INJECTABLES

Newer Understanding of Specific Anatomic

Targets in the Aging Face as Applied to
Injectables: Facial Muscles—Identifying Optimal
Targets for Neuromodulators
Jonathan M. Sykes, MD
Summary: The muscular anatomy of the face is complex. Animation patterns
Patrick Trevidic, MD
of facial muscles vary significantly among individuals. Activity of facial mus-
Gustavo A. Suárez, MD
cles determines expression and emotion and affects the eyes aperture and
Gisella Criollo-Lamilla, MD the amount and extent of facial rhytids. Injection of botulin toxin for facial
Sacramento, Calif.; Paris, France; and rejuvenation has become a very popular procedure and allows the practitioner
Barcelona, Spain the ability to modulate facial expression and to decrease the amount of facial
rhytids. A thorough knowledge of the variant facial anatomy is necessary to
maximize the efficiency of botulin toxin injection. This knowledge will also
aid in minimizing complication an untoward side effect.  (Plast. Reconstr. Surg.
136: 56S, 2015.)

T
o successfully perform any facial injection,
a systematic evaluation of facial aesthetics
is essential. In addition to this, a detailed
knowledge of the applied anatomy of the face
is necessary. This includes an understanding of
topographic landmarks that will allow predictable
identification of deeper structures.
Specifically, any practitioner who injects botu-
linum toxin should have a thorough knowledge of
all soft tissue and skeletal structures, from super-
ficial to deep. The location and action of all perti-
nent facial muscles is important. In addition, the
position of the associated muscle action potentials
is critical to maximize the impact of each injection
and to minimize the possibility of untoward side
effects.
AESTHETICS OF THE PERIORBITAL
REGION
The appearance of the periorbital region is a
composite of the skeletal structure and the overly-
ing soft-tissue volume and position.
From Facial Plastic Surgery, University of California,
Davis Medical Center; Expert2expert Group; and Depart-
ment of Otolaryngology–Head and Neck Surgery, Bellvitge
­University Hospital.
Received for publication April 22, 2015; accepted June 25,
2015.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001731
The periorbital region is an area where hyper-
function of muscles results in a tired and aged
appearance and increased rhytids. Hyperdynamic
glabellar musculature can create an angry appear-
ance, while overuse of the lateral eyelid muscles
can narrow the eyelid aperture.1 Treatment with
botulinum toxin can lessen the contraction of
hyperdynamic periorbital muscles, improve the
eyelid aperture and brow position, and decrease
periorbital rhytids.2,3
The position and orientation of the eyebrow
is related to the relative strength and contrac-
tion of the brow depressors versus the brow eleva-
tors. The main elevators of the eyebrow are the
paired frontalis muscles. The temporoparietalis
muscle is a rarely described and highly variable
muscle. In conjunction with the frontalis, it raises
the eyebrows, widens the eyes, and wrinkles the
skin of the forehead. This muscle may display a
greater mass in younger individuals. Depression
of the eyebrow is accomplished by contraction
of the midline procerus muscles and the paired
corrugator and orbicularis oculi muscles.4,5 Cor-
rect placement of appropriate amounts of toxin
to minimize rhytids, without negatively affecting
eyebrow position, is important.6
Disclosure: None of the authors has a financial
interest in any of the products, devices, or drugs
mentioned in this article.

56S www.PRSJournal.com
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 Volume 136, Number 5S • Optimal Targets for Neuromodulators

Fig. 2. Left-sided cadaver dissection showing the corrugator

Fig. 1. Left-sided cadaver dissection after removal of the skin supercilii muscle. The black arrow points to the bony origin of
showing the outline of the left frontalis muscle. Note that the the muscle and the red arrow to the supraorbital nerve. Note
upper half of the forehead is devoid of muscle in the central por- that the muscle becomes more superficial as it travels laterally.
tion of the forehead.

ANATOMY OF THE PERIORBITAL

MUSCLES
Frontalis
The frontalis muscle is a large, vertically
oriented, fan-shaped muscle that covers the
majority of the forehead and is located within
the sheaths of the galea aponeurosis (Fig. 1). It
originates from the galea aponeurosis near the
anterior hairline and inserts into the forehead
skin near the eyebrow. There is no bony origin or
insertion for the frontalis muscles. The inferior
fibers of the frontalis muscle interdigitate with
the procerus and orbicularis muscles. Medially,
the 2 halves of the frontalis muscle have a vari-
able relationship, with some right and left fron-
talis muscles having no connection, while others
interdigitate and even overlap in the lower half
of the forehead.
The motor innervation to the frontalis mus-
cle is the temporal branch of the facial nerve.
Contractions of the superior and inferior por-
tions of the muscle have different actions, with
the superior portion causing descent of the
anterior hairline and the inferior portion caus-
ing elevation of the brow. For this reason, injec-
tion of toxin into the superior frontalis muscle
can decrease forehead rhytids, without creating
brow ptosis.5
Corrugator Supercilii
The paired corrugator supercilii muscles
are obliquely oriented and are located in the
inferomedial brow deep to the inferior por-
tion of the frontalis muscles. These are the
Fig. 3. Left-sided cadaver dissection in the subgaleal plane with
the forceps grasping the corrugator supercilii muscle. The red
arrow points to the left supraorbital neurovascular bundle and
shows its relationship with the muscle.
only periorbital muscles with a bony connec-
tion, with the medial head originating from the
frontal bone at the superomedial orbit and the
insertion being into the skin of the middle por-
tion of the eyebrow and into the fascia on the
deep surface of the frontalis muscle7 (Fig.  2).
As the muscle courses laterally, it becomes
superficial, with its ending point being at a
variable location in the eyebrow skin (Fig.  3).
The muscle is pierced by the supraorbital and
supratrochlear neurovascular bundles. These
nerves exit a notch or foramen in the supraor-
bital rim, pierce the corrugator muscles, and
then pierce the frontalis muscles and branches
of the nerve travel on the superficial aspect of
the frontalis (Fig. 4).

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 Plastic and Reconstructive Surgery • November Supplement 2015
Fig. 4. Right-sided cadaver dissection after removal of the skin
showing the galea aponeurosis and frontalis muscle. The blue
tapes show branches of the supraorbital and supratrochlear nerves
as they course on the superficial surface of the frontalis muscle.
Fig. 5. Superior view of the cadaver dissection after inferior
reflection of a coronal flap. At the root of the nose in the mid-
line, the hemostat clamp is placed under the procerus muscle.
Note the relationship of the procerus muscle with the bilateral
neurovascular bundles.
The motor innervation to the corrugator
muscles is from 2 separate branches of the facial
nerve and may present a variable pattern of con-
tralateral or cross-innervation. The medial head
of the muscle is supplied by the zygomatic branch
of the facial nerve, whereas the lateral portion is
supplied by the temporal branch of the nerve.
Contraction of the muscle causes vertical grooves
in the glabellar skin and imparts an angry expres-
sion. Contraction also causes an inferomedial
descent of the medial clubhead of the brow. Injec-
tion of toxin into the corrugators decreases the
vertical glabellar rhytids and causes slight lateral-
ization of the medial brow.
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Fig. 6. Close-up view of a cadaver dissection showing the pro-
cerus muscle (P) in the midline, the bilateral corrugator supercilii
muscle (C), and the supraorbital neurovascular bundles (SO).
Procerus
The procerus is a midline flat and pyramidally
shaped muscle. It is located at the root of the nose
and contributes to nasal contour of the upper half
of the nose (Fig. 5). The procerus originates from
the periosteum and perichondrium of the nasal
bones and upper lateral cartilages and from the
fascia of the nasal superficial musculoaponeurotic
system. It inserts into the midline skin overlying
the nasal root and thus has no bony attachments.
The procerus interdigitates superiorly with the
frontalis muscle, inferiorly with the nasalis mus-
cle, and laterally with the depressor supercilii,
orbicularis oculi, and deeper corrugator muscles8
(Fig. 6).
The motor innervation to the procerus mus-
cle is supplied by the zygomatic branch of the
facial nerve. Contraction of the midline muscle
is responsible for horizontal glabellar rhytids,
descent of the medial brow, and transverse mid-
line nasal rhytids. These are different from the so-
called bunny lines or lateral nasal rhytids, which
appear on the lateral aspect of the nasal dorsum
and occur from contraction of the levator labii
superioris alaeque nasi muscle. Injection of botu-
linum toxin into the procerus can decrease the
transverse folds at the medial nasal root and can
slightly elevate the medial brow.
Orbicularis Oculi
The orbicularis oculi are paired sphincteric
muscles that are protractors of the eyelids and
depressors of the eyebrows. The muscles are
located beneath the thin eyelid and thicker
eyebrow skin. The muscles are separated into
 Volume 136, Number 5S • Optimal Targets for Neuromodulators

Fig. 7. Right-sided oblique view of a cadaver after removal of the skin and subcutaneous tissue.
The sphincteric orbicularis oculi muscle is shown with its pretarsal (PT), preseptal (PS), and orbital
(O) portions.

pretarsal (superficial to the tarsal plates), pre-

septal (superficial to the orbital septum), and
orbital (more peripheral) portions9 (Fig.  7).
These designations are not true anatomic sepa-
rations of muscle but rather names that identify
the muscle location. In fact, there are no true
separations or septa distinguishing these muscle
segments.
The origins and insertions of the orbicu-
laris muscles, as well as its anatomical relation-
ships with adjacent structures, are complex. The
muscle primarily travels in the soft tissues of the
eyelids but is fixed medially and laterally to the
bony orbital wall by the orbital retaining liga-
ments.10 The orbital retaining ligament medi-
ally to the midpupillary line is termed the tear
trough ligament and is responsible in some indi- Fig. 8. Right-sided cadaver dissection with reflection of the skin
viduals for adding to the concavity just inferior showing subcutaneous fat (SF) of the midface.
to the convex medial orbital fat, also known as
the tear trough deformity. The orbicularis mus- and inferior portions of the muscle are inner-
cles interdigitate with the corrugator and fron- vated by the zygomatic branch, and the lateral
talis superiorly. and central portions of the muscle are inner-
Laterally, the orbicularis muscles travel super- vated by the anterior portion of the temporal
ficial to the temporalis fascia; medially, the muscle branch of the facial nerve.9 Contraction of the
covers the depressor supercilii; and inferiorly, the orbicularis muscles causes closure of the eyelids
muscles travel between the superficial and deep and descent of the eyebrows. Contraction of the
(sub–orbicularis oculi fat) fat pads of the cheek11 palpebral marginal portion of the orbicularis
(Figs.  8 and 9) The inferomedial extent of the causes an involuntary weak eye closure (blink),
lower eyelid orbicularis muscles covers the leva- and contraction of the orbital more peripheral
tor labii superioris and the levator labii superioris component of the muscle creates a voluntary,
alaeque nasi muscles. sphincteric, and potentially stronger eye closure
The motor innervation of the orbicularis (squint). The orbital component is responsible
oculi muscles is innervated by multiple nerves for most eyelid wrinkles and for descent of the
and has multiple motor endplates. The medial lateral brow. Injection of the orbicularis oris

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 Plastic and Reconstructive Surgery • November Supplement 2015
Fig. 9. Right-sided cadaver dissection with inferior reflection of
the superficial fat (SF) and superior reflection of the orbicularis
oculi muscle (OO). The underlying deep fat of the midface [sub–
orbicularis oculi fat (SOOF)] is exposed. Note that the orbicularis
oculi lies between the SF and the SOOF.
muscles can decrease dynamic lateral canthal
lines, decrease rhytids of the lower eyelid, and
elevate the lateral or tail of the brow.
PERIORBITAL INJECTION OF
BOTULINUM TOXIN
Injection of botulinum toxin in the periorbital
region can be performed to decrease rhytids, to
increase the eyelid aperture, to change the eye-
brow position or shape, or to create a combina-
tion of these effects. The injection of toxin should
affect a diminished muscular contraction of the
desired muscle, while not negatively decreasing
adjacent muscle contraction.3,6,12
The relative contraction of the brow elevator
(frontalis muscle) and the brow depressors (cor-
rugators, procerus, and orbicularis oculi muscle)
affects the position and shape of the eyebrow. The
purpose of frontalis muscle injection is usually to
diminish transverse forehead rhytids. Toxin injec-
tions are usually performed in the superior half of
the muscle. Overinjection of toxin, especially in the
inferior portion of the frontalis muscle, may result
in brow ptosis.
Injection of the corrugator and procerus mus-
cle decreases the vertical and transverse folds at the
root of the nose. These injections can also affect
medial brow elevation. In that, the medial portion
of the corrugator originates from the superome-
dial orbit, and injection in this region should be
deep to treat this part of the muscle. As the muscle
travels laterally, it becomes more superficial. For
this reason, injection of the lateral portion of the
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Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
muscle should be more superficial. If the injec-
tions are placed too inferiorly, if there is diffusion
of toxin, or if there is an anatomical dehiscence in
the septum orbitale, toxin can affect the levator
aponeurosis of the upper eyelid, causing ptosis of
the lid.
Injection of the orbicularis oculi at the lateral
canthus can decrease dynamic lateral canthal lines,
elevate the lateral brow, and increase the eyelid aper-
ture. The orbicularis muscle near the lateral aspect
of the lower eyelid is quite superficial, and injections
should therefore approximate the superficial loca-
tion of this muscle. Care should be taken to avoid
superficial veins that course through the immediate
subcutaneous tissue in the lateral canthal region. It
is also important to avoid an injection in this region
which is too inferior on the upper cheek. If toxin
diffuses too inferiorly, the origin of the zygomaticus
major muscle can be affected causing asymmetry of
the smile.13
SUMMARY
Injection of botulinum toxin in the perior-
bital muscles can significantly improve periorbital
aging. The ability to modulate eyebrow position
and eyelid aperture, as well as decrease periorbital
rythids and folds, provides an important adjunct to
periorbital rejuvenation. A thorough knowledge
of muscular anatomy and the position of impor-
tant anatomical landmarks are necessary to assure
efficient injection and minimize complications.
Jonathan M. Sykes, MD
Facial Plastic Surgery
University of California, Davis Medical Center
2521 Stockton Boulevard, Suite 6200
Sacramento, CA 95817
jmsykes@ucdavis.edu
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