Botulinum Toxin Injection

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Complete Reflection



I’d like to introduce our next model here, Michelle, who is currently 33 years old. If we look at her face, we notice that her face shape is essentially oval, however, she has a prominent jaw, and this has the effect of perhaps making her face look a little bit more square. The reason for this prominent jaw is that she has a very hypertrophic masseter muscle, and she tells me that she clenches her teeth, especially at night, often leading to headaches. So we can see that if we were able to contour the jaw, we would be able to give her face a more oval and more attractive facial shape.


When we look at Michelle’s eyes, we will notice that she has thick bands below each eye – these are due to hypertrophy of the orbicularis oculi muscle. If Michelle smiles, we notice that they thicken even more, and this can lead to a heavy appearance of the lower eye. You will also notice that at rest she has a very narrow aperture of the eye, so the narrowed aperture plus the thickened orbicularis makes her a good candidate for Botox treatment in the infraorbital region. If we are going to do this, we should assess the skin and integrity of the lower lid. If I pinch the skin and pull it away, you notice that it snaps back immediately, and we would expect this because she’s young. Her distraction test is also normal, therefore we can treat her with Botox for this indication.


Let’s look at Michelle’s nose – she has a typical Asian nose, with a low, flat dorsum and a wide alar base. She is seeking an enhancement here, and by injecting along the dorsum, we can create more central projection, which may have the effect of narrowing the nose by creating better definition.


When Michelle smiles, notice that we can see excessive gum above her teeth, called a gummy smile, or smile with excessive gingival display. This is something that may be amenable to treatment as long as there are no other underlying causes, such as dental or skeletal issues. If I turn Michelle to the side, we can see in profile, she has, as we saw from the front, good cheekbone projection and a strong jawline. We can see some chin dimpling that is almost certainly due to an overactive mentalis muscle. We can also see, if I turn her a little bit more, that she has a flat dorsum of the nose and a very closed angle of the nasolabial area, and her current radix is in line with her lower lash line. Ideally, we want to increase the radix to the upper lash line, as this will give the appearance of a longer, sharper nose.


Finally, her nasolabial angle is very acute, probably less than 90 degrees, and we need to increase that to 100 degrees. When we view Michelle from the front, we are aware of some dimpling at the base of her chin at rest. If I get her to activate her mentalis muscle by bringing her lip out, we can see very extensive and diffuse dimpling due to an overactive muscle. This, again, makes her a candidate for Botox.

Injection site markings and treatment

When I treat Michelle for the hypertrophic orbicularis oculi, I first get her to smile. I will then approach her eye so that my needle is tangential to the globe. It needs to be very superficial, and ideally the patient should have their eye open. You need to warn them that it may be a little uncomfortable and that they may get a reflex tear. I create an intradermal bleb of 2 units and then I will move onto the other side and repeat the same action again. If you do see a little bleb appearing on the skin after treatment, this merely indicates a very superficial placement, which is ideal.

Treatment outcome at 6 weeks

Let’s welcome back Michelle at her 6 week review, we can instantly see that she has had a significant impact from her treatment, with now an obviously thinner and more contoured face due to the fact that we have achieved our jawline contouring. We can also see that at rest her chin appears smoother. Michelle underwent filler treatment to her nose, Botox to the infraorbital area, and Botox for gummy smile, mentalis, and jawline contouring. Let’s remind ourselves of what she looked like before, and we can instantly see that her eye aperture has opened up considerably, she has a more elegant nose, and the baseline dimpling she had has gone, but the most important change is the contouring in the jawline. If we look at her face shape, she has gone from square to oval. Now let’s look at her in animation – you can see she has a very nice, natural, pleasing smile, and when she smiles, she can open up the mouth without causing the excessive gingival display that she had pre-treatment. If we now also look at the gap between her nose, we can see that she has got improvement in the area between the nose and the upper lip, and we can also see that the eyes remain open during smile as the hypertrophic orbicularis aspect has been treated.


Finally, from profile, we are already aware of an improvement in her lateral profile, and we need to remind ourselves of what she looked like before – we can see a higher radix point, a significantly greater nasolabial angle, and also improvement in a chin and jawline contour. All of this has been achieved with combination therapy. Accordingly, Michelle has had a nice and subtle but impactful treatment with dermal filler and botulinum toxin.