Clinical anatomy of the face in relation to contouring using fillers and botulinum toxin

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It would seem that you can learn something new about an anatomical area with which you have been working for quite a long period of time, periodically filling in knowledge from a variety of sources - from old notes and books from student times, posts from colleagues on social networks and to professional atlases, scientific research .

The lifestyle of a modern aesthetic medicine specialist is oversaturated with information and limited free time - sometimes it is very difficult to concentrate and find the necessary and at the same time useful information for your work in the most concise form. But thanks to the efforts of the authors Hee-Chin Kim, Kyle K. So, Hong-Ki Lee, Chisu Kim and editor I. E. Khrustaleva, you can purchase the book “Clinical anatomy of the face in relation to contouring using fillers and botulinum toxin,” which will become an indispensable assistant in clinical injection practice.

You can purchase the book via the link: https://afisha.bhub.com.ua/event/books/anatomiya-golovy-i-shei/klinicheskaya-anatomiya-lica-primenitelno-k-konturnoj-plastike-s-pomoshchyu-fillerov- i-botulotoxina

Section from the book “Clinical anatomy of the face in relation to contouring using fillers and botulinum toxin” :

2.1 Introduction

2.1.1 Indications for the use of botulinum toxin in the correction of wrinkles

Wrinkles (furrows) can be divided into dynamic and static. Static wrinkles, in turn, are divided into superficial and deep. Dynamic wrinkles appear in the area between the eyebrows when frowning or in the periorbital area when smiling. Eyebrow wrinkles and nasolabial furrows are examples of deep wrinkles. Wrinkles are dynamic at first and then become fixed over time. With age, fine wrinkles deepen and gradual atrophy of the underlying soft tissue occurs.

Although botulinum toxin is often considered the mainstay of wrinkle correction, its use is not effective for all wrinkles. Botulinum toxin injections are indicated mainly for the correction of dynamic wrinkles of the forehead, between the eyebrows, wrinkles around the eyes, in the dorsum of the nose, around the mouth, as well as platysma bands. The essence of the correction is to cause paralysis of the facial muscles located under the wrinkles. However, botulinum toxin injections are ineffective for deep wrinkles (furrows). In this regard, filler injections are recommended to correct deep wrinkles and pathological folds, including nasolabial folds, marionette lines and glabella lines.

Some statistical wrinkles and folds, such as horizontal neck folds and carpal folds, cannot be corrected with botulinum toxin because they are natural folds that are already present at birth. On the other hand, fine facial wrinkles, which are formed due to the habitual contraction of the underlying facial muscles, can be smoothed out to one degree or another with the help of botulinum toxin injections. Examples include wrinkles in the forehead, glabella and lateral canthus. There are several possible mechanisms of action of botulinum toxin in the correction of fine wrinkles. Firstly, it weakens the tone of the facial muscles located under wrinkles and attached directly to the skin. As a result, wrinkles at rest are smoothed out. Secondly, paralysis of the facial muscles intertwined with the dermis leads to difficulty in the outflow of lymph and the appearance of edema of the dermis, which also makes fine wrinkles and facial pores less noticeable.

The use of botulinum toxin is not effective for some types of dynamic wrinkles. Examples are transverse infraorbital wrinkles and zygomatic wrinkles, which are caused by contraction of the muscles that elevate the corners of the mouth when smiling. In addition, you should avoid injecting botulinum toxin into the area of the cheeks and nasolabial folds, where dynamic wrinkles deepen with contractions of facial muscles. When botulinum toxin is injected into the levator anguli oris muscles, such as the zygomaticus major, the smile may become uneven and asymmetrical. Such dynamic wrinkles can only be corrected by several intradermal injections of hyaluronic acid. (Figure 2.1).

Rice. 2.1 Localization of wrinkles, which can be corrected with botulinum toxin injections (With Saran Kim, 2016; with permission.)

The book “Clinical anatomy of the face in relation to contouring using fillers and botulinum toxin” is available for purchase here

2.1.2 Changes in muscle balance with botulinum toxin

Repeated contractions of facial muscles are one of the factors contributing to the formation of facial wrinkles. Unlike skeletal muscles, which are enclosed in a fascial sheath, facial muscles are not covered by fascia. Moreover, the fibers of facial muscles are woven directly into the dermis. Each fiber intertwines with others in complex ways, ultimately continuing into the SMAS. Thus, the facial muscles maintain a balance of thrust between the muscles of both halves of the face, as well as thrust directed up and down by the muscles of the same half of the face. In patients after an acute cerebrovascular accident with the formation of unilateral paralysis of the facial muscles, the muscles of the other, non-paralyzed side “work” more actively, resulting in a characteristic facial deformation.

Table 2.1 Levator and depressor muscles of the face

Figure 2.2 Diagram illustrating the concept of botulinum rebalancing. ((C) kwan-Hyun Youn, 2016 with permission.)

Similarly, when botulinum toxin is injected, subtle changes in facial expression may also occur due to unbalanced contractions of the facial muscles. The muscles on the side of the face opposite the side of the botulinum toxin injection contract more vigorously. This phenomenon can be called “botulinum rebalancing” (Fig. 2.2).

Facial muscles are divided into two groups: levators, or “lifters,” and depressors, or “lowers” (Table 2.1). The frontalis muscle is only a levator brow muscle, while the orbicularis oculi muscle, corrugator muscle, depressor brow muscle and proud muscle are all part of the depressor brow muscle group. The perioral muscles include five levators and three depressors. The levators of the perioral region include the zygomatic major and minor muscles, the levator labii superioris and ala nasi, and the levator anguli oris muscle. The group of perioral depressors includes the depressor labii labii muscle, the depressor anguli oris muscle, and the saphenous muscle of the neck.

Botulinum toxin can be effectively used to lift the eyebrow, corner of the mouth and cheek when it is sagging due to the effect of botulinum rebalancing. Depressor palsy caused by botulinum toxin injection can lead to elevation of the eyebrow, corner of the mouth, and cheek due to levator hyperactivity. This happens due to the mechanism of botulinum rebalancing. Raising the brow by weakening the brow depressor muscles, such as the orbicularis oculi, corrugator, and procerus muscles, is a prime example of botulinum rebalancing (Figure 2.3). Raising the corner of the mouth is also possible by weakening the depressors of the corner of the mouth. The injection of botulinum toxin into the subcutaneous muscle cords involved in the appearance of sagging cheeks (“jowls”) can to some extent help in correcting this aesthetic defect.

On the other hand, one of the unwanted side effects of botulinum rebalancing is the formation of new wrinkles near the injection area. For example, when botulinum toxin is injected only into the area of the lateral canthus, wrinkles located below the medial canthus become more noticeable. Rabbit lines may become more pronounced after botulinum toxin is injected into the area between the eyebrows.

If you are interested in the information from this section, you can purchase the full printed version of the book “Clinical anatomy of the face in relation to contouring using fillers and botulinum toxin”, available for purchase here