better idea than flooding the dermis and sub-q with filler.
A no-downtime option here is toxin into the superficial fibers
of the orbicularis oris to reduce constant lip pursing.3
These patients can be identified with careful observation
as they hold tension in their lips and seem to be in a state
of constant pursed lips, looking stern and unfriendly. Here
I typically start with superficial injections of 6-8 units (Figures
9 and 10).
If when the patient smiles, the tip of the nose dips, 2-3 units
into the base of the columella can raise the tip and give it a
youthful lift. Injection into the upper lateral nose weakens the
nasalis “bunny lines†that can be strengthened from glabellar
injections.
When the patient smiles and the gums show, that is called the
"gummy smile". It is from excess action of the levator labii alaeque
nasi muscles. I start with 2 units into the canine fossa-ala
junction (Figures 11 and 12). Here again, better to under- than
over-treat. Over-treatment here results in both a longer distance
from nose to lip (which is very aging) and/or a Jimmy Carter -like
frozen upper lip. This technique is never a good idea in someone
with a pencil-thin upper lip.
Injections beyond the lips can also yield important results.
Injection of neurotoxin into the depressor angularis oris (the
DAO), is becoming a favored treatment to improve downturned
oral commissures.4,5,6
The results work best when combined with filler for any volume
loss in this area (Figures 13 and 14). Dimpled chins (golf-ball chin)
can be softened by injection into the mentalis muscle (Figures 15
and 16).5,7 When you combine toxin injections into the DAO with injections
into the superior platysma insertion at the prejowl sulcus,
a lifting effect can be seen at the jawline and a shrinking effect of
the sub-mandibular salivary gland can be seen as well. Combining
orbicularis oris injections with mentalis gives a rejuvenating effect
to the entire mouth/chin complex (Figures 17 and 18).
