Patient: A 44-year-old woman with a horseshoe-shaped mouth. When her facial muscles are at rest, it gives her the unintentional appearance of anger.
Treatment Issue: Combining botulinum toxin type A (Botox Cosmetic) and a filler agent, in this case Restylane, to correct the appearance of a downturned smile.
Treatment
Botox 3 units into each depressor anguli oris along with Restylane 0.35 cc apiece into each oral commissure.
Technique
Precise placement of both products is paramount. We recommend the principle of “filler first” before Botox, as our standard procedure is to massage the filler to achieve more precise placement. This must be done before injecting Botox in order to prevent unwanted diffusion of the toxin.
The Restylane is placed first while the patient seated upright. Each commissure is divided into a triangle and injections started with the medial arm of the triangle, using a mid-dermal linear threading technique. The material is fanned from medial to lateral, paying careful attention not to augment the redundant skin at the lateral commissure. The use of the fanning technique also helps subcise some of the fibrous banding in this area.
The patient is then asked to make a series of animated expressions to identify a few appropriate, small, serial puncture sites within this triangle. Gentle massage is then performed with a gloved hand with your index finger placed into the patient’s mouth and your thumb on the surface of the patient’s skin.
After the filler injection is completed, we next inject Botox. To ensure proper placement, request that your patient animate to demonstrate the depressor anguli oris. Ask the patient to “show his or her lower teeth”, which demonstrates the muscle very nicely. Carefully identify and palpate the muscle. Then position the syringe of Botox at the posterior aspect of the depressor anguli oris 3 mm above the mandible. Inject the Botox aiming the needle laterally. Of supreme importance is that the injection is at the posterior aspect of the muscle aiming laterally because too medial an injection can diffuse to the depressor labii inferioris and result in slurred speech.
Tips
1. Filler first to allow for massage.
2. Place the Botox by aiming laterally at the posterior aspect of the depressor anguli oris.
Points to Remember
Precision is a must because placing Botox too medially can lead to diffusion to the depressor labii inferioris, resulting in slurred speech.
Avoid treating wind instrument players, avid scuba divers/snorkelers, and broadcast journalists. Add to the consent form that this can lead to asymmetry or limited ability to whistle, drink from a straw, or enunciate “p” or “b” for several weeks.
Patient: A 44-year-old woman with a horseshoe-shaped mouth. When her facial muscles are at rest, it gives her the unintentional appearance of anger.
Treatment Issue: Combining botulinum toxin type A (Botox Cosmetic) and a filler agent, in this case Restylane, to correct the appearance of a downturned smile.
Treatment
Botox 3 units into each depressor anguli oris along with Restylane 0.35 cc apiece into each oral commissure.
Technique
Precise placement of both products is paramount. We recommend the principle of “filler first” before Botox, as our standard procedure is to massage the filler to achieve more precise placement. This must be done before injecting Botox in order to prevent unwanted diffusion of the toxin.
The Restylane is placed first while the patient seated upright. Each commissure is divided into a triangle and injections started with the medial arm of the triangle, using a mid-dermal linear threading technique. The material is fanned from medial to lateral, paying careful attention not to augment the redundant skin at the lateral commissure. The use of the fanning technique also helps subcise some of the fibrous banding in this area.
The patient is then asked to make a series of animated expressions to identify a few appropriate, small, serial puncture sites within this triangle. Gentle massage is then performed with a gloved hand with your index finger placed into the patient’s mouth and your thumb on the surface of the patient’s skin.
After the filler injection is completed, we next inject Botox. To ensure proper placement, request that your patient animate to demonstrate the depressor anguli oris. Ask the patient to “show his or her lower teeth”, which demonstrates the muscle very nicely. Carefully identify and palpate the muscle. Then position the syringe of Botox at the posterior aspect of the depressor anguli oris 3 mm above the mandible. Inject the Botox aiming the needle laterally. Of supreme importance is that the injection is at the posterior aspect of the muscle aiming laterally because too medial an injection can diffuse to the depressor labii inferioris and result in slurred speech.
Tips
1. Filler first to allow for massage.
2. Place the Botox by aiming laterally at the posterior aspect of the depressor anguli oris.
Points to Remember
Precision is a must because placing Botox too medially can lead to diffusion to the depressor labii inferioris, resulting in slurred speech.
Avoid treating wind instrument players, avid scuba divers/snorkelers, and broadcast journalists. Add to the consent form that this can lead to asymmetry or limited ability to whistle, drink from a straw, or enunciate “p” or “b” for several weeks.
Patient: A 44-year-old woman with a horseshoe-shaped mouth. When her facial muscles are at rest, it gives her the unintentional appearance of anger.
Treatment Issue: Combining botulinum toxin type A (Botox Cosmetic) and a filler agent, in this case Restylane, to correct the appearance of a downturned smile.
Treatment
Botox 3 units into each depressor anguli oris along with Restylane 0.35 cc apiece into each oral commissure.
Technique
Precise placement of both products is paramount. We recommend the principle of “filler first” before Botox, as our standard procedure is to massage the filler to achieve more precise placement. This must be done before injecting Botox in order to prevent unwanted diffusion of the toxin.
The Restylane is placed first while the patient seated upright. Each commissure is divided into a triangle and injections started with the medial arm of the triangle, using a mid-dermal linear threading technique. The material is fanned from medial to lateral, paying careful attention not to augment the redundant skin at the lateral commissure. The use of the fanning technique also helps subcise some of the fibrous banding in this area.
The patient is then asked to make a series of animated expressions to identify a few appropriate, small, serial puncture sites within this triangle. Gentle massage is then performed with a gloved hand with your index finger placed into the patient’s mouth and your thumb on the surface of the patient’s skin.
After the filler injection is completed, we next inject Botox. To ensure proper placement, request that your patient animate to demonstrate the depressor anguli oris. Ask the patient to “show his or her lower teeth”, which demonstrates the muscle very nicely. Carefully identify and palpate the muscle. Then position the syringe of Botox at the posterior aspect of the depressor anguli oris 3 mm above the mandible. Inject the Botox aiming the needle laterally. Of supreme importance is that the injection is at the posterior aspect of the muscle aiming laterally because too medial an injection can diffuse to the depressor labii inferioris and result in slurred speech.
Tips
1. Filler first to allow for massage.
2. Place the Botox by aiming laterally at the posterior aspect of the depressor anguli oris.
Points to Remember
Precision is a must because placing Botox too medially can lead to diffusion to the depressor labii inferioris, resulting in slurred speech.
Avoid treating wind instrument players, avid scuba divers/snorkelers, and broadcast journalists. Add to the consent form that this can lead to asymmetry or limited ability to whistle, drink from a straw, or enunciate “p” or “b” for several weeks.
