Mandibular Rim Trilogy with Botulinum Toxin Injection:

Reduction, Projection, and Lift

Renpeng Zhou1, *, Benyun Pan1, *, Chen Wang1, Danru Wang1

• 1
Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai
Jiao Tong University School of Medicine, Shanghai, People's Republic of China

Further Information

• Abstract
• Full Text
• References
• Figures

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• Abstract
• Patients and Methods
o Injection Technique
o Measurement
o Statistical Analysis
• Results
• Discussion
o Reduction of Lower Jaw in Asian Facial Contour
o Projection of Chin in Asian Facial Contour
o Lift of Lower Face in Asian Facial Contour
o Lift of Oral Commissure in Asian Facial Contour
o Advantages of Multiple-Region Therapy
• Complications and Limitations
• Conclusion
• References

Abstract
“Onabotulinum toxin A (Botox) revolution” has brought the fundamental change in the facial
rejuvenation as well as the concept of microinjection. The aesthetic standard tends to be the
“globalization”; however, Asians have different aesthetic cultures and unique facial features
compared with Caucasians. A new rejuvenation concept is proposed during our practice; the
Asian face should preserve the original facial identity during Botox treatments. The lower
face is treated with botulinum toxin to achieve a harmonious facial profile. Twenty young
females ranging in age from 30 to 45 years consented and received the three-pronged
procedure from March 2014 to April 2015; photography at baseline and follow-up visit were
taken and analyzed. After posttreatment for 2 months, significant improvement was
observed compared with the baseline. And the reduced masseter prominence and prominent
chin were obtained, showing a favorable facial contour and harmonious appearance during
the follow-up. The novel three-pronged approach to lower facial rejuvenation was aimed at
the Asian characteristic of hypertrophic masseter, chin retrusion, and the facial sagging
during the aging process. Botox treatment was a quite effective and safe strategy to improve
the appearance and contour of the lower face in Asian patients.
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Keywords
onabotulinum toxin A (Botox) - lower face - rejuvenation - contour - Asian

In the past 20 years, the nonsurgical onabotulinum toxin A (Botox) injection has been widely
accepted and favored by Asian patients who seek aesthetic and better appearance. In recent
years, Botox has been extensively used for upper and middle face rejuvenation.[1] [2] [3] As
Asian patients favor a harmonious and natural face, physicians also have attempted to apply
Botox to lower facial appearance.[4] [5] [6] [7]

Angular and wide jaw region and chin retrusion are considered as unsatisfactory lower facial
contour in Asian female patients as these features are related to the masculine image and
flat face. The hypertrophic masseter[8] forms a square contour in the lower face, while the
Asian female favors a narrow and smooth jawline. The hyperactive mentalis[9] pulls the
mental soft tissue in upward–inward direction, and the chin retrusion is discordant with the
projection of the glabella and malar portion.

On the other hand, many features are associated with the aging appearances in the lower
third face. Drooping of the cheek and mouth corner leads to a gloomy and tired expression,
which is due to the hyperactivity of the platysma and depressor anguli oris. The platysma
inserts into the margin of the mandible and has a closely anatomical relationship with the
superficial musculoaponeurotic system (SMAS).[10] The hypercontraction of this broad, thin
muscle results in lower face ptosis. The depressor anguli oris[11] originates from the
mandible and inserts into the angle of the mouth, which causes the downward motion of the
mouth corners, resulting in a sad and frustrated expression.

The Asian patients presented a square face with lack of anterior projection and prefer to look
like good-looking Asians, rather than attractive Caucasians.[12] And they also seek an oval-
shaped face.[13] Botox treatment effectively reshapes the lower facial contour. The relatively
high dose of Botox can be applied to the hypertrophic masseter, creating a narrow contour in
the lower face. Botox treatment also weakens the mentalis. The vertical height of chin would
be augmented with the downward-outward movement of mental soft tissue. In addition, the
slacked platysma and depressor anguli oris will lift the lower cheek and corner of mouth,
showing a youthful, attractive appearance. So Botox injection is suitable for patients with
moderate facial sagging and/or angular and wide jaw region and chin retrusion.

In this article, we proposed a novel three-pronged approach: reduction, projection, and lift
([Fig. 1]). The multiple-region therapy provides an effective and acceptable minimally
invasive method for lower facial rejuvenation.

Fig. 1 The concept and technique of projection,

reduction, and lift of the lower face.
Patients and Methods
Participants were 20 young females who presented with wide lower face and/or chin
retrusion from March 2014 to April 2015. Average age was 35.3 ± 4.3 years (range, 30–45
years). Informed consent was obtained from participants before all procedures in this study.
Patients with facial paralysis, pregnancy, and botulinum toxin allergy were excluded.

Injection Technique
The Botox was dissolved in sterile saline. The recommended dilution was 100 U/2 mL or 50
U/1 mL. For masseter, the injection sites were three points in the safety zone, consisting of
the earlobe-oral commissure line, the mandibular border, and the anterior and posterior
edge of masseter ([Fig. 2A, B]). The masseter lies deep to the SMAS, and the needle should
be advanced to the periosteum and then withdrawn slightly to locate in the masseter.
Twenty-five units of Botox were injected into the most superior point (red point D 1), and five
units each into the remaining two points (red points D2 and D3). These three points were
located approximately 1 cm from each other.

Fig. 2 Points of injection to project (black point A),

reduce (red points D1–D3), and lift (blue point B and C1–C6). (a) The frontal view. (b) The
lateral view. The masseter underlying the SMAS was shown. The red points lie deep to the
SMAS.
For mentalis, we estimated the muscle by physical examination as well as asking the patients
to purse the lower lip and marked the injection point with the following principle. The point
was located at the belly of mentalis, approximately 0.5 cm lateral from facial midline on each
side horizontally, and more than 1 cm below the lower lip in the vertical direction ([Fig. 2A],
black point A). Then the mentalis was held by thumb and index, four units of Botox were
injected using a 30-gauge needle per each point.

For platysma, the injection sites were 5 to 7 points with the distance of 1.5 cm from each
other, distributed along the inferior border of the mandible ([Fig. 2A], [B], blue points C2–
C6). For each point, 2 to 2.5 units of Botox were injected intramuscularly.

The injection site for depressor anguli oris was located on the line from the ipsilateral nasal
ala to the corner of the mouth. The point (indicated as [Fig. 2B], blue points B) was
approximately 1 cm from the corner of the mouth in the lateral and inferior direction along
the above line. Superficial hypodermic injection was recommended to avoid the unwanted
spread into depressor labii inferioris muscles. Approximately 1 to 2 units of Botox were used
for each side.

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Measurement
All photographs at baseline (preinjection) and 8-week follow-up (postinjection) were taken
by the same physician with same standardized photography and the measurements were
performed by another team member. Before photography, all the patients were instructed to
relax. After the pictures were taken, the measurement points were marked to analyze the
treatment effect ([Fig. 3A, B]). The measurement items are illustrated in [Table 1]. The
distance D (nasal width) was the linear distance between the nasal alars, and its value was
relatively consistent. To compare the change of masseter, the horizontal line was drawn
through the oral fissure. The point (m1, m1′) was the intersection of this line with margin of
the lower jaw. The distance C was the linear distance between the points m1 and m1′. The
reduction effect was evaluated by the lift index (the ratio of distance C to distance D). To
assess the lift effect, the vertical lines were drawn through the pupil (point p) and lateral
canthus (point lc), respectively ([Fig. 3A]). The points (m2, m2′) and (m3, m3′) were the
intersections of these vertical lines with margin of lower jaw, respectively. The
distances A and B were the linear distances between points (lc,lc′) and (m2, m2′), and points
(p, p′) and (m3, m3′), respectively. The lift effect was evaluated by the life index
([A + A′ + B + B′]/2D). To estimate the change of the chin, the infraorbital rim was marked to
identify the auriculo-infraorbital plane before photography.[14] Obtaining the photograph,
we connected the line from upper border of tragus to infraorbital rim at the lateral view.
Then a perpendicular line through the subnasal was made to compare the perpendicular
distance of the chin. The distance E was the linear distance between the point ac and the
point prn, and its value was also relatively consistent, and the distance F was the linear
distance between the point pg and the point pe ([Fig. 3B], [Table 1]). The projection effect
was evaluated by the calculated projection index (10F/E). Adobe Photoshop CS4 (Adobe
system, Inc.) was used to measure the linear distances based on the aforementioned
reference points.

Fig. 3 Reference points and linear distance for

measurement. (a) The frontal view. (b) The lateral view.

Table 1
Measurement items

Item Description

Point

al (al′) Outmost point of the nasal ala

p (p′) Pupil

lc (lc′) Lateral canthus

m1 (m1′) The intersection of horizontal line through the oral fissure with margin of lower jaw

m2 (m2′) The intersection of vertical line through the lateral cantus (lc) with margin of lower jaw

m3 (m3′) The intersection of vertical line through the pupil (p) with margin of lower jaw

ac Outmost point of the basal curve of the nasal ala

prn Most protruded point of the nasal tip

pg Pogonion

pe The intersection of perpendicular distance from pogonion (pg) to the line that is perpendicular
to the auriculo-infraorbital plane
 Table 1
Measurement items

Item Description

Linear distance

A (A′) The distance between lc (lc′) and m2 (m2′)

B (B′) The distance between p (p′) and m3 (m3′)

C The distance between m1 and m1′

D The distance between al and al′

E The distance between ac and prn

F The distance between pg and pe

Index

Lift index (A + A′ + B + B′)/2D

Reduction C/D
index

Projection 10F/E
index

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Statistical Analysis
Data were presented as mean ± standard deviation. The SPSS10.0 software was used for
statistical analysis. A paired t-test (Student's t-test) was performed between two
groups. p < 0.05 was considered to be statistically significant.

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Results
The total units (both sides) of Botox for platysma is 28.3 ± 8.1 units, and total 3.5 ± 0.9
units, 71 ± 6.2 units, and 8.1 ± 1.3 units for depressor anguli oris, masseter, and mentalis,
respectively. At 2 months after Botox injection, the reduction of masseter prominence, the
lift effect of lower face, and the projection of chin were observed in the patients ([Figs. 4]
and [5]). The lift index ([A + A′ + B + B′]/2D) at baseline was 4.86 ± 0.15, and showed
4.25 ± 0.15 two months postinjection. The reduction index (C/D) was 2.86 ± 0.072
preinjection and 2.52 ± 0.075 postinjection. Before the injection, the projection index (10F/E)
was 4.00 ± 0.15, and 3.13 ± 0.24 after 2 months ([Fig. 5]). Changes of index were
statistically significant (the p-values <0.05). During the follow-up visits, two patients
experienced the asymmetric masseter, needing a second correction at 4 months after
injection. Transient weakness in chewing occurred in one patient, and spontaneously
resolved at 3 weeks after injection. No other adverse events were observed. Almost all the
patients were satisfied with their results during follow-up.

Fig. 4 Photographs of a patient (a–d). The frontal view, (a) the

preinjection hypertrophic masseter and (b) lower face reduction 2 months after injection.
(The asymmetry of the face may be due to unilateral mastication on right side.) The lateral
view, (c) the pre-injection less prominent chin and (d) postinjection chin projection.
Photographs of another patient (e–h). (eand g) Baseline, (f and h) followed up at 2 months.

Fig. 5 Significant changes of lift index, reduction

index, and projection index from baseline (pre) to 2 months postinjection (post),
respectively.
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Discussion
Botox has been widely used for the treatment of the lower facial rhytides and contour around
the world.[7] [15] [16] Although the golden ratio is universally accepted as one of the
principles of facial beauty, the concept of facial aesthetics differs by the diversity of culture
and intrinsic ethnic features.[17] The oval face is considered beautiful and attractive by
Asian female. For Asian young female, the hypertrophic masseter is a common complaint.
The angular contour in the angular jaw region indicates a robust appearance. Seeking for a
mellow appearance has become increasingly popular among these patients.

The traditional lower third facial rejuvenation often requires performing SMAS and/or
platysma ectomy.[18] Although the surgical intervention has a relatively long-term face lift
effect, it has drawbacks such as the long recovery period and inevitable scar. Compared with
the surgical procedure, Botox injection has advantages of minimal invasion, convenience to
treat, little pain to suffer, and short recovery period. The botulinum toxin would take effect
approximately 2 to 3 weeks after treatment, and the maximal change would be achieved
within 2 to 3 months, lasting for 4 to 6 months. When clinical effect of the injectable Botox
appears to diminish, patients are recommended to receive repeated treatment. The mean
age of patients in this study was 35.3 ± 4.3 years, and the mean number of treatments of
the patients in their 30s[8] was 4.11 times. The total cost of this repeated three-pronged
approach is almost one-third of that of surgical intervention for improving the facial contour,
including the silicone chin implants, mandibular angle ostectomy, and SMAS facelift
rhytidectomy. When informed about the cost of surgical and nonsurgical options and the
necessity of repeated injection with this nonsurgical procedure, an increasing number of
Asian young females prefer this nonsurgical option, probably due to the benefit of more
natural appearance and aforementioned advantages.

Among many factors that have association with facial beauty, the contour and wrinkles are
crucial to the appearance. The masseteric hypertrophy is associated with the angular jaw.
The lower facial skin sagging and drooping occurs as a result of platysma hypercontraction.
The marionette line is caused by excessive actions of the depressor anguli oris. The facial
fine wrinkles also form because of the hyperactivity of facial muscles.

Considering the chin retrusion, wide jaw region and sagging facial skin are main complaints
in Asian patients. The novel three-pronged approach “Reduction, Projection, and Lift” was
proposed to reshape and lift the lower third face in young Asian females. The comprehensive
effect including reshaping and lifting the lower face contributes to form a harmonious
appearance with the whole face. And patients who do not desire surgical operation are also
good candidates.

As young females have better skin elasticity than the middle-aged women who always have
volume deficiencies in the lower face needing combination therapy with Botox and hyaluronic
acid (HA) filler, young females are best candidates for Botox treatment with our three-
pronged approach.

Reduction of Lower Jaw in Asian Facial Contour

Clinically, Asian females show a wide prominent jaw[12] [13] and they frequently favor a
narrow jawline and seek for the feature of smooth facial contour. The surgery of filing down
the mandible is invasive and surgical reduction of the masseter has the risk of edema, scar,
and facial nerve damage. And the volume to reduce is inaccurate due to the tissue edema
during operation. So the hypertrophic masseter is a good indication for nonsurgical Botox
injection. The treatment of Botox blocks the release of acetylcholine into the neuromuscular
junction and causes the masseter atrophy. The atrophic masseter will present a narrow
contour in the lower third face. Appropriate injection should be noted during Botox therapy.
The anterior area of the masseter should be avoided when we perform botulinum toxin
injection, as the atrophy of anterior portion will cause a sunken cheek shape.

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Projection of Chin in Asian Facial Contour
As the chin is less prominent in Asians, chin implant[19] is popular for chin augmentation.
However, it is difficult to achieve a natural beauty and there are surgical complications, such
as implant displacement, asymmetry, and scarring. The mentalis is a dome-shaped muscle,
originating from the alveolar process below the incisors and attaching below the labiomental
sulcus.[9] The hyperactive mentalis pulls the chin in upward-inward movement, causing chin
retrusion. And relaxing this muscle helps chin projection. The botulinum toxin should be
injected into the mentalis 1 cm below the lower lip to avoid the diffusion into adjacent
orbicularis oris. Four units of Botox will relax the mentalis and reduce the antagonistic effect
to the levator muscle, and then cause the projection of soft tissue of chin. High-dose of
Botox injection is not recommended because of the complication of mentalis atrophy. More
anterior projection contributes to a three-dimensional face appearance, being harmonious
with the glabella and malar projection in the upper and middle third face.

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Lift of Lower Face in Asian Facial Contour
The continuous gravity and platysma account for the drooping of the face. The low-dose of
Botox can obviously relax the platysma along the inferior border of the mandible. The slack
platysma acts less drooping force on the SMAS, having a lifting effect on the lower third face.
Considering that the change of lower face lifting is supposed to assess in three dimensions,
further studies on the measurement and evaluation of the volumetric face lift effect are
necessary.

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Lift of Oral Commissure in Asian Facial Contour
The mouth frown is the consequence of the hypercontraction of depressor anguli oris. The
corner of the mouth is pulled down by the muscle, showing the expression of sadness as well
as causing marionette line. Botox treatment could elevate the corner of the mouth,
presenting youthful features and charming characters.

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Advantages of Multiple-Region Therapy
For Asian female patients, ideal oval face is desired. Our novel three-pronged approach can
effectively improve the facial contour by reshaping the masseter and mentalis, and attenuate
the facial aging signs by weakening the platysma and depressor anguli oris. The low risk and
reversible effect make Botox treatment suitable for the patients who are unwilling to accept
surgical operation or dramatic change.

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Complications and Limitations
Transient masticatory difficulty, local bruising, and edema are possible complications, but
most are transient and will recover in a few days. Asymmetric masseter was observed in two
patients, which may be caused by unilateral mastication. It can be adjusted by the
asymmetric treatment (higher dose for larger side) in the next treatment. Formation of
antibodies[20] [21] after several times may cause resistance to Botox and reduce the
treatment effect.

Standard photography[22] is a convenient method to assess the changes in facial

morphology. In this article, we propose a useful quantifiable measurement method to
evaluate the changes in lower facial contour. However, there are some limitations with this
two-dimensional (2D) analysis method. Although we have tried to keep the same distance
from subject and same lens focal length, the inevitable distortion and slightly different angle
would be the source of the error in measurement. No et al[23] described using three-
dimensional (3D) CT image to exactly estimate the masseter volume. It also has drawbacks
such as high cost and harmful radiation. Application of 3D laser scan (Vivid 9i laser
scanner)[24] [25] or 3D camera system (Vectra 3D stereophotogrammetry system)[26] [27]
is an objective and reliable method for lower facial contour evaluation. Further study should
focus on the effect of three-pronged approach on lower facial rejuvenation using the 3D
quantitative evaluation.

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Conclusion
Botox is a safe and biocompatible therapeutic agent, which is available for the indications
including the hypertrophic masseter, chin retrusion, and facial sagging. With this three-
pronged approach, the aesthetic result of narrow jaw line, augmentation, and face lift could
be achieved. Combined multiple-region therapy can reshape and lift the lower face
simultaneously, achieving better cosmetic appearance. This novel three-pronged approach
provides a replicable and reliable strategy for lower facial rejuvenation in Asian young
patients.

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Funding
None of the authors have had any financial interest in any products, devices, or drugs
presented in the article. There is no conflict of interest related to any commercial
associations or financial relationships (consultancy, stock ownership, equity interest, patent
licensing arrangements, or payments for conducting or publicizing the study contained in the
manuscript).

*
Renpeng Zhou and Benyun Pan contributed equally.