Botox can help the lines that extend up and down from the upper and lower lips (lipstick lines), soften deep folds going from nose to mouth corner (nasolabial fold), and diminish the lines running from the mouth corner toward the chin (mesolabial fold). It can make the lip longer, and smooth out the chin. Botox will help mild-moderate wrinkles. More severe problems require fillers, laser therapy, or surgery.
Patient selection is the most important factor for successful cosmetic procedures. Wrinkles are smoothed by relaxing the facial muscles but not to the point of completely paralyzing the face and causing complications. Therefore, there may be a tendency to under treat initially and bring patients back for touch ups. People expecting huge changes immediately will be disappointed. People who require optimal control of the mouth like singers may risk compromising their careers. Because areas around the mouth are heavily worked (eating and talking), the Botox will wear off sooner there.
General Techniques
Good pictures should be taken before and after treatment to document results. Patients need to sign informed consent forms. Blood thinners are stopped 2 weeks before. Target muscles are identified with the patient contracting and relaxing the area several times. The area is cleaned and target muscles marked. Ice can be pressed on the skin immediately before injection for anesthesia and to help avoid bruising. Patients are treated setting up in a mechanical chair that can be flattened out of they become dizzy.
Wrinkles Around the Mouth
Lines around the mouth are from the orbicularis oris muscle that encircles the mouth. They worsen with age, smoking, and sun exposure. This muscle is necessary to close the mouth, to chew, to speak, and to show what mood your in. Botox is often used with fillers like collagen or Restylane to fill in deeper lines.
Botox may increase lip fullness. 1-2 units are injected at four evenly spaced spots along the upper lip margin. 1-2 units can be put along the lower lip border as well. Follow up can be done at 2 weeks and additional 1-2 unit injections can be given. Improvements do not last as long as on the fore head, and injections are needed every 2-3 months for best results. The side effects include an asymmetrical appearance and trouble kissing, sipping, and speaking. Complications can often be avoided by decreasing the dose by as little as 1 unit.
Injection sites for Botox treatment of vertical lip lines
Examples of vertical lip lines
Lip Lengthening
The gummy smile occurs when the levator labii superioris alaquae nasi (LLSAN) muscle pulls up the lip too high and exposes more gum than teeth. Injection of the LLSAN elongates the upper lip to show less gum during a smile. 1 unit is injected into the groove just outside of the nostril. A 2-3 week follow up is done with the option of more injections if necessary. Up to 5 units can be injected at each site. Risks include a disfigured smile with lip sagging, lip protrusion, and lopsided results. Overdone lip elongation can make you look like you have no teeth.
Before and after treatment for the “gummy smile”
Nasolabial Folds
The nasolabial fold is the groove that runs from outside the nostril to the corner of the mouth. In younger people in their 30-50’s, this is more from muscle activity and is better suited for Botox therapy. However, in older folks, cheek sagging contributes more to this fold and they may be better served with injectable fillers or face lifts.
Injecting the LLSAN helps smooth the upper and middle part of the fold. Injecting the cheek muscle may help but risks leading to sagging at the mouth corners. This may resolve in about 6 weeks. Marionette lines or drool lines are grooves that run from the mouth corners to the outer aspects of the chin. They are caused by activity of the depressor anguli oris muscle. It makes people look sad or angry. Treatment of this muscle can raise the corner of the mouth and give one a happier look.
Raising the mouth corners by injecting the depressor anguli oris muscle
When used with fillers, it can smooth out the drool grooves. Botox, 1-2 units is injected into each side. After 2-3 weeks more can be given with a maximum dose of 4-7.5 units per side. The injections must be placed just right. Too far inside and the lower lip sticks out making you look like Gomer Pyle. Injections too far outside hit the deeper chewing muscle and leads to biting and tearing up the inside of the mouth.
Chin Softening
An overactive mentalis muscle causes the apple dumpling or peach pit chin. It can cause a cleft in the chin as well. Peach pit chin is injected with 2.5-5 units of Botox at the end of the chin. The cleft chin is treated with 2 injections of 2.5-5 units each to get both bands of the double muscle. A total of 10-15 units can be given. Risks include trouble with speech and closing the mouth.
Injecting the mentalis Before and after treatment of the peach pit chin
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