10/10/2011

Here in Morristown New Jersey we offer a complete gamut of injectable services in addition to the surgical procedures. I believe that a plastic surgeon who is familiar with the anatomy of the facial muscles and their function, is best positioned to provide these services.

Botox will paralyze about a half-inch segment of any facial muscle where it is injected. It is therefore extremely important to know which muscle to treat and for what purpose. The facial muscles are there to give us expression. Some expressions are very important and should not be changed. For example smiling. Asymmetry should also be avoided. The knowledge of the facial musculature concerning Botox injection is absolutely essential.  As plastic surgeons we work around the facial muscles every day and we know the anatomy as a practical matter. The non-surgeons face a major disadvantage in this area. Below I have modified a facial anatomic drawing to show the various muscles treated with the neuromodulators. All these muscles occasionally cause unwanted effects on facial expression that can be treated with Botox or Dysport.

The muscles are usually paired and bilateral except the orbicularis oris which goes around the mouth and the procerus. The five muscle indicated on the left side of the above drawing are:

  1. The Procerus is a midline muscle that lifts the skin of the nose and lowers the medial aspect of the eyebrows. When it is hyperactive, it will  cause a horizontal line across the upper part of the nose, between the eyebrows.
  2. The pre-tarsal orbicularis oculi is indicated only to say that it should never be treated with Botox. This muscle is in charge of closing the eye and creating reflex blinking of the eyes to keep the eyes moist and prevent corneal drying.
  3. Levator Labi Superioris (LLS) raises the upper lip mostly during smiling. This muscle is occasionally treated with Botox to help with a gummy smile.
  4. Levator Alaeque Nasi raises the base of the nostril during smiling and in some cases gives the tip of the nose a droopy look. Treating this very thin muscle will help this situation.
  5. Depressor Anguli Oris pulls the corner of the mouth down and worsens the marionette lines. It also can give a person a sad look. As you can see this muscle is more superficial than the depressor labi inferioris  which is slightly deeper and should not be treated with Botox.

On the right side of the drawing you can see the following muscles:

  1. Frontalis elevates the eyebrows. This action creates horizontal wrinkles on the forehead. If the function of this muscle is completely eliminated by a less knowledgeable injector the brow could droop lower with a dreadful result. Proper injection in this area could remove the most visible forehead line and achieve a pleasing brow position.
  2. Corrugator is a deeper muscle under the orbicularis and the procerus which I am showing on the right side, but this muscle exists on both sides. The corrugators depress the eyebrows and pull them medially causing the frown lines. The toxins can eliminate this muscle’s function and improve the frowning or the so called elevens. I would like to remark here that both Botox and Dysport are only approved to be used in this area. All the other uses are off label. This is ok because doctors are allowed to make the judgment to use a product for a different area for the benefit of the patients.
  3. Orbicularis Oculi is a sphincter muscle around the eyes that creates the crow’s feet. The medial and lateral aspect of this muscle lowers the brow. The central part of this muscle, the part which is over eyelid coartilages (tarsus), is responsible for the eyelid closure and causes the reflex blinking of the eyes. Judicious use of toxins in the orbicularis muscle as well as the procerus, frontalis and corrugators allows me to place the brow in its ideal position and eliminate the undesired lines and wrinkles.
  4. Orbicularis Oris is another sphincter muscle that helps close the mouth and keep the food and water from leaking out while we eat or drink. The function of this muscle is very important for the oral competence. The contraction of this muscle along with loss of elasticity in the skin creates vertical radiating lines in the lips. Occasionally careful minimal toxins in the upper lip can help the vertical lines. The lower lip is not injected in order to avoid drooling.
  5. Platisma Muscles exist bilaterally in the neck and go from the cheeks to the clavicle. Contraction of these muscles creates the bands seen below the chin on either side of the mid line and sometime further laterally. These muscles are superficial and present within the fatty layer immediately under the skin. The bands could be carefully injected with Botox to eliminate them. A deep injection in the neck can have terrible consequences.

All the other muscles of the face should not be injected even though they are in close proximity to the ones that we treat. Here, I am exposing the anatomy of the facial musculature and it’s complexity. It may be difficult for the lay person to understand this anatomic and functional unit that makes our face, but it is easy to realize that for the best results with these neuromodulators (Botox, Dysport), one should go to the most expert doctor, preferably a plastic surgeon who is really familiar with this anatomy. This wood increase the odds of getting the best possible results and avoiding complications. Neuromodulators ( toxins ) have been a great invention and a wonderful tool in experienced hands to give the patients results that were difficult to obtain in the past. This is definitely a serious procedure that should never be done casually in a party setting. It should be done carefully in an experienced doctors office, one patient at a time with no distraction.