The majority of patients seeking treatment for fine lines and wrinkles will be mainly concerned initially with the upper third of the face, notably the forehead, frown and eye areas. In my experience once they have experienced your clinical and patient skills they will seek additional areas to be corrected with Botulinum Toxin A.
In this article I will look at the areas we can treat in the lower third of the face. Before we look at specific areas, I need to draw your attention to the slightly different approach we have for treating the lower third of the face compared to the upper third.
In the upper third of the face the muscles are large and generally independent of each other, therefore we are not overly concerned with the spread and diffusion of the toxin. However, in the lower third of the face, the muscles are generally much smaller and in close proximity to a number of other muscles. Therefore we need to be wary of the diffusion and spread of our toxin much more. I practice the technique of baby stepping when treating the lower third with toxin. I would rather they come back fro a review appointment and administer any top ups than over dose and cause unwanted side effects in neighbouring muscles.
* When discussing specific units, I will be referring to Azzalure® and Speywood units in the following examples.
Not technically in the lower third of the face, but I thought it would be advantageous to talk about this area. These lines appear on the side of the nose when the patient scrunches their nose. The lines are the result of the contraction of the naslis muscles.
I would normally inject 10 Speywood units on each side at a superficial level no more than 4mm depth maximum. you don’t want to go to deep since you will hit bone and this will be painful to the patient. You would inject where the biggest mass of muscle is.
These are vertical rhytides that occur in the upper lip and lower lip region. These lines occur from the contraction of the Oribcularis Oris. This is a circular muscle around the lower and upper lip. It is responsible for the closure of the lip and pushing the lips forward (puckering/pouting). it is common, but not limited to smokers.
There are 3 ways to treat these lines:
dermal fillers only
combination of both
My criteria for treating with toxin only is if the lines are superficial, worsen when the patient pouts their lips and the patient does not want any fillers to increase the size of their lips. I do warn these patients that we cannot guarantee to eliminate the lines. The toxin is placed very superficially and I would place as a starting point no more than 5 Speywood units per injection site. I avoid the philtrum area and inject close the the vermillion border. I warn the patient that they may feel numb and find it hard to whistle or say certain letters for a couple of days post procedure.
Dermal filers would be used in isolation if the patients main concerns are the lack of volume in the lips, lack of definition of the vermillion border and they do not want any toxin placed.
If the lines are very deep and do not worsen when they pout their lips, then I would sue a combination of toxin and dermal fillers. The toxin will help relax the muscle and the dermal filler will increase the volume of the lips/borders to help stretch the skin and reduce the appearance of these lines.
I always tell my patients that we cannot guarantee to eliminate the smokers lines and they may need additional treatments such as laser skin resurfacing.
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