1
FACIAL PLASTIC
Anatomic Considerations for
Treatment with Botulinum Toxin
a b,
Gary M. Petrus, MD , David Lewis,
- Basic treatment
Frown lines/glabellar lines (procerus
and corrugator supercili muscles)
- Advanced treatment
Forehead wrinkles (frontalis muscle)
Crow’s feet (orbicularis oculi muscle)
Lower lid lines (orbicularis oculi muscle)
Lateral recruitment lines (orbicularis oculi
muscle)
Treatment of facial and neck wrinkles with botu-
linum toxin type A (Botox, Allergan, Irvine, Califor-
nia) remains by far the most common aesthetic
procedure performed in the United States. More
than 3.2 million of these procedures were per-
formed in 2005, compared with 2.8 million in
2004 and only 65,000 in 1997 [1]. During 2005,
botulinum toxin type A injections accounted for
28.8% of all cosmetic procedures (surgical and
nonsurgical). Botox acts by inhibiting the release
of acetylcholine (neurotransmitter) at the neuro-
muscular junction, thereby producing partial chem-
ical denervation of the muscle and a resultant
localized reduction in muscle activity [2]. This arti-
cle reviews the anatomic basis for the treatment of
facial and neck rhytids caused by hyperfunctional
muscle activity. The sole U.S. Food and Drug Ad-
ministration–approved indication for the cosmetic
use of Botox is the treatment of hyperfunctional
procerus and corrugator supercili muscles, which
are the muscles responsible for creating glabellar
a
504 McCain Boulevard, Suite 114, North Little Rock, AR 72116-7624, USA
b
The Maas Clinic, 2400 Clay Street, San Francisco, CA 94109, USA
* Corresponding author.
E-mail address: lewisd03@hotmail.com (D. Lewis).
1064-7406/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
SURGERY CLINICS
OF NORTH AMERICA
Facial Plast Surg Clin N Am 15 (2007) 1–9
b
MD *, Corey S. Maas, MD
Bunny lines (nasalis muscle)
Lip lines (orbicularis oris muscle)
Downturned oral commissure (depressor
anguli oris muscle)
Chin dimpling (mentalis muscle)
Masseter hypertrophy (masseter muscle)
Vertical platysmal bands (platysma muscle)
Necklace lines (platysma muscle)
- Summary
- References
(frown) lines; however, any muscle of the face can
be treated ‘‘off-label’’ as long as one uses the same
principles used to treat the glabellar lines.
Common facial wrinkles and lines are the result
of other hyperfunctional muscles (Box 1). There-
fore, an understanding of facial and neck muscle
anatomy is essential for optimal results and ad-
vanced applications. It is important to keep in
mind that this anatomy varies slightly from one in-
dividual to another, among genders, and among
races. Adding to the complexity is the significant
amount of misinformation that exists in the medi-
cal literature. Many texts and academic papers use
inconsistent or incorrect nomenclature, incorrect
descriptions of muscle action, and incorrect ana-
tomic diagrams. The intent of this article is to cor-
rectly describe facial and neck anatomy as it
pertains to cosmetic Botox treatments and point
out some of the misconceptions that are present
in the literature. This information should help to
improve results while avoiding pitfalls.
doi:10.1016/j.fsc.2006.12.003
2 Petrus et al
Box 1: Common cosmetic Botox treatments:
treatment site, muscles targeted
Upper face
Forehead, frontalis
Glabella, procerus and corrugator supercili
Crow’s feet, orbicularis oculi
Chemical browlift, orbicularis oculi
Lower lid lines, orbicularis oculi
Bunny lines, nasalis
Lateral recruitment lines, orbicularis oculi
Lower face
Lip lines, orbicularis oris
Downturned oral commissure, depressor anguli
oris
Chin dimpling, mentalis
Masseter hypertrophy, masseter
Neck
Platysmal bands, platysma
Necklace lines, platysma
Basic treatment
Frown lines/glabellar lines (procerus
and corrugator supercili muscles)
The muscles of facial expression are all cutaneous
muscles that are innervated by the facial nerve (cra-
nial nerve VII). These muscles lie within the super-
ficial fascia, originate from fascia or bone, and
insert into the skin [3]. Many of these muscles are
Fig. 1. Fronto-orbital anatomy. (From Maas CS. Botulinum neurotoxins and injectable fillers: minimally invasive
management of the aging upper face. Facial Plast Surg Clin North Am 2006;14(3):242; with permission.)
intimately associated with one another. When in-
jecting botulinum toxin A, it is helpful to visualize
the underlying muscle anatomy and attempt to in-
ject the actual muscle belly. Typically, the glabellar
region is treated with several injections targeted at
the hyperkinetic procerus and corrugator supercili
muscles (Fig. 1). The procerus muscle is a single,
flat, midline muscle that is oriented vertically and
originates from the nasal bones to insert into the
subcutaneous tissues between the medial brows
and slightly more superiorly. Contraction of this
muscle produces one or more transverse (horizon-
tal) wrinkles in the region of the nasion (root of
the nose). Therefore, one or more Botox injections
targeted at the belly of this muscle improve trans-
verse nasal lines and other horizontal glabellar
lines, if present. In some individuals, however,
these transverse lines may not be present. Careful
evaluation of the glabellar region is required to as-
sess whether procerus treatment is indicated.
The vertical glabellar lines are often paired and
may be symmetric or asymmetric. These lines are
primarily the result of action of the paired corruga-
tor supercili muscles. The inferior aspect of these
vertical rhytids may have an oblique or horizontal
portion caused by the procerus muscle. The corru-
gator supercili muscles originate from the procerus
muscle medially and insert, laterally, into the orbi-
cularis oculi muscle (by interdigitation) and the
soft tissues just at and slightly above the medial

eyebrow. In most individuals, this muscle orienta-
tion is nearly horizontal. Therefore, contraction of
this muscle produces a vertical wrinkle. In a few in-
dividuals, however, the corrugator supercili muscle
is oriented more vertically, and contraction may
cause an oblique wrinkle orientation. It is crucial
that Botox injections be placed properly in the cor-
rugator supercili muscle to create a smoothing ef-
fect, and, more importantly, avoid any unnatural
facial appearances. In many textbooks and dia-
grams, the corrugator supercili muscle is depicted
as a long, vertically oriented muscle that inserts
into the frontalis muscle in the mid-forehead.
This is rarely the case. As a result, a common mis-
take with Botox treatment is to inject the corrugator
supercili muscle too far superiorly, actually treating
the frontalis muscle. This frontalis muscle relaxa-
tion may cause an unnatural result: splaying of
the medial eyebrows or medial eyebrow ptosis
(Fig. 2). The correct placement of Botox into the
corrugator supercili muscles of most individuals is
more inferior, just at or slightly above the medial
clubhead of the eyebrow. A second, small dose of
Botox also is given approximately 3 to 5 mm lateral
to the initial injection to treat the entire length of
the corrugator supercili muscle (Fig. 3). With
proper placement into the muscle, 10 units to
each side are typically all that is necessary.
Advanced treatment
Forehead wrinkles (frontalis muscle)
The frontalis muscle is a wide, flat muscle that actu-
ally represents the frontal belly of the occipitofron-
talis muscle. The frontalis muscle originates as an
extension of the galea aponeurotica superiorly, in-
serts inferiorly, and interdigitates with the procerus
muscle, the corrugator supercili muscles, and por-
tions of the orbicularis oculi muscle [4]. The fronta-
lis muscle may present as a single, continuous
muscle without dehiscence, but more commonly
consists of two separate bellies that are variably
Fig. 2. Medial brow ptosis. (From Maas CS. Botulinum
neurotoxins and injectable fillers: minimally invasive
management of the aging upper face. Facial Plast
Surg Clin North Am 2006;14(3):244; with permission.)
Treatment with Botulinum Toxin 3
dehiscent in the midline of the forehead. In some
individuals, especially men, the frontalis muscle
may be larger and have a greater thickness. Contrac-
tion of the frontalis muscle raises the brows, as in
the surprised patient, and creates horizontal creases
in the forehead that are curvilinear at their outer as-
pect. This anatomy is variable depending upon the
forehead height, frontal bossing, forehead slope,
and hairline position. As a result, forehead rhytids
may be minimal or several rows of lines may be
present.
Frequently, botulinum toxin A is used off-label to
relax the frontalis muscle and improve the appear-
ance of forehead lines. The most important points
in the cosmetic treatment of the frontalis muscle
with neuromodulation are avoiding or minimizing
brow ptosis and symmetric placement of Botox
injections.
To avoid brow ptosis, botulinum toxin A injec-
tions should not be placed within 1.5 cm above
the upper margin of the brows lateral to the midpu-
pillary line. Severe preexisting brow ptosis can be
a relative contraindication to treatment of the fron-
talis muscle; however, this is an uncommon find-
ing. For most patients, however, brow position is
adequate, allowing frontalis muscle treatment. The
goal is to strike a balance between frontalis muscle
relaxation and adequate brow position. Some pa-
tients, especially the elderly, compensate for under-
lying brow ptosis by partially contracting the
frontalis muscle. The provider should be aware
and recognize the patients who give themselves
a ‘‘browlift’’ by compensatory frontalis contraction,
especially when looking in a mirror or being photo-
graphed. Careful physical examination and physi-
cian–patient discussion before treatment should
help to minimize any problems.
Asymmetric placement of botulinum toxin A in-
jections by the injector is another pitfall associated
with treating forehead wrinkles. Asymmetric injec-
tions could result in noticeably asymmetric brows.
Again, it is important to diagnose any preexisting
asymmetry in eyebrow position and discuss this
finding with the patient. Some brow asymmetries
may be compensated for and corrected, in experi-
enced hands, with Botox injections. Typically, Bo-
tox is administered in a series of four to six
injections spaced evenly along the forehead at inter-
vals of approximately 1 cm (Fig. 4). The most lat-
eral injection along the forehead line is placed
approximately 1 cm medial to the lateral end of
the wrinkle. If these lateral-most forehead injec-
tions are not performed, the result may appear un-
natural, causing a laterally arched eyebrow (the
‘‘Joker’’ or ‘‘Jack Nicholson’’ look) (Fig. 5). Soften-
ing forehead lines with a small dose of Botox (eg,
2–10 units) produces a natural result for most
4 Petrus et al

Fig. 3. Standard Botox glabellar therapy. (Adapted from Facial Plast Surg Clin North Am 2006;14(3); with
permission.)

Fig. 4. Standard injection sites in the upper face. (From Maas CS. Botulinum neurotoxins and injectable fillers:
minimally invasive management of the aging upper face. Facial Plast Surg Clin North Am 2006;14(3):243; with
permission.)

Fig. 5. Laterally arched eyebrow, in (A) relaxed and
(B) contracted states, avoided by administering injec-
tion along the forehead line approximately 1 cm
medial to the lateral end of the wrinkle.
patients. Some patients or providers, however, pre-
fer a flat, flaccid, and heavily treated forehead/
frontalis muscle. Therefore, Botox dosing should
be adjusted individually to account for the ana-
tomic variations of the frontalis muscle or the es-
thetic preferences of the particular patient being
treated. For example, men or individuals with a large
frontalis muscle require more botulinum toxin A.
Paralysis of the temporal branch of the facial
nerve, which innervates the frontalis muscle, causes
a unilateral brow ptosis and loss of forehead mo-
tion [5]. This deformity may be seen with trauma,
iatrogenic temporal branch injury, Bell’s palsy,
and many other etiologies. Botox may be used to
treat this asymmetry by injecting the frontalis mus-
cle on the normally functioning side to recreate
forehead symmetry.
Crow’s feet (orbicularis oculi muscle)
The orbicularis oculi muscle is a flat, wide, bilateral
muscle that encircles each orbit and extends into
both eyelids. The orbicularis oculi muscle is arbi-
trarily divided into four parts:
Outermost portion, or ring of muscle, overlying
the orbital margins (orbital)
Treatment with Botulinum Toxin 5
Middle portion, or ring, overlying the orbital
septum (preseptal)
Innermost portion, or ring, overlying the supe-
rior and inferior tarsal plate (pretarsal)
Lacrimal portion
The orbicularis oculi muscle insertion into and
around the medial canthal tendon is termed the lac-
rimal portion. The lacrimal pump mechanism is
created by the complex anatomy of orbicularis oculi
muscle heads originating from the medial canthal
tendon, lacrimal fossa, and posterior lacrimal crest.
Therefore, the orbicularis oculi muscle functions
not only as a sphincter of the eye, for eye closure
and blinking, but also as a nasolacrimal duct pump.
The portion of the orbicularis oculi muscle that is
located along the lateral orbit is responsible for cre-
ating radial lines, known as ‘‘crow’s feet,’’ in the thin
periocular skin. Excessive muscle activity, during
squinting or blinking, results in pleating of the over-
lying skin [6]. The lateral orbicularis oculi muscle is
the largest and most powerful depressor of the brow.
Therefore, the goals of facial rejuvenation in the lat-
eral orbital region are twofold: (1) relaxing the radial
‘‘crow’s feet’’ lines by targeting the lateral, vertically
oriented portion of the orbicularis oculi muscle
and (2) providing brow elevation by neuromodula-
tion of the brow depressor function by treating the
entire length of the lateral orbicularis oculi muscle.
The senior author’s (CSM) previous work demon-
strated the impact that botulinum toxin treatment of
the lateral orbicularis oculi muscle can have on brow
position [7,8]. Because the orbicularis oculi muscle
is a circular, sphincter-like muscle, careful attention
must be paid to the vectors of force during contrac-
tion. The vectors of contraction at 12 o’clock and
6 o’clock are predominately horizontal, whereas
the vectors of contraction at 3 o’clock and 9 o’clock
are predominately vertical. The crow’s feet rhytids
are treated by injecting the lateral orbicularis oculi
muscle in several locations. Botulinum toxin A injec-
tions are placed at least 1 cm from the lateral orbital
rim to minimize the chance of orbital complications.
Intraorbital drift of Botox could result in diplopia or
eyelid ptosis. A typical dose of 10–15 units per side is
used to treat the crow’s feet areas, with the injection
needle oriented away from the orbit. The injections
are placed carefully to achieve maximum effect on
the orbicularis oculi muscle and to avoid injecting
or injuring any superficial blood vessels.
Lower lid lines (orbicularis oculi muscle)
Lower eyelid rhytids occur with photoaging of the
thin eyelid skin and may be exacerbated by a hyperki-
netic orbicularis oculi muscle. Botulinum toxin A
treatment of the lower eyelid should be performed
by skilled practitioners and is an advanced, off-label
6 Petrus et al
use. A pretreatment snap test should be performed to
evaluate the lower eyelid laxity. Abnormal laxity of
the lower lid signifies the chance for the develop-
ment of lower eyelid retraction (not ectropion). Small
doses of Botox (1–2 units) are given in these loca-
tions to minimize the chance of intraorbital drift or
weakening of the inferior oblique extraocular mus-
cle (see Fig. 4). Bruising is common in this location,
so injections should be given with minimal trauma.
Lateral recruitment lines (orbicularis oculi
muscle)
Some facial lines may occur just above the brow in
the midpupillary region following glabellar Botox
treatment. These lines, termed ‘‘lateral recruitment
lines,’’ often are related to horizontal fibers of the or-
bicularis oculi muscle at the 12 o’clock position. Be-
cause the procerus muscle and corrugator supercili
muscle have already been treated, the orbicularis oc-
uli fibers are ‘‘recruited’’ to provide animation in the
area. A small dose of botulinum toxin A is used of-
ten to soften the lateral recruitment lines; it is in-
jected at the level of, or just slightly above, the brow.
Bunny lines (nasalis muscle)
When wrinkling the nose, several ‘‘bunny lines’’
may appear on each side of the nose extending in-
feriorly. These lines are treated effectively with
Botox and result from contraction of the nasalis
muscle, particularly the transverse portion. The
levator labii superioris alaeque nasi muscle also
may contribute to the appearance of ‘‘bunny lines.’’
The nasalis muscle is a paired, fan-shaped, trans-
versely oriented muscle that originates from the
maxilla at the inferior nasal aperture; it crosses the
nasal dorsum to insert into the aponeuroses of
the procerus muscle and contralateral nasalis mus-
cle [9]. A small amount of Botox injected into these
muscles causes a smoothing effect that can be dra-
matic with low risk. The muscles should be targeted
directly while the patient demonstrates the ‘‘bunny
lines’’ for the practitioner. Botulinum toxin A injec-
tions are aimed at the more superior portion of the
nasalis muscle to avoid inadvertent injection of the
levator anguli oris muscle or the levator labii supe-
rioris alaeque nasi muscle. The concern for acciden-
tal injection of these levator muscles is drooping of
the upper lip and other lip asymmetries [10].
Lip lines (orbicularis oris muscle)
The orbicularis oris muscle consists of two layers: su-
perficial and deep. This complex muscle primarily is
a sphincter muscle necessary for oral competence,
speech, and social expression. It functions to close
the lips, protrude the lips (superficial portion),
and to press the lips against the teeth (deep portion).
The upper lip portion of the orbicularis oculi muscle
inserts on the maxilla just superior to the canine,
whereas the lower lip portion originates on the man-
dible just lateral to the mentalis muscle. The orbicu-
laris oris muscle inserts and fuses with the depressor
anguli oris muscle and risorius muscle at the oral
commissure in the region known as the modeolus
[11]. Movement of the lips and mouth is a complex
interaction between the circular contraction of the
orbicularis oris muscle and the radial contraction
of the lip elevators and depressors (Fig. 6).
Patients develop radial lip lines as a result of skin
aging, photodamage, and the repetitive action of the
orbicularis oris muscle (eg, chewing, smoking).
These lines are especially problematic for women
because lipstick tends to run or ‘‘bleed’’ into them.
The upper lip lines may be treated with a small
amount of Botox to relax the superior portion of
the orbicularis oris muscle slightly. The total dose
for treating upper lip lines is small to maintain
oral competence. For example, four separate 1-unit
injections are spaced evenly and administered just
above the vermillion border. The same principles
apply as described previously: conservative dosing
with careful and symmetric placement of injections.
Often, relaxing upper lip lines with Botox is com-
bined with other lip procedures, such as fillers, to
help expand and, therefore, minimize the lip lines.
The lower lip portion of the orbicularis oris muscle
is not treated with botulinum toxin A for fear of cre-
ating asymmetry, incompetence, and drooling.
Downturned oral commissure (depressor
anguli oris muscle)
The bilateral depressor anguli oris muscle inserts at
the modeolus of each oral commissure from its
origination inferiorly at the oblique line of the
mandible. This muscle may become hyperkinetic
with time, resulting in downturned oral commis-
sures. The individual with downturned corners of
the mouth takes on a sad face appearance or an ex-
pression of disapproval. A few units of Botox in-
jected into the depressor anguli oris muscle relax
this downward pull vector and allow the risorius
muscle, zygomaticus major muscle, and other ele-
vators to act unopposed. The corners of the mouth
return to a neutral or even upturned position. This
positioning also can be assisted with filler material
placed inferior to the commissures. Despite often-
beneficial effects, treatment of this muscle occasion-
ally can have inconsistent results.
Chin dimpling (mentalis muscle)
Peau d’orange (orange peel) and golf ball dimpling
describe this cosmetic deformity of the chin. The
dimpled appearance is the result of the actions of
the mentalis muscle coupled with the loss of colla-
gen and subcutaneous fat in the chin [12]. The

Fig. 6. The orbicularis oris muscle anatomy, superficial and deep, indicating (A) circular contraction of the orbi-
cularis oris muscle and (B) the radial contraction of the lip elevators and depressors. m., muscle.
mentalis muscle originates from the incisor fossa of
the mandible inferiorly and inserts into the orbicu-
laris oris muscle and skin of the lower lip superiorly
[13]. Mentalis muscle contraction raises and pro-
trudes the lower lip. Low-dose Botox injections
are aimed at the inferior aspect of the mentalis mus-
cle to avoid injection of the orbicularis oris muscle.
A deep transverse mental crease also may be treated
similarly in affected individuals.
Masseter hypertrophy (masseter muscle)
The masseter muscle is a muscle of mastication,
rather than a muscle of facial expression. It is inner-
vated by the masseteric nerve, a branch of the man-
dibular division of cranial nerve V or trigeminal
nerve. This short, strong muscle originates in two
parts from the zygomatic arch and inserts along
the entire lateral mandibular ramus. The masseter
Treatment with Botulinum Toxin 7
muscle elevates the mandible for chewing. With re-
petitive chewing, such as with gum, the muscle may
become hypertrophic and result in a mild cosmetic
deformity, or slight bulge. Cosmetic improvement
results from injecting each hyperactive masseter
muscle with just 1 to 3 units of botulinum toxin
A. Aggressive masseter muscle treatment should be
avoided because of the adverse effects of weakened
mastication and the potential for malocclusion.
Vertical platysmal bands (platysma muscle)
The platysma is a broad, flat muscle whose thick-
ness varies significantly among individuals. In gen-
eral, women have a thinner platysma. The platysma
is innervated by the cervical branch of the facial
nerve; it serves to retract and depress the lower lip
by pulling the oral commissures downward. Inferi-
orly, the muscle originates from the superficial
8 Petrus et al
Fig. 7. Vertical neck bands or platysmal bands. (A) Patient in upright position, accentuating the bands.
(B) Patient after treatment.
fascia of the pectoralis muscle and subclavicular
and acromial regions. The muscle travels superome-
dially in the neck to insert in the (1) midline, form-
ing an inverted V below the chin, (2) orbicularis
oris muscle, depressor anguli oris muscle, risorius
muscle, and mentalis muscle, and (3) anterior one
third of the oblique line of the mandibular ramus
[14].
Vertical neck bands, or platysmal bands, occur
with aging and the loss of skin elasticity. Dehiscence
of the platysma muscle in the midline also contrib-
utes to the formation of neck bands and can accen-
tuate submandibular gland ptosis. Botox treatment
of these platysmal bands may be successful in se-
lected individuals. In general, patients with reason-
able skin elasticity and without significant
submental fat or submandibular gland herniation
are good candidates. The technique is similar to
other Botox treatments, with even spacing of injec-
tions along the band. The neck band may be
grasped with the fingers for treatment. The patient-
should be treated while in the upright position and
can assist with accentuating the bands during treat-
ment (Fig. 7). It is important to inject botulinum
toxin A exactly intramuscularly. Deeper injections
could result in complications, such as dysphagia,
dysphonia, or torticollis, depending on which
deep neck muscle is inadvertently affected.
Necklace lines (platysma muscle)
Necklace lines describe the transverse wrinkles in
the inferior portion of the neck. These wrinkles typ-
ically occur between the anterior borders of the
sternocleidomastoid muscles. These rhytids occur
perpendicular to the vector of contraction of the un-
derlying platysma muscle. These lines may be
treated with Botox because it is the only option of
treatment for this area; however, the results are vari-
able. Patients should be informed that the treat-
ment may result in minimal improvement in this
area. Botulinum toxin A is administered in the pla-
tysma muscle at evenly spaced intervals to provide
relaxation. Again, deeper injections must be
avoided because of the risk for weakening strap
muscles or cricothyroid muscle.
Summary
The best results of treatment with Botulinum toxin
A are obtained from a careful history and physical
examination of the patient combined with a de-
tailed understanding of facial and neck anatomy.
Fully understanding the dynamic anatomic rela-
tionships in the face is key to providing the patient
with an excellent outcome.
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