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Surgery and Cosmetics

Botulinum Toxin Around the Mouth

Doris M. Hexsel, MD, Mariana Soirefmann

Wednesday, June 15, 2011

Botulinum toxin (BT) type A is a highly effective treatment for facial rejuvenation. It blocks the release of the neurotransmitter acetylcholine, which is essential for neuromuscular transmission.1 Therefore, injections of BT relax the target muscles, successfully treating dynamic wrinkles, as well as changing the shape and position of important facial structures. BTs can also delay or prevent the need for more invasive surgical procedures, eg in the treatment of gingival smile. They can be safely combined with a series of other invasive and minimally invasive procedures, including fillers, peelings, lasers and lights, improving the cosmetic results and patients' quality of life.2

However, despite being popular and used for more than 20 years in dermatology, the use of BT in the lower face remains a challenge.

Facial Aging

Facial aging results from the association between several extrinsic and intrinsic factors, leading to alterations in the skin surface and facial outline. In the lower face, a number of factors contribute towards aging, including muscular hyperactivity and volumetric losses. In this region, aging is characterized by horizontal lip stretching, downward oral commissures, an increase in the distance between the columella and the vermilion border, loss of lip thickness, perioral wrinkles, marionette lines, and a dimpled or peau d'orange chin.3

Better results can be obtained by combining BT with different cosmetic procedures, during either the same or different treatment sessions. The most common adjunctive treatments around the mouth are fillers, but chemical peels, microdermabrasion, lasers and lights, subcision and alternative surgical procedures can be used.4

BT Injections Around the Mouth

Several muscles in the perioral area can be treated with BT.5 The major muscle in this area is the orbicularis oris muscle, and its fibers control the direct closure and protrusion of the lips.1 The muscular effects of BT usually appear 24-72 hours after the injections, reaching a maximum at around 2 weeks6 and lasting approximately 4-6 months.7 However, around the mouth, low doses are recommended, aiming for slight muscular effects rather than an effective muscular paralysis.3 As such, a shorter duration is expected, eg 1-2 months.

AbobotulinumtoxinA (Dysport®) and onabotulinumtoxinA (Botox®) are the most widely used toxins worldwide. The dose equivalence between these products adopted by the present authors is 2.5:1U, which is supported by the literature.8 The recommended doses are described in Table 1.1,3

Table 1. Suggested doses of onabotulinumtoxinA (Botox®) and abobotulinumtoxinA (Dysport®) for the lower face. Doses are expressed in total number of units per treatment divided across both sides. 1,3,9 The recommended doses are based on panel consensus and/other publications.

Each patient requires a safe and effective individual therapeutic approach that meets doctors' and patients' expectations, with safety, harmony, balance and naturalness.9 Routines regarding office sets, antisepsis and pain control are followed as recommended. It is also important to treat the lower face when treating the upper face, and to avoid the use of low doses and repeated injections in order to prevent the formation of antibodies.10

The injections must be symmetrical, not only in relation to the injection sites but also to the doses applied, except in cases of asymmetries. Below are listed some of the conditions that can be treated with BT around the mouth.

Gingival Smile

Although simply an anatomic variant, gingival or gummy smile (GS) (Figures 1 and 2) can cause esthetic concerns.11,12 A classification for GS was recently proposed,12,13 and is shown in Table 2.

Table 2. Classification of gingival smile.12,13  BT, botulinum toxin; m, muscle.


Figure 1. Gingival smile at baseline. (Image courtesy of author.)


Figure 2. The same patient as shown in Figure 1, but 1 month after their treatment. (Image courtesy of author.)


Perioral Wrinkles

Perioral wrinkles appear on the upper and lower lips and give an impression of aging.1 Fine vertical lip rhytids are also called "smokers lines" or "bar code", and result from the combined action of the orbicularis oris muscle, photodamage, intrinsic aging and heredity factors.4 Keeping this in mind, adjunctive treatments are recommended. Injections of BT are applied at the vermilion border or up to 5 mm from the border (Figures 3 and 4).4 Injections at the corners of the mouth must be avoided, because they can lead to undesirable relaxation in the depressor anguli oris muscle.1

Caution is advised when selecting doses of BT for the treatment of perioral wrinkles in actors, musicians and singers.

Figure 3. Perioral wrinkles at baseline. (Image courtesy of author.)


Figure 4. The same patient as in Figure 3, but 1 month after their treatment. (Image courtesy of author.)


Marionette Lines

This common condition is usually treated by fillers, but adjunctive treatment with BT can be considered when the corners of the mouth are permanently turned down by the action of the depressor anguli oris muscle. The selected doses of BT are applied directly above the mandibular angle, along its rim and 1 cm lateral to the oral commissures bilaterally,14 in an imaginary line that follows the direction of the nasolabial furrow.

Dimpled or "Cellulitic" Chin ("peau d'orange")

This condition is mainly caused by the mental is muscle, which originates in the jaw, covers the chin, and inserts into the skin below the lower lip. Loss of collagen and subcutaneous fat may also be involved.15 Injections are applied bilaterally at the most distal point of the orbicularis oris muscle, at the prominence of the chin (Figures 5 and 6).1,15

Figure 5. Dimpled chin at baseline. (Image courtesy of author.)


Figure 6. The same patient as in Figure 5, but 1 month after their treatment. (Image courtesy of author.)


Face Lift

Some of the platysma muscle fibers are located above the mandibular bone and cause lowering of the skin in this region. This can be treated by BT injections along and under each mandible and to the upper part of the posterior platysmal band, with a low incidence of adverse effects (Figures 7-10).16

Figure 7. Indication for nefertiti lift (at rest). (Image courtesy of author.)


Figure 8. The same patient as Figure 7, but 1 month after the treatment. (Image courtesy of author.)


Figure 9. Indication for nefertiti lift (under contraction). (Image courtesy of author.)


Figure 10. The same patient as Figure 10, but 1 month after the treatment. (Image courtesy of author.)


Masseteric Hypertrophy

Hypertrophy of the masseter muscle usually starts during childhood and causes a gradual and painless increase of the inferior-posterior portion of the mandible, leading to an increased growth of the jaw and a square face.17 This can be aggravated by grinding of the teeth. Treatment of masseteric hypertrophy is via an injection into three points of each muscle treated. A high dose is chosen to induce muscular atrophy, which usually appears after 3-6 months (Figures 11 and 12).

Figure 11. Masseter hypertrophy at baseline. (Image courtesy of author.)


Figure 12. The same patient as Figure 11, but 1 month after the treatment. (Image courtesy of author.)


Treatment of Side Effects and Complications

The most common side effects of BT are usually a result of the injections, and tend to disappear within a few hours, days or weeks. These include pain, erythema, edema, hematoma, ecchymosis, headache and short-term hyperesthesia.

BT injections are considered safe as long as they are performed by an experienced physician, skillful in delivering small doses around the mouth. The main complications 5,18,19 that can arise from BT injections around the mouth are a result of the direct action of BT, incorrect doses or incorrect injection sites. The most important are asymmetries and unwanted paralysis of the muscles related to the mouth, causing difficulty in articulating words and incompetence of mouth functions. Ptosis of the upper lip and the corners of the mouth can also occur. As the doses of BT used are low and the expected effects are mild and transitory, treatment is not usually needed.


BT can be safely used around the mouth for a number of cosmetic indications in selected patients by following recommended doses and points of injection. Considering that the musculature in the lower face is directly or indirectly related to the mouth and that these muscles are responsive to low doses of BT, proper techniques should be used and doses carefully selected for this area.


  1. Ascher B, Talarico S, Cassuto D, et al. International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit)? Part II: wrinkles on the middle and lower face, neck and chest. JEADV 2010;24:1285-1295.
  2. Sadick NS. The impact of cosmetic interventions on quality of life. Dermatol Online J 2008;14:2.
  3. Carruthers JD, Glogau RG, Blitzer A. Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: botulinum toxin type A, hyaluronic acid dermal fillers, and combination therapies - consensus recommendations. Plast Reconstr Surg 2008;121(Suppl 5):5-30; quiz 31-36.
  4. Mazzuco R. Perioral wrinkles. In: Hexsel D, Almeida AT, eds. Cosmetic use of botulinum toxin. São Paulo: AGE; 2002:158-263.
  5. Carruthers J, Fagien S, Matarasso SL, Botox Consensus Group. Consensus recommendations on the use of botulinum toxin type A in face aesthetics. Plast and Reconst Surg 2004;Suppl 6:1S-22S.
  6. Salti G, Ghersetich I. Advanced botulinum toxin techniques against wrinkles in the upper face. Clin Dermatol 2008;26:182-191.
  7. Rzany B, Ascher B, Fratila A, et al. Efficacy and safety of 3- and 5-injection patterns (30 and 50 U) of botulinum toxin A (Dysport®) for the treatment of wrinkles in the glabella and the central forehead region. Arch Dermatol 2006;142:320-326.
  8. Karsai S, Raulin C. Current evidence on the unit equivalence of different botulinum neurotoxin A formulations and recommendations for clinical practice in dermatology. Dermatol Surg 2009;35:1-8.
  9. Hexsel D, Hexsel CL. Botulinum toxins. In: Robinson JK, Hanke W, Siegel D, Fratila A. Surgery of the Skin, 2nd Edition. Elsevier, 2010:433-446.
  10. Hexsel D, Mazzuco R, Zechmeister M, et al. Complications, adverse effects and treatment. In: Hexsel D, Almeida AT, eds. Cosmetic use of botulinum toxin. São Paulo: AGE; 2002:233-239.
  11. Coscarelli JM. Gingival smile: a new technique as an aesthetic solution. In: Hexsel D, Almeida AT, eds. Cosmetic use of botulinum toxin. São Paulo: AGE; 2002:198-203.
  12. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach based on the gingival exposure area. JAAD 2010;63:1042-1051.
  13. Benedetto AV. Asymmetrcal smiles corrected by botolinum toxin serotype A. Dermatol Surg 2007;33:S32-36.
  14. Carruthers J, Carruthers A. Aesthetic botulinum A toxin in the mid and lower face and neck. Dermatol Surg 2003;29:468-476.
  15. Kogos L. Mental wrinkles. In: Hexsel D, de Almeida AT, eds. Cosmetic use of botulinum toxin. São Paulo: AGE; 2002:167-170.
  16. Levy PM. The Nefertiti lift? J Cosmet Lasers Ther 2007;9:249-252.
  17. Park MY, Ahn KY, Jung DS. Botulinum toxin type A treatment for contouring of the lower face. Dermatol Surg 2003;29:477-483.
  18. Pena MA, Alam M, Yoo SS. Complications with the use of botulinum toxin type A for cosmetic applications and hyperhidrosis. Semin Cutan Med Surg 2007;26:29-33.
  19. Klein AW. Complications and adverse reactions with the use of botulinum toxin. Semin Cutan Med Surg 2001;20:109-120.