The Botox facelift: new uses for botulinum protein

By Dr Peter Muzikants and Dr Lesley Jayne Wild

The use of Botox for cosmetic purposes began around 15 years ago with treatment for expression lines of the upper face, mainly the frown area or ‘cranky’ lines. This was to be expected as the initial clinical paper published by the Canadian doctors, Carathers et al, described these wrinkle-erasing effects of the muscle relaxant botulinum toxin following the treatment of a medical condition called blepharospasm.

However, until now it was considered taboo to use Botox for cosmetic reasons on the lower part of the face. This was because the anatomical complexity of the lower facial musculature and uncertainty of dosage required meant there was a greater risk of unwanted muscles being affected, leading to uneven facial expressions. Of particular concern was the area around the mouth, which if adversely affected could have significant effects on chewing and speaking. Though only temporary in nature, this would be a significant handicap and, equally importantly, the facial distortion could prove quite embarrassing to explain to friends and foes alike.

Now, however, due to the increasing popularity and acceptance of Botox use for the upper face, the thinking on using it for the lower face has come 180 degrees. Botox use for the upper face has become firmly established as a reliable, reproducible and effective treatment without any long-term adverse effects. The subsequent increased use of cosmetic Botox has seen enormous improvement in our assessment, injection techniques and dosage regimes. Thus, the time seems right to tackle the previously forbidden areas of the lower face.

Currently, cosmetic doctors and patients alike are very familiar with the use of injectable Botox for the upper face to treat such areas as the vertical frown lines between the brows, crow’s feet smile lines at the side of the eyes and horizontal forehead lines. The muscles in these upper facial areas are relatively easy to assess, locate and inject and side effects can, therefore, be minimised relatively easily.

The use of Botox for the lower face is rather more complex because here it is used not only to reduce lines, but also to reduce creases by inducing a “lift” to an age-affected area. This can be achieved by carefully considering which facial muscles contribute to ‘lifting’ as well as those that act to pull the face downward (thereby increasing sagging of the facial features.) The general principle for consideration when assessing a person’s face is that for every muscle relaxed, another muscle will act to increase its contraction (or act in the opposite direction.) This effect is demonstrated when we treat the upper facial muscles with Botox – for example, when treating vertical frown lines. Essentially, the net direction (or vector) from using the frowning muscles is ‘down’ because they act to depress the eyebrow and narrow the eyes. So relaxing these muscles will allow the eyebrows to be raised, the eyes to be ‘opened’ up and the baggy, upper eyelid skin to be reduced. This occurs because the forehead muscles can now ‘lift’ more, without the opposing downward resistance of the frown muscles. Conversely, if Botox is injected into the forehead ‘lifting’ muscles, the result is a ‘drop’ of the eyebrow because the lifting muscles have been neutralized; thereby allowing the ‘down’ pulling frown muscles to win out.

This neatly demonstrates Botox’s ability to lift this facial area as well as removing some expression lines. The end result of our understanding of this process enables us to correct a whole lot more and we are, in a sense, achieving an upper face lift.

For the lower face similar actions are possible; in other terms, a lower face lift is possible too. Take for instance the very deep smile creases running from side of the nose to the corner of the mouth. These are the nasolabial folds. In this area some people have very strong muscles, so that when they smile they produce a “canine smile”. (This is a smile that shows an excessive amount of teeth and gums.) Many of these people may also have very deep nasolabial creases/folds that no amount of injectable filler can correct. Most also have a strong lip elevator muscle called the levator labii superioris alquae nasi. This is longish strap muscle originating from the side of the nose and inserts, or interdiginates, with the upper lip musculature. A small amount of Botox into this muscle can result in a dramatic improvement in deep smile creases and remove the gummy smile.

Another area of the face that has been cosmetically difficult to correct are the oral commissures (creases at the corners of the mouth) and downward drooping of the corner of the mouth. This gives people a sad, even stern or angry look. In severe cases patients may even complain about saliva drooling at the corners of the mouth. Deep dermal fillers can be one solution, but often even better results can be achieved by using Botox to ‘lift’ the drooping mouth corners – sometimes even eliminating the need for fillers altogether. This can be achieved by targeting a triangular muscle whose tip attaches to the corner of the mouth whilst its base attaches to the lower jaw/chin line. This muscle is the depressor angularis oris, which acts to pull the corner of the mouth down. Relaxing this muscle with ‘Botox’ will allow the other elevator muscles connected to the corner of the mouth to increase their upward pull. Hence, one sees the removal of the droopy mouth via lifting induced by Botox relaxing its opposite muscle vectors.

Often this droopy mouth problem co-exists with a strong chin muscle that pushes up the lip resulting in the development of deep mental (chin) crease and a puckered, cobblestone texture of the chin.. A small amount of Botox injected into the mentalis muscle can correct this phenomenon of ageing.

Another new use for Botox is in its ability to reduce the jowls, thereby creating a smoother jawline. To coin the current buzz-word, this is referred to as the “Nefertiti lift” (see figures 1 and 2.) The concept of using Botox in the neck area is not exactly new, as it has been done in the past – but big doses and large areas of the neck were treated, resulting in a very expensive temporary treatment with the added risk of the large doses used likely to induce unwanted side effects such as impairment of swallowing and speech, and even difficulty in holding the head straight. The Nefertiti lift relies on a more careful assessment of the musculature in the neck and lower face, resulting in a much smaller dose and fewer injections. The total dose is reduced by 50 – 70 per cent, making it more affordable, as well as providing the same, or even better, results without the risk of side effects. Perfect! But wait, there’s more… The condition of some of the looser, sagging neck skin can also be improved if Botox is injected further down each vertical platysmal neck muscle band. This allows the looser envelope of skin to sit closer to the neck. In simpler terms, this can be termed a neck lift effect.

The intention of this article is to demonstrate the dramatic evolution of cosmetic injectable products beyond the simple notion of being line fillers. As we study the changes in the aging face, we appreciate the different contributing elements. Tackling only one aspect will give some results, but may not be what we really expect. Solely surgically cutting and removing tissue to achieve lifting is almost last century’s concept. Today it’s all about restoring youthful facial features by replacing and re-establishing the balance, without surgery. Of course there will always be indication for surgery in more extreme cases, but hopefully the need will be delayed, or be less invasive, when that time arrives.

In conclusion, Botox can now be recommended for virtually the entire face and a Botox ‘facelift’ is within the realms of possibility. It must be stressed, however, that real risks of unexpected side effects such as asymmetrical results are still present. However, though noticeable, these are temporary with most subsiding after a few weeks. Alternatively, some may be corrected by touch-up injections to redress any imbalances.

In all, what this now allows for is a more natural way of reducing the signs of ageing without the need for early surgical intervention, especially when combined with injectable fillers.

For further information, contact Ada Cosmetic Medicine: (02) 9552 1442 or visit

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