Which parts of the face can be safely injected with Botox?

Dr. BCK Patel MD, FRCS

For patients, residents, fellows, surgeons

Injection of Botox for Cosmetic Reasons

While there are several medical indications for botulinum toxin injection in the face and/or the neck, we are concentrating on the safe areas where judicious injection with botulinum toxin gives a pleasing result. 

1. Frown lines

Frown lines between the brows are often called "elevenses" or corrugator lines (vertical lines) or procerus lines (horizontal line at the bridge of the nose). However, overaction of the corrugator and procerus muscles can also give us oblique frown lines across the forehead and other, smaller lines around the brows. By injecting at the correct level and the correct amounts of botox, we can get a very nice relaxation of the corrugator and procerus muscles and improvement in these different lines. If the lines are well-established with collagen changes so that the grooves are visible even when one does not frown, a combination of a filler to fill the grooves and botox to relax the muscles is used. 

Impressive results with properly injected botox into the procerus and corrugator muscles

2. Forehead

This is where many surgeons who inject come a cropper! One has to use the finest touch to relax the frontalis muscle and improve but not completely eradicate the horizontal forehead lines. We see many patients whose horizontal frontalis lines have been abolished with the botox injections but the patient looks angry or firm or sad because the brows drop. The frontalis muscle dynamically keeps our brows in an elevated and more open position. Do not ask for all the lines to be wiped away!!

We use a micro-botox technique and slowly tease the frontalis muscle to learn to relax. This allows us to soften any forehead lines but also improve the overall appearance without dropping the brows. We also inject some micro-botox in the dermal layer of the forehead skin as it gives a nice improvement in the texture of the skin with reduction in the size of pores and a reduction in the activity of the sebaceous oil glands giving a healthier-looking skin.

3. Brow Tail

Patient frowning before (left) and after (right) injection with botulinum toxin into the corrugator and procerus muscles. Note the improvement in the shape and height of the brows and also the elevation of the brow tails

This is where subtlety and clever placement of the botox gives beautiful results. The orbital orbicularis muscle is a circular muscle that brings down the tail of the brows. When weakened sufficiently (but not completely), we get an elegant rise of the brows laterally which looks very pleasing in ladies. In men, we tend to give the injections to give a more horizontal brow so as not to effeminize the face. If overdone, you will end up with the "Spock" brow, which looked fine on old Spock but ......

4. Crow's Feet

Crow's feet wrinkles or rides "pattes d'oie". Also called "laugh lines" or lateral canthal lines. These radiate outwards from the lateral canthus of each eye and are caused by the concentric contracture of the orbicularis oculi muscle which is a circular muscle. Over time, these lines will extend well beyond the limits of the orbicularis oculi muscle because of secondary effects on the skin further out. 

Injections to soften crow's feet should be done superficially and lightly so as to reduce but not eliminate the movement of the orbicularis oculi muscle entirely. If injected too deep, the zygomaticus major and minor muscles may be affected and the smile of the mouth will be changed. 

The crow's feet area is very vascular: we use cooling simultaneously when we inject here. 

5. Bunny Lines

The bunny lines occur on the sides of the nose and are at 90 degrees to the underlying nasalis muscle. Here, again, one tries to soften the bunny lines and not completely eradicate them as the nasalis muscle is important in allowing us to flare the nostrils when more air/oxygen is needed as when exersizing, etc. 

6. Mentalis

The mentalis muscle is the "pouting muscle" as it everts the lower lip and protrudes it. This is a deep paired central muscle of the face. As we age, the mentalis causes little fluctuating movements of our chin often called dimpling. Botox is used to reduce this dimpling. Again the amount of botox injected is important so as not to change the function of the muscle as it applies to the lower lip. 

7. Depressor Anguli Oris

The depressor anguli oris (often abbreviated to DAO muscle) depresses the corners of the mouth. It is often called the "frowning muscle" because of this action of pulling the corners of the mouth down. It is a fan-like muscle that originates at the mandibular border and inserts into the modiolu sat the oral commisure. By weakening the depressor anguli oris, we allow the levator anguli oris to work unopposed and this allows the mouth corners to be elevated. If a patient is asked to curl the lip down to show the lower teeth, the DAO is seen to be active. 

Again, judicious amounts of injection must be administered to achieve an improvement in the corners of the mouth without changing the dynamic balance of the perioral region. 

Fillers in the melolabial folds together with botox into the DAO muscles gives a very nice improvement to this part of the face. 

A combination of fillers into the nasolabial and melolabial folds and injection of the depressor anguli oris muscle gives a more relaxed mouth shape

8. Lip lines and lip flip

Even in non-smokers, with collagen changes, patients will get lip lines that are vertical. They tend to be more obvious on the upper lip. These lip lines are usually treated with a laser, a filler to give a substantial improvement. The CO2 laser works best in this region. 

Micro-botox injections can also give a subtle but noticeable improvement in the lip lines. 

Lip Flip:  by using a small amount of botox into the orbicularis oris muscle, the lip will "flip" upwards and give the appearance of a more full lip. Although this is not a substitute for fillers, it is often performed in addition to fillers to recreate a more firm lip line. 

How long do the lip flip injections last? Because the amount of botox used is small, the effects wear off in about 8 weeks. 

Is a lip flip injection worthwhile if my smile disappears when I smile?  That is usually when the lip flip injections are most useful. By relaxing the orbicularis oris muscle, the upper lip does not get pushed down as much and therefore retains more of the lip show. 

Sites of injection of botox to achieve a lip flip

What is the difference beween a lip filler and a lip flip?

Lip fillers add volume to the lip and can be used to shape the lip. The white roll of the lips can be made more pronounced, thereby making lips look more youthful. The lip flip injections relax the orbicularis oris muscle and therefor allow the lips to look more "pouty" but there is no increase in the volume nor can it be used to form a firmer white roll or shape the lips.

What are the advantages of a lip flip when compared to a lip filler?

• the results of a lip flip are subtle and will give a gentle increase in the appearance of fullness of the upper lip
• useful for people who are against a filler or do not need much change in volume

What are the advantages of a dermal filler in a lip when compared to the lip flip?

• dermal fillers can be used to shape upper and lower lips
• volume is added and allows variable changes to be made in lips
• fillers will give a better improvement in vertical lip lines
• lip shape can be controlled more accurately
• fillers in lips will last about 6 months compared to 2 months for lip flip botox injections

9. Platysma

The platysma is a broad muscle in the neck which causes neck bands with aging. These are more visible in very slim patients. Even with an excellently performed facelift and neck lift, neck bands will commonly recur. Injecting botox into these bands will soften the platysma muscle and reduce the bands. 

Anatomy of the Platysma: platysma bands can be seen in this older-aged specimen

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