Botulinum Toxin Below the Eyes

Jean Carruthers, MD
Alastair Carruthers, MD

n Introduction
Botulinum toxins, particularly types A and B (BTX-A, BTX-B), have
become primary tools in the armamentarium to fight aging: The injections
are fast and convenient for the patient and require no downtime or
recovery period. But chemodenervation has become much more than
a simple fix; instead, it is a creative approach to redefining and sculpting
beauty in men and women. For experienced clinicians with a detailed
knowledge and understanding of human anatomy and an aesthetically
critical eye, there are numerous opportunities to expand an ever-widening
array of injectable treatments. This chapter outlines the most common
uses (and those becoming more popular) for botulinum toxin in the mid-
and lower face. Because the majority of our clinical experience resides with
BTX-A (BOTOX; Allergan Inc., Irvine, CA), all references hereafter refer
to the BOTOX or BOTOX Cosmetic formulations, unless otherwise spec-
ified. However, clinicians should be aware of the significant clinical differ-
ences between the sources and adjust doses accordingly.

n BTX-A in the Mid- and Lower Face

After the enormous popularity of BTX-A in the upper face, clinicians
began to use the toxin for a number of other indications (Tables 1 and 2).
In our experience, BTX-A has opened up a new arena of aesthetic
expertise. However, injecting into the lower two thirds of the face brings up
a number of issues. First, aesthetic facial reshaping in the mid- and lower
face with BTX-A begins with a comprehensive appreciation of the facial
muscular anatomy because the musculature is more complex and the risks
are greater.1 Major muscles involved in hyperkinetic wrinkles below the
133
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Table 1. BTX-A Below the Eyes

Doses and Injection Sites
‘‘Bunny’’ lines Anterior to the nasofacial groove on the lateral wall of the
nose, well above the angular vein; 3–5 units per side
Repeated nasal flare Lower nasalis fibers, which are draped over the lateral
nasal alae; 5–30 units per side
‘‘Smokers’ lines’’ 1–2 U per lip quadrant; balance injection sites on either
side of columella or lateral nasal ala to alleviate
post-treatment concern of lip proprioception; central
lip injection if appropriate central vertical rhytides
Upper gum show 1 U into each lip levator complex in each nasofacial
groove
Mouth frown 3–5 U in the depressor anguli oris; often used in
combination with soft-tissue augmentation
Melomental folds Best in combination with soft-tissue augmentation;
3–5 units as for mouth frown
Peau d’orange chin Alone or in combination with soft-tissue augmentation;
5–10 units
Mental crease 2–5 U into each mentalis

eyes have very specific functions, sometimes working as agonists, some-

times as antagonists, and any alterations can adversely affect the func-
tioning of this facial area.2 Second, facial expression and movement
influence changes caused by aging, and many aesthetic procedures fail
because the effect of animation on the final result has not been considered.1
Because of these issues, only experienced physicians should attempt to
inject some areas of the mid- and lower face and only after a thorough
understanding of the underlying facial anatomy (remembering that
individual musculature varies considerably from patient to patient).

Table 2. Mid- and Lower Facial Contouring and Sculpting with BTX-A
Doses and Injection Sites
Hypertrophic orbicularis 2 U in lower pretarsal orbicularis
Facial Asymmetry
Innervational/muscular 1–2 U in hyperfunctional zygomaticus,
asymmetry risorius, and masseter
Hypofunctional asymmetry 1–2 U in normofunctional zygomaticus,
(ie, Bell’s palsy) risorius, and orbicularis; 5–10 U in
the masseter
Asymmetry of jaw 10–15 U intraorally into the internal
movement pterygoid
Masseteric hypertrophy 2 or 3 sites, 1.5 cm apart, marked within
enlarged region; dose varies from
10–40 U per muscle, divided in 3 sites
 Botulinum Toxin Below the Eyes n 135

BTX-A Around the Mouth

Of all facial regions, the perioral region is typically the least consistent
in response to treatment by the wide variety of the most commonly used
modalities, which include laser and chemical dermabrasion, soft-tissue
augmentation, and a host of surgical procedures.1
The area around the mouth is a complex region requiring an experi-
enced physician with extensive knowledge of anatomy and BTX application.
The muscles surrounding the mouth function in mastication, deglutition,
and articulation of sounds, as well as in facial expressions.3 Because the lips
are central to the appearance of the lower face, it is essential to use caution
when injecting periorally. Injections placed too medially can weaken
the depressor labii and flatten the lower lip contour when the mouth
attempts to form an ‘‘O.’’ On the other hand, injecting too high can
jeopardize mouth competence, causing difficulties with speech and
suction or facial asymmetry. Patient selection is crucial; injections are not
recommended for singers or musicians or for patients who use their
perioral muscles with intensity.

Perioral Rhytides (‘‘Smokers’ Lines’’)

Vertical perioral rhytides, or ‘‘smokers’ lines,’’ are one of the most
common areas for which patients request treatment.4 An overactive
orbicularis oris is partly responsible, although habit and animation com-
bined with volume loss (particularly in women), heredity, and photo-
damage may all play a role. Small doses of BTX-A can greatly improve the
appearance of the lip, especially when combined with fillers like collagen
or hyaluronic acid (Fig. 1). BTX-A injections are recommended for deeper
wrinkles that may be resistant to fillers or resurfacing alone. Treatment
often results in only temporary improvement because of normal perioral
animation.1
We typically inject 1 U per lip line at or above the vermilion border in
the area of muscle contraction adjacent to the creases, with doses not

Figure 1. Perioral rhytides.

136 n Carruthers and Carruthers

exceeding 2–4 U per lip. Areas to avoid include the corners of the lips
(where injections can cause weakness of the lateral lip elevators, which
leads to lateral lip drooping and drooling) and the midline (to prevent
a flattened cupid’s bow).5
However, because even low doses of BTX-A may result in significant lip
weakening, certain patients, such as those who play wind instruments or
professional singers, should be warned of potential effects. Generally, using
conservative doses and superficial injections will avoid complications.5

Mouth Frown and Melomental Folds

The depressor anguli oris (DAO), the primary muscle responsible for
mouth frown and melomental folds (also known as ‘‘drool grooves’’ or
‘‘marionette lines’’), pulls down the corner of the mouth in opposition to
the zygomaticus major and minor muscles. Contraction of the DAO causes
a downward turn to the corner of the mouth and a negative appearance.
Because the DAO overlies the depressor labii inferioris, many patients
experienced intolerable paresis from direct injection. We now inject the
DAO at the level of the mandible but at its posterior margin, close to the
anterior margin of the masseter, and each side of the mentalis, with doses
of 3–5 U BTX-A, producing a subtle, synergistic effect. However, this
technique should only be used in patients who have experienced the
effects of BTX-A injections elsewhere and who are aware of the aim of
treatment and its possible outcomes. Patients should be counseled thor-
oughly, using a hand mirror to demonstrate the aim of treatment, and
clinicians should take active and passive photographs and follow up
2 weeks after injection to assess and document the response to treatment,
including any side effects.
Traditionally, melomental folds have been treated by soft-tissue aug-
mentation alone, but because this area of the face is highly mobile, filling
agents rarely last long. BTX-A is a useful adjunct to soft-tissue augmentation;
injected before augmentation, the toxin relaxes the muscles and lengthens
the duration of the filling agent by preventing the repeated molding
caused by regular movement. In our experience, BTX-A in combination
with tissue fillers produces the most satisfactory results (Fig. 2).

Mental Crease and Peau d’Orange Chin

Contraction of the mentalis produces a deep groove, or mental crease,
between the lower lip and the prominence of the chin. Soft-tissue augmen-
tation in the mental crease has proven largely unsatisfactory, with visible
beading and overall poor results. We have found that injecting 3–5 U BTX-A
into each side of the midline under the point of the chin, just anterior to
the bony mentum can soften the crease; however, do not inject at the level
of the crease because of the risk of weakening the orbicularis oris and
 Botulinum Toxin Below the Eyes n 137

Figure 2. Melomental folds after BTX-A and with soft-tissue augmentation.

creating mouth incompetence or other serious adverse effects that can

persist for 6 months or more, depending on the dose.
In addition to the mental crease, the mentalis also produces multiple
dimpled rhytides (‘‘apple dumpling’’ or ‘‘peau d’orange’’ chin) as it raises
and protrudes the lower lip and wrinkles the skin of the chin, showing all
too clearly the loss of dermal collagen and accumulation of subcutaneous
fat. Like many other perioral areas, chin dimples were previously treated
with soft-tissue augmentation and laser resurfacing. Now, BTX-A can be
used alone or in conjunction with augmentation. We inject 5–10 U BTX-A
into the mentalis at the prominence of the chin (at the most distal point
from the orbicularis oris) to avoid weakening the orbicularis oris. Post-
injection massage helps diffuse the toxin.

n Facial Shaping and Contouring

Recently, the application of BTX-A has become more art than science,
particularly when used for facial shaping and contouring. This type of
correction, however, necessitates not only a thorough understanding of
muscular anatomy and function but also an enormous appreciation and
eye for aesthetic balance and should only be attempted by experienced
injectors.

n Widening the Palpebral Aperture

Widening the palpebral aperture in patients with hypertrophic
orbicularis, in which the act of smiling contracts the pretarsal portion of
the orbicularis muscle, leading to a decrease in palpebral aperture size, is
a good example of the artistic results that can be achieved now with BTX-A
138 n Carruthers and Carruthers

injections (Fig. 3) and has proven a popular procedure among those

wishing for a wider eyed look.6 Flynn et al6 achieved excellent results
injecting 2 U subdermally, 3 mm inferior to the lower pretarsal orbicularis,
in addition to 3 injections of 4 U placed 1.5 cm from the lateral canthus,
each 1 cm apart: 86% of patients experienced a mean palpebral aperture
increase of 1.8 mm at rest and 2.9 mm at full smile. In our experience, 2 U
BTX-A injected subcutaneously into the lower pretarsal orbicularis (3 mm
below the ciliary margin) opens the palpebral aperture both at rest and
when smiling. However, careful patient selection is essential because fes-
tooning after injections has been reported.7 The best candidates are those
who have a good preinjection snap test and who have not had previous
lower eyelid ablative resurfacing or blepharoplasties without a coexisting
canthopexy to support the normal position of the lower eyelid. Doses
higher than 2 U are not recommended because any more in this area can
lead to symptomatic dry eye.8

n Facial Asymmetry
Correcting facial asymmetry sometimes appears to be an almost mirac-
ulous application of BTX-A, particularly for patients who cannot undergo
(or do not desire) major surgical procedures. For example, BTX-A in-
jections have been used for more than 10 years to treat hemifacial spasm, in
which repeated clonic and tonic facial movements draw the facial midline
over toward the hyperfunctional side. The toxin relaxes the hyperfunc-
tional zygomaticus, risorius, and masseter and allows the face to be
centered at rest. Wang and Jankovic9 studied 110 patients with hemifacial
spasm; 95% reported a marked to moderate improvement after BTX-A
injections. Recommended doses of BTX-A for hemifacial spasm are
1.25–2.5 U into the contracting muscles.10

Figure 3. Palpebral aperture before and after BTX-A injections.

 Botulinum Toxin Below the Eyes n 139

In patients with asymmetrical jaw movements, intraoral injections of

10–15 U BTX-A into the internal pterygoid on the hyperfunctional side can
be used to relieve discomfort and relax the jaw. Asymmetry caused by
surgical cutting of or trauma to the orbicularis oris or risorius muscles can
be corrected by injecting BTX-A into the risorius immediately lateral to the
corner of the mouth on the normally innervated side. Likewise, in patients
with congenital or acquired unilateral weakness who cannot depress the
corner of one side of the mouth, BTX-A injected into the partner muscle
will restore functional balance. In patients with hypofunctional asymmetry,
such as those with Bell palsy, injections of 1–2 U BTX-A into the
zygomaticus, risorius, and orbicularis muscles and 5–10 U into the mas-
seter can have dramatic results (Fig. 4).

n Masseteric Hypertrophy
Data support the use of BTX-A as a simple, noninvasive alternative
treatment with a short recovery period for facial contouring in patients
with masseteric hypertrophy. Although most of the studies reported have
been small,11,12 a larger study demonstrated a gradual reduction in
masseter thickness (average 1.5–2.9 mm reduction) with 25–30 U BTX-A
injected in 5 to 6 sites evenly at the prominent portions of the mandibular
angle.13 Clinical effects lasted 6 to 7 months after injection, and side effects
(mastication difficulty, muscle pain, and verbal difficulty during speech)
lasted from 1 to 4 weeks.
To et al11 injected 200–300 U of Dysport per side in 5 patients with
unilateral and bilateral hypertrophy of the masseter and found a good
response, with the maximal effect of a 31% reduction in muscle bulk
3 months after treatment. Three of 9 hypertrophic muscles needed a
secondary injection within 1 year to maintain atrophy. von Lindern et al12

Figure 4. BTX-A injection sites for the treatment of Bell palsy.

140 n Carruthers and Carruthers

reported a reduction of the masseter muscles by half in 7 patients with

unilateral and bilateral hypertrophy of the masseter and temporalis
muscles treated with an average of 100 U of Dysport. Four patients
considered the result satisfactory after a single injection.
More recently, Park et al13 injected 25–30 U BTX-A per side in 5 to
6 sites in 45 patients. Masseter thickness was gradually reduced during the
first 3 months after injection (average change in masseter thickness, 1.5–
2.9 mm, equivalent to 17%–19% of the original muscle thickness). Clinical
effects lasted 6 to 7 months after injection before the muscle thickness
returned to its initial size; at 10 months, 36 patients expressed satisfaction
with the results. Main transient side effects included mastication difficulty,
muscle pain, and verbal difficulty during speech and lasted from 1 to
4 weeks. Kim et al14 studied the effect of BTX-A on masseteric hypertrophy
via computed tomography in 11 patients and found a mean reduction of
about 22% in masseteric muscle volume (with a maximum of 35.4%); after
12 weeks, 9 patients showed aesthetically good results with a grade of
‘‘good’’ or ‘‘excellent.’’

n Possible Complications
Because most side effects and complications result from undesired
muscle weakening caused by diffusion, smaller, more concentrated doses
of BTX-A are less likely to cause problems than larger doses, which
supports a conservative approach in most patients. Most complications are
relatively uncommon and are related to poor injection techniques.15 No
long-term adverse effects have been reported, and no other systemic safety
problems have been associated with BTX-A treatment.
Complications that arise from BTX-A injections in the mid- and lower
face are usually due to overly enthusiastic use of the toxin in large doses
and misplacement of the injections, affecting both muscle function and
facial expression.15 Starting with low doses and injecting more superficially
rather than deeply limit the potential for complications (such as drooling
and asymmetry), and injections should be symmetrical to ensure uniform
postinjection movement. Avoid injections in singers, musicians, or other
patients who use their perioral muscles with intensity. When injecting the
DAO, avoid areas too close to the mouth, injection into the mental fold,
and interaction with the orbicularis oris, all of which can result in a flaccid
cheek, incompetent mouth, or asymmetrical smile.

n Conclusion
The application of BTX-A in facial rejuvenation has widened
dramatically in the past 10 years to include indications previously
 Botulinum Toxin Below the Eyes n 141

considered ‘‘unthinkable.’’ No longer used simply to smooth hyperkinetic

lines, BTX-A can be applied to more artistic applications, such as facial
contouring and shaping. However, when used below the eyes, BTX-A re-
quires a knowledgeable, experienced hand and should not be attempted
lightly; although serious complications are rare, they do result from
overzealous—and usually inexperienced—injectors, and careful attention
and respect must be paid to the interaction of muscles forming the basis of
facial expression and animation.

n References
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frontalis sling. Ophthal Plast Reconstr Surg. 1992;8:137.
3. Sposito MM. New indications for botulinum toxin type A in cosmetics: mouth and
neck. Plast Reconstr Surg. 2003;112:76S–85S.
4. Fagien S. Botox for the treatment of dynamic and hyperkinetic facial lines and furrows:
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the upper face. Semin Cutan Med Surg. 2001;20:71–84.
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eyelid improves infraorbital rhytides and widens the eye. Dermatol Surg. 2001;27:703–
708.
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measurement. Br J Plast Surg. 2001;54:197–200.
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treatment of hypertrophy of the masseter and temporal muscle: an alternative
treatment. Plast Reconstr Surg. 2001;107:327–332.
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contouring in the lower face. Dermatol Surg. 2003;29:477–483.
14. Kim HJ, Yum KW, Lee SS, et al. Effects of botulinum toxin type A on bilateral
masseteric hypertrophy evaluated with computed tomographic measurement. Dermatol
Surg. 2003;29:484–489.
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toxin. Dermatol Surg. 2003;29:549–556.