Botulinum therapy of the perioral area

Authors:

Evgeniy Shagov , chief physician, co-owner of the aesthetic medicine center Anti Age Clinic , member of the international associations ESLD , AAAAM , national trainer for botulinum therapy at Ipsen Pharma (Ukraine, Donetsk).

Anna Shanina , dermatovenerologist, cosmetologist at the Anti Age Clinic aesthetic medicine center , national trainer for botulinum therapy at Allergan (Ukraine, Donetsk).

More than thirty years have passed since the appearance of botulinum neurotoxin preparations in the arsenal of clinical medicine. In 1987, Jean and Alastair Carruthers noted that patients who received botulinum toxin for blepharospasm had smoother wrinkles in the glabellar region. In 1992, they published the first paper on the use of botulinum neurotoxin type A for the correction of transverse wrinkles in the glabellar region. Thus began an era in minimally invasive cosmetic surgery [1]. According to English professor D. Lowe, botulinum toxin has opened a new era of non-surgical control of facial muscles.

Of course, in your practice you should use effective and the safest methods of aesthetic correction. As for working with the perioral area, the arsenal of techniques today is diverse. The most effective, from our point of view, include:

• injection procedures,
• hardware techniques,
• medium and deep chemical peels, dermabrasion with a milling cutter.

However, none of these methods, when used in isolation, achieves the desired therapeutic effect. It is also worth remembering the significant role that plastic surgery and dentistry rightfully occupy in the correction of this area.

Aesthetic correction of the perioral area using botulinum toxin injections is not among the officially approved indications for the leaders of this market - neither Dysport nor Botox. In other words, botulinum therapy in this area is an “off label use” technique (that is, the use of the original drug according to indications, dosage form, dosage regimen, for a population (for example, age group) or for other parameters of use not mentioned in the approved instructions ). The main, and often the only reason for the occurrence of such complications is the lack of qualifications of the practicing physician, primarily in the field of knowledge of topographic anatomy and techniques for botulinum therapy.

Twenty years of aesthetic botulinum therapy is a long period of time, during which approaches to the tactics of injections of botulinum neurotoxin type A have been significantly modified. These changes affected not only and not so much the knowledge of topographic anatomy (anatomy, in fact, remains unchanged), but the understanding of the role of this knowledge by the practicing physician and, as a consequence, the methodology for presenting the material. And second: in recent years, significant changes have occurred in relation to botulinum neurotoxin injection techniques (dosages, degree of dilution of the drug, points and depth of its injection). All this has made it possible to significantly increase not only the safety of botulinum therapy when working with the lower third of the face, but also its effectiveness in this anatomical area.

The purpose of this article is to review current data on botulinum therapy in the perioral area. In particular, the following tasks were implemented:

1. modern data on the topographic anatomy of the muscles of the perioral region are summarized;
2. provides data on modern botulinum therapy techniques for the purpose of aesthetic correction in this area, including data from the “Consensus of the International Expert Council on the use of botulinum toxin type A” [3];
3. The actual results of botulinum therapy in the form of monotherapy and within the framework of complex programs for aesthetic correction of the lower third of the face were systematized.

ANATOMY OF MUSCLES OF THE PERIORAL REGION

An in-depth knowledge of the three-dimensional anatomy of the perioral region is the main condition for successful and impeccably accurate botulinum therapy. It is also a guarantor of excellent therapeutic results with minimal predictable side effects, which, although temporary, are always difficult to tolerate by patients [2].

Considering the fact that the target of botulinum therapy, based on the main mechanism of action of botulinum toxin - muscle relaxation, is precisely the muscle fibers, more precisely the neuromuscular synapse, we should dwell in detail on the anatomy of the muscles belonging to the perioral region.

The main muscle groups responsible for motility of the perioral region are:

1. Levators:

• m. levator labii superioris et alaeque nasi,
• m. levator labii superioris,
• mm. zygomaticus major et minor,
• m. levator anguli oris,
• m. risorius.

2. Depressors:

• m. orbicularis oris ,
• m. depressor anguli oris,
• m. depressor labii inferioris,
• m. mentalis
• individual platisma cords .

To successfully correct the facial activity of the perioral region, it is necessary to understand in detail the three-dimensional anatomy of the muscles that are the “targets” of botulinum therapy.

Orbicularis oris muscle ( m . orbicularis oris ) [7,8,9,10]

According to the results of topographic-anatomical studies conducted by Expert2Expert doctors, the orbicularis oris muscle ( m . orbicularis oris ) consists of two separate parts. Its peripheral part ( pars peripheralis ), covered with skin, functions as a dilator, while the marginal part ( pars marginalis ) is located in the red border, occupies the anterior part of the frontal plane and performs the function of a sphincter. Its contraction ensures that the lips close and move forward.

A decrease in the skin tone of the upper lip, combined with hypertonicity of the orbicularis oris muscle, causes the formation of “purse-string” wrinkles around the lips. This phenomenon occurs as a result of involutional changes in subcutaneous adipose tissue and photodamage to the skin due to the negative effects of external factors such as ultraviolet radiation and smoking. However, loss of muscle tone, leading to the appearance of wrinkles on the upper lip, also occurs in young women, but the reasons for this are not yet well understood.

Muscle depressor anguli oris ( m . depressor anguli oris ) [5,11]

The depressor anguli oris muscle ( m . depressor anguli oris ) is a triangular muscle with a wide base, which is attached to the outer edge of the lower jaw. In the upper part, its fibers are woven into the deep layers of the dermis and intertwined with the fibers of the muscles located in the perioral region, forming a muscle knot, the so-called “ modiolus ”. This muscle is located posterior to the “puppet” wrinkles in the formation of which it participates. The muscle lowers the corner of the mouth, partly covers both the muscular belly of the muscle that lowers the lower lip ( m . depressor labii inferioris ) and the attachment points of this muscle to the bone.

This muscle is involved in the formation of “puppet” wrinkles and pulls the labial commissures downward, giving the face a sad expression.

Subcutaneous muscle of the neck ( m . platisma )

The subcutaneous muscle, or platysma [5], originates in the superficial fascia ( fascia superficialis ) of the pectoralis major ( m . pectoralis major ) and deltoid ( m . deltoideus ) muscles, crosses the acromioclavicular region, rises and attaches to the chin, labial commissures and anterior third of the edge of the lower jaw, posterior to the depressor anguli oris muscle and the mandibular muscle. Platysma pulls down the lower jaw and, together with the depressor anguli oris muscle, pulls the commissures of the mouth downwards and outwards. In order to correct marionette lines and labial commissures, some specialists inject botulinum neurotoxin into both muscles: the platysma and the depressor anguli oris muscle.

Muscle that lifts the upper lip and alae nasi ( m . levator labii superioris et alaeque nasi )

The fibers of this long narrow muscle are directed vertically - from the place of attachment to the bone at the base of the frontal process of the upper jaw to the place of superficial attachment to the skin of the upper lip and to the skin of the lateral region of the nostrils. The upper part of this muscle is thicker, and narrows downward at the place where it is woven into the skin.

The muscle is responsible for the formation of the groove in the upper third of the nasolabial fold and raises the wings of the nose and the inside of the upper lip. Injections of botulinum toxin into this muscle are aimed at correcting the exposure of the gums (the so-called gingival smile), reducing the depth of the upper part of the nasolabial fold and reducing the action of the muscle on the wings of the nose [5].

Mentalis muscle ( m . mentalis )

The mentalis muscle [6] is a flat, triangular-shaped muscle that originates on the anterior surface of the mandible at the level of the mental fossa, on either side of the symphysis of the mandible.

The oblique (downward-inward) muscle fibers of the left and right mental muscles form a central V-shaped triangle, which contains adipose tissue inside. The mentalis muscle is attached to the skin of the chin (lower area of attachment of the mentalis muscle) and, together with the muscle that depresses the lower lip, forms the mental groove (upper area of attachment of the mentalis muscle). Hypertonicity of the mentalis muscle causes the appearance of a tuberous chin (uneven skin texture), atrophy of skin, muscle and fatty tissues, deepening of the mental groove, raising and protrusion of the lower lip.

Injecting botulinum toxin into this muscle smoothes uneven skin texture, relaxes the chin and reduces the severity of the mental groove [2].

Muscle that depresses the lower lip ( m. depressor labii inferioris )

The depressor labii inferioris is a flat rectangular muscle that originates on the anterior surface of the edge of the mandible, inferior to the depressor anguli oris muscle, covering the exit of the mental nerve. The oblique (upward-inward) fibers of the muscle cover the exit of the mental nerve, intertwine with the fibers of the orbicularis oris muscle and attach to the deep layers of the skin of the lower lip.

The fibers of the depressor labii inferioris and the depressor anguli oris muscles diverge and form a V-shaped triangle (open upward). Muscle activity of the depressor labii muscle and the mentalis muscle leads to the formation of the mental groove. The depressor labii muscle turns and pulls the lower lip downward and outward [2].

TECHNIQUES FOR PERFORMING BOTULINUM NEUROTOXIN INJECTIONS

Below are current expert recommendations regarding aesthetic correction of the most common indications for botulinum therapy in the perioral area, including data from the “Consensus of the International Expert Council” [3]. Among them:

• radial wrinkles around the mouth (“purse-string” wrinkles),
• folds in the corners of the mouth (marionette lines or bitterness lines),
• gummy smile,
• lumpy chin (orange peel effect).

Radial wrinkles around the mouth (“purse-string” wrinkles)

Radial wrinkles around the lips make the face look very old. Injections of botulinum toxin preparations allow for fairly effective correction of these wrinkles. However, optimal results are achieved by combining botulinum toxin with the introduction of fillers along the border of the red border and in the area of the columns of the filtrum, restoration of lip volume and/or bite correction if necessary.

The most important role in the correction of static wrinkles and deep skin creases in this area belongs to methods of improving the condition of the skin in the perioral area (biorevitalization, chemical peels, dermabrasion, laser resurfacing, fractional laser remodeling).

When performing BTA injections in the perioral area, it should be remembered that the muscles located around the lips are involved in the implementation of important physiological functions. Therefore, correction of this zone must be carried out very carefully.

Injection points, doses and administration technique

To correct wrinkles around the lips, it is recommended to inject Dysport into 4-6 points: two points on each side of the upper lip and one point on each side of the lower lip, if necessary.

The injection points are located on the border of the red border of the lips, while the lateral points are marked at a distance of at least 1.5 cm from the corners of the mouth at the intersection of the border of the red border of the lips and vertical lines drawn from the outer wing of the nose. The medial points should be at a distance of 1 mm from the columns of the philtrum.

Recommended total dose for tone correction m . orbicularis oris is 4–12 Dysport units, 1–2 units are injected into each point. The dose is determined by the tone of the orbicularis oris muscle, the severity of hyperkinetic wrinkles and the degree of skin elastosis.

Injections are carried out superficially intramuscularly, the needle is inserted perpendicularly, shallowly, with only its cut being immersed.

Security questions

If too large a dose of BTA is administered, functional weakening of the lips may occur, leading to impairment of speech, food and fluid intake. Since complete removal of wrinkles is not the goal of the procedure, BTA must be injected shallowly and in a minimal dose. To ensure safety, injections should be started with small doses and gradually increased until the desired result is achieved.

Lateral points are placed as far as possible from the corners of the mouth to avoid possible asymmetry, drooping of the corners of the mouth and drooling.

For patients whose professional activities involve active work of the orbicularis oris muscle, this procedure is not recommended.

Correction of lower lip wrinkles using BTA injections is quite risky, so it should be avoided unless necessary.

“Marionette” wrinkles or “bitter folds”

Drooping corners of the mouth make the face sad or dissatisfied. In this case, it is recommended to prescribe complex therapy using BTA and fillers, which compensate for tissue depression in the commissure area of the lips and allow smoothing out “marionette” wrinkles running from the corners of the mouth to the chin.

Anatomical features of this zone

The corners of the mouth are raised due to the work of the zygomaticus major muscle and the levator anguli oris muscle. The corners of the mouth are pulled down by the depressor anguli oris muscle and the fibers of the subcutaneous muscle of the neck (platysma). The interaction of the levator muscles with the depressor muscles determines the position of the corners of the mouth.

Injection points, doses and administration technique

In order to lift the corners of the lips and smooth out marionette wrinkles, members of the International Expert Council recommend injections into the muscle that depresses the corners of the mouth, at one point on each side. The muscle can be easily palpated if you ask the patient to grind his teeth or make a grimace, implying downturned corners of the lips. The BTA injection sites are located just medial to the point of intersection of the edge of the lower jaw with the line continuing the nasolabial fold.

The recommended total dose is 10-20 Dysport units (5-10 units at each point). Patients with highly developed muscles that lower the angle of the mouth are given a higher dose of the drug.

Before performing the injection, the doctor isolates and fixes the muscle with his fingers. The injection is carried out intramuscularly, the needle is inserted perpendicularly to the middle third of the length (30 G needle, 13 mm long ).

Security questions

If you use too much BTA and/or inject close to the corners of the mouth, the effects of the toxin may spread to the levator muscles. As a result, adverse effects such as drooling, speech impairment, or mouth asymmetry may occur. Therefore, it is necessary to begin therapy with a shallow injection of small doses of the drug, placing the injection points at a sufficient distance from the corners of the mouth.

Gummy smile [2, 12, 13, 14]

In the literature, a gingival-exposing smile is defined as excessive (more than 2 mm) display of gingiva when smiling. This is a fairly common problem.

Some experts believe that a gummy smile is caused by the joint work of several facial muscles: the levator labii superioris and ala nasi, the levator labii superioris and the zygomaticus minor. Other authors believe that the orbicularis oris muscle and the depressor septum muscle are involved in the formation of a gingival smile. And finally, some experts link a gummy smile to the activity of the muscle that lifts the upper lip and ala nasal, emphasizing that this muscle is the only one that should be affected.

In addition to botulinum therapy, there are alternative correction methods that provide permanent results, but they are more invasive. For example, myotomy of the levator labii superioris muscle results in repositioning of the upper lip, while frenectomy involves removal of the frenulum of the upper lip. Subperiosteal dissection of the gingival mucosa in the upper jaw in combination with orthognathic surgery and subcutaneous dissection are also surgical methods for correcting a gummy smile.

As for non-surgical methods for correcting this type of unaesthetic smile, the injection of botulinum toxin into the levator labii superioris and ala nasi muscle, which is considered the main culprit, has proven effective. As long as injection technique is strictly followed, the results of this simple method are excellent and the risk of complications is low.

Injection points, doses and administration technique

The BTA insertion point is 5 mm below the orbital margin, on the inner canthal line. Insertion depth: deep, until contact with the bone. We recommend 5-7.5 units of Dysport per injection point.

Security questions

The injection points into the muscle that lifts the upper lip and ala nasi should not be too low. Otherwise, there is a risk of an asymmetrical smile as a result of diffusion of botulinum toxin into the orbicularis oris muscle. Diffusion results in a positive effect when the muscle is at rest, but also results in an asymmetrical smile.

Lumpy chin (orange peel effect)

Dimples on the chin are formed as a result of contraction of the mentalis muscle. Dysport injections can make your chin appear smoother. However, optimal results are achieved with combination therapy, including injection plastic surgery.

Injection points, doses and administration technique

When correcting a lumpy chin, the drug is administered at two symmetrical points located along the edge of the lower jaw closer to the center. The doctor determines the injection points by asking the patient to reach the tip of the nose with his lower lip.

The total dose is 10-20 Dysport units depending on muscle mass. In the case of simultaneous correction of drooping corners of the lips and dimples on the chin, injections are performed at the same points (4 points in total), but using a lower dose of BTA.

The injection should be intramuscular, shallow, the needle is inserted perpendicular to the surface of the skin to the middle third of the length (30 G needle 13 mm long ). Despite the fact that the mentalis muscle is located quite deep, shallow injections give good results.

Security questions

Injecting more than the recommended dose or injecting too close to the lower lip may impair the function of the depressor labii inferioris and orbicularis oris muscles, causing drooling, articulation problems, oral asymmetry, and ptosis of the lower lip. To avoid adverse events, you should adhere to the recommended doses and points of administration.

COMBINATION OF BOTULIN THERAPY WITH OTHER AESTHETIC CORRECTION METHODS

Correction of the perioral area is one of the most popular procedures in aesthetic medicine. Traditionally, this is the sphere of activity of three specialists: dermatocosmetologists, plastic surgeons, and dentists.

Involutional changes in the lower third of the face directly correlate with the state of the dental system, and often, the orthodontic status determines the limit of the possibilities of aesthetic correction. In the case of a violation of the physiological occlusion or the integrity of the dentofacial apparatus, the possibilities of dermatocosmetology are limited and in this case it is advisable to begin aesthetic correction with a visit to the dentist. High-quality orthognathic correction often allows you to restore the balance of the face, the function of closing the mouth at rest and the bony support of the lips, which certainly leads to increased attractiveness.

In case of excessive lengthening of the upper lip as a result of the aging process, the formation of excess skin and severe ptosis of the soft tissues of the face, the aesthetic correction program should begin with plastic surgery.

In all other cases, and these are the majority, aesthetic correction should begin with a visit to a dermatocosmetologist.

As noted above, the arsenal of methods for aesthetic correction of the perioral area today is diverse. According to our observation, the most effective ones include the following:

• injection procedures (introduction of fillers, botulinum therapy, biorevitalization and PRP therapy),
• hardware techniques (CO2 and erbium laser resurfacing, fractional laser and RF skin remodeling, IPL therapy, ultrasonic SMAS lifting),
• dermabrasion with a milling cutter, medium and deep chemical peels.

Often, none of these methods, when used in isolation, achieves the desired therapeutic effect 100%. The use of botulinum neurotoxin in monotherapy in the vast majority of cases gives results that are understandable and visible to the doctor, but, according to patients, are insufficient from the point of view of aesthetic correction.

This situation is even more relevant for a dermatocosmetologist practicing in Ukraine, since of the three types of skin aging - finely wrinkled, tired and deformed - the latter predominates among residents of Eastern Europe. This type of aging, by definition, is more difficult to correct than others using injection techniques, especially when it comes to the lower third of the face.

Therefore, to obtain excellent results, it is advisable to combine botulinum therapy with other methods of aesthetic correction:

• when correcting facial contours - with fillers, ultrasonic SMAS lifting, in some cases - radio wave lifting;
• when correcting the condition and texture of the skin - with biorevitalization and PRP therapy, laser technologies, IPL therapy, in case of pronounced age-related changes - with medium and deep peelings, dermabrasion with a milling cutter.

The time and place of botulinum therapy in complex programs for aesthetic correction of the perioral area depends on what procedures it is combined with:

• when working with fillers, it would be logical to first stabilize facial activity and achieve an optimal balance of depressor and levator muscles by introducing BTA in advance - 2 weeks in advance;
• when correcting the perioral area through the use of procedures that cause significant heating of the tissues and/or a significant improvement in microcirculation in them (laser skin correction, IPL therapy, ultrasonic SMAS lifting, medium and deep peelings), it is advisable to introduce BTA at the final stage of the program;
• when combined with procedures whose effects are aimed directly at the skin (biorevitalization, bipolar radio wave lifting, etc.), the use of BTA is also possible during the course (in an ideal situation - 1-2 weeks before or after other procedures).

CONCLUSIONS

1. Botulinum therapy is one of the main, effective methods of aesthetic correction of the perioral area.
2. The key to effective and safe work when correcting this anatomical area of the face is a deep knowledge of topographic anatomy and modern data on botulinum toxin injection techniques, as well as a high-quality clinical analysis of the face. According to the unequivocal opinion of world-famous experts, today our patients need not so much an ideal botulinum toxin (since it already exists), but rather an ideal doctor who knows exactly what drug is needed for this particular patient on this particular day, for this specific area and how to inject it correctly.
3. Each of us is either already such a specialist or can become one. It's all about our desire and readiness to receive adequate knowledge in sufficient volume. Fortunately, a sufficient amount of professional literature, video materials, and various types of training events are available today in our country.
4. To achieve the best results you need to: be a highly qualified doctor, use BTA injections in combination with other methods of aesthetic correction in this area.

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Source: KOSMETIK international journal, No. 2 (56), 2014, pp. 16-23