COSMETIC

Facial Assessment and Injection Guide for

Botulinum Toxin and Injectable Hyaluronic
Acid Fillers: Focus on the Lower Face
Maurício de Maio, M.D.
Woffles T. L. Wu, M.D.
Greg J. Goodman, M.D.
Gary Monheit, M.D.
on behalf of the Alliance
for the Future of Aesthetics
Consensus Committee
São Paulo, Brazil; Singapore; South
Yarra, Melbourne, Victoria, Australia;
and Birmingham, Ala.
Summary: This third article of a three-part series addresses techniques and rec-
ommendations for aesthetic treatment of the lower face. The lower face is con-
sidered an advanced area for facial aesthetic treatment. In this region, soft-tissue
fillers play a more important role than neuromodulators and should be used
first to provide structure and support before neuromodulators are considered
for treatment of dynamic lines. Treatment of the lip, perioral region, and chin,
in addition to maintaining balance of the lower face with the face overall, is chal-
lenging. Procedures on the lip should avoid overcorrection while respecting the
projection of the lips on the profile view and the ratio of lip size to chin. The
chin is often neglected, but reshaping the jawline can provide dramatic improve-
ment in facial aesthetics. Both profile and anterior views are critical in assessment
and treatment of the lower face. Finally, rejuvenation of the neck region requires
fillers for structural support of the chin and jawline and neuromodulators for
treatment of the masseter and platysma.  (Plast. ­Reconstr. Surg. 140: 393e, 2017.)

T AESTHETICS OF THE PERIORAL AREA

his is the final part of a three-part series on
injection techniques for aesthetic procedures
involving use of injectable fillers and/or neu-
romodulators. Recommended needles for each
product are listed in Table 1 and recommended
Allergan plc (Dublin, Ireland) portfolio products
and volumes/doses for each area of the midface
are illustrated in Table 2. Other filler and neuro-
modulator options are available and can be used
in the treatment areas described; good results are
as much dependent on injector technique as on
the product utilized. We provide detail specific to
Allergan products because of our extensive experi-
ence with these products in clinical practice. This
article discusses techniques in the lower face, one
of the most challenging areas to treat. The lip is
challenging to reshape with fillers; comprehensive
assessment is necessary to avoid improper correc-
tion. The chin is one of the most neglected areas,
but reshaping the jawline can provide dramatic
improvement in facial aesthetics. Finally, the neck
is a challenging area, where both fillers and neuro-
modulators may be necessary.
AND LIPS
The perfect lip includes a visible transition
line or border between the vermillion and skin, a
V-shaped Cupid’s bow, a full medial tubercle and
vermillion, an ascendant line in the oral commis-
sures, and an upper-to-lower lip ratio of 1:1.618.1
AGING OF THE PERIORAL AREA AND
LIPS
Intrinsic lip volume loss, photodamage, and
lip muscle movement lead to static and dynamic
wrinkles, lip elongation and thinning, flatness
of the vermillion border, loss of Cupid’s bow, lip
Disclosure: Dr. de Maio and Dr. Goodman are
­Allergan plc consultants for speaking events and mar-
keting strategy. Dr. Wu is a consultant for Allergan
plc, Galderma, and Merz for speaking events and ad-
visory boards. Dr. Monheit has no conflicts to disclose.

From the Clinica Dr. Maurício de Maio; the Woffles Wu
Aesthetic Surgery and Laser Centre; the Dermatology Insti-
tute of Victoria; and the Total Skin and Beauty Dermatology
Center.
Received for publication April 13, 2016; accepted February
10, 2017.
Copyright © 2017 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000003646
Supplemental digital content is available for
this article. Direct URL citations appear in the
text; simply type the URL address into any Web
browser to access this content. Clickable links
to the material are provided in the HTML text
of this article on the Journal’s website (www.
PRSJournal.com).

www.PRSJournal.com 393e
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • September 2017

dryness, and downturned oral commissures.1–3 In and radiating from the lip border, particularly
the aging lip, the perioral tissues of the cutaneous in the area above the lips.5 These lines develop
lip also atrophy.4 Age-related deepening of the because of perioral soft-tissue volume loss, lip
nasolabial fold may be caused by repeated con- atrophy, hyperdynamic contractions of the peri-
traction of the levator labii superioris and levator oral musculature, and underlying resorption of
labii superioris alaeque nasi muscles during wrin- mandibular bone.5
kling of the nose and by ptosis of the superficial
musculoaponeurotic system.1 With aging, perioral ASSESSMENT OF THE PERIORAL AREA
lines become evident perpendicular to the lips AND LIPS
Assessment should be made at rest and during
Table 1.  Recommended Needle Sizes for Delivery of animation (i.e., while smiling and while puckering),
Soft-Tissue Fillers and OnabotulinumtoxinA including the projection of the lips on the profile
view.1 Assess preservation of lip landmarks, including
Product Needle Size
the vermillion border, vermillion body, Cupid’s bow,
Injectable fillers philtrum, and oral commissures, and any loss of lip
 Ultra 30-gauge, ½-inch (13 mm)
 Ultra Plus 27-gauge, ½-inch (13 mm) and perioral volume. Also, assess the dental arcade
 Volbella 30-gauge, ½-inch (13 mm) for the presence of occlusions and the inclination
 Volift 30-gauge, ½-inch (13 mm) of the teeth. Evaluate for asymmetry at rest and dur-
 Voluma 27-gauge, ½-inch (13 mm) ing animation, excessive inversion of the vermillion,
OnabotulinumtoxinA 30-gauge, ½-inch (13 mm)
and whether the gingiva are prominent. Assess the

Table 2.  Recommended Allergan plc Portfolio Product and Volume/Dose for Individual Areas
Region Product Volume/Dose Range
Hyaluronic acid filler
 Nasolabial fold Ultra Plus 0.5–1.0 ml per side
Volift
Voluma 0.1–0.3 ml per side
 Lip border Ultra Plus 0.1–0.2 ml per quadrant
Ultra
Volift
Volbella
 Vermillion linear technique Ultra Plus 0.5–1.0 ml for both lips
Ultra
Volift
Volbella
 Vermillion aliquot technique Ultra Plus 0.05 ml per bolus
Ultra 0.5–1.0 ml for both lips
Volift
 Commissures Ultra Plus 0.05–0.1 ml per side
Volift
 Philtrum Ultra Plus 0.05–0.1 ml per side
Ultra
Volift
 Perioral lines Ultra ≤0.25 ml per quadrant
Volbella
 Marionette lines Ultra Plus 0.5–1.0 ml per side for lower injection
Volift 0.5–1.0 ml per side for upper injection
 Mental crease Ultra Plus 0.2–0.5 ml per side
Volift
 Chin apex Ultra Plus 0.2–0.3 ml per site
Voluma
 Prejowl area Ultra Plus 0.5–1.0 ml per side
Voluma
 Mandible body and angle Ultra Plus 0.5–1.0 ml for subcutaneous injection; 0.25 ml for bolus injections
Voluma
Neurotoxin
 Gummy smile OnabotulinumtoxinA 2.0 U per site; total dose: 6.0 U, moderate; 10.0 U, severe
 Upper lip and lower lip lines OnabotulinumtoxinA 1.0 U per site; total dose: upper lip, 2.0–4.0 U; lower lip, 2.0 U
 Depressor anguli oris muscle OnabotulinumtoxinA 2.0–4.0 U per site; total dose, 4.0–8.0 U
 Mentalis muscle OnabotulinumtoxinA 4.0–6.0 U per site; total dose, 6.0–24.0 U per side
  Masseter muscle OnabotulinumtoxinA 4.0–8.0 U per site; total dose, 4.0–24.0 U
 Platysma muscle/jawline OnabotulinumtoxinA 2.0–4.0 U per site; total dose, 12.0–24.0 U per side
 Platysma bands OnabotulinumtoxinA 2.0 U per site; total dose, 8.0 U per lateral band; 6.0 U per medial band

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 Volume 140, Number 3 • Injection Guide for the Lower Face
surrounding areas for perioral wrinkles, nasolabial
folds, and marionette lines. Before treating the naso-
labial fold, the midface region should always be eval-
uated and treated. In rare cases, the nasolabial fold
may be treated only by a direct approach.
ANATOMY OF THE PERIORAL AREA
AND LIPS
The superior and inferior labial arteries found
in the submucosal layer (wet part) are branches of
the facial artery and supply the upper and lower
lips, respectively.1 The infraorbital nerve and
mental nerve provide sensory innervation of the
upper and lower lips, respectively, whereas the
buccal branch of the facial nerve provides motor
innervation to these areas.1
FILLER INJECTION TECHNIQUE FOR
INDICATIONS IN THE PERIORAL AREA
AND LIPS
Nasolabial Fold
Injections of Ultra Plus or Volift are made at
two areas (Fig. 1, left). Injectors should be alert to
the facial artery and vein and exercise caution dur-
ing augmentation of the proximal nasolabial folds
because of a risk of vascular compromise of the
facial artery and nose branches (Fig. 1, right).6 For
the retrograde linear injection (area 1), position the
needle and aspirate before injection. Stretch the
skin using two fingers to better visualize the fold.1
Stay slightly medial to the fold, and insert the needle
angled upward parallel to the fold to deliver a super-
ficial subcutaneous injection. [See Figure, Supple-
mental Digital Content 1, which shows the linear
retrograde technique for treatment of nasolabial
Fig. 1. Treatment of nasolabial folds using either Ultra Plus or Volift (left). Aspiration is mandatory before each injec-
tion. Areas of caution (right). a., artery; v., vein.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
folds; inject into the superficial subcutaneous space.
For fanning technique (not shown), deliver a slow
and superficial subcutaneous injection medial to
the fold, http://links.lww.com/PRS/C311.] Use a
slow, continuous-movement, low-volume, linear
retrograde injection. Do not overinject, as overin-
jection may lead to irregularities. For injection on
the medial aspect of the fold, position the needle
more superficially and deliver a subcutaneous injec-
tion using a fanning technique. Inject more slowly as
the injection approaches the nose. Massage to shape
after each injection; do not overfill.
Use of Voluma for nasolabial folds is indicated
in patients with severe volume loss to compensate
for bone retrusion. Specific training for this area is
advised. Voluma is injected very deeply at the canine
fossa (Fig. 2, left). Inspect the skin surface to deter-
mine the vascular pattern, and avoid the facial artery
and nose branches, the facial vein, and the inferior
alar artery branch of the angular artery (Fig. 2,
right).6 Position the needle perpendicular to the skin
surface. Touch the bone, and aspirate before injec-
tion. Inject very slowly with low pressure to deliver
a supraperiosteal small bolus. (See Figure, Supple-
mental Digital Content 2, which shows the injection
technique for retruded canine fossa. Insert needle
perpendicular to skin surface, and inject very slowly
with low pressure, http://links.lww.com/PRS/C312.)
Massage to shape and avoid overfilling.
Lip Border
Reshaping the lip border (Fig. 3) is achieved
using Ultra Plus, Ultra, Volift, or Volbella.5 (See Fig-
ure, Supplemental Digital Content 3, which shows
the injection technique for lip border. Inject very
slowly and avoid inadvertent displacement of the
filler, http://links.lww.com/PRS/C313.) Assess any
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 Plastic and Reconstructive Surgery • September 2017
Fig. 2. Treatment of the retruded canine fossa using Voluma (left). Inspect skin for vascular pattern to avoid areas of
high caution, including facial artery and vein and the inferior alar artery branch of the angular artery (right). Aspiration
is mandatory before injection.
Fig. 3. Treatment of the lip border using Ultra Plus, Ultra, Volift, or Vol-
bella. The product is injected along the lip border. Areas of caution:
avoid the labial artery and vein in the intraoral submucosal plane.
asymmetry before injection, and respect the propor-
tions between the upper lip and the lower lip. When
identifying injection sites, avoid the labial artery
and vein in the intraoral submucosal plane (i.e., wet
part of the lip). Position the needle at the vermil-
lion border near the lateral edge of the mouth, and
insert the needle below the mucocutaneous junc-
tion. Inject very slowly using an anterograde linear
technique with deposition of a linear thread as the
needle is being advanced into the skin. Avoid inad-
vertent displacement of the product outside of the
intended treatment area. Injection into the sensitive
Cupid’s bow is performed very slowly. Administer
equal volumes of filler on both sides unless gross
asymmetry is evident.5 Avoid overcorrecting the lip
border and producing excessive anterior projection
of the upper lip.
Vermillion
Enhancing the shape or volume of the ver-
million can be achieved with Ultra Plus, Ultra,
Volift, or Volbella. Two different techniques are
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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
recommended (Fig. 4). With the first technique,
the filler is administered at one site in each quad-
rant of the lip body. Administer Ultra Plus, Ultra,
and Volift by means of intramuscular anterograde
linear threading and Volbella by means of retro-
grade linear threading into the dry submucosa.
[See Figure, Supplemental Digital Content 4,
which shows the injection techniques for vermil-
lion. Inject very slowly either linearly in the sub-
mucosa (left, technique 1) or in small aliquots
intramuscularly (right, technique 2), http://links.
lww.com/PRS/C314.] Avoid the labial artery and
vein in the intraoral submucosal plane. Insert the
needle into the lip mucosa at a 30-degree angle
to the lip body.5 Enter through the skin and inject
very slowly to avoid bleeding in this bruise-prone
area. The second technique can be used with
Ultra Plus, Ultra, and Volift. Filler is administered
at three injection sites per quadrant. To avoid pain
and bruising, insert the needle at points 2 mm
superior to the upper lip border and 2 mm infe-
rior to the lower lip border, and place the filler
inside the vermillion. Deliver very small intra-
muscular bolus injections very slowly. Massage is
mandatory to avoid irregularities and nodules.
The precautions outlined for enhancing the lip
border should also be followed for the vermillion.
Commissures
Restoring the commissures may be achieved
with Ultra Plus or Volift. Before treating the com-
missures, the lip border should be treated, if indi-
cated. Insert the needle superficially at the lateral
edge of the mouth angle, and deliver a very small
bolus injection intramuscularly and/or into the
mucosa (Fig. 5). Be alert to avoid the labial artery
 Volume 140, Number 3 • Injection Guide for the Lower Face

Fig. 4. Treating the vermillion with Ultra Plus, Ultra, Volift, or Volbella. These fillers can be injected either
linearly (above) or in small aliquots (below). Areas of caution: avoid the labial artery and vein in the intra-
oral submucosal plane.

Fig. 5. Treating the oral commissures with Ultra Plus or Volift.
These fillers are injected at one site on each side. Areas of cau-
tion: avoid the labial artery and vein. Inject very slowly.
and vein. Inject very slowly. Avoid overcorrection
because of the possibility of creating a bulging
area or displacement during animation. Overcor-
rection may lead to an abnormal smile.
Philtrum
The ridge between the nose and lips, known
as the nasal philtrum, tends to flatten with aging.
Reshaping of the philtrum can be achieved with
Fig. 6. Augmentation of the philtrum with Ultra Plus, Ultra,
Volift, or Volbella. These fillers are injected at one site on each
side. Areas of caution: avoid the columella branches of the
upper labial artery near the nose.
Ultra Plus, Ultra, Volift, or Volbella with one injec-
tion site per side (Fig. 6). Avoid the columella
branches of the upper labial artery near the nose.
Pinch the philtral column using two fingers, and
insert the needle at the base of the philtrum with
the needle pointed upward and the needle bevel
inward. (See Figure, Supplemental Digital Content
5, which shows the injection technique for phil-
trum. Pinch the philtral column, and insert the

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 Plastic and Reconstructive Surgery • September 2017
needle upward with the bevel facing inward; inject
slowly, http://links.lww.com/PRS/C315.) Administer
a superficial subcutaneous injection using a linear
retrograde technique. Ensure that the inverted-V
shape of the philtrum is preserved. Avoid widen-
ing the philtral columns and avoid overcorrection
that may result in elongating the upper lip.
Perioral Lines
Correction of perioral lines can be achieved
with Ultra or Volbella (Fig. 7). Be alert to the peri-
oral vasculature, including branches of the upper
labial artery. Insert the needle perpendicular to
the wrinkles and administer a superficial subcuta-
neous injection using a linear technique. (See Fig-
ure, Supplemental Digital Content 6, which shows
the injection technique for perioral lines. Inject
slowly and evenly perpendicular to the wrinkles;
massage after the injection, http://links.lww.com/
PRS/C316.) Inject slowly and evenly, and massage
after each injection. Do not chase superficial lines.
Avoid elongation and flattening of the upper lip
because of overinjection and avoid overcorrec-
tion.6 In many aged lips, judicious volumization
with Ultra or Volift will aid in treatment of lines.
ONABOTULINUMTOXINA INJECTION
TECHNIQUE FOR INDICATIONS IN THE
PERIORAL AREA AND LIPS
Gummy Smile
Gummy smile refers to the showing of exces-
sive gum while smiling or laughing. In moderate
gummy smile, the levator labii superioris alaeque
nasi muscle elevates and everts the upper lip, and
the depressor septi nasi muscle draws the nasal tip
downward and lifts the medial tubercle.7 In severe
gummy smile, the levator labii superioris and
zygomatic minor muscles also raise the upper lip.7
Fig. 7. Correction of perioral lines with Ultra or Volbella. These
fillers are injected at one site in each quadrant. Areas of caution:
perioral vascularization (branches of the upper labial artery).
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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Injections of onabotulinumtoxinA for correction
of gummy smile are made at three sites if mod-
erate and at five sites if severe (Fig. 8). The total
dose is 6 to 10 U of onabotulinumtoxinA, depend-
ing on severity and muscles involved. [See Figure,
Supplemental Digital Content 7, which shows the
injection technique for gummy smile. For each
injection, insert the needle pointed upward to
one-half of its depth; inject into the depressor
septi nasi (left) and levator labii superioris alaeque
nasi (right). Assess for asymmetry before and after
injection, http://links.lww.com/PRS/C317.] Exces-
sive doses may lead to upper lip elongation and
lip ptosis. Patients with a short upper lip are ideal
candidates, whereas care should be exercised in
patients with gummy lip and a long upper lip.
Upper Lip and Lower Lip Lines
Vertical lines on the upper and lower lips occur
with aging and may remain after dermal filler treat-
ment.7 The orbicularis oris is the main muscle in
the lips, with superficial fibers responsible for lip
protrusion.7 Upper lip lines are treated at one or
two sites per side (Fig. 9), whereas lower lip lines are
treated at one site per side. Insert only the needle
bevel pointed upward. (See Figure, Supplemental
Digital Content 8, which shows the injection tech-
nique for upper lip lines. For each injection, insert
the needle to the depth of the bevel, with the bevel
Fig. 8. Treatment of gummy smile with onabotulinumtoxinA.
Injections are made at three sites for moderate gummy smile
(yellow X) and at two additional sites for severe gummy smile
(blue X). The symbol X indicates one-half needle depth.
 Volume 140, Number 3 • Injection Guide for the Lower Face
Fig. 9. Treatment of upper and lower lip lines with onabotu-
linumtoxinA. Injections are made at one or two sites per side.
pointed upward. Assess for asymmetry before and
after injection, http://links.lww.com/PRS/C318.)
Avoid administering excessive doses, which may
lead to flattening of the lips and restrict lip purs-
ing, or injecting too close to the mouth, which may
impact lip function and cause drooling.8
AESTHETICS OF THE CHIN AND
JAWLINE
The chin should be oval and delicate in women,
with less fullness concentrated at its lateral part,
whereas it may have more square, heavier features
and a stronger appearance in men.1 For both men
and women, good chin projection and a youthful
jawline are considered the standards of beauty.1,9
ASSESSMENT OF THE CHIN AND
JAWLINE
The chin assessment should include evalu-
ations of occlusion, skeletal and dental relation-
ships, lateral fullness, and projection along the
subnasal vertical line.1 The ratio of the upper lip to
lower lip/chin should be one-third to two-thirds.1
The jawline assessment should consider the chin-
neck angle (submental-neck line); 121 degrees is
considered optimal in women. The jawline should
be smooth from the angle of the jaw until the
chin, uninterrupted by the jowl or postjowl and
prejowl sulcus. Viewing this area from the front
and sides is critical in assessment. Evaluate for the
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
presence of marionette lines, including sagging
skin or manifest lines.7 Finally, assess the platysma
for the presence of neck lines and for active con-
traction of the platysma bands when speaking.7
ANATOMY OF THE CHIN AND JAWLINE
The mental and submental arteries, which are
branches of the inferior alveolar artery and facial
artery, respectively, supply the chin.1 The mental
nerve provides sensory innervation to the chin
and lower lip; it exits the mental foramen below
the second mandibular premolar.1 Particular
attention should be paid to the facial artery and
marginal mandibular facial nerve branch, as they
cross superficially just anterior to the masseter
muscle in the postjowl sulcus.
FILLER INJECTION TECHNIQUE FOR
INDICATIONS IN THE CHIN AND
JAWLINE
Marionette Lines
Marionette lines give the face a sad or hard
appearance. Treatment of marionette lines may
be achieved with Ultra Plus or Volift. Injections
are made at two sites on each side (Fig. 10). Injec-
tors should be alert to avoid the inferior labial
and sublabial arteries and veins. Using a linear
retrograde technique, deliver a superficial sub-
cutaneous injection. Inject slowly, and deliver
most of the volume to the top third of the fold
while staying medial to the marionette line. The
upper injection is made by inserting the needle
inferior to the modiolus and injecting slowly using
a vertical column technique, in which the filler
is injected as the needle is withdrawn from the
deeper tissue. [See Figure, Supplemental Digital
Content 9, which shows the injection technique
Fig. 10. Correction of marionette lines with Ultra Plus or Volift.
Fillers are delivered by means of injections at two sites per side.
Areas of caution: avoid the inferior labial and sublabial arteries
and veins.
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 Plastic and Reconstructive Surgery • September 2017

for marionette lines. The upper injection is made

in the modiolus using a smaller volume. For the
linear retrograde technique, deliver a superficial
subcutaneous injection (not shown). Keep both
injections medial to the marionette line, http://
links.lww.com/PRS/C319.]

Mental Crease
The labiomental or mental crease is a horizon-
tal line that develops during aging just above the
chin.5 These lines develop because of soft-tissue
volume loss, dermal atrophy, reduced skin elastic- Fig. 11. Treatment of a mental crease with Ultra Plus or Volift.
ity, hyperdynamic contractions of the lower facial Fillers are delivered by means of linear retrograde or antero-
muscles, and underlying resorption of mandibular grade injection. Areas of caution: avoid the sublabial artery and
bone.5 A reduction in the depth of a mental crease vein.
may be achieved with Ultra Plus or Volift. Filler is
delivered to one injection site per side (Fig. 11).
Injectors should be alert to avoid the sublabial
artery and vein. Deliver a superficial subcutaneous
injection through a linear retrograde technique.
[See Figure, Supplemental Digital Content 10,
which shows the injection technique for mental
crease. Injections are made by means of linear ret-
rograde technique. Alternatively, injection using
a linear anterograde technique can be made if
starting laterally (not shown). Injections should be
made slowly, http://links.lww.com/PRS/C320.] Mas-
sage after each injection, and avoid overinjection, Fig. 12. Augmentation of the chin apex with Ultra Plus or
as overinjection may lead to irregularities. Voluma. Both fillers are delivered by means of injections at two
to three sites. Areas of caution: avoid the mental artery and vein.
Chin Apex
A recessed chin is aesthetically undesirable;
augmentation increases the anterior projection and
rounding of the chin.5 Augmentation of the chin
apex can be achieved with Ultra Plus or Voluma.
Each product is delivered to two to three injection
sites (Fig. 12). Injectors should be alert to avoid the
mental artery and vein. For the first injection, posi-
tion the needle at the midline of the jawline, and
aspirate before injection. (See Figure, Supplemen-
tal Digital Content 11, which shows the injection
technique for augmentation of chin apex. Aspirate
before injection and inject slowly. Pinch the chin to Fig. 13. Filling of the prejowl area with Ultra Plus or Voluma.
avoid unwanted displacement of the filler, http:// Both fillers are delivered by means of a deep subcutaneous
links.lww.com/PRS/C321.) Inject slowly and deliver injection using a fanning technique. Areas of caution: avoid the
a supraperiosteal small bolus. Compare symmetry mental artery and vein and the mental nerve.
before and after the injection by watching from the
cephalic view. Maintain the injection in the mid-
line and avoid chin deviation. Use two fingers to Prejowl Area
pinch the chin to avoid unwanted displacement The prejowl area is the triangular area from
of the filler. Do not inject the filler too low, as this the mental foramen to the midlateral zone of the
can lead to formation of a “witch’s chin,” and do mandible (Fig. 13).1 Filling of jowls can be achieved
not overfill. Massage after the injection. Deliver the with Ultra Plus or Voluma. Injectors should be alert
other two injections in the same manner at supero- to avoid the mental artery and vein and the men-
lateral sites on either side of the chin. tal nerve. Position the needle at the jawline of the

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 Volume 140, Number 3 • Injection Guide for the Lower Face

prejowl area, and aspirate before injection. (See Fig-

ure, Supplemental Digital Content 12, which shows
the injection technique for filling of the prejowl
area. Inject very slowly and use fingers to control
the placement of the product. Aspiration before
injection is necessary, http://links.lww.com/PRS/
C322.) Make a deep subcutaneous injection using a
fanning technique to deliver filler to the distal parts
of the triangular prejowl area. Inject slowly, use fin-
gers to control placement of the product, and exer-
cise care with displacement of the filler over the
mandibular ligament. Overcorrection lateral to the
ligament may worsen the jowl area.
Fig. 14. Treatment of the mandible body and angle with Ultra
Mandible Body and Angle Plus or Voluma. Both fillers are delivered by means of a super-
The injection of fillers in this area creates ficial subcutaneous injection over the mandible body and by
a more defined jawline contour.1 This may be supraperiosteal small-bolus injections over the mandible angle.
achieved using Ultra Plus or Voluma, with injec- Areas of caution: palpate and avoid the facial artery and vein,
tions at two to three sites per side (Fig. 14). Injec- and avoid the parotid gland.
tors should be alert to palpate and avoid the facial
artery, facial vein, and parotid gland. For the sub-
cutaneous injection, pinch the skin above the man-
dible body and position the needle superficially to
avoid the facial artery. [See Figure, Supplemental
Digital Content 13, which shows the injection tech-
nique for the mandible body. For the subcutaneous
injection, pinch the skin to avoid the facial artery.
The supraperiosteal injections are delivered over
the mandibular angle (not shown). Aspirate before
each injection, inject slowly, and avoid scratching
the periosteum, http://links.lww.com/PRS/C323.]
Do not inject deep at this level. Aspirate before
injection, and inject slowly using a linear retro-
grade technique. For the supraperiosteal injections,
deliver one or two small boluses at the mandibular
angle. This is ideal for male patients. A subcutane-
ous approach is preferable for female patients. Aspi-
rate before each injection, inject slowly, and avoid
scratching the periosteum. The treatment area is
prone to development of deep hematomas, espe-
cially the site of the supraperiosteal injections. Fig. 15. Treatment of the depressor anguli oris muscle with ona-
botulinumtoxinA. Injections are made at one site per side. The
ONABOTULINUMTOXINA INJECTION symbol X indicates one-half needle depth.
TECHNIQUE FOR INDICATIONS IN THE
CHIN AND JAWLINE 4 U of onabotulinumtoxinA is injected at each site.
Insert the needle near the jawline to one half of its
Depressor Anguli Oris Muscle depth and at least 1 cm away from the corner of the
The depressor anguli oris muscle draws the cor- mouth.7 (See Figure, Supplemental Digital Content
ners of the mouth down, creating a crease descend- 14, which shows the injection technique for the
ing from the corner of the mouth that imparts a depressor anguli oris muscle. For each injection,
sullen or dissatisfied appearance.7 Treatment of insert the needle to one-half its depth. Assess for
these lines, resulting from excessive contraction of asymmetry before and at 2 weeks after injection,
the depressor anguli oris muscle, is made at one http://links.lww.com/PRS/C324.) Assess for asymme-
site on each side of the face (Fig. 15). A dose of 2 to try before and at 2 weeks after injection, as this area

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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • September 2017

is at risk for asymmetrical results. Excessive dosing

and medial injections may lead to paralysis of the
depressor labii inferioris muscle, resulting in an
asymmetrical smile.

Mentalis Muscle
Contraction of the mentalis muscle may lead to
a cobblestone or dimpled chin, and may increase
the mentolabial crease while pushing the lower
lip forward.7 Treatment of a cobblestone chin may
be achieved by injecting onabotulinumtoxinA at
a midline point approximately 0.5 to 1 cm above
the inferiormost point of the chin and no closer
than 1.5 cm from the lower lip.7 Some patients,
however, may benefit from injections made at two
additional lateral sites parallel to the midline and/
or from higher doses (Fig. 16). A dose of 4 to 8
U of onabotulinumtoxinA should be delivered.
(See Figure, Supplemental Digital Content 15,
which shows the injection technique for the men-
talis muscle. Insert the needle to its full depth and
maintain the injection in the midline, http://links.
lww.com/PRS/C325.) Maintain the injection in the
midline. Excessive lateral displacement of the nee-
dle may lead to paralysis of the depressor labii infe-
rioris muscle, resulting in an asymmetrical smile.
Masseter Muscle
The masseter muscle elevates the mandible
and is important during chewing; it may become
Fig. 17. Treatment of masseteric hypertrophy with onabotu-
linumtoxinA. Injections are made at three sites on each side of
the face. Square symbols indicate full-needle depth.
enlarged from repeated clenching of the jaw,
resulting in bulging of the lateral jawline, a con-
dition known as masseteric hypertrophy.10 Treat-
ment with onabotulinumtoxinA is made at three
sites on each side of the face (Fig. 17). A dose of
4 to 8 U of onabotulinumtoxinA at each point
should be delivered with the needle inserted
perpendicular to the skin to its full depth. (See
Figure, Supplemental Digital Content 16, which
shows the injection technique for masseteric
hypertrophy. For each injection, insert the needle
perpendicular to the skin to its full depth. Shown
is the injection at the apex point. Inject lateral
to the anterior margin of the masseter muscle,
http://links.lww.com/PRS/C326.) Ask the patient
to clench before marking the injection site, and

Fig. 16. Treatment of the mentalis muscle with onabotulinum-

toxinA. An injection is made at a midline point 0.5 to 1 cm above Fig. 18. Treatment of the platysma muscle/jawline with ona-
the chin and symmetrically on either side. Square symbols indi- botulinumtoxinA. Injections are made at six sites on each side at
cate full-needle depth. one-third needle depth.

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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 140, Number 3 • Injection Guide for the Lower Face
inject lateral to the anterior margin of the masse-
ter muscle. Superficial and higher injections may
cause asymmetry during animation. This area is
prone to deep hematomas. Asian patients with
severe hypertrophy may require higher doses of
40 U or more of onabotulinumtoxinA.11–16
Platysma Muscle/Jawline
The platysma muscle draws down the lower
jaw and the corners of the mouth.7 Treatment of
lines resulting from excessive contraction of the
platysma muscle at the jawline is made at six sites
on each side (Fig. 18). (See Figure, Supplemen-
tal Digital Content 17, which shows the injection
technique for the platysma muscle/jawline. For
each injection, insert the needle to one-third of
its depth. Avoid injecting too deeply or with exces-
sive doses, as they impair swallowing, http://links.
lww.com/PRS/C327.) This area is prone to bruis-
ing. Deep injections and excessive dosing may
lead to impaired swallowing. Patients with a highly
overactive platysma may benefit from two sessions
to optimize the dosage of onabotulinumtoxinA.
Platysma Bands
The caudal parts of the platysma muscle are
thin muscle sheets that run down the lateral neck
and insert into the fascia pectoralis.7 Contrac-
tion of the platysma expands and extends the
skin in vertical lines in the form of bands. Treat-
ment of lateral platysma bands is made at four
sites per band (Fig. 19, left), whereas treatment
of medial platysma bands is made at three sites
per band (Fig. 19, right). Pinch the band to help
guide the injection into the contracted muscle.7
(See Figure, Supplemental Digital Content 18,
Fig. 19. Treatment of the platysma bands with onabotulinumtoxinA. Injections are made at four sites on each lateral band
(left) and at three sites on each medial band (right).
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
which shows the injection technique for platysma
bands. Asterisks indicate one-third needle depth.
Pinch the band and insert the needle to one-third
of its depth. Avoid injecting too deeply or with
excessive doses, as they impair swallowing, http://
links.lww.com/PRS/C328.) This area is prone to
bruising. Deep injections and excessive dosing
may lead to impaired swallowing. Patients with a
highly overactive platysma may benefit from two
sessions to optimize the dosage of onabotulinum-
toxinA. Consideration should be given to inject-
ing the lateral bands at the first session and then
reevaluating whether any medial bands need
treatment.
Injections in medial platysmal bands are more
challenging than lateral bands; the overall dose
of neurotoxin should be lower. Although these
injections can reduce the hypertonicity of medial
platysmal bands, they can also lead to skin lax-
ity. Proper patient selection is important. Ideally,
these injections should be considered in patients
without skin excess in this area.
The OnabotulinumtoxinA Microdroplet
Technique for Lower Face and Neck
This technique has been previously described
and is a useful adjunct for improving the appear-
ance of the skin and contours of the lower face
and neck.17 The product is injected into the der-
mis or the junction between the dermis and the
superficial fibers of the platysma (which insert
into the undersurface of the dermis) over an area
starting three fingerbreadths above the mandibu-
lar border, one fingerbreadth behind the mario-
nette line, and over the entire neck anterior to the
sternocleidomastoids. This results in an improved
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 Plastic and Reconstructive Surgery • September 2017
cervicomental angle, elevation and flattening of
the jowls, reduction of horizontal skin creases
and vertical platysmal banding, and an improved
sheen and texture of the overlying skin. The even
distribution of these microdroplets at a superficial
plane reduces the risk of difficulty in swallowing
or weakness of the sternocleidomastoid muscles.
CONCLUSIONS
Soft-tissue fillers are more important than neu-
romodulators in the lower face.18 Fillers should
be used first to provide structure and support,
and then assessment of dynamic lines should be
evaluated to determine whether neuromodulator
treatment is required. The lip is one of the most
challenging areas to reshape with fillers. Compre-
hensive assessment of dental arches and occlusion
is important to avoid improper correction. When
volumizing the lips, respect the projection of the
lips on the profile view and respect the ratio of
lip size to chin. Rejuvenation of the neck region
is also challenging, where fillers are needed for
structural support of the chin and jawline and
neuromodulators are needed to treat the masse-
ter and platysma.
Maurício de Maio, M.D.
Clinica Dr. Maurício de Maio
Avenida Ibirapuera, 2907 cj 1202
Moema EP 04029200
São Paulo-SP, Brazil
mauriciodemaio@uol.com.br
ACKNOWLEDGMENTS
This article was sponsored through an educational
grant from Allergan plc, Dublin, Ireland. Medical writ-
ing assistance was provided by Barry Weichman, Ph.D.,
of Peloton Advantage, Parsippany, New Jersey, and
funded by Allergan plc. No honoraria or other forms of
payment were made for authorship.
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