The final article in this series on treating the face focuses on the lower aspects of the face, including the jowls, the chin and more.
The lower third of the face is probably the least understood and undertreated region of the face. Treating the lips is a large enough topic to be the subject of a separate article, so they will not be covered here. As with other parts of the face, global treatment is becoming more important and botulinum toxins and fillers (and maybe bimatoprost for that swarthy look) are common. Volume loss in the lower third of the face can be the most work to correct.
Treatment Options
Perioral rhytids are a frequent source of referral to a dermatology and/or plastic surgery practice. These may be treated with injections of botulinum toxins into the orbicularis muscle for lines caused by hyperdynamic muscles, as well as fillers. When filling these lines, it is important to select a filler that matches the depth of the line and thickness of the skin. For example, Belotero, Juvederm or Restylane will frequently be the appropriate filler for fine lines around the mouth. Injections made with a 30 or 32 gauge needle can minimize the risk of developing lumps and bumps. One other method for treating perioral rhytids involves reconstitution of fillers. When I reconstitute, I typically inject equal parts of either saline or lidocaine with Restylane, Belotero or Juvederm to achieve the correct consistency. Reconstituting the products in this manner helps to gently inflate the lines without creating the spokes that may be seen with products that are not reconstituted.
The chin and jowl area of the lower face is a region that deserves particular attention. This zone can lead to the most dramatic results of lower facial treatment. In women who are middle age or older, bone recession combined with mid-face laxity produce a jowl as the scaffolding and suspension systems diminish. I like to inject stiff fillers such as Perlane or Radiesse into the chin area to make the area more defined. Using 0.5 mL to 1.0 mL can produce dramatic results, and the addition of a well-defined chin can make a huge difference. Canadian and European physicians are using Voluma for this area.
Injections of botulinum toxins into the mentalis, masseter and depressor anguli oris (DAO) can also help improve the appearance of the lower face. The mentalis not only creates a pebbly appearance but also serves as a depressor for the lower face. Injection of 2 to 4 units of Botox, 5 to 10 units of Dysport or 3 to 6 units of Xeomin can help to relax the mentalis. Effective treatment for the corners of the mouth requires the use of fillers in addition to toxins. Injections into the mentalis may either be made as a single injection placed centrally or as a split injection placed in each portion of the lower mentalis. The DAO pulls the corners of the mouth inferiorly, and relaxing them has a tendency to move the corners of the mouth upward. However, it is an injection that is fraught with difficulty, as it can also affect the depressor labii; when this occurs, it results in a crooked smile. Injections into the DAO may be made by inserting the needle at the anterior aspect of the masseter at the inferior margin of the mandible. The amount of units varies, but typically 2 to 3 units of Botox, 3 to 5 units of Xeomin or 5 to 8 units of Dysport are used for each side.
Reshaping the Face
Facial shaping for the lower portion of the face will increasingly involve injections of botulinum toxins into the masseter. While these injections are very popular in Asia, they are not frequent injections in the United States. Injections of botulinum toxins into the masseter (and parotid) can be accomplished using 5 to 10 injections per side and between 20 to 30 units of Botox, 30 to 50 units of Xeomin and 50 to 80 units of Dysport. Injections into the masseter will not only help decrease the “squareness” of the lower face but may also help alleviate some people who have TMJ (although it is not approved for this indication).
Loss of definition of the lower jaw can produce jowls. Definitive treatment for jowls may involve surgery and/or liposuction to get rid of fat in the area and remove laxity and extra skin. However, judicious use of fillers such as Restylane, Perlane and Radiesse can help camouflage the jowling. I inject fillers just above the periosteum when treating this region. Typically, I inject enough to bridge the gap between the two protruding areas so that the hill/valley/hill seen with jowls is significantly less prominent. While I am not fixing the underlying issues, I am improving the appearance, and, for many patients, this is sufficient.
The profile of the lower face changes dramatically as bone and soft tissue are lost. As these losses occur, the projection of the lower face recedes. This is seen most graphically in the chin, where the mental crease becomes more visible and the inferior aspect becomes less prominent. Injections of soft tissue in these areas can transform the dynamics of the lower face and make the mental crease less prominent while making the lower aspect of the chin more prominent. This shifts the gaze and attention from a prominent rhytids to a more harmonious facial ratio. When injecting these areas, it is reasonable to match the depth of the wrinkle and amount of projection desired with the thickness of the product. I have used Juvederm Ultra Plus, Restylane, Perlane and Radiesse in the mental crease and the chin and have been pleased with each. Product selection depends on a variety of factors, including the thickness of the skin.
The lower third of the face is likely to be the next area of growth. From a proportional and esthetic perspective, this area contributes significantly to facial appearance. Having a lower face that is too bulky or disproportional to the upper face conveys images of aging or of sadness. I believe that treating the lower face is the key to facial harmony.
Dr. Beer is in private practice in West Palm Beach, FL. He is also a Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University and Director of the Cosmetic Bootcamp meeting.
Disclosure: Dr. Beer is an owner of Theraplex LLC, and consults, speaks or performs clinical trials for Medicis, 3M, Sanofi Aventis, Bioform Medical, Allergan and Stiefel. He is also a Director of the Cosmetic Bootcamp meeting.
The final article in this series on treating the face focuses on the lower aspects of the face, including the jowls, the chin and more.
The lower third of the face is probably the least understood and undertreated region of the face. Treating the lips is a large enough topic to be the subject of a separate article, so they will not be covered here. As with other parts of the face, global treatment is becoming more important and botulinum toxins and fillers (and maybe bimatoprost for that swarthy look) are common. Volume loss in the lower third of the face can be the most work to correct.
Treatment Options
Perioral rhytids are a frequent source of referral to a dermatology and/or plastic surgery practice. These may be treated with injections of botulinum toxins into the orbicularis muscle for lines caused by hyperdynamic muscles, as well as fillers. When filling these lines, it is important to select a filler that matches the depth of the line and thickness of the skin. For example, Belotero, Juvederm or Restylane will frequently be the appropriate filler for fine lines around the mouth. Injections made with a 30 or 32 gauge needle can minimize the risk of developing lumps and bumps. One other method for treating perioral rhytids involves reconstitution of fillers. When I reconstitute, I typically inject equal parts of either saline or lidocaine with Restylane, Belotero or Juvederm to achieve the correct consistency. Reconstituting the products in this manner helps to gently inflate the lines without creating the spokes that may be seen with products that are not reconstituted.
The chin and jowl area of the lower face is a region that deserves particular attention. This zone can lead to the most dramatic results of lower facial treatment. In women who are middle age or older, bone recession combined with mid-face laxity produce a jowl as the scaffolding and suspension systems diminish. I like to inject stiff fillers such as Perlane or Radiesse into the chin area to make the area more defined. Using 0.5 mL to 1.0 mL can produce dramatic results, and the addition of a well-defined chin can make a huge difference. Canadian and European physicians are using Voluma for this area.
Injections of botulinum toxins into the mentalis, masseter and depressor anguli oris (DAO) can also help improve the appearance of the lower face. The mentalis not only creates a pebbly appearance but also serves as a depressor for the lower face. Injection of 2 to 4 units of Botox, 5 to 10 units of Dysport or 3 to 6 units of Xeomin can help to relax the mentalis. Effective treatment for the corners of the mouth requires the use of fillers in addition to toxins. Injections into the mentalis may either be made as a single injection placed centrally or as a split injection placed in each portion of the lower mentalis. The DAO pulls the corners of the mouth inferiorly, and relaxing them has a tendency to move the corners of the mouth upward. However, it is an injection that is fraught with difficulty, as it can also affect the depressor labii; when this occurs, it results in a crooked smile. Injections into the DAO may be made by inserting the needle at the anterior aspect of the masseter at the inferior margin of the mandible. The amount of units varies, but typically 2 to 3 units of Botox, 3 to 5 units of Xeomin or 5 to 8 units of Dysport are used for each side.
Reshaping the Face
Facial shaping for the lower portion of the face will increasingly involve injections of botulinum toxins into the masseter. While these injections are very popular in Asia, they are not frequent injections in the United States. Injections of botulinum toxins into the masseter (and parotid) can be accomplished using 5 to 10 injections per side and between 20 to 30 units of Botox, 30 to 50 units of Xeomin and 50 to 80 units of Dysport. Injections into the masseter will not only help decrease the “squareness” of the lower face but may also help alleviate some people who have TMJ (although it is not approved for this indication).
Loss of definition of the lower jaw can produce jowls. Definitive treatment for jowls may involve surgery and/or liposuction to get rid of fat in the area and remove laxity and extra skin. However, judicious use of fillers such as Restylane, Perlane and Radiesse can help camouflage the jowling. I inject fillers just above the periosteum when treating this region. Typically, I inject enough to bridge the gap between the two protruding areas so that the hill/valley/hill seen with jowls is significantly less prominent. While I am not fixing the underlying issues, I am improving the appearance, and, for many patients, this is sufficient.
The profile of the lower face changes dramatically as bone and soft tissue are lost. As these losses occur, the projection of the lower face recedes. This is seen most graphically in the chin, where the mental crease becomes more visible and the inferior aspect becomes less prominent. Injections of soft tissue in these areas can transform the dynamics of the lower face and make the mental crease less prominent while making the lower aspect of the chin more prominent. This shifts the gaze and attention from a prominent rhytids to a more harmonious facial ratio. When injecting these areas, it is reasonable to match the depth of the wrinkle and amount of projection desired with the thickness of the product. I have used Juvederm Ultra Plus, Restylane, Perlane and Radiesse in the mental crease and the chin and have been pleased with each. Product selection depends on a variety of factors, including the thickness of the skin.
The lower third of the face is likely to be the next area of growth. From a proportional and esthetic perspective, this area contributes significantly to facial appearance. Having a lower face that is too bulky or disproportional to the upper face conveys images of aging or of sadness. I believe that treating the lower face is the key to facial harmony.
Dr. Beer is in private practice in West Palm Beach, FL. He is also a Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University and Director of the Cosmetic Bootcamp meeting.
Disclosure: Dr. Beer is an owner of Theraplex LLC, and consults, speaks or performs clinical trials for Medicis, 3M, Sanofi Aventis, Bioform Medical, Allergan and Stiefel. He is also a Director of the Cosmetic Bootcamp meeting.
The final article in this series on treating the face focuses on the lower aspects of the face, including the jowls, the chin and more.
The lower third of the face is probably the least understood and undertreated region of the face. Treating the lips is a large enough topic to be the subject of a separate article, so they will not be covered here. As with other parts of the face, global treatment is becoming more important and botulinum toxins and fillers (and maybe bimatoprost for that swarthy look) are common. Volume loss in the lower third of the face can be the most work to correct.
Treatment Options
Perioral rhytids are a frequent source of referral to a dermatology and/or plastic surgery practice. These may be treated with injections of botulinum toxins into the orbicularis muscle for lines caused by hyperdynamic muscles, as well as fillers. When filling these lines, it is important to select a filler that matches the depth of the line and thickness of the skin. For example, Belotero, Juvederm or Restylane will frequently be the appropriate filler for fine lines around the mouth. Injections made with a 30 or 32 gauge needle can minimize the risk of developing lumps and bumps. One other method for treating perioral rhytids involves reconstitution of fillers. When I reconstitute, I typically inject equal parts of either saline or lidocaine with Restylane, Belotero or Juvederm to achieve the correct consistency. Reconstituting the products in this manner helps to gently inflate the lines without creating the spokes that may be seen with products that are not reconstituted.
The chin and jowl area of the lower face is a region that deserves particular attention. This zone can lead to the most dramatic results of lower facial treatment. In women who are middle age or older, bone recession combined with mid-face laxity produce a jowl as the scaffolding and suspension systems diminish. I like to inject stiff fillers such as Perlane or Radiesse into the chin area to make the area more defined. Using 0.5 mL to 1.0 mL can produce dramatic results, and the addition of a well-defined chin can make a huge difference. Canadian and European physicians are using Voluma for this area.
Injections of botulinum toxins into the mentalis, masseter and depressor anguli oris (DAO) can also help improve the appearance of the lower face. The mentalis not only creates a pebbly appearance but also serves as a depressor for the lower face. Injection of 2 to 4 units of Botox, 5 to 10 units of Dysport or 3 to 6 units of Xeomin can help to relax the mentalis. Effective treatment for the corners of the mouth requires the use of fillers in addition to toxins. Injections into the mentalis may either be made as a single injection placed centrally or as a split injection placed in each portion of the lower mentalis. The DAO pulls the corners of the mouth inferiorly, and relaxing them has a tendency to move the corners of the mouth upward. However, it is an injection that is fraught with difficulty, as it can also affect the depressor labii; when this occurs, it results in a crooked smile. Injections into the DAO may be made by inserting the needle at the anterior aspect of the masseter at the inferior margin of the mandible. The amount of units varies, but typically 2 to 3 units of Botox, 3 to 5 units of Xeomin or 5 to 8 units of Dysport are used for each side.
Reshaping the Face
Facial shaping for the lower portion of the face will increasingly involve injections of botulinum toxins into the masseter. While these injections are very popular in Asia, they are not frequent injections in the United States. Injections of botulinum toxins into the masseter (and parotid) can be accomplished using 5 to 10 injections per side and between 20 to 30 units of Botox, 30 to 50 units of Xeomin and 50 to 80 units of Dysport. Injections into the masseter will not only help decrease the “squareness” of the lower face but may also help alleviate some people who have TMJ (although it is not approved for this indication).
Loss of definition of the lower jaw can produce jowls. Definitive treatment for jowls may involve surgery and/or liposuction to get rid of fat in the area and remove laxity and extra skin. However, judicious use of fillers such as Restylane, Perlane and Radiesse can help camouflage the jowling. I inject fillers just above the periosteum when treating this region. Typically, I inject enough to bridge the gap between the two protruding areas so that the hill/valley/hill seen with jowls is significantly less prominent. While I am not fixing the underlying issues, I am improving the appearance, and, for many patients, this is sufficient.
The profile of the lower face changes dramatically as bone and soft tissue are lost. As these losses occur, the projection of the lower face recedes. This is seen most graphically in the chin, where the mental crease becomes more visible and the inferior aspect becomes less prominent. Injections of soft tissue in these areas can transform the dynamics of the lower face and make the mental crease less prominent while making the lower aspect of the chin more prominent. This shifts the gaze and attention from a prominent rhytids to a more harmonious facial ratio. When injecting these areas, it is reasonable to match the depth of the wrinkle and amount of projection desired with the thickness of the product. I have used Juvederm Ultra Plus, Restylane, Perlane and Radiesse in the mental crease and the chin and have been pleased with each. Product selection depends on a variety of factors, including the thickness of the skin.
The lower third of the face is likely to be the next area of growth. From a proportional and esthetic perspective, this area contributes significantly to facial appearance. Having a lower face that is too bulky or disproportional to the upper face conveys images of aging or of sadness. I believe that treating the lower face is the key to facial harmony.
Dr. Beer is in private practice in West Palm Beach, FL. He is also a Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University and Director of the Cosmetic Bootcamp meeting.
Disclosure: Dr. Beer is an owner of Theraplex LLC, and consults, speaks or performs clinical trials for Medicis, 3M, Sanofi Aventis, Bioform Medical, Allergan and Stiefel. He is also a Director of the Cosmetic Bootcamp meeting.
