A 34-year-old Caucasian female with a complaint of vertical muscle columns around the mouth.
Using botulinum toxin A (onabotulinum toxin A) to soften radiating muscle columns, and to attempt to delay or to minimize the etching of imprinted lines around the mouth. Ever since the first reports on the cosmetic use of botulinum neurotoxin A (BoNTA) in 1990, the interest in this agent has been growing at a rapid pace, making it the most commonly performed cosmetic procedure today. This neuro-modulatory agent is synthesized by the Clostridium botulinum bacterium and is one of seven exotoxins produced by the species. Type B toxin has been approved for cervical dystonia, but the majority of procedures performed in the United States utilize type A toxin. At this point, onabotulinum toxin A (Botox) and abobotulinum toxin A (Dysport) both have cosmetic indication for glabellar use, while incobotulinum toxin A (Xeomin) currently only has therapeutic approval for cervical dystonia and blepharospasm. All BoNTA products act at the neuromuscular junction by clipping SNAP-25, a protein necessary for exocytosis. Consequently, they impair the release of acetylcholine and effectively temporarily denervate the adjacent targeted muscle. When used in small, carefully placed doses, BoNTA can help to improve dynamic rhytids by selectively reducing the muscle movement responsible for their formation. The success of onabotulinum toxin and abobotulinum toxin in softening glabellar musculature is due in large part to the highly reproducible nature of efficacy, a low rate of adverse effects, and its popularization in the mass media. Originally approved for the treatment of glabellar lines, their use first extended to other areas of the upper face (forehead and lateral canthal rhytids); now BoNTA is also commonly used off-label for the treatment of the lower face and neck. The perioral area is becoming an increasingly popular site for BoNTA injections in young women trying to delay the onset of vertically etched furrows. The treatment softens the muscle columns of the orbicularis oris and helps to minimize them from imprinting radiating lines around the mouth. In fact, treatment of this area not only improves the vertical lip lines, but also frequently gives the appearance of fuller lips (a so-called “pseudo-augmentation”). This is due, at least in part, to the decreased hollowing within the vertical muscular bands and to an apparent hyper-functional strap-like pull by the residual perioral muscles. Patient satisfaction in this area depends on the injector’s technique, as well as proper patient selection and realistic expectations. The ideal patient is one who has no or at most mild vertical resting lines etched into the skin texture. With moderate rhytids at rest — a condition typically seen earlier in smokers and sunbathers — a combination of BoNTA injection and other treatment modalities, such as soft-tissue fillers, laser resurfacing, dermabrasion, or chemical peels, may be employed for greater efficacy. As a word of caution, patients may sometimes experience a decreased ability to purse lips, whistle, drink from a straw, create a seal around a spoon, or enunciate the letters “p,” “b,” and, occasionally, “j” and “g.” Hence, this procedure is generally not recommended for broadcast journalists, musicians playing wind instruments and scuba divers.
Treatment of our Patient
We find it most helpful to treat both the upper and lower lips during each session to achieve a more uniform feeling in animation for the patient. Injections are placed superficially in the cutaneous lip, 1 mm to 2 mm from the vermilion border. When using a 31-gauge short-needle insulin syringe (BD, Franklin Lakes, NJ), the needle hub is inserted approximately halfway into the skin. Usually, two injections per quadrant are placed in each of the four quadrants, with a slightly larger dose used in the case of thicker muscle prominence. Additionally, a third injection may be performed superiorly on each side of the upper cutaneous lip (Figure 1) for taller muscle columns. For smaller muscle columns (ie, short, thin and shallow), a total of six units of onabotulinum toxin A is typically used, with four units injected into the upper lip and two units into the lower one (Figures 2A and B). When using abobotulinum toxin A, a total of 15 units is usually required. Patients with more significant — thick, tall or deep — muscle columns, similar to the present case, 8 to 10 units of onabotulinum toxin A or 20 to 25 units of abobotulinum toxin A are typically more appropriate. In either case, approximately two-thirds of the total dose is placed in the upper lip, with the remainder injected into the lower one.
A proper consent form discussing the specific risks of perioral botulinum toxin injection is recommended. In addition, pre-procedure perioral photographs at rest and with animation are very useful to serve as a baseline, and to help document the final cosmetic improvement during patient follow-up. Since injections into the perioral area tend to be associated with more discomfort than less innervated areas, cooling the area with ice immediately prior to the injection can be very helpful, as it may potentially lead to vasoconstriction and reduce the risk of bruising. Because of the small total dosage required for the treatment of this region of the face, a higher dilution of BoNTA using 2.5 mL to 5 mL of preserved saline is recommended. For the upper lip, two injection points spaced approximately 1 cm to 1.5 cm apart are usually selected along the vermilion border at the most prominent muscle column peaks on each side. In addition, as mentioned above, a third site, located 1 cm above the vermilion border, is frequently injected for those with longer muscle columns, as shown in Figure 1. It is very important to inject symmetrically on both sides to ensure preservation of the philtral position. For the lower lip, two sites of muscle prominence, spaced approximately 1.5 cm to 2 cm from the midline, are injected along the vermilion border on each side of the lip. Toxin is placed intramuscularly at these locations. To achieve this, the patient is first asked to purse his or her lips. The orbicularis oris muscle may then be pinched between the thumb and the index finger, thus allowing a better visualization of the injection depth. Pinching also serves to reduce the overall pain of the injection. Following the injection, mild pressure applied to the site for several seconds facilitates mild product diffusion and minimizes bruising. Icing may also be used post-operatively to reduce swelling and bruising.
1. Although generally safe, effective, and well-tolerated, BoNTA at this location is best reserved for patients with a history of successful results in the upper face. 2. Patients need to know that BoNTA will soften, but not completely prevent, vertical muscle columns with animation. With continued treatments, permanent etched-in lines in the perioral area may be minimized or, in some cases, prevented. 3. Toxin duration at this location is typically 7 to 10 weeks, shorter than that seen in other regions, but still on par with other highly dynamic areas such as nasalis lines. Thus, while the total number of units used per treatment session is small, patients treated for perioral rhytids usually become frequent customers for the practice. In addition, synergistic treatments, such as hyaluronic acid fillers, fractional perioral resurfacing and chemical peels, may often be employed several days after BoNTA treatment with enhanced results or, in the case of fillers, improved longevity. 4. Because of the small total dosage, a follow-up visit is recommended at 2 weeks following treatment to assure patient satisfaction, efficacy and symmtry. 5. Although the upper and lower lips may be treated separately, injecting both at the same time helps to avoid a common complaint of differential feeling between lips with animation. n Dr. Berlin is the Director of Mohs and Cosmetic Surgery at US Dermatology Medical Group in Arlington, TX. He is also Clinical Assistant Professor of Dermatology at the New Jersey Medical School in Newark, NJ. Dr. Berlin’s practice focuses on Mohs and laser surgery as well as cosmetic dermatology. Dr. Cohen is the Director of AboutSkin Dermatology and DermSurgery in Colorado. His practice focuses on Mohs surgery and cosmetic dermatology. He is Past President of the Colorado Dermatologic Society, and the Past Chair of the ASDS Patient Education Committee. He is also on the volunteer faculty as an Associate Clinical Professor at the University of Colorado Department of Dermatology. Disclosures: Dr. Cohen has performed clinical research in conjunction with Palomar Medical Technologies. Dr. Berlin has no disclosures relevant to the material or products discussed in the article. Sources 1. Carruthers JDA, Glogau RG, Blitzer A. Advances in facial rejuvenation: botulinum toxin type A, hyaluronic acid dermal fillers, and combination therapies – consensus recommendations. Plast Reconstr Surg. 2008 May;121(5 Suppl):5S-30S.
2. Semchyshyn N, Sengelmann RD. Botulinum toxin A treatment of perioral rhytides. Dermatol Surg. 2003;29(5):490-5.
3. Kadunc BV, Trindade DE Almeida AR, Vanti AA, DI Chiacchio N. Botulinum toxin A adjunctive use in manual chemabrasion: controlled long-term study for treatment of upper perioral vertical wrinkles. Dermatol Surg. 2007;33(9):1066-72.