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Neuromodulators in the Lower Face: Guidelines for Success


Posted: 6/28/2013

Editor's Note:

Botulinum neurotoxin type A products for aesthetic use are approved by the US Food and Drug Administration for the temporary improvement in the appearance of moderate to severe glabellar lines associated with procerus and corrugator muscle activity in adult patients younger than 65 years of age. Other uses are off label.


Are there any special considerations for using botulinum toxin in the lower face?

Response from James Spencer, MD
Professor of Clinical Dermatology,
Mount Sinai School of Medicine,
New York, New York;
Private Practice, Spencer Dermatology,
St. Petersburg, Florida

Much care must be taken when using neurotoxins in the lower face. The muscles of the lower face are essential for many functions of daily life -- such as talking, eating, and facial expression -- and complete paralysis is unacceptable. In addition, the musculature of the lower face is highly integrated, making this area extremely sensitive to excessive neurotoxin dosing and imprecise injection.

Despite these cautions, judicious use of neurotoxin in key locations can be an effective strategy for softening wrinkles in the lower face. An experienced injector with a solid understanding of facial anatomy and who applies a precise injection strategy can achieve favorable results without affecting vital function. The following muscles are commonly treated in the lower face:

  • Depressor anguli oris (to soften marionette lines)
  • Mentalis (to soften lines and skin pebbling in the chin)
  • Orbicularis oris (to soften lip lines)

Treatment of each of these muscles requires a careful injection and dosing strategy. In general, effective dosing in the lower face tends to be quite low and injectors should be conservative when making dosing decisions.

The specifics of how to approach treatment areas in the lower face is beyond the scope of this answer, but I encourage anyone interested in initiating treatment in these areas to take advantage of expert-led education, such as that available at major dermatology and plastic surgery conferences or through medical education providers such as Medscape.

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