatologic Surgery 26(1):55–60
Huilgol SC, Carruthers A, Carruthers JD 1999 Raising eyebrows
with botulinum toxin. Dermatologic Surgery 25(5):373–375;
discussion 376
Hunt T, Clarke K 2009 Potency evaluation of a formulated drug
product containing 150-kd botulinum neurotoxin type A.
Clinical Neuropharmacology 32(1):28–31

elevation. To test this they injected 20 units of botulinum
toxin A in the corrugator supercilii and procerus muscle
of 30 patients and found that the eyebrow height at the
mid-pupillary and medial canthal level rose in 48 and 32%
of patients. Virtually all subsequent studies on eyebrow
height in which the brow depressors were treated without
concurrent treatment of the forehead have confirmed this
finding.
In 2007 Alastair and Jean Carruthers published their
dose-ranging randomized controlled trial assessing brow
height following glabellar injections of botulinum toxin A.
In this study they used a standard glabellar injection
pattern, with seven sites treated with 10, 20, 30, or 40
units of botulinum toxin A. Brow height was assessed
retrospectively with photographs at baseline, and then
every 2 weeks until week 20. Statistically significant
increases in brow height were seen at all sites in the sub­
jects treated with 20, 30, and 40 units. In the patients
treated with doses of 20 or more units there was a dra­
matic elevation of the lateral brow within the first 2
weeks, followed by a gradual elevation of the medial brow
that peaked at 12 weeks. Interestingly, the patients ran­
domized to 10 units had an initial, significant, decrease in
brow height. The brows of these patients gradually ele­
vated until the 16th week, beginning with the lateral brow.
13 
Eyebrow height / shaping
Jason Sneath, Massimo Signorini
Introduction
Eyebrow height and shape are key determinants of per­
ceived youthfulness and beauty. They also play a central
role in an individual’s ability to convey expression to
others. Botulinum toxin offers a simple and effective way
to subtly enhance brow height and contour, thereby aug­
menting the subject’s apparent attractiveness.
Following the first published report of glabellar frown
lines treated with botulinum toxin in 1992, several clini­
cians began to note a subtle brow elevation with treatment
of the glabella. Frankel and Kamer postulated that, because
medial eyebrow height and shape were a result of the
interplay between the brow-elevating frontalis muscle and
the brow depressors, selective treatment of the depressors
with botulinum toxin A would result in medial brow
Summary and Key Features
•
Eyebrow height and shape play a key role in
attractiveness, emotional expression, and
perceived youthfulness; the ideal brow for an
individual depends on many factors
•
Enhancement of brow height and contour following
treatment with botulinum toxin is well documented
•
The standard injection pattern in the glabella leads
to inactivation of the brow depressors and portions
of the frontalis; it is likely that the compensatory
increase in the resting tone of the frontalis leads to
brow elevation
•
Brow ptosis and a ‘mephisto’ brow are the most
common complications of treatment and an
understanding of the relevant anatomy can help to
prevent this
•
Hyaluronic acid fillers can be a useful adjunct to
botulinum toxin if there has been volume loss
beneath the brows
•
Eyebrow asymmetry is a common problem and
symmetric treatment with botulinum toxin may
offer a simple, non-surgical, method of correction
Pearl 1 
The peak effect of botulinum toxin A on eyebrow height
occurs at 12 weeks’ post-injection as opposed to the usual
4 weeks in skeletal muscle. This is believed to be due to the
slower adjustments in the resting tone of the untreated
portion of the frontalis muscle.
Of note, despite the fact that the most lateral injection
in this study was above the mid-pupillary line, the earliest
and most dramatic elevation was at the lateral brow. It
seems, then, that brow elevation following treatment of
the glabella with botulinum toxin A has less to do with
weakening of the brow depressors as this would not
impact the lateral brow. The brow elevation is more
likely a result of the weakening of the inferomedial fron­
talis, causing a compensatory increase in the resting tone
of the lateral remainder of this muscle. Knowing that the
untreated frontalis compensates with increased elevation,

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Botulinum toxin
The ideal eyebrow in men sits lower than the female
brow, just above the superior orbital rim. The brow shape
is more horizontal with minimal arching.
Anatomy
The height and shape of the eyebrows are determined by
the opposing forces of the brow elevating frontalis muscle,
and the brow depressors. The paired frontalis muscle
originates superiorly at the galea aponeurotica and has no
bony insertion points. Instead, it is continuous medially
with the procerus muscle, and attaches centrally to the
corrugator supercilii and laterally to the orbicularis oculi.
The frontalis muscle is connected to the skin of the eye­
brows through its attachment to these brow depressors,
which in turn insert to the skin of the brows.
The medial eyebrow depressors include the procerus,
the corrugators supercilii, the depressor supercilii, and the
medial portion of the orbicularis oculi. Lateral brow
depression is performed by the lateral aspect of the orbi­
cularis oculi muscle, which also is responsible for produc­
ing crows feet.
The corrugator supercilii is a 2–3 cm, small but strong,
pyramidal muscle arising at the glabellar prominence of
the frontal bone, about 7 mm from the midline and
11 mm above the orbital margin. It sits beneath the fron­
talis muscle and passes upward and laterally between the
adjustments to the shape of the brow can be made by
changing the dose or site of the injections in the medial
aspect of this muscle.
Ahn et al produced mid-pupillary and lateral brow
elevations of 1 mm and 4.8 mm by injecting 7–10 units
of botulinum toxin A into the superolateral orbicularis
oculi at three sites inferior to the lateral brow (superior
and lateral to the orbital rim). Huang et al used a similar
technique, injecting 10 units along four sites inferior to
the lateral brow, and an additional 5 units in each corruga­
tor above the medial brow. The mean increase was 3.9 mm
on the left and 1.9 mm on the right, with the greatest
elevation in the central brow.
Eyebrows and attractiveness
The importance of the eyebrow should not be underesti­
mated. It is one of the primary determinants of static
facial attractiveness. In addition to this, it plays an essen­
tial role in the human ability to convey emotion to others.
The ideal brow is influenced by many factors including
gender, age, culture, ethnicity, and current fashion trends.
In ancient Greece an ideal brow extended across the
midline over the nose, known today in popular culture as
a ‘uni-brow’. Unfortunately for Bert, from Sesame Street,
this style of eyebrow is no longer considered to be the
ideal.
The modern concept of the ideal contour of the female
brow was proposed by Westmore in 1974 (Fig. 13.1). This
schema applies best to an oval-shaped face, and serves as
a good starting point since there is no clear definition of
an ‘ideal brow’ that can be applied to all faces (Fig. 13.2).
Several authors have suggested that the ideal apex of the
brow is actually more lateral than the lateral limbus as
Westmore had proposed. If the apex is too medial and
overelevated it creates a surprised appearance.
Variations to Westmore’s ideal brow have been sug­
gested to account for variations in face shape and inter­
canthal distance. Baker et al confirmed that, in the case
of a long face and square face, observers preferred eye­
brows planned by a makeup artist who accounted for
these factors, rather than the Westmore ideal (see Fig.
13.2, Box 13.1).
In contrast to what one might expect, Matros et al
found that as women age there is a paradoxical increase
in the resting medial eyebrow height. Younger women
tend to have more lateral elevation of the brow, and lower
medial eyebrows. This finding helps explain the disap­
pointing cosmetic results of surgical brow lifts when they
elevate the entire brow.
Figure 13.1  The medial aspect of the brow should begin on a
vertical plane with the nasal ala, and curve with the apex above the
lateral limbus. The lateral brow ends on a horizontal plane with the
medial brow at a point where an oblique line can be drawn from
the ala through the lateral canthus.
A
B
C
D
E
Pearl 2 
As women age there is a paradoxical increase in the medial
brow height. A youthful brow tends to have more lateral brow
elevation, a lateral slant from the apex toward the medial
eyebrow, and a gentle arch.

87
13 
Eyebrow height / shaping
a starting dose depending on the strength of the glabellar
muscles as measured by range and blanching of the fur­
rowed skin. We recommend pretreatment photographs as
a part of this assessment. Any brow asymmetries noted
should be pointed out to the patient. The patient’s face
shape, age, treatment goals, and asymmetries should be
taken into account when determining treatment goals.
The standard injection pattern for glabella typically has
five to seven injection sites and most studies looking at
brow height have used this template (Figs 13.3, 13.4). We
recommend an initial total dose of 20–30 units for women
and 40–60 units for men (Box 13.2), distributed as shown
in Figure 13.3. The first injection is typically 5–10 units
into the belly of the procerus muscle. The site of the
injection can be found at the center of an imaginary X
drawn between the top of the medial brow and the con­
tralateral medial canthus. The next injections are 7–10
units (15–20 units in men) bilaterally into the belly of the
corrugator supercilii, which overlies the depressor super­
cilii and medial portion of the orbicularis oculi. The site
for this injection is directly above the inner canthus, just
above the supraorbital ridge. Although this landmark is
typically just superior to the medial brow, the site should
be chosen based on the muscular and bony landmarks
regardless of the brow position. The supratrochlear artery
runs just medial to this injection site so proper landmarking
and post-injection pressure are important to avoid excess
bruising. Next 4–5 units are injected bilaterally 1 cm above
the supraorbital rim in the mid-pupillary line. This injec­
tion is the most likely to cause lid ptosis so it is important
to measure 1 cm above the supraorbital rim, to inject
strictly intradermally in an upwards direction, and to avoid
firm massage that may displace the botulinum toxin, since
the ptosis is likely caused by diffusion of the botulinum
toxin into the levator palpebrae superioris (Fig. 13.5).
palpebral and orbital fibers of the orbicularis oculi to insert
into the skin of the eyebrow at the mid-pupillary line.
With contraction, the corrugator supercilii pulls the medial
eyebrow downward and medially, causing a frown. The
corrugator supercilii is thickest 2 cm from the nasion at
the center of the medial brow.
The orbicularis oculi is a sphincteric muscle responsible
for closing the eyelids. The thicker, outer portion of the
orbicularis oculi arises from the medial orbit and extends
both superiorly and inferiorly around the eye to form a
ring. Contraction of the thicker, outer ring will close the
eyes tightly, and can pull the brows downward. The thin,
inner palpebral portion of the orbicularis oculi muscle
closes the eyes more gently. This often occurs involun­
tarily, as in blinking.
For a more detailed review of the anatomy of the gla­
bella please refer to the relevant preceding sections.
Technique
At the initial visit the subject should undergo a resting and
dynamic evaluation of the brows. In addition to this obser­
vation, the corrugator supercilli and procerus muscle
should be palpated to find the belly of these target
muscles. This assessment can also be helpful in choosing
Figure 13.2  Face shapes.
Key:
Oval face – ideal.
Round face – to make the face appear more oval eyebrow lines should go up. A high arched brow with a lateral apex is ideal.
Long face – horizontal eyebrows draw the eye from side to side, making the face appear more oval.
Square face – angled brows balance the strong jaw line. The apex of the brow should be above the square of the jaw if possible.
Heart-shaped face – a rounded brow adds curves, softens the appearance, and emphasizes the shape.
Diamond face – a rounded brow will soften the angular face. If the face is particularly wide a peaked brow will draw the eyes up and make the
face appear more oval.
Oval
face shape
Round
face shape
Long
face shape
Square
face shape
Heart
face shape
Diamond
face shape
Box 13.1 
Intercanthal distance
For patients with ‘wide-set’ eyes the increased intercanthal
distance will appear smaller if the brow extends just medial
to the medial canthus. Conversely, in the case of ‘close-
set’ eyes, the brow should begin lateral to the medial
canthus.

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Botulinum toxin
In addition to lid ptosis, another possible complication
of brow treatment is monolateral or bilateral hypereleva­
tion of the brow’s apex, known as a ‘mephisto brow’ (Figs
13.6, 13.7).
Figure 13.3  Botulinum toxin brow lift – subject 1: (A) Typical glabella markings (black: 5 units, red: 2.5 units) plus 10 units per side in the
upper lateral orbicularis oculi (yellow: 10 units). (B) The result, with good elevation and shaping of the brows. This patient also had concurrent
treatment of the crow’s feet.
A
B
Figure 13.4  (A, B) Botulinum toxin brow lift – subject 2: same dose and pattern as in Figure 13.3.
B
A
Pearl 3 
Individual response to treatment varies greatly and so keeping
a record of the dose and site treated is critical.
Box 13.2 
Botulinum units
Botox® is distributed as a vacuum-dried 100 U (Allergan
units) vial that is typically reconstituted with 1 mL of pre­
served saline for a concentration of 100 U/mL. Dysport®
comes in a 500 U (Ipsen units) vial and it is recommended
that it be reconstituted with 2.5 mL of physiological saline
to obtain a concentration of 200 U/mL. As known, Allergan
and Dysport® units are not equivalent and not interchange­
able, and appropriate conversion ratios must be adopted
if switching from one product to the other. Although some
sources have used a higher volume of diluents, we recom­
mend these volumes as they allow for more precise
low-volume, high-concentration injections. Please refer to
Chapter 9, Comparison of botulinum toxins, for a more
detailed discussion. For simplicity, we have used Allergan
units in this discussion.
Pearl 4 
The site of highest risk for lid ptosis when treating the brows
is at the mid-pupillary line. It is advisable to stay at 1 cm
above the supraorbital rim, strictly intradermally, and avoid
firm massage.

89
13 
Eyebrow height / shaping
muscle elevating the brow. Risks with this technique
include diffusion of the botulinum toxin into the levator
palpebrae superioris leading to ptosis and bruising if the
injections are too deep.
When treating eyebrows, lateral brow elevation is a
common goal because it gives a more youthful appearance.
In addition to the standard injection pattern previously
described, some authors have achieved lateral brow eleva­
tion by treating the lateral orbicularis oculi. To achieve this
7–10 units of botulinum toxin A can be injected intrader­
mally just inferior to the lateral brow (see Figs 13.3, 13.4).
Concurrent treatment of the crow’s feet will also help to
weaken the lateral orbital orbicularis oculi and contribute
to brow lift. When performing this procedure it is impor­
tant not to treat the lateral frontalis since this is the
Figure 13.5  Left upper eyelid ptosis following botulinum toxin treatment and immediate correction with apraclonidine eye drops.
A
B
Figure 13.6  Prevention of mephisto eyebrow: (A) Deep glabella lines, mild frontal lines. (B) When the patient activates the frontalis, a
significant lateral elevation is apparent. (C) The index and middle fingers block elevation of the central part of frontalis, while the lateral part
remains active and in fact elevates even more for compensation. In this subject a 1–2 U injection is indicated to prevent mephisto eyebrow
where the frontalis lines are more visible above the peak of the eyebrow.
A
B
C
Figure 13.7  Treating mephisto eyebrow: (A) Mephisto eyebrow on the right side. (B) With full frontalis action, the injection point is determined
at the peak of the brow, where the lines appear strongest (1 U is usually enough). (C) Correction is achieved.
A
B
C
Pearl 5 
If treating the lateral brow with injections at the lateral
orbicularis oculi it is important to leave the lateral frontalis
untreated since it is responsible for the brow elevation.

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Botulinum toxin
In men, and in women with particularly long faces, a
more horizontal brow is preferable, so an injection at the
mid-pupillary line will prevent a more pronounced apex.
The lateral aspect of the frontalis muscle will also likely
need to be treated in order to maintain a horizontal brow
position as the increase in resting tone of this muscle will
cause a brow elevation. In contrast, a patient with a round
face will benefit from a high arched brow with a lateral
apex. In addition to the standard injection pattern, treat­
ment inferior to the lateral brow may help to elevate the
lateral brow and give the face a more oval appearance. This
must also be a consideration when treating horizontal fore­
head lines in these patients as they will need the lateral
frontalis left largely untreated so as to lift the brow. A
peaked brow with a slightly more medial apex draws the
eyes upward, making a diamond-shaped face appear more
oval. To achieve this it may be necessary to omit the injec­
tion above the mid-pupillary line.
As an adjunct to the brow elevation and contouring
achieved with botulinum toxin A, Lambros suggests that
adding some volume to the brows with hyaluronic acid
can restore a more youthful appearance (Fig. 13.8). This
is achieved by adding small amounts in several deep passes
beneath the brows, never going below the supraorbital
rim. The amount of hyaluronic acid used is very subject
specific. The ideal candidates for this procedure are those
who have lost volume medially, giving them a worried
appearance, and those patients who have lost volume
across the entire length of the brow. This is also typically
seen in upper blepharoplasty patients, especially when
over-resection of fat has been performed. In these cases,
the use of botulinum toxin to elevate the brows and of
hyaluronic acid to compensate for iatrogenic volume loss
is particularly beneficial. Intravascular injections are the
most serious complication from this treatment. This risk
can be lessened by using lidocaine with epinephrine for
vasoconstriction and injecting small amounts at low pres­
sure. The fine blunt-tipped cannulas may also help to
minimize this risk.
Figure 13.8  The same usual dose and pattern of BoNT-A, but to achieve extra elevation and fullness 0.3 mL of hyaluronic acid was injected
just below the lateral portion of the brow.
A
B
CASE STUDY 1 
A 40-year-old woman visits your office for the first time to
discuss the possibility of cosmetic treatment with botulinum
toxin. Her primary concern is that she would like to have a
younger appearance. She does not have any significant
horizontal forehead lines at rest, but has static glabellar lines
and has significant glabellar blanching when she furrows her
brow. You also note she has a round face, slightly wider set
eyes, and her eyebrows are horizontal with a slight apex just
lateral to the mid-pupillary line.
This patient would benefit from treatment of the glabella to
reduce her glabellar lines and to elevate the lateral brows. The
ideal eyebrow shape for this patient would be a high arching
brow with a lateral apex, and the brow beginning just medial
to the medial canthus. These adjustments to the brow will
give her face a more oval appearance and make the increased
intercanthal distance less noticeable.
Pearl 6 
Hyaluronic acid fillers as an adjunct can be helpful in restoring
a youthful appearance to the brows when volume has
been lost.
Eyebrow asymmetry
Eyebrow asymmetry is common in the general population,
although minimal data exist regarding the incidence. The
minimum asymmetry noticeable to individuals is 2 mm,
so many people with mild eyebrow asymmetry may not
be aware of it. Box 13.3 lists the many potential causes of
eyebrow asymmetry.
The impact of facial asymmetry on attractiveness is
controversial. An evolutionary explanation in support of
symmetry is that those with more symmetric faces have
been buffered against external and internal stressors and

91
13 
Eyebrow height / shaping
Techniques suggested for correction of eyebrow asym­
metry include adjustment of the dose and location of the
injections. Muhlbaher & Holm have tried unilateral injec­
tion of botulinum toxin; however, it can be very difficult
to find the right dosage to correct the problem. Other
experts believe that an increased injection depth at the
medial eyebrow delivers more BoNT-A to the depressor
supercilii, resulting in increased elevation. This technique
has been applied to patients with a deep injection on the
side of the lower brow, and a more superficial injection,
into the brow elevating the frontalis, on the opposite side.
In our experience this technique is not effective in cor­
recting the asymmetry, probably owing to the easy diffu­
sion of botulinum toxin between the muscle layers.
A study by Tiryaki & Ciloglu treated a group of 115
patients with eyebrow asymmetry of at least 2 mm with
bilaterally symmetric injections of botulinum toxin A.
There was a statistically significant decrease in the dis­
crepancy and in 72.1% of the patients the asymmetry was
corrected to less than 2 mm. Given the positive results
of this study, it seems reasonable to begin by treating
asymmetric brows with symmetric botulinum toxin A
injections and make adjustments at future visits if the
asymmetry persists (Fig. 13.9).
are therefore better mates. It has been well documented
that an ‘average’ face, or the compilation of many faces
into one, is more attractive than an individual face. Despite
this, studies attempting to demonstrate the relationship
between facial symmetry and beauty have not yielded
clear results. Kowner found some evidence that facial
symmetry becomes more predictive of attractiveness in
older individuals. Asymmetries were also found by
Springer et al to have a more negative impact on attrac­
tiveness the closer they are to the midline of the face.
Botulinum toxin offers an excellent non-surgical
approach to correcting eyebrow asymmetry. The usual
approach is to try to raise the lower brow to match the
opposite side. In preparation, it will be necessary to assess
the patient both at rest and dynamically as the discrepan­
cies can be more apparent with expression.
Box 13.3 
Causes of eyebrow asymmetry
Structural:
n
Trauma
n
Surgery
n
Skeletal asymmetry
Neurological:
n
Facial palsy
n
Eyelid ptosis
Muscular hyperactivity:
n
Repeated mimetic brow asymmetry as part of
expression can lead to a unilateral hyperkinesia of
the frontalis
n
A unilateral hyperactive corrugator supercilii can pull
down the medial brow
Figure 13.9  Improvement of eyebrow asymmetry with symmetric BoNT-A treatment.
A
B
Pearl 7 
Most cases of eyebrow asymmetry can be corrected by
symmetric treatment of the brows with botulinum toxin A.
Conclusion
The eyebrows have a subtle but important role in an indi­
vidual’s perceived attractiveness, age, and mood. Under­
standing the dynamic interplay of the muscles affecting
the brows allows us to use a non-surgical approach, botu­
linum toxin, to effectively improve the height, position,

92
Botulinum toxin
Frankel AS, Kamer FM 1998 Chemical brow lift. Arch Otolaryngol
Head Neck Surg 124:321–323.
Gunter JP, Antrobus SD 1997 Aesthetic analysis of the
eyebrows. Plastic and Reconstructive Surgery 99:1808–
1816
Huang W, Rogachefsky AS, Foster JA 2000 Brow lift with
botulinum toxin. Dermatologic Surgery 26:55–60
Kowner R 1996 Facial asymmetry and attractiveness judgment in
developmental perspective. Journal of Experimental Psychology.
Human Perception and Performance 22:662–675
Lambros V 2009 Volumizing the brow with hyaluronic acid fillers.
Aesthetic Surgery Journal 29:177–179
Matros E, Garcia JA, Yaremchuk MJ 2009 Changes in eyebrow
shape and position with aging. Plastic and Reconstructive
Surgery 124:1296–1301
Muhlbauer W, Holm C 1998 Eyebrow asymmetry: ways of
correction. Aesthetic Plastic Surgery 22:366–371
Springer IN,Wannicke B, Warneke PH, et al 2007 Facial
attractiveness: visual impact of symmetry increases significantly
towards the midline Annals of Plastic Surgery 59:156–162
Tiryaki T, Ciloglu NS 2007 Eyebrow asymmetry: definition and
symmetrical correction using botulinum toxin A. Aesthetic
Surgery Journal 27:513–517
Westmore MG 1975 Facial Cosmetics in Conjunction with Surgery
(course presented at the Aesthetic Plastic Surgical Society
Meeting, Vancouver, British Columbia, May)
and symmetry of the brows. By altering the contour of
the brows, it is possible to enhance a subject’s appearance.
Botulinum toxin is a simple, safe and effective instrument
to achieve this goal.
Further reading
Ahn MS, Catten M, Maas CS 2000 Temporal brow lift using
botulinum toxin A. Plastic and Reconstructive Surgery
105:1129–1135
Baker SB, Dayan JH, Crane A, et al 2007 The influence of brow
shape on the perception of facial form and brow aesthetics.
Plastic and Reconstructive Surgery 119(7):2240–2247
Benedetto AV, Lahti JG 2005 Measurement of the anatomic
position of the corrugator supercilii. Dermatologic Surgery 31(8
pt 1):923–927
Carruthers A, Carruthers J 2001 Botulinum toxin type A: history
and current cosmetic use in the upper face. Seminars in
Cutaneous Medicine and Surgery 20:71–84
Chen AH, Frankel AS 2003 Altering brow contour with botulinum
toxin. Facial Plastic Surgery Clinics of North America
11:457–464
de Almeida AT, De Boulle K 2007 Diffusion characteristics of
botulinum neurotoxin products and their clinical significance in
cosmetic applications. Journal of Cosmetic and Laser Therapy
9(suppl 1):17–22
Fashion Bomb Daily. Online. Available: http://
fashionbombdaily.com/2010/06/08/beauty-
bomb-how-to-shape-and-care-for-eyebrows/

also commonly used cosmetically in other areas on the
face and neck. The frontalis is a large forehead muscle
responsible for the development of horizontal forehead
lines (HFLs) due to contraction – which raises the eye­
brows and upper eyelids, and over time results in these
contraction lines etching into the forehead. The forehead
is thus a major target area for botulinum toxin treatment
owing to the vertical movement of the underlying frontalis
muscle to lift the eyebrows during animation. The inferior
frontalis fibers insert into periocular muscles including:
the procerus, corrugator supercilii, orbicularis oculi, and
depressor supercilii. Superiorly, the fibers course horizon­
tally and insert into the galea of the scalp, often with no
fibers in the midline between the hairline and the middle
of the forehead.
Side effects
Potential side effects from botulinum toxin use in the
forehead include injection site pain, swelling, and bruising,
as well as headache, eyebrow ptosis, eyelid ptosis, diplo­
pia, and the development of new rhytides. New rhytides
may appear as a result of overcompensation of untreated
adjacent muscles. A case series by Kang et al (2011)
of four patients receiving BoNT-A for HFLs reported
the development of lower frontalis and glabellar protru­
sions as well as new unilateral forehead rhytides above
the eyebrow. In all patients, most of the new rhytides
were almost completely resolved within 4 weeks without
further treatment. Indeed, the majority of side effects
resulting from cosmetic use of botulinum toxin in the
forehead as well as in other aesthetic regions resolve spon­
taneously without treatment.
Other possible side effects from botulinum toxin treat­
ment of HFLs include eyebrow and eyelid ptosis and
periorbital edema, which are also self-limited. BoNT-A
agents have been shown to spread up to 3 cm from the
site of injection, but this may depend on the actual agent
used and the method of dilution. Certain predisposing
factors for eyebrow ptosis include age greater than 50
years and patients with mild eyebrow ptosis at baseline.
Patients with pre-existing low eyelid platforms (i.e. the
upper eyelid itself hangs down to or near the level of
eyelashes) and dermatochalasis (Fig. 14.1; redundant skin
at the eyebrow that hangs down toward the eyelid) should
also be carefully evaluated to decide whether or not to
14 
Frontalis and HFL
Austin Liu, David M. Ozog, Joel L. Cohen
Introduction
Botulinum toxin has been employed for clinical cosmetic
use for over twenty years. Currently it is the most com­
monly performed non-surgical facial cosmetic procedure
and is also widely used for non-cosmetic purposes. Botu­
linum toxin type A (BoNT-A) is produced from Clos­
tridium botulinum and acts on presynaptic neurons to
block acetylcholine release by cleavage of the SNAP-25
protein. There are three formulations of BoNT-A that are
currently approved cosmetically by the Food and Drug
Administration (FDA) for the treatment of moderate
to severe glabellar rhytides: (Botox® – Allergan, US),
(Dysport® – Medicis / Ipsen, Arizona, US and France),
(Xeomin® – Germany). Following cosmetic botulinum
toxin A injections, the effects begin to be noticeable
within 1 to 3 days and will typically last for 3 to 4 months.
Although these botulinum toxin A formulations are
FDA approved only for treating glabellar rhytides, they are
Summary and Key Features
•
Botulinum toxin can be safely utilized to treat
horizontal forehead lines
•
Most adverse effects resulting from the cosmetic
use of botulinum toxin resolve spontaneously
•
The risk of adverse outcomes after forehead
treatment is increased by certain predisposing
factors: age greater than 50 years, mild brow
ptosis at baseline, pre-existing low eyelid
platforms, and dermatochalasis
•
Individualized injection techniques are
recommended for individuals with tall (wide) and
short (narrow) foreheads
•
The frontalis muscle is very responsive to
treatment and therefore low doses of toxin should
be utilized initially
•
Botulinum toxin (given around the time of suturing)
has also been shown to be effective for minimizing
the appearance of scars due to surgical and
traumatic wounds

94
Botulinum toxin
horizontal line of injection for those with short foreheads.
However, these lines are not usually absolutely straight
and typically we employ a higher injection point above the
mid-brow in women, to avoid flattening an arched femi­
nine brow.
In a study reported by Ozsoy et al in 2005, 90 patients
with short and tall foreheads were treated with BoNT-A
using different injection techniques. In the study, a
glabella–frontal hairline distance greater than 70 mm was
considered to be a tall forehead, while a distance less than
60 mm was classified as a short forehead. For tall fore­
heads, three vertical lines of injections were performed;
for short foreheads, three horizontal lines of injections
were given. The authors reported effective results in all
patients without any instances of ptosis or brow asym­
metry. In this study, the average age of male and female
participants ranged from 41.5 to 42.3 years. In an older
population, brow repositioning may develop and become
problematic, especially for those with dermatochalasis
who depend on the lower lateral frontalis muscle to hoist
up the affected brow.
In addition to the physical variability of each patient,
there are also differences in the properties of the botuli­
num toxin products currently available on the market. The
different formulations of BoNT-A are made from different
bacterial strains and processing methods. The commonly
used formulations in the United States include onabotu­
linumtoxinA (Botox Cosmetic®; Allergan Inc., Irvine, CA,
USA) and abobotulinumtoxinA (Dysport®; Ipsen Ltd,
Slough, UK). Both products are commonly used cosmeti­
cally for treating the head and neck region and they have
been compared for the treatment of HFLs. Xeomin®
(incobotulinumtoxinA; Merz Pharmaceuticals GmbH,
Frankfurt, Germany) has been recently approved, but has
not been widely used in the United States. A randomized,
double-blinded, split-face study of 24 patients compared
onabotulinumtoxinA and abobotulinumtoxinA for the
Figure 14.1  Dermatochalasis: redundant skin at the eyebrow that hangs down toward the eyelid, with eyes (A) closed and (B) open.
A
B
Pearl 2 
Evaluate forehead and brow position prior to treatment
by studying the frontalis at rest and with animation, and
document each of these appearances with a photograph
prior to treatment (Fig. 14.2).
Pearl 1 
Consider avoiding poor frontalis candidates by declining
treatment to patients over 60 years of age with pre-existing
brow ptosis. (Tip: look for patients who continuously use their
lateral frontalis to hoist up their lateral brow even at baseline
when not animating.)
proceed with treatment of the HFLs. Techniques that
may help to prevent eyebrow ptosis include simultaneous
treatment of brow depressors (especially the superior–
lateral aspect of the orbicularis oculi) and to avoid eyelid
ptosis by choosing injection points sufficiently superior to
the orbital rim.
Injection techniques
Numerous different injection points and total units have
been suggested for treating the forehead rhytides. The
difficulty associated with treating this region is related to
individual differences in frontalis muscle and forehead
structure, as well as how the muscle is used functionally
for facial expression. Individualized injection techniques
are typically required, especially for patients with tall
(wide) and short (narrow) foreheads, in order to achieve
effective results and prevent complications such as
eyebrow depression. For example, some physicians will
perform two or more horizontal lines of injection for
patients with tall foreheads while administering only one

95
14 
Frontalis and HFL
Pearl 3 
Keep injections at least 1–2 cm above eyebrows to minimize
eyebrow ptosis. However, to maintain a natural appearance
it is also helpful to avoid treating patients with significant
muscle activity in this 1–2 cm supra-brow area.
Figure 14.2  Clinical photograph of horizontal forehead lines at rest and with brows raised: (A, B) before and (C, D) after treatment with
botulinum toxin type A.
A
B
C
D
treatment of forehead rhytides and their effects on elec­
tromyographic (EMG) activity of the frontalis muscle. A
3 : 1 conversion ratio was used and patients were observed
for 20 weeks following injection. AbobotulinumtoxinA
was found to have longer-lasting effects than onabotu­
linumtoxinA at a 3 : 1 conversion ratio. Based on these
findings, the authors concluded that the conversion ratio
of 3 : 1 may still be too high for bioequivalence.
Similar results for these two products have also been
reported with the use of other dose ratios, for example
by Nestor & Ablon (2011). A randomized, double-blinded,
split-face study of 20 patients compared abobotulinum­
toxinA and onabotulinumtoxinA at a 2.5 : 1 dose ratio, for
the treatment of horizontal forehead lines. Abobotulinum­
toxinA was shown to have a significantly longer duration
of effect when compared with onabotulinumtoxinA. The
median duration of full efficacy for abobotulinumtoxinA
was 103 days and for onabotulinumtoxinA it was 87
days. Indeed, the optimal conversion ratio for complete
bioequivalence has not yet been elucidated and it may be
possible that 2.5 : 1 is too high as well, and that these
products should be considered as completely independent
products.
In 2004, consensus recommendations for the use of
Botox Cosmetic® were published by Carruthers et al.
With regards to the treatment of HFLs, there was a wide
range in the number of injection points suggested by the
panel, ranging from two to 12 sites, with most falling
between four and six. Regardless of the number of injec­
tion sites, the panel of experts recommended them to be

96
Botulinum toxin
at least 1–2 centimeters above the orbital rim to decrease
the likelihood of brow ptosis. Furthermore, it was sug­
gested treatment avoids the first horizontal forehead
rhytid above the eyebrows and instead utilizes injectable
fillers in the lower forehead lines. Regarding total doses
for treating the forehead, a range of 10–20 units was
recommended for women and 20–30 units for men.
Lastly, clinical reassessment of eyebrow position 2 weeks
after injection was recommended to determine the need
for further treatment. However, in the Carruthers et al
2008 Consensus (published in 2011), the actual recom­
mended dosage in the forehead was essentially reduced
by half after other consensus reviews began to advocate a
‘natural relaxed look’.
Pearl 5 
Start with minimal injection dosages regardless of the toxin
utilized and encourage follow-up at 2 weeks to re-evaluate
(Fig. 14.3).
Pearl 4 
Use filler rather than toxin to treat the first horizontal rhytid
above the eyebrows – this helps occupy volume and thus
softens the rhytid prominence without affecting the frontalis
muscle at this site. Repeat filler injection after 4–5 months is
often expected initially, as this is a highly dynamic area with
the muscle still functioning normally without BoNT-A.
The optimal total number of BoNT-A units for treating
forehead lines has been evaluated and the results have
varied. In a study involving 59 female patients with mod­
erate to severe horizontal forehead rhytides, three doses
of BoNT-A (Botox®, Botox Cosmetic®; Allergan Inc.,
Irvine, CA, USA) were compared for their safety and
efficacy by Carruthers et al in 2003. The total amounts
utilized were 16, 32, and 48 units, administered over eight
injection sites of the brow elevators and brow depressors.
Efficacy was evaluated by monitoring the response rate
and duration using the facial wrinkle scale (FWS) for a
total of 48 weeks. The authors found greater efficacy and
longer duration of effect with the higher doses. Side
effects encountered in the study were mild to moderate
and included but were not limited to injection site pain,
swelling, bruising, and headache. There was no significant
increase in adverse effects in patients treated with higher
overall doses.
In contrast, a 2006 prospective study by Levy et al of
BoNT-A (of Vistabel®, which is the name for Botox® in
European markets; Allergan Inc., Irvine, CA, USA) com­
pared two lower doses (5 and 10 units) for the treatment
of forehead rhytides in 24 patients. These total units were
given over five injection sites. There was an 8-month
follow-up period during which the investigators evaluated
the patients clinically via standardized photography and
objectively through 3D in vivo skin profilometry with
computer-assisted evaluation. No differences were
observed between the two groups, as both doses demon­
strated significant improvement with the same level of
effectiveness and duration. In this study, the authors rec­
ommended using lower doses for treatment of the fron­
talis muscle given the similar clinical improvement when
compared with higher doses.
Consensus recommendations by Ascher et al 2010
for the use of Dysport® (Ipsen Ltd, Slough, UK) and
Azzalure® (Galderma SA, Lausanne, Switzerland), which
is the name for Dysport® in European markets, have also
been published by leaders in the field. Together, both
products are quantified in units derived from the company
that first developed the product (Speywood Biopharm
Ltd, Maidenhead, Berkshire, UK), in Speywood Units
(s.U). With regards to treatment of HFLs, it was recom­
mended to use four to six injection points given in a
V-shaped pattern, which should be slightly curved in
women and straight in men. Lateral injection points
should be made on the external orbital rim lines. For
physicians who are less experienced with BoNT-A injec­
tions, these injections should be at least 4–5 above the
orbital rim or on the upper two-thirds of the forehead.
The injections should be made perpendicularly and super­
ficially into the frontalis muscle. The total doses for HFLs
suggested by the panel were 20–60 s.U, with 5–10 s.U
per injection point. Importantly, the consensus panel also
recommended starting at low doses, as did the consensus
guidelines for Botox Cosmetic®, since the frontalis is very
responsive to treatment. It is important to note, however,
that in many patients the V-pattern of injection can look
quite unnatural, especially upon animation, and appear as
the so-called ‘mephisto look’. Therefore again, the pattern
of injection must be individualized depending on frontalis
prominence, positioning, and eyebrow shape, as well as
degree of dermatochalasis.
Treatment of scars
In addition to the management of rhytides, botulinum
toxin has been an effective adjuvant treatment for mini­
mizing scars (Fig. 14.4). This beneficial effect on scars is
believed to be related to a decreased amount of tension
and movement around an incision or wound site from
toxin-mediated immobilization. The decrease in tension is
believed to shorten the duration of the inflammatory
phase of wound healing. Areas subject to greater tension
and movement such as the chest, shoulders, and scapula
are prone to hypertrophic scarring and keloid formation.
A randomized-controlled trial reported by Gassner et al
in 2000 involved six primates treated with BoNT-A versus
placebo after undergoing symmetric pairs of standard
excisions on either side of the forehead. The sides treated
with BoNT-A were found to heal with a significantly
better appearance than placebo-treated sides. The authors
also noted that immobilization allows the surgeon to use
finer sutures for closure, further contributing to a superior
cosmetic outcome.

97
14 
Frontalis and HFL
Figure 14.4  Botulinum toxin type A injection: (A) immediately after closure of surgical defect and (B) clinical appearance at 4 months’ postop.
A
B
Figure 14.3  Clinical photograph of horizontal forehead lines: (A) before and (B) after treatment with botulinum toxin type A.
A
B
C
D
Similar studies of BoNT-A in wound healing involving
human subjects have also been performed. In a study by
Wilson in 2006, 40 patients with traumatic and surgical
scars of the forehead and cheek underwent scar revision
procedures followed immediately by BoNT-A injections.
The majority of patients had significant improvement of
the final scar appearance, by subjective and objective
assessment scales, over a 12–16-month follow-up period.
One limitation of the study was the lack of a control group
undergoing scar revision without BoNT-A treatment. In
2006, another randomized controlled trial (by Gassner
et al) evaluated and treated 31 patients at the Mayo Clinic

98
Botulinum toxin
with either forehead lacerations or excision of forehead
masses. The patients received either BoNT-A or placebo
injections to the wound site within 24 hours of surgery.
During a 6-month follow-up, the areas treated by BoNT-A
were found to have significantly better results than
placebo, measured by a visual analog scale.
A study by Kadunc et al (2007) on the use of botuli­
num toxin A prior to resurfacing of the upper lip for upper
perioral vertical rhytides demonstrated better results on
the BoNT-A pretreated side. The authors suggested that
this improvement may be not only related to less mechani­
cal movement and stress across the healing wound, but
also possibly to a decrease in metabolic activity in the area.
Therefore, the effect of BoNT-A in helping to decrease
scarring in sutured closures may be related to both
phenomena.
More recently, a retrospective study by Flynn (2009)
described the findings of patients receiving intraoperative
botulinum toxin type A or B following reconstructive
surgery after Mohs micrographic surgery for non-melanoma
skin cancers and one case of melanoma in situ. Of the
eighteen patients, the most commonly treated area was the
forehead and the remaining areas included the nose, chin,
glabella, scalp, and zygoma. Botulinum toxin was placed
in a 1–2 cm radius around the suture lines. All patients
exhibited good to excellent results with good apposition
of wound edges. Again, a limitation of the study was the
lack of a control group undergoing Mohs micrographic
surgery and reconstruction without botulinum toxin injec­
tion. The authors noted that botulinum toxin type B
(BoNT-B) has been reported to be faster-acting and of
shorter duration – therefore type B may be better suited
for use following surgical reconstruction. However, in
this study, no differences were seen between sites treated
with botulinum toxin type A and those treated with
type B.
With reference to onset and spread between sub-types
A and B of botulinum toxin, a small prospective split-face
study involving eight patients, reported in 2003 by Flynn
& Clark, examined the rate of onset and area of diffusion
of botulinum toxin types A and B for moderate to severe
forehead rhytides. Utilizing computer analysis and time-
lapse motion pictures, botulinum toxin type B was found
to have a slightly faster onset and larger radius of diffusion
than BoNT-A. However, whether this difference is signifi­
cant enough to produce a clinically visible difference in
surgical scar healing remains to be seen.
Conclusion
Botulinum toxin continues to be the most commonly per­
formed non-surgical facial cosmetic procedure today. It
remains an effective treatment modality for HFLs and
its use in this region requires careful individualized plan­
ning to achieve optimal results and minimize the risk of
complications. Due to the significant variability of this
anatomical region, many techniques and guidelines have
been published to help refine the approach of treating
physicians. The use of BoNT-A is also gaining attention
as an adjuvant treatment to help minimize the ultimate
cosmesis of surgical and traumatic wounds. Future studies
will help to determine the most effective treatment
parameters for this relatively new indication.
Further reading
Ascher B, Talarico S, Cassuto D, et al 2010 International consensus
recommendations on the aesthetic usage of botulinum toxin
type A (Speywood Unit) – Part I: upper facial wrinkles. Journal
of the European Academy of Dermatology and Venereology
24(11):1278–1284
Borodic GE, Ferrante R, Pearce LB, et al 1994 Histologic
assessment of dose-related diffusion and muscle fiber response
after therapeutic botulinum A toxin injections. Movement
Disorders 9(1):31–39
Carruthers A, Carruthers J, Cohen J 2003 A prospective,
double-blind, randomized, parallel-group, dose-ranging study
of botulinum toxin type a in female subjects with horizontal
forehead rhytides. Dermatologic Surgery 29(5):461–467
Carruthers A, Cohen JL, Cox SE, et al 2007 Facial aesthetics:
achieving the natural, relaxed look. Journal of Cosmetic and
Laser Therapy 9(suppl 1):6–10
Carruthers J, Fagien S, Matarasso SL 2004 Botox Consensus
Group. Consensus recommendations on the use of botulinum
toxin type a in facial aesthetics. Plastic and Reconstructive
Surgery 114(6 suppl):1S–22S
Carruthers JD, Glogau RG, Blitzer A 2008 Facial Aesthetics
Consensus Group Faculty. Advances in facial rejuvenation:
botulinum toxin type a, hyaluronic acid dermal fillers, and
combination therapies – consensus recommendations. Plastic
and Reconstructive Surgery 121(5 suppl):S5–S30; quiz S31–
S36.
Dubois V, Vickers S 2006 Bilateral inferior oblique palsies following
botulinum toxin injections to the frontalis muscle. Journal of
Plastic, Reconstructive and Aesthetic Surgery 59(10):1122
Flynn TC, Clark RE 2nd 2003 Botulinum toxin type B
(MYOBLOC) versus botulinum toxin type A (BOTOX) frontalis
study: rate of onset and radius of diffusion. Dermatologic
Surgery (5):519–522; discussion 522.
Flynn TC 2009 Use of intraoperative botulinum toxin in facial
reconstruction. Dermatologic Surgery 35(2):182–188
Garcia A, Fulton JE Jr 1996 Cosmetic denervation of the muscles
of facial expression with botulinum toxin. A dose-response
study. Dermatologic Surgery 22(1):39–43
Gassner HG, Brissett AE, Otley CC, et al 2006 Botulinum toxin to
improve facial wound healing: A prospective, blinded,
placebo-controlled study. Mayo Clinic Proceedings
81(8):1023–1028.
Gassner HG, Sherris DA, Otley CC 2000 Treatment of facial
wounds with botulinum toxin A improves cosmetic outcome in
primates. Plastic and Reconstructive Surgery 105(6):1948–1953;
discussion 1954–1955
Kadunc BV, Trindade DE, Almeida AR, et al 2007 Botulinum toxin
A adjunctive use in manual chemabrasion: controlled long-term
study for treatment of upper perioral vertical wrinkles.
Dermatologic Surgery 33(9):1066–1072; discussion 1072.
Kang SM, Feneran A, Kim JK, et al 2011 Exaggeration of wrinkles
after botulinum toxin injection for forehead horizontal lines.
Annals of Dermatology 23(2):217–221
Karsai S, Adrian R, Hammes S, et al 2007 A randomized double-
blind study of the effect of Botox and Dysport / Reloxin on
forehead wrinkles and electromyographic activity. Archives of
Dermatology 143(11):1447–1449
Levy JL, Pons F, Jouve E 2006 Management of the ageing eyebrow
and forehead: an objective dose-response study with botulinum

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Frontalis and HFL
toxin. Journal of the European Academy of Dermatology and
Venereology 20(6):711–716
Nestor MS, Ablon GR 2011 Duration of action of
abobotulinumtoxinA and onabotulinumtoxinA: a randomized,
double-blind study using a contralateral frontalis model. Journal
of Clinical and Aesthetic Dermatology 4(9):43–49
Ozsoy Z, Genc B, Gözü A 2005 A new technique applying
botulinum toxin in narrow and wide foreheads. Aesthetic Plastic
Surgery 29(5):368–372
Ozsoy Z, Genc B, Gözü A. 2005 A new technique for the
application of botulinum toxin in short and tall foreheads.
Plastic and Reconstructive Surgery 115(5):1439–1441
Wilson AM 2006 Use of botulinum toxin type A to prevent
widening of facial scars. Plastic and Reconstructive Surgery
117(6):1758–1766; discussion 1767–1768

of emotions, from surprise, to fear, and happiness. By
integrating the concepts of facial symmetry, sexual dimor­
phism, and ethnic diversity, along with a global under­
standing of the anatomy and aesthetics of the periocular
region, the clinician can achieve successful facial rejuvena­
tion. The overall result may emerge from a comprehensive
treatment algorithm, including topical skin care, botuli­
num toxin injection, soft tissue augmentation, skin tight­
ening, and cutaneous rejuvenation and resurfacing. In this
chapter, we will focus on the indications and treatment
guidelines for botulinum toxin in the periocular region.
Anatomy of ‘crow’s feet’ lateral
orbital rhytides
A thorough understanding of the functional anatomy of
the periocular region must precede treatment. Eyelid skin
is elastic and among the thinnest of the body, with essen­
tially no underlying subcutaneous fat. Crow’s feet are fine
or coarse rhytides originating from the lateral ocular
canthus and projecting outward, often in a partial or full
fan-like distribution. Most prominent during the so-called
‘dynamic’ states of smiling or squinting, crow’s feet can
be appreciated in repose, the ‘static’ posture, in certain
patients. Several factors contribute to the development of
crow’s feet, including sun exposure, smoking, lack of sub­
cutaneous fat, and redundant skin.
In addition, rhytides develop in the setting of hyperki­
netic muscle contractions of the orbicularis oculi, an ellip­
tical muscle that functions in closing the eyelids and
protecting the globe by acting as the sphincter of the eye.
The orbicularis oculi encircles the eye, with a predomi­
nantly vertical orientation at the lateral canthus, and has
three distinct subparts: the orbital, palpebral, and lacrimal
portions. The lacrimal portion of the muscle runs deep to
the lacrimal sac and inserts on the upper and lower eyelids
at the tarsal plates. Contraction of this part of the muscle
draws the eyelids against the globe and compresses the
lacrimal sac, thus assisting tear flow. The palpebral portion
is the innermost aspect of the muscle and passes into the
eyelid superficial to the septum from the bifurcation of
the medial palpebral ligament to the lateral palpebral
raphe. The palpebral portion is subdivided into preseptal
and pretarsal components, and each portion is superficial
to the corresponding named portion of the eyelid. Con­
traction of the palpebral portion of the orbicularis oculi
15 
Treatment of crow’s feet
Melanie Warycha, Jeffrey S. Dover, Murad Alam
Introduction
Patients frequently seek aesthetic rejuvenation of the peri­
ocular region. Age-related changes of the bony facial skel­
eton and soft tissue, in combination with photodamage
of the overlying periorbital skin, can lead over time to
eyebrow ptosis, drooping of the upper eyelids, and lateral
canthal rhytides or ‘crow’s feet’, with a resultant tired or
sad appearance. In fact, the periocular region is often a
candid indicator of someone’s age, with crow’s feet devel­
oping early on in the aging process, often by the 3rd and
4th decades of life. The eyes serve as an integral com­
ponent of facial recognition and have been considered a
marker for physical attractiveness and beauty. During
non-verbal communication, subtle differences in eyebrow
and eyelid contour and position convey a broad range
Summary and Key Features
•
Treatment of crow’s feet with botulinum toxin is
safe and effective, with predictable cosmetic
results
•
Preoperative assessment of the periocular region,
including analysis of dynamic and static rhytides,
lower lid laxity, and upper lid ptosis, can improve
the precision and safety of treatments
•
A snap-test can be useful for measuring lower lid
laxity
•
Stretching the skin and side lighting can help avoid
injection into superficial vessels and resultant
ecchymoses
•
Superficial injections into the dermis, combined
with frequent needle changes, may reduce
injection discomfort, ecchymoses, and / or spread
into nearby lip elevators
•
Adjunctive non-invasive procedures of the
periocular region, including laser resurfacing,
pigment laser treatments, and soft tissue
augmentation, may be combined with crow’s feet
injections for more comprehensive periorbital
rejuvenation

101
15 
Treatment of crow’s feet
In an article by Kane et al, four lateral canthal rhytid
patterns were identified, reflecting divergent muscle con­
traction patterns: (1) full-fan distribution of rhytides from
the upper eyelid to the upper cheek, (2) rhytides of the
lower lid / upper cheek, (3) rhytides of the upper eyelid
skin down to the lateral canthus, and (4) central zone of
rhytides at the lateral canthus only (Fig. 15.2). Although
standard injection points can be helpful for beginner injec­
tors, treatment should be individualized to take into
account this diversity in lateral canthal rhytides, which
may deviate from published patterns and require care and
attention to understand, document, and address specifi­
cally. Some patients may exhibit right–left differences in
the distribution and size of lateral canthal rhytides. Lateral
canthal rhytides are generally classified as static, dynamic,
or a combination of the two. Dynamic rhytides develop
secondary to repeated muscle contractions, and remit
during relaxation, and hence are most immediately ame­
nable to treatment with botulinum toxin. Static rhytides,
which are present in the absence of muscle contractions,
may best be treated with soft tissue fillers or resurfacing
procedures, and will be addressed later in this chapter.
Alternatively, ongoing and repeated treatments with botu­
linum toxin may soften static rhytides over long time
intervals, as reduction of coincident dynamic creases
reduces the incidence of repeated microtrauma to the
underlying collagen and elastin. Botulinum toxin treat­
ments may also prevent the extension or deepening of
static creases through a similar mechanism.
The youthful eye
Eyes are critical in non-verbal communication, with eye
contact considered an innate aspect of human interaction
provides less forceful involuntary closure of the eyelid, as
with blinking. The orbital portion represents the outer­
most aspect of the muscle overlying the bony orbit, with
origins at the nasal process of the frontal bone, frontal
process of the maxilla, and the medial palpebral ligament.
This portion of the muscle blends into surrounding
musculature, interdigitating at its superior aspect with the
frontalis muscle, corrugator supercilii, depressor superci­
lii, and procerus muscles, and at its inferior margins with
the levator labii superioris alaeque nasi, levator labii supe­
rioris, and zygomaticus minor and major muscles (Fig.
15.1). By providing forceful eye closure and eyebrow
depression, this outer aspect of the muscle pulls on overly­
ing skin and contributes most to the formation of lateral
orbital rhytides. The outer orbicularis is typically treated
with botulinum toxin, although the preseptal aspect of
the inferior palpebral portion of the orbicularis oculi can
be treated in some situations as well. The zygomaticus
muscles, both major and minor, can also contribute to
inferior periorbital rhytides, as contraction of this muscle
elevates skin superiorly into the periocular region. The
zygomaticus major originates deep to the orbicularis oculi
muscle at the zygomatic bone just anterior to the zygo­
maticotemporal suture line and courses diagonally where
it inserts into the modiolus, lifting the corner of the
mouth. The zygomaticus minor muscle courses from the
zygomatic bone and inserts into the upper lip, where it
causes upward and lateral elevation of the oral commis­
sure. The risorius muscle originates from the connective
tissue and fascia overlying the parotid gland, platysma,
and runs horizontally towards the oral commissure, where
it inserts into the modiolus. Contraction of this muscle
pulls the mouth laterally, retracting the corners of the
mouth.
Figure 15.1  The muscles of facial
expression.
Depressor
superclilii m.
Frontalis m.
Risorius m.
Procerus m.
Corrugator
supercilii m.
Zygomaticus minor m.
Zygomaticus major m.
Levator labii superioris
aleaque nasi m.
Orbicularis oculi m.
orbital portion
Preseptal portion
Pretarsal portion

102
Botulinum toxin
brow ptosis, with the eyebrow sitting flat against the
orbital rim. Similarly, volume loss leads to drooping of the
upper eyelid that induces folds of redundant skin and
shadows in the upper lid sulcus; in elderly patients, any
visibility of the upper lid may be effaced. As previously
mentioned, lateral canthal rhytides and associated lateral
atrophy also develop as part of the aging process. In the
lower eyelid, a loss of orbital volume creates a ‘hollowing’
or depression that separates the lower eyelid from the
cheek.
Preoperative assessment
A detailed medical and surgical history is often obtained
prior to botulinum toxin injection. Specifically, history
elements that may result in technique modification include
prior facial surgery, including blepharoplasty, brow or face
lift, as well as previous injection of soft tissue fillers or
botulinum toxin. At the initial consultation, a comprehen­
sive evaluation is undertaken of the periorbital complex,
including eyebrows, eyelids, glabella, forehead, and lateral
canthus. In order to objectively evaluate postoperative
results, the clinic should document any pre-existing asym­
metries photographically prior to treatment. Patients
should also be made aware of these asymmetries, such as
brow ptosis, upper eyelid ptosis, globe prominence due to
exophthalmos or orbital hypoplasia, variation of intercan­
thal axis or tilt, lower eyelid position, scleral show, or
differences in the malar prominence.
Pre-existing ocular conditions such as persistent or
intermittent tearing, dry eyes, or previous LASIK surgery
may be associated with increased risk of dry eyes after
botulinum toxin treatment. As patients may not volunteer
the use of over-the-counter medications, it may be infor­
mative to question them specifically regarding the use of
and expression. Large prominent eyes are a defining
feature of beauty and facial recognition. Truthfulness, sin­
cerity, and a genuine smile can be conveyed through minor
modifications of eye position and ocular muscle constric­
tion (see Paul Eckman and Alam et al). Although several
attributes contribute to a youthful eye unit that conveys
happiness and relaxation, maintenance of volume in the
area framing the eye is a central component. The eyebrow
should be full with enough volume to keep it elevated and
away from the bony orbital rim. Laterally, the eye–eyelid
complex should be delineated by a full and convex temple
region. The upper eyelid area below the brow should be
full rather than deeply recessed, and ideally there would
be only a few millimeters of upper lid showing. A subtle
but defined superior–lateral slope of the eyelids is associ­
ated with beauty. The one shadow that should be promi­
nent is the eyelid crease over the upper lid lash line, and,
in an attractive eye, this will run nearly parallel to the lash
line. Starting at the tarsal insertion, the lower eyelid flows
in a smooth convexity all the way down to the nasolabial
fold and buccal region. In a youthful face, there is no sharp
step-off or boundary between the lower eyelid and the
cheek. While a slight to modest nasojugal hollow is appro­
priate, excessive volume loss should not be apparent. A
single light reflex should be evident off the cheek and
another off the lateral brow.
The aging eye
The aging process in the periocular region is characterized
by volume loss, with the eyes appearing hollowed-out or
sunken, surrounded by shadows and / or dark under-eye
half-moon circles. Patients may complain of looking tired,
sad, or malnourished. Volume loss and skin laxity, in addi­
tion to frontalis muscle weakening, can lead to lateral
Figure 15.2  (A–D) Various typical crow’s
feet patterns, as described by Kane et al.
A
B
C
D

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15 
Treatment of crow’s feet
Figure 15.3  Snap test to measure lower lid laxity can be performed
by pulling the lower lid outward and downward, then allowing the
eyelid to snap back against the eye.
eye drops for dry eyes. If there is a concern that decreased
tear production may exist before treatment, a Schirmer’s
test can measure tear production using calibrated strips of
filter paper placed within the lower eyelid, or a rose bengal
test can employ a dye to detect corneal scratches associ­
ated with dry eye. Injection treatments around the eye
may be modified in the context of systemic conditions
with ocular manifestations, including Graves’ disease,
Hashimoto’s thyroiditis, Sjögren’s syndrome, and other
collagen vascular diseases. A lower eyelid ‘snap-test’ can
estimate the risk for development of ectropion or scleral
show after infraorbital toxin injections. The snap is
assessed by pulling gently downward and outward on the
lower eyelid and then quickly releasing; a rapid return to
the rest position without requiring an eyelid blink suggests
a fully functional orbicularis muscle and a low risk of
excessive eye rounding after botulinum toxin injections
(Fig. 15.3). A positive test is defined as a slow return to
baseline, with the eyelid staying in a distracted position
until the patient blinks, or until several seconds elapse and
the lid very slowly resumes its normal apposition against
the globe.
Photoaging, including dyschromias and actinic damage,
of the periorbital region is often appropriately noted prior
to treatment. Before commencing cosmetic treatment
with botulinum toxin, it may be useful to discuss with
patients adjunctive modalities, like resurfacing and
pigment lasers, that may be helpful in correcting any such
photoaging; this reassures patients that all their cosmetic
deficits are treatable, and also makes clear that additional
procedures in addition to toxin injections may be neces­
sary to modify skin complaints other than fine lines and
wrinkles. Postponing this discussion until after toxin injec­
tions can lead patients to erroneously conclude that the
toxin injections failed to achieve their full effect, and the
physician is now attempting to rationalize this incomplete
effect. Anticoagulant medications and those that interfere
with platelet function that are not medically necessary,
including aspirin, supplements such as garlic and vitamin
E, in addition to alcohol, should be discontinued at least
1 week prior to injections.
An assessment of lateral canthal rhytides should be
performed at rest and while the patient is making deliber­
ate muscle contractions, as during smiling or squinting. As
previously mentioned, both dynamic and static rhytides
may be noted, with the latter potentially responding to a
lesser extent to treatment with botulinum toxin. The
presence of horizontal forehead rhytides may signify a
compensatory response to eyebrow ptosis, with contrac­
tion of the frontalis muscles allowing for elevation of the
eyebrow. In addition to eyebrow position, eyebrow shape
should also be considered, since this may be modified by
toxin injections along the upper lateral brow. While indi­
vidual and ethnic differences may intrude, in general,
feminine eyebrows should be high and mildly arched,
whereas the male ideal is generally a lower, straight brow,
perpendicular to the nose. Pretreatment eyelid ptosis
should be documented so that there is no subsequent
concern that this was induced by the toxin injections, and
so toxin injections can be placed in a manner that does
not exacerbate the baseline finding. Usually, the normal
adult upper lid lies 1.5 mm below the superior corneal
limbus.
Treatment
Although treatment of crow’s feet with botulinum toxin
has only recently been approved for abobotulinumtoxinA
and is currently pending for onabotulinumtoxinA, it is a
highly effective and frequently sought after procedure.
When performing injections in the periocular region, the
patient is typically seated upright or slightly reclined.
Although some physicians may find standing on the same
side as the treatment area more natural, others may
choose to stand on the opposite side so that the needle is
pointed away from the eye, and yet others may stand
facing the patient. To minimize the risk of ecchymoses,
injections are placed as a wheal superficially into the
dermis rather than deep into the muscle (Fig. 15.4).
Cleansing the skin with alcohol prior to treatment, in
addition to side lighting and stretching of the skin, may
help to identify any superficial vessels along the treatment
area (Fig. 15.5). Injections should be performed meticu­
lously and slowly, with the needle changed frequently to
prevent it from becoming blunt. The hand is typically
braced to avoid inadvertent sideways motion or deeper
placement, both of which may predispose to trauma and
bruising. It goes without saying that the needle tip should
be aimed to minimize the risk of inadvertently spearing
the globe. Some injectors prefer to insert the needle
head on vertically, and others insert the needle from the
side, almost tangential to the skin, occasionally tenting the
skin. Vertical injections are associated with a marginal
higher risk of deeper than desired placement, and lateral

104
Botulinum toxin
units of onabotulinumtoxinA (Botox®) are injected per
side as three to four injections along a 90–180° arc, spaced
at 1–1.5 cm intervals, as recommended in the studies by
Matarasso & Matarasso and by Lowe et al. In the latter
study, evaluating the safety and efficacy of 6, 12, and 18
units of onabotulinumtoxinA (Botox®) in the treatment of
crow’s feet, there was no statistically significant difference
in the efficacy or safety profile among the tested doses. In
the trials by Lowe and co-workers, at 4 weeks post-
treatment 89% of patients in the 6-unit group and 95% of
patients in the 12- and 18-unit group had an improvement
of at least 1 point from baseline on the Facial Wrinkle
Scale; these authors also noted that a second injection of
the same dose resulted in a longer duration of action
compared with the first injection, with up to half of the
patients still one grade above baseline 16 weeks after the
second injection. Notably, like many such small, relatively
underpowered studies, this research was susceptible to
type II error, i.e. the failure to detect small real differ­
ences that may have been statistically and clinically sig­
nificant. In general, smaller doses may be sufficient for
women with minimal movement of the lateral canthal
rhytides, whereas certain men, patients with stronger
muscles, and those with larger faces may need higher
cumulative doses. In patients with protuberant globes,
lowering the dose may reduce the risk for ectropion or
incomplete eyelid closure. When injecting lower malar
crow’s feet, especially those that blend into the diagonal
rhytides of the mid and lateral cheeks, extreme caution
should be exercised as direct injection or spread into the
zygomaticus major and minor muscles can cause ipsilateral
facial paralysis and lip ptosis. In order to prevent such
complications, injections below the level of the superior
zygomatic arch should be avoided. Again, discussing with
patients why far lower infraorbital rhytides cannot be
safely injected with toxin may reduce their disappoint­
ment when these persist after treatment.
injections course through more dermis, thus being at
greater likelihood of perforating a small blood vessel.
Overall, superficial injections no more than 2–3 mm deep
minimize the risk of spread or direct injection into nearby
lip elevators, including the zygomaticus minor and major
muscles. Smaller volumes may aid with precision and
prevention of migration; on the other hand, more dilute
solutions may enable a wider radius of action, and reduce
the number of injections needed.
For standard treatment of periorbital rhytides, injec­
tions are commonly placed 1.5 cm from the lateral canthus
or 1 cm lateral to the bony orbital rim. Some injectors
place the injection on or even inside the orbital rim with
equal effect and no increase in side effects. The injected
dose and pattern is adjusted to account for individual
patient preference, as well as the strength and size of the
orbicularis oculi muscle (Figs 15.6, 15.7). In general, 6–18
Figure 15.4  (A) Injection wheals illustrating the superficial injection
technique of botulinum toxin around the periocular region.
(B) Placement of botulinum toxin into the dermis rather than
the underlying muscle or at the level of periosteum.
A
B
Figure 15.5  Stretching of the skin and side lighting can aid in
identifying and then avoiding blood vessels during botulinum toxin
injection.

105
15 
Treatment of crow’s feet
Figure 15.6  (A–F) Representative botulinum
toxin injection sites of the lateral canthus,
with variations appropriate for different
muscle strengths and locations across
individuals. Quantities are of
onabotulinumtoxin A.
A
B
C
D
E
F
Figure 15.7  (A) Before and (B) after pictures
of botulinum toxin injection into lateral
crow’s feet. Note static rhytides may persist
and even some dynamic rhytides may
respond only partially.
A
B
With regards to abobotulinumtoxinA (Dysport®), a
study by Ascher et al evaluated the efficacy and safety of
15-, 30-, and 45-unit injections per side in the treatment
of crow’s feet. At week 4, response rates at maximum
smile were 42% in the 15-unit group, 60% in the 30-unit
group, and 57% in the 45-unit group, with response defined
as an improvement in crow’s feet severity of at least one
grade from baseline on both sides. This improvement in
rhytides was maintained for up to 8 weeks in the 15-unit
group and for up to 12 weeks in the 30- and 45-unit
groups. While a statistically significant difference in effi­
cacy was not appreciated when comparing the 30- and
45-unit groups, one patient in the 45-unit group did
develop eyelid ptosis, which resolved by day 31. Beyond
this, no difference in the safety profile between the tested
doses was noted. This study also documented a trend
towards improved response in subjects 50 years of age or
younger compared with those over 50 years of age.
IncobotulinumtoxinA (Xeomin®), which was FDA-
approved in 2011 for the treatment of glabellar frown
lines, cervical dystonia, and blepharospasm, is differenti­
ated from onabotulinumtoxinA (Botox®) based on the
lack of complexing proteins in the former. In a random­
ized, double-blind, split-face design study by Prager and

106
Botulinum toxin
modalities. Several non-invasive procedures including soft
tissue augmentation, laser resurfacing, and skin tightening
can be employed to optimize aesthetic outcomes and
improve patient satisfaction. Conversely, the outcomes of
some of these other procedures are enhanced secondary
to toxin treatment, and synergies are possible.
For instance, botulinum toxin pretreatment of the peri­
orbital region has been shown to impede recurrence and
severity of dynamic rhytides after laser resurfacing. In a
prospective, randomized, placebo-controlled study by
Yamauchi et al, of 33 patients receiving either 18 units
of onabotulinumtoxinA (Botox®) or saline into the peri­
orbital region followed 2–6 weeks later by erbium–
YAG resurfacing, patients receiving onabotulinumtoxinA
(Botox®) demonstrated a more significant reduction in
periorbital rhytides as well as textural and pigmentary
changes. In a separate study by Zimbler et al, in which 10
patients were pre-treated on one side of the face with
onabotulinumtoxinA (Botox®) 1 week prior to laser resur­
facing, the greatest improvement in facial rhytides was
observed in the crow’s feet region that had been pre-
treated with onabotulinumtoxinA (Botox®). Ideally, pre-
treating patients with botulinum toxin and then repeating
treatment well into the postoperative period could
enhance and prolong the aesthetic effects of laser resur­
facing. In the same manner, the effects of soft tissue
augmentation in the periorbital region may last longer
when muscle activity is inhibited with botulinum toxin.
Prominent periorbital hollows may disappear after volume
replacement with hyaluronic acids fillers, thus contribut­
ing to global facial rejuvenation and the beneficial effect
of rhytid reduction induced by toxin injections (Fig. 15.8).
Given that areas of volume loss often develop in regions
with greater movement, a comprehensive strategy that
combines soft tissue augmentation and chemodenervation
may optimize patient outcomes.
colleagues, of 21 patients comparing 12 units of incobotu­
linumtoxinA (Xeomin®) and 12 units of onabotulinum­
toxinA (Botox®) in the treatment of crow’s feet, no
statistically significant difference in response rates over a
4-month study period was observed. At 1 month, a 95%
response rate was noted on the side treated with incobotu­
linumtoxinA (Xeomin®), compared with a 90% response
rate on the side treated with onabotulinumtoxinA
(Botox®), with response defined as an improvement of at
least 1 point on the Facial Wrinkle Scale.
Pearl 2 
Patients who are receiving toxin injections at the crow’s feet
location for the first time sometimes do not respond as well
as they expect as this location appears more operator and
patient dependent than the traditional forehead and glabella
sites. They should be reassured, and another treatment
attempt made, if they are willing. Retreatment with a slightly
higher dosage and injection of more than one point at the
lateral canthal area may improve response.
Pearl 1 
If more than 12–14 units of onabotulinumtoxinA (or equivalent
dosage of another botulinumtoxin A) are required per side for
treatment of crow’s feet, it may be prudent to deliver the
residual amount 1–2 weeks later to avoid the risk of adverse
events, and to customize and optimize the effect.
Pearl 4 
A beginning approach to crow’s feet entails 3 injections of
3–4 units each of onabotulinumtoxinA, or 10–12 units of
abobotulinumtoxinA, in an arciform array centered around a
point 1.5 cm lateral to the lateral canthus, and separated by
1–1.5 cm.
Pearl 3 
Different formulations of botulinum toxin A (ona-, abo, and
inco- types) do not appear to be significantly different in
terms of safety, effectiveness, or longevity of action for
treatment of crow’s feet. Reported differences are probably
more due to differences in dosage, dilution, and operator
technique than underlying differences in the drugs.
Adjunctive treatments
Although botulinum toxin injections are highly effective
in reducing the appearance of dynamic lateral canthal
rhytides, patients presenting with advanced facial aging,
including static rhytides, photodamage, skin laxity, and
volume loss, may benefit from adjunctive treatment
Figure 15.8  Areas of volume loss or hollowing in the infraorbital (tear
trough and nasojugal fold) and lateral canthal regions, which may be
amenable to treatment with soft tissue augmentation.

107
15 
Treatment of crow’s feet
generally results in only a temporary deficiency in ana­
tomical function, which tends to return to baseline in a
matter of weeks, long before the end of the 3-month
longevity period of toxin injections. As with all cutaneous
injections, the first adverse effect of toxin injections is
injection pain upon delivery. Injection discomfort can be
ameliorated by using very small needles, injecting slowly,
gently rubbing or tickling nearby skin with the injector’s
finger, pre-treating with ice and topical anesthetic prepa­
rations, or with forced cold air during the procedure, and
reconstituting the toxin in preserved rather than unpre­
served saline.
Ecchymoses can develop both during and after injec­
tions, and have been reported (in a 2005 study by Lowe
and co-workers) to occur in up to 25% of patients receiv­
ing injections for crow’s feet. Although this is not surpris­
ing given the thin nature of periorbital skin, several
strategies can be employed to reduce the risk of ecchy­
moses. Completely removing all make-up by washing the
face and then using alcohol pads can help in identifying
and avoiding vessels. Similarly, stretching the skin and side
lighting, injecting superficially in the dermal plane with
only the needle tip inserted, and using a 31- or 32-gauge
needle may also minimize the likelihood of a bruise. If
bleeding does occur upon injection, pressure should be
applied immediately for up to 5 minutes to mitigate the
risk of ecchymoses.
CASE STUDY 3 
A healthy 51-year-old patient presents to you for treatment
of the crow’s feet with botulinum toxin. She tells you that she
bruises easily and is taking self-prescribed 81 mg of aspirin
daily for prophylactic reasons.
Never rush into a cosmetic treatment. Recommend that the
patient stop the aspirin for 2 weeks and have her return for
treatment then. Use no larger than a 30-gauge needle,
change the needle at least once per side, inject very slowly
and superficially, and hold pressure over each injection site
for at least 5 minutes after injecting.
CASE STUDY 2 
A patient returns to you 2 weeks after having undergone
onabotulinumtoxinA (Botox®) injections of the crow’s feet,
with 12 units injected on each side. She reports minimal
improvement in dynamic rhytides. How do you counsel this
patient?
This case highlights the importance of follow-up examination
of patients undergoing botulinum toxin injections. There are
a few reasons why injections may be ineffective in certain
patients. One possibility is that, although 12 units per side in
a woman are usually sufficient to weaken the dynamic
creases, a higher dose may be needed in this patient.
Alternatively, the placement of injections in the periocular
region may be the problem. Typically, injections are 1.5 cm
from the lateral canthus or 1 cm lateral to the bony orbital rim,
but other injection sites may be necessary to achieve a result
in a given patient. Retreatment can be considered. Very far
lateral injections may not reach the target muscles.
CASE STUDY 1 
A patient presents to you requesting treatment of her crow’s
feet (Fig. 15.9). How do you counsel this patient?
In evaluating this patient, you should appreciate that her
crow’s feet are quite broad, extending from the lateral canthus
inferiorly down the cheek. Caution should be exercised in
injecting the inferior border of these rhytides. In general,
injections below the level of the superior zygomatic arch
should be avoided. Drooping of the upper lateral lip can occur
if botulinum toxin spreads or is injected directly into the
zygomaticus major, zygomaticus minor, levator labii superioris
alaeque nasi, or levator labii superioris muscles. The patient
should thus be educated that eradication of all rhytides is not
possible without risk of lip ptosis.
Figure 15.9  Case study: evaluation of crow’s feet.
Complications
While complications secondary to botulinum toxin injec­
tions in the periocular region can occur, they are usually
mild, self-limited, and quickly resolving. Even when the
rare instance of brow or eyelid ptosis occurs, this

108
Botulinum toxin
Pearl 7 
Wiping off make-up around the lateral eye and infraorbital
area with several alcohol wipes greatly improves visualization
of fine blue vessels and hence avoidance of these during
injection.
post-treatment difference in contour may be relatively
more prominent during smiling. It appears more common
in young women with prominent zygomatic arches or
prominent malar prominence. Thus, caution should be
exercised, with the inferior injection site omitted or lower
doses considered in this subset of patients.
Rarely, eyelid ptosis can occur as a result of migration
of toxin into the levator palpebrae superioris muscle,
which functions to elevate the upper eyelid. Fortunately,
this complication can be treated with alpha-adrenergic
drops, such as Iopidine® (apraclonidine 0.5%), which
stimulates the Müller muscles to contract quickly and
raise the upper eyelid. One to two drops three times daily
can be used until ptosis resolves. It is important to recog­
nize that both eyelid and, more commonly, eyebrow ptosis
can also occur secondary to inadvertent weakening of the
frontalis muscle, which can no longer compensate for a
Pearl 9 
When bruising occurs, treatment with pulsed-dye laser at
non-bruising fluences can speed resolution.
Pearl 8 
Injecting very slowly, while holding the needle stable against
the patient, is likely to reduce bruising risk and discomfort.
Pearl 6 
Injections deeper than a superficial dermal bleb are likely to
elicit bruising, and are not necessary for effect.
Pearl 5 
To minimize bruising or excessive discomfort in susceptible
patients, consider changing the needle often, and in some
cases for every injection.
Although rare, lip ptosis can occur after botulinum
toxin injections for crow’s feet (Fig. 15.10). This can result
either from direct intramuscular injection or spread of
toxin into the zygomaticus major, zygomaticus minor,
levator labii superioris alaeque nasi, or levator labii supe­
rioris muscles, all of which have fibers that blend with the
orbicularis oculi muscle. Lip ptosis has been estimated to
occur in far less than 1% of treated patients and is char­
acterized by an inability to elevate the corner of the
mouth. Patients who have undergone facial surgery prior
to treatment may be at increased risk of inadvertent injec­
tion or diffusion into the lip elevators due to aberrant
muscle fiber realignment or planes of dissection. Although
there is no treatment for this complication, Lowe et al
reported in 2002 that muscle function should normalize
by 6 weeks post-injection, much sooner than the recur­
rence of periorbital rhytides, but when the injection is
placed too far inferior or deeply and the bulk of toxin is
injected into the zygomaticus major the ill effects can last
as long as 4 months.
Some patients also describe a bunching of skin or a new
fold beneath the eye or along the malar prominence that
is noticeable after effacement of inferior canthal rhytides.
This is thought to arise secondary to contraction of the
zygomaticus muscle and subsequent elevation of the cheek
into a now-flattened infraorbital / nasojugal region. This
Figure 15.10  Upper lip ptosis secondary to direct injection or
diffusion of botulinum toxin into zygomaticus major, zygomaticus
minor, levator labii superioris alaeque nasi, or levator labii superioris
muscles.

109
15 
Treatment of crow’s feet
sagging eyelid or eyebrow. This most often occurs second­
ary to diffusion of toxin when performing forehead injec­
tions too close to the eyebrow or from injections in the
periocular region. To prevent this complication, injections
should be performed at least 1 cm above the eyebrow.
Furthermore, patients should be warned against vigorous
massaging after botulinum toxin injections in the periocu­
lar region. Some botulinum toxin A formulations, such as
abobotulinumtoxinA, may spread slightly further from the
point of injection at equivalent dilutions per unit of
potency; if these are used, it may be prudent to inject
slightly higher than 1 cm above the mid brow.
Conclusion
In conclusion, treatment of crow’s feet with botulinum
toxin injections is safe and effective. Appropriate patient
selection and preoperative assessment increase the likeli­
hood of an optimal result. Injection technique is now
well defined, and some variation is possible based on the
patient’s functional anatomy and the injector’s prefer­
ence. Adverse events are rare and, without exception,
self-limited and spontaneously resolving. Annoying rare
outcomes like eyelid ptosis and dry eye, or an excessively
rounded eye, usually remit within weeks to months. Botu­
linum toxin injections at the crow’s feet are routinely
performed in conjunction with other modalities, like laser
or light treatment of sun-induced dyspigmentation, laser
resurfacing, and hyaluronic acid fillers, for more compre­
hensive rejuvenation of the periocular space. At present
there is little reliable data to differentiate between the
utility and safety of the several FDA-approved botulinum
A toxins in treating the periorbital region.
Further reading
Alam M, Barrett KC, Hodapp RM, et al 2008 Botulinum toxin and
the facial feedback hypothesis: can looking better make you feel
happier? Journal of the American Academy of Dermatology
58(6):1061–1072
Ascher B, Rzany BJ, Grover R 2009 Efficacy and safety of
botulinum toxin A in the treatment of lateral crow’s feet:
double-blind, placebo-controlled, dose-ranging study.
Dermatologic Surgery 35(10):1478–1486
Kane MA 2003 Classification of crow’s feet patterns among
Caucasian women: the key to individualizing treatment. Plastic
and Reconstructive Surgery 112:S33–S39
Lowe NJ, Ascher B, Heckmann M, et al 2005 Double-blind,
randomized, placebo-controlled, dose-response study of the
safety and efficacy of botulinum toxin type A in subjects with
crow’s feet. Dermatologic Surgery 31(3):257–262
Lowe NJ, Lask G, Yamauchi P, et al 2002 Bilateral, double-blind,
randomized comparison of 3 doses of botulinum toxin type A
and placebo in patients with crow’s feet. Journal of the
American Academy of Dermatology 47(6):834–840
Matarasso SL, Matarasso A 2001 Treatment guidelines for
botulinum toxin type A for the periocular region and a report
on partial upper lip ptosis following injections to the lateral
canthal rhytids. Plastic and Reconstructive Surgery (1):208–
214
Prager W, Wissmuller E, Kollhorst B 2010 Comparison of two
botulinum toxin type A preparations for treating crow’s feet: a
split-face, double-blind, proof-of-concept study. Dermatologic
Surgery 36:2155–2160
Yamauchi PS, Lask G, Lowe NJ 2004 Botulinum toxin type A gives
adjunctive benefit to periorbital laser resurfacing. Journal of
Cosmetic and Laser Therapy 6(3):145–148
Zimbler MS, Holds JB, Kokoska MS, et al 2001 Effect of
botulinum toxin pretreatment on laser resurfacing results: a
prospective, randomized, blinded trial. Archives of Facial Plastic
Surgery 3(3):165–169

of the periorbital area, alone or in combination with other
rejuvenating modalities. However, treatment in the upper
and lower lids – the thinnest skin in the human body –
requires an in-depth understanding of anatomy and the
aging process, appropriate patient selection, and careful
attention to individualized treatment.
Anatomy of the eye
Complete knowledge and understanding of both dynamic
and volumetric changes in the face, as well as the interac­
tion between and function of various facial musculature
and the surrounding soft tissue, are critical to ensuring
successful outcomes with the use of BoNT in the peri­
orbital region. Although in-depth examinations of facial
anatomy have been published elsewhere, this chapter
focuses on the anatomy of the eye relevant to the use of
BoNT in the upper and lower eyelids (Fig. 16.1).
16 
Infraorbital / upper and
lower eyelids
Shannon Humphrey, Steven Fagien
Introduction
The appearance of the mid-face – in particular the peri­
orbital region – marks the cornerstone of facial attractive­
ness, an important factor in social and interpersonal
interactions. As ‘window to the soul’, the eye can express
a variety of emotions and is one of the most compelling
features of any face. The use of botulinum toxin (BoNT)
in the periocular area has a long history; indeed, the dis­
covery of the toxin’s benefits were first noted in patients
treated for strabismus and blepharospasm, and it has since
been used therapeutically in the eyelid for the treatment
of numerous other blepharospastic conditions and sys­
temic diseases affecting the periorbital area, such as facial
palsies and lid retraction in thyroid ophthalmopathy. Since
then, BoNT has become an important part of the arma­
mentarium for the cosmetic or functional improvement
Summary and Key Features
•
Successful periorbital rejuvenation demands close
attention to patient’s desires and expectations,
general anatomical variations, detection of subtle
asymmetries, and individualized treatment
•
Careful patient selection requires a thorough
exploration into the patient’s desired outcome and
concerns, a detailed medical and cosmetic history,
and a thorough and comprehensive aesthetic
assessment
•
Precise placement of injections and
accurate / individualized dosing are crucial in
obtaining the most beneficial effects and avoiding
adverse events
•
Small doses in the lower lid can minimize
infraorbital rhytides and widen the eye
•
BoNT may also be used to correct eyelid
malposition, including ptosis and asymmetry
•
Poor patient selection, inappropriate injection
techniques, and diffusion of the toxin can lead to
serious adverse events and complications
Pearl 1 
The key to consistent, favorable outcomes is a deep
understanding of functional anatomy as it relates to volume
and the three-dimensional nature of the face.
The upper eyelid extends from the eyelid margin to
the eyebrow superiorly, with the superior palpebral sulcus
(associated with the upper eyelid skin crease) located
lengthwise between the medial canthus and the lateral
orbital rim, approximately in the range of 8–11 mm supe­
rior to the eyelid margin. The lower eyelid extends below
the inferior orbital rim to join the cheek. In youth, the
inferior palpebral sulcus (lower eyelid fold) is located
3–5 mm from the lower lid margin.
The orbicularis oculi – the sphincter muscle of the
eyelids – is a wide, concentric band of muscle comprising
the palpebral component, which can be further divided
into pretarsal and preseptal portions and is responsible for
blinking and gentle eyelid closure, and the orbital compo­
nent, responsible for forceful lid closure and the produc­
tion of lateral canthal and lower eyelid rhytides. Superiorly,
the orbital component interdigitates with other superficial
muscles of facial expression, including the frontalis, cor­
rugator, and the depressor supercilii muscles, laterally it
comes into proximity of the overlying fascia of the

111
16 
Infraorbital / upper and lower eyelids
while radial wrinkles appear on the lateral aspect of the
orbit.
Patient assessment and selection
Because successful use of BoNT in the periorbital region
demands close attention to anatomical variations and indi­
vidualized treatment, a thorough evaluation of every
patient is mandatory. Comprehensive assessment will
include patient education and counseling, medical history,
and physical examination of the periorbital region and area
to be treated.
Communication between patient and clinician builds
trust and ensures that expectations do not exceed realistic
outcomes. Evaluation of periorbital concerns in discussion
as well as physical examination will avoid post-injection
problems. Interviews should address the patient’s current
ophthalmic status including the presence of dry eye symp­
toms as well as the transient nature of BoNT injections,
the need for frequent touch-ups, common injection-
related side effects, and potential complications. Informed
consent is essential.
A complete medical and ophthalmic history is neces­
sary, including previous experiences with rejuvenation
procedures, surgery, and any other conditions that might
influence treatment plans or outcome. The degree of rhyt­
ides and their potential response to treatment can be
assessed via the Glogau photoaging scale (Table 16.1).
Moreover, the quality of skin around the eye will also
determine a treatment plan: patients with excessive skin
above the eye, prominent fat pads in the lower lid, septal
fat herniation, or severe elastosis (identified by a positive
snap test), may require additional rejuvenating procedures
such as laser or light-based therapies or even surgery prior
to augmentation. All findings (including any sign of ptosis
or asymmetry) should be noted and discussed with the
patient, and standard digital photographs taken both
before and after any treatments. Photographs should
display the face in repose and at maximal expression to
document changes on animation.
Figure 16.1  Periorbital anatomy.
Septal obicularis oculi
Orbital obicularis oculi
Medial canthus
Table 16.1  Wrinkle severity and rejuvenation
requirements
Group
severity*
Description
Rejuvenation modalities
II
Moderate; wrinkles
in motion
Responds well to BoNT
alone
III
Advanced; wrinkles
at rest
BoNT plus additional
correction, such as soft
tissue augmentation
IV
Severe; only
wrinkles
BoNT plus deeper skin
resurfacing for maximal
improvement
*Based on the Glogau classification of photoaging.
temporalis muscles, and the muscles of the inferior qua­
dratus labii superioris and zygomaticus complex. Inferi­
orly, the orbicularis lies flat across the cheek and is
considered a part of the superficial musculoaponeurotic
system (SMAS), which translates muscle movement into
movement of the skin. At the junction of the lower lid
with the cheek, the orbicularis oculi muscle forms a direct
attachment with the orbital rim at the junction of the
palpebral and orbital portions.
Periorbital aging
Aging in the face is most prominent in the mid-facial and
periorbital regions, due to both dynamic and volumetric
changes. Bony changes and atrophy of subcutaneous soft
tissues lead to a loss of cutaneous support, muscles
become lax, and skin that was once smooth and youthful
becomes rough and dry with irregular pigmentation and
uneven texture. As the skin repositions itself over the
changing landscape of the face, wrinkles and fine lines
begin to appear and become prominent as dynamic turns
to static.
Eyelid skin is the thinnest on the body (<1 mm), with
sparse underlying subcutaneous fat. Over time, the deli­
cate lids are prone to further thinning and stretching by
too-vigorous rubbing or surgical procedures to rejuvenate
the area. The lower lid is subject to fat redistribution,
laxity, and weakening of the connective tissue. The nor­
mally smooth transition from lower lid to cheek becomes
more prominent, with puffiness, dark circles, or derma­
tochalasis under the eye. Orbital laxity, atrophy, and
pseudoherniation give the impression of a sunken eye,

112
Botulinum toxin
General considerations
Injections into the lower lid are mildly uncomfortable;
topical anesthesia (applied for 15–20 minutes prior
to treatment) or the application of ice (for 5 minutes)
can reduce injection-related pain. BoNT reconstituted
with preserved saline has been shown to be less painful
than reconstitution with non-preserved saline. Consensus
guidelines report a range of dilutions (1–3 mL/vial) that
relies on area to be injected and clinician preference.
Similarly, choice of syringe and needle depends on
the injector. The authors have used both a dilution of
1 U/0.01 mL (SH) and a 3 U/0.1 mL (SF) in a single-use
insulin syringe with a 31-gauge needle for injections in the
periorbital area. Most important is not the exact dilution
used rather understanding the volumes required to deliver
precise dosing. The needle should be held tangentially to
the globe, with the non-dominant hand stabilizing the
patient’s head, to prevent inadvertent head movement;
especially direct injury to the eye should the patient move
suddenly and unexpectedly.
Box 16.1 
Contraindications and precautions to periocular
BoNT treatment
Contraindications
Precautions
n
Active infection or
inflammatory skin
condition at site(s) of
injection
n
History of
neuromuscular
disorders
n
Use of
aminoglycosides or
other drugs that act at
the neuromuscular
junction
n
Pregnancy or lactation
n
Severe elastosis (risk
of scleral show)
n
Pre-existing conditions
that may be worsened
by treatment (e.g.
mid-facial paresis,
symptomatic dry eyes)
n
History of lower eyelid
blepharoplasty
n
Body dysmorphic
disorder
n
Stable or progressive
muscular dystrophic
conditions causing
blepharoptosis
n
Already-compromised
function of orbicularis
oculi
Pearl 3 
Aesthetic evaluation should examine facial expression at rest
and on animation to assess the range of motion of the
involved muscles and detect asymmetry.
Pearl 2 
Perform a ‘snap test’ to determine whether the eyelid skin is
elastic enough to perform BoNT injections. A skin retraction
time >3 seconds places a patient at risk for edema following
BoNT injections.
Not everyone is a candidate for BoNT therapy. Aside
from general contraindications (Box 16.1), caution should
prevail in patients with a history and especially complica­
tions related to previous lower eyelid blepharoplasty and
injections avoided in patients with lower lid laxity, due to
the risk of scleral show, pre-existing conditions that could
be worsened by treatment, such as mid-facial paresis or
symptomatic dry eyes, stable or progressive muscular dys­
trophic conditions causing blepharoptosis, or anyone with
already-compromised function of the orbicularis oculi.
Indications and techniques
Consensus recommendations have been developed for
dosing and techniques in all areas of the face, although
treatment must be individualized according to muscle size
and function and desired outcome. In the upper and lower
lid, precise placement of injections and conservative doses
are crucial in avoiding adverse effects and obtaining the
most beneficial effects.
Pearl 4 
A BD Ultra-Fine II 31 gauge 3/10 mL insulin syringe facilitates
periocular BoNT-A injections by allowing precise delivery
of small doses and preventing any loss of BoNT-A in the
needle hub.
Hypertrophic orbicularis, infraorbital rhytides,
and widening of the eye
Infraorbital rhytides radiating below the eyes toward the
cheek arise from concentric contraction of the orbicularis
oculi peripheral to the lines. Moreover, such hypertrophy
of the pretarsal portion of the orbicularis oculi contributes
to the perception of lower eyelid bags (a ‘jelly roll’ appear­
ance) and a narrowing of the palpebral aperture, particu­
larly when the patient smiles. A series of studies conducted
by Flynn & Carruthers have shown that 2 U BoNT placed
subdermally in the lower eyelid in the midpupillary line,
3 mm below the ciliary margin (Fig. 16.2) can relax and
flatten the pretarsal orbicularis, improving the appearance
of the lower lid. Similar injections in the lower lid with
concomitant treatment of the lateral canthal rhytides
(three injections of 4 U each, for a total of 12 U) can
produce increases of approximately 2–3 mm in the verti­
cal palpebral aperture at rest and full smile, respectively,
giving the lower eyelid a more rounded appearance (Fig.
16.3). Further examination by Flynn & Carruthers dem­
onstrated a clear dose response when the lower lid was
treated alone; however, higher doses led to an increase in
side effects and did not further enhance the size of the
palpebral aperture. The authors therefore recommend a
conservative approach with the smallest dose (1–2 U at
two sites) in the lower lid, with retreatment after 2–4
weeks if necessary.

113
16 
Infraorbital / upper and lower eyelids
Figure 16.2  Flattening of hypertrophic orbicularis oculi and widening of the palpebral aperture following 2 U BoNT-A mid-pupillary line 3 mm
inferior to lash margin: (A) before, (B) after, and (C) injection technique.
A
B
C
Figure 16.3  Improvement of rhytides and widening of palpebral
aperture: (A) before and (B) after 2 U BoNT (Botox®) under the eye
and 12 U in the lateral canthal rhytides.
A
B
CASE STUDY 1 (see Fig. 16.2) 
A healthy 32-year-old Filipino-Canadian woman presented
complaining of a ‘jelly roll’ underneath her eyes when she
smiled. She requested a more western wide-eyed look and
reduction of the ‘jelly roll’. Figure 16.2A demonstrates a
hypertrophic orbicularis oculi. A ‘snap-test’ demonstrated
excellent elasticity, which, in conjunction with the youthful
tone and texture of the skin, indicated that the patient was a
suitable candidate for infraorbital BoNT-A treatment. In order
to achieve a wider aperture and flattening of hypertrophic
orbicularis oculi (Fig. 16.2B) 2 U of BoNT-A were injected in
the mid-pupillary line 4 mm below the lid margin bilaterally.
Figure 16.2C demonstrates the injection site and technique.
Lid ptosis, malposition, and asymmetry
BoNT is an effective treatment for the temporary manage­
ment of mild-to-moderate upper lid ptosis, malposition,
and eyelid-fissure asymmetry. Research by Fagien indi­
cates that correct placement, dosing, and careful patient
selection will determine predictability of response. Typi­
cally, eyelid malposition of any etiology has been treated
by surgical correction of the underlying cause, with non­
surgical options for upper lid ptosis limited to adrenergic
topical ophthalmic drops. Low-dose subdermal injection
of BoNT (0.5–1.5 U) into the extreme medial and lateral
aspects of the pretarsal region of the orbicularis just above
the lash line (Figs 16.4 and 16.5) allows unopposed activity
of the levator palpebrae and Müller’s muscle, and a return
to symmetry.
Likewise, lower lid asymmetry and malposition (such
as retraction, ectropion, and entropion) have historically
been treated with surgical intervention to tighten or
shorten the horizontal length of the lower eyelid to achieve
symmetry with the contralateral side. Malposition and
symmetry can be restored to the lower eyelid by weaken­
ing the lower lid elevators on the side opposite the lower
lid retractions by two injections of BoNT: one placed
at the extreme lateral aspect of the lower eyelid, the
other at the mid aspect of the lower eyelid pretarsal
region, located approximately mid-pupil, inducing a
similar, retracted effect.

114
Botulinum toxin
Topical agents
Topical treatment of the skin around the eye begins with
photoprotection, both behavioral and topical, and patient
education of the risks associated with UV radiation. Topical
retinoids used regularly over a period of several months
has been shown to improve skin texture, dyschromia, and
fine wrinkling, though they have a tendency to cause cuta­
neous irritation particularly in eyelid skin. Alpha-hydroxy
acid (AHA)-based emollients (such as lactic acid and gly­
colic acid) aid in skin rejuvenation by decreasing cell adhe­
sion in the upper layers of the epidermis, improving the
process of exfoliation, although over-the-counter prepara­
tions may be only minimally effective.
Surgery
When used in the pre- or post-surgical setting, BoNT can
facilitate manipulation of tissues, more effectively conceal
the surgical incision, and reduce tension exerted on a
wound or surgical incision, promoting better healing with
less scar formation and a superior aesthetic surgical result.
Pre-treatment of the lateral canthal rhytides prior to
upper and lower lid blepharoplasty, for example, may
allow the surgeon to hold the incision line within the
confines of the bony orbital margin and permits a more
accurate estimation of the amount of skin to be resected
during surgery. After lower eyelid ectropion and ‘round
eye’ repair (reoperative blepharoplasty), the lateral fibers
of the orbicularis actively pull on the medial side of the
surgical incision, leading to dehiscence of the temporal
repair of the distal tarsus to the lateral canthal tendon.
Pre-treatment with BoNT can allow for a more effective
surgical result by reducing the orbicularis forces that may
counteract the surgical attempt for correction. Fagien &
Brandt recommend injection of BoNT when performing
lateral canthal suspension procedures such as the lateral
tarsal strip or lateral retinacular suspension; injections
reduce orbicularis function, further protecting the secu­
rity of the lateral canthus reconstruction. BoNT may also
be used in a postoperative setting after surgical correction
of eyelid malposition.
Lasers and light-based therapies
Ablative and non-ablative resurfacing is used for photoag­
ing and scars and can be used in the periorbital area with
little risk of demarcation lines. In addition to lasers, non-
ablative radiofrequency and focused ultrasound devices
and intense pulsed light (IPL) are used for non-invasive
treatment of periorbital rhytides. However, the habitual
reuse of the muscles recreates the folds and wrinkles,
which may be thicker and more noticeable than before
treatment. Combination therapy (either before or imme­
diately following resurfacing) targets both the effects of
photodamage as well as the underlying musculature and
exerts a synergistic effect, eliminating the dynamic con­
tribution to the rhytides long enough to affect more per­
manent eradication of wrinkles in the newly remodeled
Figure 16.4  Upper eyelid ptosis: (A) before and (B) after treatment
at the extreme medial and lateral aspects of the pretarsal region
(injection sites marked by blue dot).
A
B
Figure 16.5  Injection pattern for correction of upper lid ptosis
(injection sites marked by blue dot).
Doses in the upper and lower lids range from 0.5 to
1.5 U per injection site, with higher doses reserved for
cases of lower eyelid hypertrophy and severe ptosis, or
when changing the position of the lower eye.
Adjunctive treatments for the lid
Increasingly, each aspect of facial rejuvenation is viewed
as a whole, using combination therapies to provide the
best possible outcomes. There are a variety of treatments
aimed at improving the appearance of the eye that can be
used in combination with BoNT for a synergistic effect,
targeting not only improvement in rhytides but also in
pigmentation, texture, scarring, and laxity.

115
16 
Infraorbital / upper and lower eyelids
the lower lid following treatment. In rare cases, but par­
ticularly in patients with excessive lower lid laxity, this
may manifest as edema that is worse in the morning. It is
believed that this results from inactivity of the orbicularis
oculi, which aids in the drainage of lymphatic fluid. Rare
complications in the periocular area include lower eyelid
laxity, scleral show, epiphora, ectropion, diplopia, dry eye,
incomplete eyelid closure, and ptosis. Careful patient
selection and attention to anatomical features of the peri­
orbital region can aid in avoiding most of these side effects,
all of which eventually disappear over time due to the
transient effect of BoNT. Goldman reported a case of
prominent festoon formation after 2 U 2–3 mm below the
ciliary margin in the mid-pupillary line and 10 U (single
injection) in the mid-lateral canthal region. Only at the
follow-up visit did the patient admit to a previous facelift,
forehead lift, and lower eyelid blepharoplasty 8 years pre­
viously. This case scenario emphasizes the importance of
pre-treatment history and physical examination of the
lower eyelid structure and function before treatment with
even small doses of BoNT. Upper eyelid complications can
also be avoided by careful thought, injection technique,
and placement. Mild lagophthalmos can be induced in the
upper eyelid by greater than necessary dosages and can
generally be avoided with doses less than 1.5 U. This too,
stresses the need for an initial conservative approach that
can be titrated to the most effective dose.
Administering injections peripheral to the orbital rim
and using a higher concentration and smaller volume may
also avoid infiltration of the toxin into the vicinity of the
extraocular muscles. Avoiding the pretarsal region (and
choosing the lateral preseptal area) for the treatment of
lower lid rhytides will both improve the aesthetic effect
and decrease the likelihood of functional adverse effects
and malposition.
Conclusion
The aim of rejuvenation to the infraorbital eye involves
targeting fine lines and wrinkles and restoring harmony
and balance that may have been lost in the aging process.
BoNT injections can achieve that goal, alone or in combi­
nation with other cosmetic procedures or applications
around the eye, with certain caveats: the injecting clinician
must have an in-depth awareness of functional anatomy
and the interplay of muscles of facial expression, and
careful screening of patients must occur prior to any treat­
ment. Many of the more serious adverse events can be
attributed to misplaced injections, poor technique, or
inappropriate patient selection.
Further reading
Balikian RV, Zimbler MS 2007 Primary and adjunctive uses of
botulinum toxin type A in the periorbital region. Otolaryngology
Clinics of North America 40:291–303
Carruthers J, Carruthers A 2005 Adjunctive botulinum toxin type
A: fillers and light-based therapies. International Ophthalmology
Clinics 45:143–151
skin. Regular injections every 3–6 months will provide
continuing results.
Soft tissue augmentation
BoNT paired with soft tissue augmentation has proven to
be an ideal marriage: fillers are excellent treatment for
correcting the deep folds and static wrinkles that cannot
be alleviated by BoNT alone, while also serving to correct
volume loss in the periorbital complex that occurs as part
of the aging process. Ideally (yet not always practical)
preceding the augmentation by approximately 1–2 weeks,
BoNT reduces the dynamic component of rhytid forma­
tion, prevents the distortion of the filler, and prolongs the
beneficial effects of tissue augmentation. Alternatively,
these treatments can be performed simultaneously with
comparable efficacy.
Bimatoprost
In 2001, the Food and Drug Administration (FDA)
approved bimatoprost, a prostaglandin analog, for use in
glaucoma to reduce high intraocular pressure. Reports of
beneficial ‘side effects’ – an increase in length, fullness,
and darkness of the eyelashes – led to clinical evaluation
and eventual approval of Latisse® (Allergan Inc., Irvine,
CA) for hypotrichosis by Smith & Fagien. Current evi­
dence by Cohen suggests bimatoprost is safe and effective
for enhancing the appearance of the eyelash, with a sig­
nificant level of patient satisfaction.
Adverse events
Bruising and ecchymosis are the most common injection-
site reactions to BoNT in the periorbital area. The addition
of sublingual Arnica montana immediately following and
then four times a day for 2–3 days may minimize bruising,
as will superficial injections and the application of ice
immediately following treatment.
More serious adverse effects can occur, usually due to
inappropriate dosing or injection technique (Table 16.2).
Some patients describe a temporary feeling of ‘fullness’ in
Table 16.2  Injection-related complications
Cause
Complication
Treatment of lower lid
pretarsal orbicularis in
patients with severe
elastosis and retraction
Ectropion, scleral show;
accentuation of drooping or
rhytides in lower lid; lower lid
fat herniation
Diffusion of toxin behind
orbital septum
Eyelid Ptosis
Injections near trochlea in
upper or lower eyelid
Diplopia
Paralysis of orbicularis oculi
Epiphora; ectropion

116
Botulinum toxin
Flynn TC, Carruthers JA, Carruthers JA 2001 Botulinum-A toxin
treatment of the lower eyelid improves infraorbital rhytides and
widens the eye. Dermatologic Surgery 27:703–708
Flynn TC, Carruthers JA, Carruthers JA, et al 2003 Botulinum A
toxin (BOTOX) in the lower eyelid: dose-finding study.
Dermatologic Surgery 29:943–950
Glaser DA, Patel U 2010 Enhancing the eyes: use of minimally
invasive techniques for periorbital rejuvenation. Journal of Drugs
in Dermatology 9:S118–S128
Glavas IP, Purewal BK 2007 Noninvasive techniques in periorbital
rejuvenation. Facial Plastic Surgery 23:162–167
Glogau RG 1996 Aesthetic and anatomic analysis of the aging skin.
Seminars in Cutaneous Medicine and Surgery 15:134–138
Goldman MP 2003 Festoon formation after infraorbital botulinum
A toxin: a case report. Dermatologic Surgery 29:560–561
Harris PA, Mendelson BC 2007 Eyelid and midcheek anatomy. In:
Fagien S (ed) Putterman’s Cosmetic Ocuplasticsurgery, 4th edn.
WB Saunders, Philadelphia, p 45–63
Matarasso SL, Matarasso A 2003 ‘M’ marks the spot: update on
treatment guidelines for botulinum toxin type A for the
periocular area. Plastics and Reconstructive Surgery
112:1470–1472
Smith S, Fagien S, Whitcup S, et al 2011 Eyelash growth in
subjects treated with bimatoprost: A multicenter, randomized,
double-masked, vehicle-controlled, parallel group study. Journal
of the American Academy of Dermatology Sep 5 [Epub ahead
of print]
Carruthers J, Fagien S, Matarasso SL; Botox Consensus Group
2004 Consensus recommendations on the use of botulinum
toxin type a in facial aesthetics. Plastic Reconstructive Surgery
114(6 suppl):S1–S22
Cohen JL 2010 Enhancing the growth of natural eyelashes:
the mechanism of bimatoprost-induced eyelash growth.
Dermatologic Surgery 36:1361–1371
Fagien S 1999 Botox for the treatment of dynamic and hyperkinetic
facial lines and furrows: adjunctive use in facial aesthetic
surgery. Plastic Reconstructive Surgery 103:701–713
Fagien S 2003 Botulinum toxin type A for facial aesthetic
enhancement: role in facial shaping. Plastic and Reconstructive
Surgery 112(5 suppl):S6–S18
Fagien S 2004 Temporary management of upper lid ptosis, lid
malposition, and eyelid fissure asymmetry with botulinum toxin
type A. Plastic and Reconstructive Surgery 114:1892–1902
Fagien S, Brandt FS 2001 Primary and adjunctive use of botulinum
toxin type A (Botox) in facial aesthetic surgery: beyond the
glabella. Clinics in Plastic Surgery 28:127–148
Fagien S, Raspaldo H 2007 Facial rejuvenation with botulinum
neurotoxin: an anatomical and experiential perspective. Journal
of Cosmetic and Laser Therapy 9(suppl 1):23–31
Fagien S 2010 Management of hypotrichosis of the eyelashes:
Focus on bimatoprost. Cosmetic, Clinical, and Investigational
Dermatology 3:1–10
Flynn TC 2003 Periocular botulinum toxin. Clinics in Dermatology
21:498–504

is important to be aware of proper conversions / dilutions
for each toxin (Table 17.1). Small errors in absolute dosage
make a large difference in the percentage of the intended
doses in this area. The activity of onabotulinumtoxinA
(Botox®) and incobotulinumtoxinA (Xeomin®) is mea­
sured in murine lethal units (U), with both agents avail­
able as 50 U or 100 U per bottle with unit equivalency.
It is best to use a higher concentration (e.g. 100 U/mL
for Botox®) in the mid- and lower face to minimize toxin
diffusion. Abobotulinum toxin A (Dysport®) activity is
measured in Speywood units (sU) with either 500 sU or
300 sU/bottle, with a typical dilution of 250 sU/mL.
As such, onabotulinum / incobotulinum toxin units and
abobotulinum units are not interchangeable, and the
exact conversion factor is controversial. According to
FDA-approved labeling for the treatment of the glabella,
1 U Botox® is approximately equal to 2.5 sU Dysport®.
However, studies have found abobotulinumtoxinA : ona­
botulinumtoxinA unit ratios to be in the range of 2.5–5 : 1.
Some studies such as that by Husseman & Mehta have
found abobotulinumtoxinA (Dysport®) to have greater
diffusion than onabotulinumtoxinA, meriting even addi­
tional caution given the intimately associated nature of the
muscles in this area.
Additional points to bear in mind when treating the
mid-face are that it is critical to avoid initial overtreat­
ment; a standard of low starting doses and upward dose
titration as needed should be adopted. Exact placement
of the neurotoxins is critical – and marking the injection
site before inserting the needle is suggested. Photographic
documentation of the marked sites can be a helpful part
of the patient’s records. The expectation that botulinum
toxin alone will achieve all of the aesthetic correction in
the mid-face is fallacious. Fillers are often used in this area
to correct age-associated volume loss. Botulinum toxins
can improve the appearance of the mid-face and, with
proper patient selection, rigorous knowledge of facial
anatomy and precise injection technique, toxins can prove
a useful tool in this area.
‘Bunny’ / nasal sidewall scrunch lines
‘Bunny’ lines or nasal sidewall ‘scrunch’ lines are angled,
horizontal rhytides that traverse the nasal bridge. While
not necessarily associated with aging, many patients find
them distressing as they convey the impression of distaste.
17 
Treatment of the mid-face with
botulinum toxin
Ian A. Maher, Timothy C. Flynn
Introduction
The mid-face is the region between the zygomatic arches
superiorly and the intercommis ural line inferiorly. The
mid-face has complex muscular anatomy demanding full
anatomical knowledge and precise injection technique.
The small muscles in this area are important in expressing
emotion, elevating the upper lip, and smiling. These
smaller muscles are more closely arranged than their
upper facial counterparts, and functionally integrated
through the superficial muscular aponeurotic system
(SMAS). The upper lip elevators function to produce a
smile and are essential for the accurate conveyance of
positive emotion. Even minor dysfunction of these muscles
can have dire social consequences. Injection in the mid-
face area is not for the novice injector, but can deliver real
and tangible benefit for the patient when applied
correctly.
The smaller mid-facial muscles require smaller doses
when compared with their upper facial counterparts,
especially in initial treatments. The advent of multiple
botulinum toxin formulations has added another layer of
complexity to this already challenging application and it
Summary and Key Features
•
The mid-face is an area of complex muscular
anatomy, with intimately associated, small muscles
•
Proper function of these muscles is essential for
accurate emotional conveyance, and particularly
smiling. Smile dysfunction can be profoundly
disfiguring
•
Small starting doses are necessary in the mid-face
to obtain desired results and avoid overtreatment,
and all precautions should be taken to maximize
proper placement and minimize diffusion
•
Careful patient selection and full exploration of the
risks and benefits of treatment should occur before
botulinum toxin injection in this area
•
Treatment of the mid-face is for the experienced
injector

118
Botulinum toxin
placed only superficially (i.e. intradermally, raising a bleb)
to avoid increased diffusion in the low-resistance subna­
salis plane. The typical dose ranges have been reported as
2–8 U for onabotulinumtoxinA on each side or 10–20 sU
for abobotulinumtoxinA. Figure 17.2 shows a patient
before and after bunny line treatment. If LLSAN has a
large role in the formation of bunny lines, and the patient
is a candidate for LLSAN treatment (as discussed below),
that area can be treated concomitantly.
Table 17.1  Mid-facial indications and dosages for botulinum toxin
Muscle
Indication
Onabotulinum / incobotulinumtoxinA
initial dosage (U) per side
AbobotulinumtoxinA initial
dosage (sU) per side
Nasalis
Bunny lines
2–8
5–20
Levator labii superioris
alequae nasii
Anterior gummy smile
Middle third of melomental fold
1–2.5
2.5–6
Zygomaticus complex
(zygomaticus major
and minor)
Facial asymmetry
Posterior gummy smile
1–2
2.5–5
Risorious
Facial asymmetry
Paracommissural wrinkles
1
2.5 U
Figure 17.1  The nasalis muscle traverses
the nasal bridge. The injection site for
chemodenervation of this muscle is labeled
with an ‘X’.
Depressor
anguli oris
Platysma
Mentalis
Nasalis
(transverse part)
Nasalis
(alar part)
Risorius —
present in
6% only
Depressor
septi
Depressor
labii inferioris
X
Pearl 1 
Bunny lines are highly variable. Inject the fold for best results.
Bunny lines may appear in individuals who have had a
number of BoNT-A treatments in the glabella. Bunny lines
result primarily from contraction of superior nasalis (pars
transversalis) fibers with accessory action from the levator
labii superioris aleque nasii (LLSAN) and inferomedial
orbicularis oculi.
Injection sites / dosage
Injection sites for bunny lines are highly individualizable,
as are the patterns of the lines. In general, one should
‘inject the fold’ within the following parameters. Injection
sites should be kept high on the lateral nasal sidewall
(Fig. 17.1) and well medial to the nasofacial sulcus to
avoid inadvertent LLSAN weakness. Injections need to be

119
17 
Treatment of the mid-face with botulinum toxin
flares the alar base superolaterally; therefore it can give
the appearance of a ptotic nasal tip on smiling. Finally,
maximal contraction of the LLSAN can contribute to
‘bunny lines’.
Treatment of this muscle is performed primarily for
two desired outcomes. The first is to treat ‘gummy smile’
by lengthening the upper lip in order to reduce the full
incisor and upper gum show, as demonstrated in Figure
17.4. Treatment of this muscle can also be used to attenu­
ate the medial nasolabial fold (NLF) in patients whom the
etiology is primarily muscular (young patients with a mild
to moderate NLF). As for the latter indication, it is impor­
tant to remember that lip lengthening will occur concomi­
tantly. Most patients in whom dermatoheliosis and soft
tissue descent are primarily responsible for the melolabial
fold, and in whom a ‘gummy smile’ is absent, will be
better served by filler injection for treatment of the melo­
labial fold.
Adverse effects
As with other applications of botulinum toxin, adverse
effects in this area stem from toxin diffusion and with
inadvertent weakening of surrounding muscles. Weakness
of the nearby LLSAN can lead to central lip droop
on smiling. This unpleasant adverse effect can be avoided
by keeping injection sites superficial and away from
the nasofacial sulcus. Weakness of orbicularis oculi can
lead to lower lid droop / ectropion or increased medial
scleral show.
Levator labii superioris alequae nasii
This small, but long, muscle originates on the medial
maxilla before bifurcating and inserting into the medial
orbicularis oris and nasal ala. Contraction of this muscle
has several sequelae. First, it works with the levator labii
superioris to elevate the upper central lip. Hyperactivity
of this muscle may lead to excessive elevation of the upper
lip on smiling and producing upper lip gum show or a
‘gummy smile’. The LLSAN’s dermal SMAS connections
contribute to the medial part of the melolabial fold It also
A
Figure 17.2  Bunny lines (A) before and (B) after 5 units of
onabotulinumtoxinA injected per side. The patient’s glabellar complex
was also treated with 6 units placed in the procerus and 8 units per
corrugator muscle.
B
Figure 17.3  The LLSAN is treated with a deep injection at the apical
triangle of the upper lip.
X
Pearl 2 
Start with 1 unit of the onabotulinumtoxinA / incobotulinum­
toxinA in this area. A little goes a long way and you can
always add additional units later.
Injection sites / dosage
The LLSAN should be injected at the pyriform aper­
ture / apical triangle of the upper lip, 1 cm above
the lateral extent of the ala (Fig. 17.3); inject 1–2.5 U
onabotulinum toxin per side in the supraperiosteal plane.
The effect can be long lasting (~ 6 months) making rigor­
ous patient selection and injection technique paramount.
Figure 17.4 shows a patient before and after botulinum
toxin injection to the LLSAN.

120
Botulinum toxin
Injection sites / dosage
The main indication for the treatment of these muscles
is restoration of facial symmetry and desired emotional
conveyance of facial expression, rather than rhytidosis.
In a proportion of patients, hyperactivity of zygomaticus
complex results in gingival show above the molars giving
rise to the ‘posterior gummy smile’. Patients can benefit
from botulinum toxin treatment of this area. Targeting of
these muscles for the treatment of rhytidosis – treating
the zygomaticus minor to attenuate the NLF – is fraught
with peril and other modalities should first be considered.
Relaxation of the zygomaticus minor can cause lip droop,
giving a simian appearance to the smile. Other modalities
may be advisable to avoid the risks of disfiguring the
smile.
When treating asymmetry, the cause should be care­
fully considered while making your corrective plan. In the
case of hyperdynamic asymmetry (muscular hyperactiv­
ity) the hyperactive side must be targeted to attenuate its
movement and more closely resemble that of contralateral
normoactive side. In the case of hypodynamic / adynamic
asymmetry (one side moves less or not at all, as in Bell’s
palsy, facial nerve paralysis, or surgical section of muscles),
the normoactive side can be injected, so that it moves less,
thus promoting symmetry.
Adverse effects
This technique must be used with care in correction of
the melolabial fold as patients who do not have associated
‘gummy smiles’ may experience unacceptable lengthen­
ing / droop of the central upper lip on smiling. Injection or
diffusion of the toxin inferiorly or superficially may erro­
neously target the superior fibers of the orbicularis oris
leading to dysfunction of the oral sphincter.
Zygomaticus complex
The zygomaticus complex is composed of the zygomaticus
major and minor muscles (Fig. 17.5). The zygomaticus
major originates laterally on the zygomatic arch deep to
the orbicularis oculi muscle and inserts in the modiolus.
It therefore pulls the lateral oral commissure superolater­
ally and dilates the oral aperture. Symmetrical movement
of this muscle is perceived as smiling, whereas unilateral
movement can give an impression of ‘sneering’. Addition­
ally, dermal connection of this muscle through the SMAS
may contribute to dimple formation.
The zygomaticus minor originates on the zygoma
medial to the zygomaticus major and inserts on the supe­
rior fibers of the orbicularis oris. Like the LLSAN, the
zygomaticus minor has dermal attachments through
SMAS that may contribute to the middle third of the
NLF. The zygomaticus minor may not be present in all
patients.
Figure 17.5  Anatomical drawing with the mid-facial musculature
labeled. The ‘X’ signifies the injection site for the zygomaticus minor,
at the intersection of a horizontal line drawn through the alar base,
and a line connecting the lateral canthus to the ipsalateral oral
commissure.
Levator labii
superioris
(reflected)
Zygomaticus
minor (present
in 36% only)
Zygomaticus
major — bifid
in 34%
Levator anguli
oris (deep)
Nasalis
Levator labii
superioris
aleque nasi
Levator labii
superioris
(superficial)
Zygomaticus
major
Risorius —
present in
6% only
Depressor
septi
X
Pearl 3 
Start with 1 unit of the onabotulinumtoxinA / incobotulinum­
toxinA in this area. A little goes a long way and you can
always add additional units later.
Figure 17.4  (A) Before and (B) 2 weeks following gummy smile
treatment, with 2 units of onabotulinumtoxinA injected per side in the
apical triangle of the lip.
A
B

121
17 
Treatment of the mid-face with botulinum toxin
Injection sites / dosage
The risorious injection site should be identified by drawing
a horizontal line through the oral commissure. Move
laterally along this line away from the oral commissure
for 2 cm. From this point enter the skin at a 30° angle
with the needle pointed laterally, away from the oral
commissure (Fig. 17.6). The typical risorius dosage is 1 U
onabotulinumtoxinA.
Adverse effects
Injection too medially in this location can lead to weaken­
ing of orbicularis oris with resulting oral sphincter dys­
function. This may be caused by the simple act of injecting
from lateral to medial surfaces instead of away from the
modiolus as described above.
Similarly superior or inferior deviation of toxin from
the intercommissural line may weaken the lip elevators or
depressors, which insert at the modiolus leading to facial
asymmetry.
Conclusion
The mid-face is an anatomically complex region with
smaller, more intimately associated muscles than the
upper face. These mid-facial muscles categorically have
important functions for the conveyance of emotion and
interpersonal communication in addition to their role in
the pathogenesis of rhytides. As such patients must be
carefully selected, and other corrective options, such as
fillers, explored. An inexperienced injector should not
attempt injection of these muscles.
Further reading
Ascher B, Talarico S, Cassuto D, et al 2010 International consensus
recommendations on the aesthetic usage of botulinum toxin
type A (Speywood unit) – Part II: wrinkles on the middle and
lower face, neck and chest. Journal of the European Academy of
Dermatology and Venereology 24(11):1285–1295
Figure 17.6  The injection site for the
risorious is located by drawing a horizontal
line through the oral commissures. Move
2 cm lateral to the commissure along that
line. The needle should enter the skin
at a 30° angle moving away from the
commissure, and remaining on the
intercommissural line to avoid inadvertent
paralysis of other perioral muscles.
Pearl 4 
Remember, when correcting asymmetry the side that is more
active should always be injected.
Regardless of indication, the zygomaticus complex may
be targeted in the following way. Draw a line connecting
the lateral canthus to the oral commissure. Draw a hori­
zontal line through the columellal base. The intersection
of these two lines in the mid-cheek is your desired injec­
tion site. Start with low doses (1–2 U incobotu­linumtoxinA
or onabotulinumtoxinA), with follow-up at 2 weeks for
reinjection if necessary. Remember, when correcting
asymmetry the side that is more active should always be
injected. Thus, when treating hyperdynamic asymmetry
inject the ipsalateral (hyperactive) side, and when treating
hypodynamic asymmetry inject the contralateral (normo­
dynamic) side. Additionally, although hyperdynamic
asymmetry may require higher corrective doses than other
indications in this area, it is always best to start low and
titrate up.
NLF correction with botulinum toxin relies on target­
ing the zygomaticus minor, which contributes to the for­
mation of the middle third of the melolabial fold. Whereas
some injectors may favor this, we believe that filler and
LLSAN injection represent safer options for this indica­
tion. Some patients with primarily dynamic NLF may
achieve benefit by attenuating the middle third of the
melolabial fold.
Risorius
This muscle arises from the parotid fascia and inserts on
the modiolus, functioning to pull the corner of the mouth
laterally, as in smiling. Hyperactivity can cause a sneering
expression and can also contribute to fine paracommis­
sural wrinkles.

122
Botulinum toxin
Basting RT, da Trindade R de C, Flório FM 2006 Comparative
study of smile analysis by subjective and computerized methods.
Operative Dentistry 31(6):652–659
Carruthers J, Carruthers A 2004 Botulinum toxin A in the mid and
lower face and neck. Dermatologic Clinics (22):151–158
Carruthers JD, Glogau RG, Blitzer A 2008 Advances in facial
rejuvenation: botulinum toxin type A, hyaluronic acid dermal
fillers, and combination therapies – consensus recommendations.
Plastic and Reconstructive Surgery 121:S5–S30
Husseman J, Mehta RP 2008 Management of synkenesis. Facial
Plastic Surgery 24(2):242–249
Mazzuco R, Hexsel D 2010 Gummy smile and botulinum toxin: a
new approach based on the gingival exposure area. Journal of
the American Academy of Dermatology 63(6):1042–1051
Raspaldo H, Baspeyras M, Bellity P, et al 2011 Consensus Group.
Upper- and mid-face anti-aging treatment and prevention using
onabotulinumtoxin A: the 2010 multidisciplinary French
consensus – part 1. Journal of Cosmetic Dermatology
10(1):36–50
Raspaldo H, Baspeyras M, Bellity P, et al 2011 Consensus Group.
Lower-face and neck antiaging treatment and prevention using
onabotulinumtoxin A: the 2010 multidisciplinary French
consensus – part 2. Journal of Cosmetic Dermatology
10(2):131–149
Sattler G, Callander MJ, Grablowitz D, et al 2010 Noninferiority
of incobotulinumtoxinA, free from complexing proteins,
compared with another botulinum toxin type A in the treatment
of glabellar frown lines. Dermatologic Surgery 36(suppl 4):
2146–2154
Spiegel JH, Derosa J 2005 The anatomical relationship between the
orbicularis oculi muscle and the levator labii superioris and
zygomaticus muscle complexes. Plastic and Reconstructive
Surgery 116(7):1937–1942
Toffola ED, Furini F, Redaelli C, et al 2010 Evaluation and
treatment of synkinesis with botulinum toxin following facial
nerve palsy. Disability Rehabilitation 32(17):1414–1418
Trindade de Almeida AR, Marques E, et al 2007 Pilot study
comparing the diffusion of two formulations of botulinum toxin
type A in patients with forehead hyperhidrosis. Dermatologic
Surgery 33(1):S37–S43

In the lower face, treatment strategies are traditionally
focused on volume restoration; however, controlling
hypermobility is also essential. Botulinum toxin is used as
monotherapy or as an adjunct to other procedures in lower
face rejuvenation. Treatment options include dermal
fillers, chemical peels, laser resurfacing, non-invasive
tightening modalities, and facelifts (with or without
chin / pre-jowl implants) (Table 18.1). Although rhytidec­
tomy can reduce the nasolabial and labiomandibular folds,
this procedure cannot enhance the lip region owing to its
anatomy. The perioral tissues include supportive ligaments
that must be preserved, and there is a high risk of motor
innervation injury affecting the perioral area through a
facelift. This is due to the buccal and marginal mandibular
branches of the facial nerve, which course superficially,
ramify extensively, and are challenging to identify. Motor
innervation injury leads to muscle weakness. A combina­
tion treatment with BoNT and fillers in the lower face
has emerged as the gold standard because it addresses a
broader spectrum of facial aging changes, without the
need for surgery.
This chapter aims to address the use of BoNT in the
orbicularis oris, mentalis, and depressor anguli oris (DAO)
muscles, as they directly affect the appearance of the
perioral and chin regions.
Anatomy
The perioral region, also called the lip unit, is one of the
facial cosmetic units. It extends from the base of the nose
(subnasal) superiorly to the nasolabial folds laterally, and
to the labiomental crease inferiorly. The free edges of the
vermilion borders subdivide this region into the upper lip
and lower lip. Below the labiomental crease is another
facial unit, the chin.
The upper lip is subdivided into the cutaneous upper
lip, the vermilion upper lip, and the philtrum. The lower
lip is subdivided into the cutaneous lower lip and the
vermilion lower lip.
The musculature of the perioral and chin area is
complex and includes the orbicularis oris, risorius, DAO,
zygomaticus major, zygomaticus minor, levator anguli oris,
levator labii superioris, levator labii superioris alaeque
nasi (LLSAN), depressor labii inferioris, mentalis, and the
platysma (Fig. 18.1).
18 
Orbicularis oris, mentalis,
depressor anguli oris
Fredric S. Brandt, Annelyse C. Ballin,
Jeremy B. Green, Joely Kaufman, Alex Cazzaniga
Introduction
Botulinum toxin (BoNT) chemodenervation has revolu­
tionized cosmetic surgery. Botulinum toxin treatments
complement, and in some cases preclude, traditional inva­
sive surgical procedures. Chemodenervation with BoNT
is the cornerstone of minimally invasive upper facial reju­
venation. The safety and efficacy of BoNT in the upper
face have been extensively documented. However, BoNT
use in the lower face is less well established in well-
designed clinical trials.
Summary and Key Features
•
Aging of the perioral and chin regions is
characterized by radial perioral rhytides (so-called
smokers’ lines or lipstick lines), decrease in
vermilion fullness, inversion of the vermilion,
lengthened appearance of the cutaneous portion
of the upper lip, downward turn of the oral
commissures, pre-jowl notch or sulcus, and chin
dimpling. Also, prominence of the labiomandibular
(marionette lines), labiomental, and nasolabial folds
occurs
•
The goal of treatment of the lower face with
botulinum toxin (BoNT) is to soften dynamic
rhytides through muscular relaxation instead
of completely paralyzing the target muscle
•
The muscular anatomy of the lower face is
complex; therefore caution is advised when
performing BoNT injections
•
BoNT can be used as monotherapy or as an
adjunct to other procedures in lower face
rejuvenation
•
BoNT as monotherapy can be used for younger
patients whose primary concern is not volume
loss, but rather fine dynamic and / or static radial
perioral rhytides due to muscular activity
•
A combination treatment of BoNT and dermal
fillers in the lower face has emerged as the gold
standard for lower face rejuvenation

124
Botulinum toxin
Table 18.1  Treatment options
Entity
Botulinum toxin
Dermal fillers
Laser resurfacing
Chemical peels
Non-invasive
tightening
Facelift
Vermilion
atrophy / inversion
√
Radial perioral rhytides
√
√
√
√
Marionette lines
√
√
√
√
√
Pre-jowl sulcus
√
√
√
√
Chin dimpling
√
√
√
Note: except for vermilion atrophy / inversion, all other entities are best treated with a combination of treatment options.
Figure 18.1  Musculature of the lower face: a) levator labii superioris
alaeque nasi, b) levator labii superioris, c) zygomaticus minor, d)
zygomaticus major, e) levator anguli oris, f) orbicularis oris, g) risorius,
h) DAO, i) depressor labii inferioris, and j) mentalis.
f
g
d
e
c
b
c
b
a
i
j
h
The orbicularis oris muscle origins are in the deep
surface of the perioral skin, the angle of the mouth, supe­
riorly the median plane of the maxilla, and inferiorly the
mandible. This muscle inserts into the mucous membrane
of lips. It is innervated by the buccal and mandibular
branches of the facial nerve. Its tonus closes the rima oris;
its phasic contraction compresses and protrudes the lips,
aiding mastication, expression, phonation, and the actions
of whistling, sucking, and kissing. Additionally, when
blowing this muscle has a role resisting distension. The
orbicularis oris muscle is necessary for correct speech and
allows for enunciation of the letters F, M, O, and P.
The mentalis muscle originates in the body of the man­
dible and inserts into the orbicularis oris muscle and the
skin of the chin. It elevates and protrudes the lower lip,
is important for drinking, and elevates the skin of the chin
when showing doubt. The mentalis is innervated by the
mandibular branch of the facial nerve.
The depressor anguli oris is shaped like a triangle with
the vertex located at the angle of the mouth. DAO arises
from the oblique line on the anterior mandible. Its fibers
blend with the orbicularis oris and are inserted into the
corner of mouth. The marginal mandibular branch of the
facial nerve innervates this muscle. Its main action is
pulling the angle of the mouth inferiorly and laterally.
Perioral and chin aging
Aging of the perioral and chin regions is characterized by
radial perioral rhytides (so called smokers’ lines or lipstick
lines), decrease in vermilion fullness, inversion of the ver­
milion, downward turn of the oral commissures, length­
ened appearance of the cutaneous portion of the upper
lip, pre-jowl notch or sulcus, and chin dimpling. Addition­
ally prominence of the labiomandibular (marionette lines),
labiomental, and nasolabial folds can occur (Fig. 18.2A,B).
The pathophysiology of the aging perioral and chin
regions is multifactorial, and culminates in the aforemen­
tioned aesthetically undesirable appearance. Extrinsic
factors, including smoking and sun exposure, can potenti­
ate intrinsic factors. An article published in 1965 by
Gonzalez-Uloa & Flores, perhaps the first comprehensive
study of facial aging elements, described the decreased
thickness and elasticity of skin, decreased adherence
between the skin and subcutaneous tissue, sagging of the
soft tissues, absorption of fat, resorption of the craniofa­
cial skeleton, and weakening of the muscles.
The paradigm of muscular involvement in the aging
face has shifted. It was thought that muscle weakness
and laxity caused downward displacement of soft tissue,
whereas current theories implicate persistent contraction

125
18 
Orbicularis oris, mentalis, depressor anguli oris
to DAO hyperactivity, the effects of gravity, mandible and
maxillary bone resorption, and fat absorption.
A prominent mentalis muscle can accentuate the
horizontal labiomental crease, or produce a cobblestone
appearance on the chin. Both effects are accentuated with
volume loss.
The labiomental fold is a horizontal fold located
between the lower lip and the chin (see Fig. 18.2A,B). It
is produced by the depressor anguli oris and the mandibu­
lar ligament. The nasolabial fold will be addressed in
another chapter.
The pre-jowl sulcus develops with aging as an indenta­
tion of the external inferior margin of the jawline between
the chin and the jowl, anterior to the marionette line. This
notching increases with aging due to atrophy of the soft
tissues and bone resorption.
The repetitive muscular actions of the orbicularis
oris and volume loss contribute to the radial perioral
rhytides.
Differences in the use of BoNT for the upper
and lower face
A ‘frozen’ corrugator or procerus muscle affects facial
expression, but does not present any functional problems.
In contrast, paralysis of the orbicularis oris, DAO or men­
talis muscles affect important functions such as oration,
expression, and mastication. Therefore, the goal in treat­
ment of the lower face is to soften the rhytides through
muscular relaxation rather than complete paresis of the
target muscle.
Beyond that, patients who require precise enunciation
and / or tight control of their lips such as singers, musi­
cians, and public speakers are not good candidates for
rejuvenation of the lower face with BoNT treatment.
The anatomy of the lower face is complex; therefore
caution is advised when administering BoNT injections.
and increased resting tone in the muscle’s role in facial
aging. Repetitive contractions wrinkle the skin in the same
way the act of folding and unfolding a paper eventually
causes a crease. The increased resting tone exerts constant
pressure on the underlying bone, favoring its erosion and
posterior remodeling, and projects underlying fat anteri­
orly. This forms the rationale for BoNT in facial rejuvena­
tion and explains its excellent results when used
consistently.
The marionette lines are a consequence of facial aging
and form as curvilinear wrinkles extending downward
from the oral commissures to the jawline. The etiology of
marionette lines is unclear, but they are probably related
Figure 18.2  Some aging perioral and chin areas characteristics:
a – prominence of the nasolabial folds, b – marionette line,
c – radial perioral rhytides, d – pre-jowl sulcus, e – vermilion atrophy,
f – prominence of the labiomental folds. Part (A) shows a, c and d;
part (B) shows a, b, c, e and f.
A
a
a
c
d
B
a
a
b
b
c
e
e
f
Pearl 1 
Always undertreat the lower face when using botulinum toxin.
Volume loss is often prominent in lower face aging;
therefore adjunctive use of fillers is usually necessary.
Rejuvenation
Patient selection for botulinum toxin perioral
and chin rejuvenation
Patients are encouraged to verbalize their concerns about
their face and their expectations of any intervention. A
handheld mirror is indispensible during the consultation.
If the patient has realistic expectations and the physician
feels that these expectations can be met with an acceptable
safety profile, the likelihood of success is maximized.
Botulinum toxin injections are extremely safe, but
patients who require precise enunciation and / or tight

126
Botulinum toxin
Preparation of botulinum toxin solution
Clinicians should use the BoNT dilution with which they
are most familiar. Our preferred dilution of BoNT-A
(Botox®, Allergan Inc., Irvine, CA, USA) is 2.0 mL of
preserved normal saline per 100-unit vial, yielding a con­
centration of 5 units of Botox®/0.1 mL. Injection occurs
with a half-inch (13 mm) 32-gauge needle attached to a
1 mL syringe (1 mL syringes are commercially available
with 50 gradation marks per syringe, allowing for precise
dosing at 1 unit of Botox® per gradation mark).
For the radial perioral rhytides a 1 mL syringe contain­
ing 0.1 mL of the solution described above is diluted with
0.9 mL of preserved normal saline. A concentration of 5
units of Botox®/mL is obtained, facilitating the injection
of 1 unit or less per point, and allowing a greater spread
of the toxin.
Dosage and injection technique
Prior to treatment, a topical anesthesia is applied to the
target region. The authors use 4% lidocaine.
When BoNT and fillers are used in the same session,
the authors prefer to administer fillers first.
Before injection the area is cleaned with an alcohol pad
and the patient is asked to repeatedly contract and relax
the target muscles, helping to aid in the visibility of the
targets.
The amount of units below refers to Botox®.
Orbicularis oris
Injections are placed along or slightly above the vermilion
border. Administration close to the vermilion border mini­
mizes the spread of the toxin to the surrounding muscu­
lature (LLSAN and zygomaticus minor), thus reducing the
risk of complications (Fig. 18.3A). Injections are superfi­
cial, just under the dermis.
control of their lips such as singers, musicians, and public
speakers are not good candidates for lower face and more
specifically perioral rejuvenation with BoNT.
After understanding the patient’s wishes, the physician
must choose which approaches are most effective and safe
(see Table 18.1). For the lower face, usually a combination
of approaches is necessary. Patients whose principal
concern is not volume loss, but the end results of muscle
hyperactivity, can benefit from BoNT as monotherapy
(Table 18.2).
Recently, Carruthers et al have shown that the combi­
nation treatment of BoNT and fillers is safe, more effec­
tive and longer lasting than either treatment alone.
Botulinum toxin and fillers can be used concomitantly
to enhance radial perioral rhytides, the downward turn of
the oral commissures, the lengthened appearance of the
cutaneous upper lip, the pre-jowl sulcus, and chin dim­
pling. Additional indications include reduction of labio­
mandibular (marionette lines), labiomental, and nasolabial
folds.
Target muscle
Orbicularis oris
Relaxation of the orbicularis oris muscle through the
use of BoNT can reduce radial perioral rhytides and
afford a slight increase in vermilion border eversion and
exposure.
Mentalis
Botulinum toxin injection into the mentalis muscle can
reduce chin dimpling (aka peau d’orange chin) and reduce
the prominence of the labiomental crease. It is very effec­
tive for the young patient with chin dimpling. However,
for chin dimpling and labiomental crease due to volume
loss, fillers are necessary adjuncts. Moreover, BoNT can
be useful as an adjuvant to fillers for patients with mentalis
diastases causing a bipartite chin.
Depressor anguli oris
Botulinum toxin into the DAO can reduce marionette
lines, the downward turn of the oral commissures, and a
long nasolabial fold, although again dermal fillers are gen­
erally required to optimize outcomes.
Table 18.2  Botulinum toxin as monotherapy
Muscle target
Patient characteristics
Orbicularis oris
Radial perioral rhytides
Depressor anguli oris
Oral commissure turned downward
without much volume loss
Mentalis
Dimpling chin
Pearl 2 
Inject the orbicularis oris near the vermilion border.
For the upper lip, the authors start with 1–2 units at
four uniformly spaced sites, up to 4 units. For the lower
lip, the authors inject 1 unit, up to 2 units, at two uni­
formly spaced sites.
Depressor anguli oris
Each DAO is treated with one injection into the mid to
lower thirds of the muscle where its fibers are more
numerous and are interspersed with fibers of the pla­
tysma, which also contributes to the inferior pull of the
oral commissures and accentuates the marionette lines.
The injections should be done laterally to the oral com­
missures to avoid injecting the depressor labii inferioris
muscle, which can cause lip protrusion. Care must also be
taken to avoid injecting so laterally that the buccinator
muscle is affected. The anterior border of the buccinator

127
18 
Orbicularis oris, mentalis, depressor anguli oris
Figure 18.3  Points of BXT injection: (A) orbicularis oris muscle;
(B) depressor anguli oris; (C) mentalis muscles.
A
B
C

128
Botulinum toxin
laterally, whereas paresis of the orbicularis oris is a result
of the injection being placed too superiorly; these may
affect speech or sphincteric function.
Further reading
Carruthers A, Carruthers J, Monheit GD, et al 2010 Multicenter,
randomized, parallel-group study of the safety and effectiveness
of onabotulinumtoxinA and hyaluronic acid dermal fillers
(24-mg/ml smooth, cohesive gel) alone and in combination
for lower facial rejuvenation. Dermatologic Surgery 36:2121–
2134
Carruthers A, Carruthers J, Monheit GD, et al 2010 Multicenter,
randomized, parallel-group study of the safety and effectiveness
of onabotulinumtoxinA and hyaluronic acid dermal fillers
(24-mg/ml smooth, cohesive gel) alone and in combination for
lower facial rejuvenation: Satisfaction and Patient-Report
Outcomes. Dermatologic Surgery 36:2135–2154
Carruthers JDA, Glogau RG, Blitzer A 2008 Advances in facial
rejuvenation: botulinum toxin type A, hyaluronic acid dermal
fillers, and combination therapies – consensus recommendations.
Plastic and Reconstructive Surgery 121(5S):S5–S30
Fitzgerald R, Graivier MH, Kane M, et al 2010 Update on facial
aging. Aesthetic Surgery 30(suppl):S11–S24
Gonzales-Ulloa M, Flores ES 1965 Senility of the face: basic study
to understand its causes and effects. Plastic and Reconstructive
Surgery 36:239–246
Le Louarn C, Buthiau D, Buis J 2007 Structural aging: the facial
recurve concept. Aesthetic Plastic Surgery 31(3):213–218
Semchyshyn N, Sengelmann RD 2003 Botulinum toxin A treatment
of perioral rhytides. Dermatologic Surgery 29(5):490–495
Vleggaar D, Fitzgerald R 2008 Dermatological implications of
skeletal aging: a focus on supraperiosteal volumization for
perioral rejuvenation. Journal of Drugs in Dermatology
7(3):209–220
muscle can be found by asking the patient to clench the
teeth. The injection can be placed slightly anterior to this
landmark (Fig. 18.3B).
Figure 18.4  Complication of DAO injection placed too medially
affecting the depressor labii inferioris.
Pearl 3 
Place injections into the DAO lateral to the oral commissure
and medial to the anterior border of the buccinator muscle.
Pearl 4 
When injecting the mentalis, stay close to the midline of the
inferior portion of the chin.
Two units injected below these points at the inferior
border of the mandible bone can be useful to further
smooth the inferior portions of the marionette lines.
The authors usually inject 4 units/side, but some
authors prefer 1–3 units/side, up to 7.5 units/side.
Mentalis muscle
The mentalis muscle may be injected with 3–5 units of
BoNT lateral to the midline at the chin’s prominence
(Fig. 18.3C).
Complications
Orbicularis oris
Complications include lip asymmetry, difficulty with
articulation or elocution, and inadvertent whistling. Che­
modenervation can also lead to difficulty drinking with a
straw and pursing the lips. Some patients may present
lengthening of upper cutaneous lip.
Placing injections just under the dermis, into the most
superficial layer of the orbicularis oris, can mitigate the
risk of these complications, as the function of the deeper
muscle fibers remains intact.
Depressor anguli oris
Injections placed too medially can affect the depressor
labii inferioris and cause flattening of the contour of the
lower lip (Fig. 18.4). Injections placed too high may reach
the orbicularis oris and result in problems with speech and
suction. Additionally, flaccid cheeks, asymmetric smile,
and lower lip weakness can occur.
Mentalis
Paresis of the depressor labii inferioris can occur when an
injection intended for the mentalis muscle is placed too

face and neck. It is becoming commonplace to treat the
depressor anguli oris, orbicularis oris, chin, masseter, and
platysma. These indications have the main objective of
‘lifting’ lower face features, sharpening the jawline, and
thus creating the clinical effect of a ‘mini-lift’.
Brandt & Bellman were the first to document their
clinical use of BoNT-A for the aging neck. The aging
process causes rhytides to appear on the neck and the skin
to become increasingly slack. The authors observed that
these effects diminished and appearance improved when
BoNT-A was injected directly into the platysma muscle.
They also noted an improvement in platysma bands that
procured ‘an overall tightening of the neck and recontour­
ing of the jawline’ even though their primary objective was
not to improve facial contouring. High doses (50–100
units onabotulinum toxin A) were used, with some
patients receiving as many as 200 units in one session.
When 50–200 units were employed, adverse events such
as muscle soreness, neck discomfort, mild neck weakness,
and headaches were reported by patients. This rather
expensive high-dose regimen translated into non-specific
aesthetic improvements and an important array of possible
unwanted side effects.
In this chapter we discuss how to use BoNT-A to treat
vertical platysma bands and horizontal neck folds, and then
we will focus on the ‘the Nefertiti Lift®’ – a ‘low-dose’
technique described in 2007 that restores a sharper and
more defined jawline while lifting the corners of the mouth.
The platysma: anatomy and dynamic
aesthetic clinical implications
The platysma is a large, flat cutaneous muscle stretching
from the upper décolleté to the mid cheek. It originates
inferiorly from the pectoralis and deltoid fascia. The fibers
ascend upwards and at the mandible some fibers insert
directly into bone under the mandible, its only bony inser­
tion. The other fibers blend into the modiolus, the depres­
sor anguli oris, the lower lip, the depressor labialis inferioris
and mostly continue to ascend above the mandible where
they blend into the SMAS (superficial muscular aponoretic
system). In the midline of the neck the platysma is absent
except when the fibers from each side decussate (inter­
twine) with the other side under the chin (Fig. 19.1).
When the platysma contracts it acts as a major depres­
sor on the skin of the lower face and the medial fibers and
19 
Platysma and the Nefertiti Lift®
Phillip M. Levy
Introduction
Botulinum toxin type A (BoNT-A) is now extensively used
for the upper face to correct wrinkling of the glabella,
forehead, and periocular regions thereby promoting reju­
venation and postponing the need for surgical intervention.
A more youthful and attractive appearance is achieved
when fillers are combined with BoNT-A to smooth rhyt­
ides and eradicate deep folds in the upper and mid face,
but the lower face and neck should not be ignored or there
could be a risk of creating an aesthetic imbalance.
As clinicians gain experience and confidence with
BoNT-A, they should consider treating areas of the lower
Summary and Key Features
•
The platysma acts as a major depressor in the
lower face
•
Anterior and posterior platysma bands can be
treated with a total of 10–30 units of onabotulinum
toxin A (BoNT-A) in women and with a total of
10–40 units in men (3–5 injection sites per band)
•
The Nefertiti Lift® uses BoNT-A to redefine and
sharpen the jawline whilst helping to lift the corners
of the mouth. Dosage is 15–20 units onabotulinum
toxin A per side injected intradermally
•
Complications such as dysphagia and dysphonia
can be avoided if injections are intradermal, there
is no excessive toxin migration, and the total dose
per session does not exceed 40 units
•
Asymmetric smile, a rare adverse event associated
with the Nefertiti Lift®, can be prevented through
precise dosing (maximum dose of 20 units
onabotulinum toxin A or equivalent per side, per
session) and accurate intradermal injection
•
Poor candidates for the Nefertiti Lift® include:
patients with excessive submental fat, heavy jowls,
or poor downward pull of the platysma with no
prominent posterior platysma band
•
Excellent candidates for the Nefertiti Lift® include:
patients with prominent posterior platysma band
and disappearing jawline with platysma contraction

130
Botulinum toxin
Platysma
posterior band contribute to lowering the corners of the
mouth. When the upper and lower parts contract they pull
the skin towards the center of the muscle like a com­
pressed accordion. This creates prominent anterior and
posterior vertical platysma bands at the two lateral borders
of the muscle and forcefully pulls down the lower cheek,
the corner of the mouth, and some of the lower lip.
Injection techniques for the neck
Vertical bands
After asking the patient to contract their platysma the
practitioner should hold the band to be injected between
the thumb and index finger. Deep intradermal injections
of 2.5–5 units should be injected equidistantly in 3–7 sites
per band. A maximum of 30 units for women and 40 units
for men should be respected per session (Fig. 19.2).
Horizontal folds
To treat horizontal neck folds approximately 2 units
should be injected in a superficial intradermal wheal raised
equidistantly in the folds themselves, for a maximum of
30 units per treatment session.
Pearl 1 
Overall total dose in the neck (all sites and indications
included) per treatment session should not exceed 40 units
of onabotulinum toxin A.
The Nefertiti Lift®
Nefertiti was an Egyptian queen famed for her beauty. A
statue of her bust can be seen in the Neues Museum in
Berlin. It is one of the most recognizable works from
Ancient Egypt thanks to her perfect facial proportions,
elegant neck, and sharp jawline and angle (Fig. 19.3).
The Nefertiti Lift® is a novel technique that is used for
the specific recontouring of the jawline. It relies on modi­
fying the elevator and depressor vectors in the zone
encompassing the corner of the mouth and the mandibular
border by weakening the platysma depressor action on this
area. This effect amplifies the elevator muscle dynamics
of the cheek and corner of the mouth resulting in sharper
skin draping along the jawline and creating the visual
effect of a ‘mini lift’.
The technique is straightforward; however, the com­
plexity of the musculature of the lower face requires
the physician to clearly identify injection points and use
precise doses and intradermal tangential injections of
BoNT-A to avoid adverse events such as asymmetric smile,
dysphagia, dysphonia, and anterior neck weakness.
Patients should be carefully assessed for their suitabil­
ity prior to treatment. To do this patients should be in a
sitting position then asked to pull down hard on their
platysma muscle to make the posterior vertical platysma
band clearly visible. If this action causes the mandibular
border to disappear it is a good indication that treatment
is likely to be successful (Fig. 19.4).
Prior to treatment, injection points under the mandible
going posteriorly and into the contracted vertical posterior
platysma band should be marked on the skin. Injection of
2–2.5 units of onabotulinum toxin A should be adminis­
tered intradermally and tangentially in four points, 1–2 cm
apart, under each mandible and into the upper half of the
posterior vertical platysma band for a total of 15–20 units
per side. In this way a double dose equating to 4–5 units
should be administered at the point where the horizontal
and vertical injection points meet (see Fig. 19.5).
Pearl 2 
Total maximum treatment dose of 20 units of onabotulinum
toxin A should be split 50% under the mandible and 50%
into the posterior platysma band.
During treatment of the platysma band the patient
should be asked to contract the platysma muscle and the
band should then be grasped and injected at the previously
marked points. For the four injections under the mandible
the patient should, on the contrary, be told to relax the
platysma.
Pearl 3 
The submandibular jawline injections are most effective when
placed under the mandible, the platysma is relaxed, and
injections are intradermal and tangential to the skin. Inject in
a posterior direction towards the mandibular angle.
Figure 19.1  The platysma muscle.

131
19 
Platysma and the Nefertiti Lift®
Figure 19.2  Anterior platysma bands: (A) before and (B) after treatment with BoNT-A.
A
Before
B
After
Patients should experience only the minor discomfort
during the procedure. As for any BoNT-A consultations,
patients should be followed up approximately 2 weeks
after their initial treatment and touch-ups performed if
necessary.
The average duration of effect with the Nefertiti Lift®
is 6 months and patient satisfaction is very high.
CASE STUDY 1 
‘I don’t want cosmetic surgery!’
A 50-year-old female patient with no previous experience of
aesthetic procedures consulted for global facial rejuvenation.
She emphasized that she did not want surgery but would
consider minimally invasive treatment requiring no recovery
time. Her main concern was how to avoid having to admit to
her husband that she had had aesthetic treatment.
Clinical assessment showed that she would benefit from
relaxation of the glabella and periocular regions as well as
recontouring of the lower face. To test her suitability for the
Nefertiti Lift®, she was asked to strongly contract her platysma
muscle. Upon contraction the platysma bands were prominent
and the jawline was completely effaced. This confirmed that
she would be an ideal candidate for this procedure.
BoNT-A was used to treat the upper face according to
standard protocols. For the lower face 20 units of BoNT-A
were injected under each mandible and into the top part of the
posterior platysma band on each side of the neck (Fig. 19.5).
Following treatment, the patient was invited to return for a
follow-up visit 2 weeks later. At the second visit the patient
expressed her delight with the results. She had suffered
minimal discomfort during the procedure and reported no
adverse events. She had received compliments on her ‘relaxed
and glowing’ appearance from family and friends and said she
felt more attractive.
The before and after photographs clearly illustrate the effect
of the Nefertiti Lift® in redefining the jawline, reducing jowling,
and improving skin laxity (Fig. 19.6).
Pearl 4 
There is no aesthetic benefit in injecting lower than the top
half of the posterior platysma band.