Botulinum Toxin in Facial Reanimation

Map of the Facial Musculature and Dosage

Tracy VandeWater, MD a, Laura Hetzler, MD a,b,*

KEYWORDS
 Facial paralysis  Nonflaccid facial paralysis  Synkinesis  Chemodenervation  Botulinum toxin  Facial spasticity

KEY POINTS
 Individuals recovering from facial paralysis can develop nonflaccid facial paralysis or synkinesis.
 Nonflaccid facial paralysis is commonly treated with botulinum toxin, or chemodenervation.
 Individualized assessment of a patient in a multidisciplinary setting creates a specific, targeted facial muscle assessment
and chemodenervation regimen.
 Appropriate follow-up post-chemodenervation is essential to titrate the injection map for each patient.
 This article describes the relevant facial musculature, anatomy, suggested injection patterns, and dosages for treating
these patients.

Video content accompanies this article at http://www.oralmaxsurgeryatlas.theclinics.com.

Introduction motion of recovered musculature and is most effective when

Recovery of the facial nerve may evolve with variable outcomes,
even within the same hemiface. Facial synkinesis, or nonflaccid
facial paralysis, is thought to occur because of aberrant nerve
regeneration. Recovery can be absent with continued flaccidity,
or synkinetic, with voluntary muscle movements causing a
simultaneous, involuntary contraction of other muscle groups.
Facial nerve recovery can also be mixed, with both synkinesis
and weakness in independent muscle groups on the same side of
the face. Emotional expression relies on independent and subtle
facial movements and is lost with disorganized and simultaneous
hyperactivity of the facial muscles.
Management of facial nerve recovery has evolved greatly in
the last decade. Chemodenervation with botulinum toxin-A is
the most commonly used treatment for patients with synkinesis.
While the serotype of botulinum toxin-A onabotulinumtoxinA
(BotoxÒ, Allergan, Irvine, CA, USA) is more frequently used by
the authors, other serotypes available worldwide include abo-
botulinumtoxinA (DysportÒ, Ipsen, Paris, France) and incobotu-
linumtoxinA (XeominÒ, Merz Pharmaceuticals GmbH, Frankfurt,
German). All listed dosages in this article are for onabotuli-
numtoxinA (BT). This therapy selectively reduces undesired or
overactive synkinetic muscles to allow for more organized
Financial Disclosures or Conflicts of Interest: None.
a
Department of OtolaryngologyeHead & Neck Surgery, Louisiana
State University Health Sciences Center, 533 Bolivar Street, Suite 566,
New Orleans, LA 70112, USA
b
Center For Facial Nerve Disorders, Our Lady of The Lake Regional
Medical Center, 4950 Essen Lane, Suite 402, Baton Rouge, LA
70809, USA
* Corresponding author.
E-mail address: lhetzl@lsuhsc.edu
used in conjunction with facial retraining and mobilization
therapy. This article outlines a detailed algorithm for chemo-
denervation that should be considered for patients suffering
from postfacial paralysis synkinesis.
Preoperative Planning
Patient assessment should begin with the patient upright, with
initial assessment in repose prior to evaluating motion. Assess-
ment should begin in the upper face and move systematically to
the lower face. The interaction of multiple muscle groups in the
same region must be considered. Muscular weakness versus
impaired muscle function must be distinguished. Preintervention
photographs (Fig. 1) should be obtained before any intervention
and at each treatment session. This is important, as the initial BT
pattern is often titrated up or down for the appropriate effect.
Preparation and Patient Positioning
The patient should be sitting upright in an appropriate
examination or procedure chair. Skin may be cleaned
with alcohol wipe before injection. BT may be reconstituted at
the provider’s discretion. The author uses 2 cc for a 100 U vial
of BT, injecting with a 1 cc syringe and 30 g needle.
Surgical Approach
Botulinum toxin injection of the muscles of facial expression
Forehead and scalp
1. Frontalis (Video 1)
a. Anatomy: the only brow elevator
i. Origin: galea aponeurotica

Atlas Oral Maxillofacial Surg Clin N Am 31 (2023) 71–83

1061-3315/23/Published by Elsevier Inc.
https://doi.org/10.1016/j.cxom.2022.09.007 oralmaxsurgeryatlas.theclinics.com
72
Fig. 1 Systemic analysis of facial nerve function consisting of the following movements: (A) repose, (B) brow elevation, (C) gentle eye
closure, (D) firm eye closure, (E) closed mouth smile, (F) open mouth smile, (G) snarl, (H) pucker, (I) show bottom teeth, (J) wide mouth
opening, (K) puff out cheeks, (L) nasal base view.
ii. Insertion: dermis below the eyebrows and superior
nasal dorsum
b. Injection site: synkinesis may result in more brow
elevation than intentional motion; in this case, ipsilat-
eral frontalis may be treated. The contralateral frontalis
maybe addressed for overall improved symmetry across
the forehead.
c. Dose: 3 to 6 U can be used on either side (Fig. 2)
2. Occipitalis
a. Anatomy: originates from the superior nuchal line of the
occipital bone, contiguous with the frontalis via the
galea aponeurotica
b. Injection: rare but thought to be associated with strong
frontal and auricular synkinesis
3. Auricular muscles (Video 2)
a. Anatomy: 3 separate muscles: the anterior, superior,
and posterior auricular muscles; synkinesis can cause
VandeWater & Hetzler
elevation or posterior deflection of the auricle with
associated tension, headaches, and discomfort
i. Origin: epicranial aponeurosis
ii. Insertion: medial surface of the auricle
b. Injection: 3 separate locations along the superior and pos-
terior auricle
c. Dose: 1 U each location (Fig. 3)
Periocular
4. Corrugator supercilii (CS) (Videos 3e5)
a. Anatomy: medial brow depressor; may contribute to a
mounding or fullness above the ipsilateral medial brow
resulting in brow depression
i. Origin: bone above the superior orbital rim
ii. Insertion: skin of the glabella
b. Injection: target mounding on ipsilateral side for
softening and to allow medial brow elevation; target
bilateral for overall glabellar softening
Botulinum Toxin in Facial Reanimation 73

Fig. 2 (A) Demonstrates asymmetry of brow during repose in patient with left-sided facial paralysis. (B) Patient is asked to raise his or
her brow to target injection. (C) Shows injection of right brow for symmetry. (D) Red circles mark targets for injection.

c. Dose: 5 to 7.5 U (Fig. 4) synkinesis even in the setting of persistent and minimal
1. Procerus (Videos 3e5) lagophthalmos.
a. Anatomy: brow depressor i. Origin: broad attachment to frontonasal area,
i. Origin: over the nasal bone and upper lateral lacrimal bone and medial palpebral ligament
cartilages ii. Insertion: lateral palpebral raphe
ii. Insertion: glabellar skin b. Injection: do not inject if any dry eye symptoms are
b. Injection: treat in conjunction with corrugator reported or persistent lagophthalmos; proceed with
c. Dose: see corrugator (Fig. 5) caution as aggressive injections may cause lagoph-
2. Orbicularis oculi (Video 6) thalmos or blepharoptosis (inadvertent effect to the
a. Anatomy: functions as sphincter; may present as a nar- levator palpebrae superioris). Varying patterns tar-
rowed palpebral fissure at rest. More often results in geted on the upper eyelid, lower eyelid, and lateral
synkinetic eye closure with animation; can have dynamic canthus can be performed safely at varying distances
74 VandeWater & Hetzler

Fig. 3 Example of auricular muscle injection. Left photo demonstrates superior sites of injection with red circles, and right photo
demonstrates postauricular sites.

Fig. 4 Image on left has arrow demonstrating corrugator mounding and brow depression on the patient’s synkinetic side. Image on right
highlights sites of injection with red circles targeting ipsilateral corrugator, yellow circles targeting procerus, and green circles targeting
contralateral corrugator.
Botulinum Toxin in Facial Reanimation
Fig. 5 Photo demonstrating chemodenervation of procerus muscle.
from the lashline; lateral, infrabrow injection can
address the pull of the orbicularis oculi to achieve a
lateral brow lift; this, in conjunction with the corru-
gator injection for medial browlift, can alleviate subtle
amounts of brow ptosis related to facial paralysis
(Video 6).
c. Dose: superficial and subcutaneous injection patterns of
0.5-2.25 U for upper lid, lower lid, and lateral canthus
i. Expect to titrate as needed (Fig. 6)
Midface
3. Nasalis muscle (Videos 7e9)
a. Anatomy: 2 separate muscles: compressor (CN) naris or
transverse wrinkles the skin of the nose and constricts
the ala as it wraps around the ala to the maxilla; dilator
naris (DN) or alar depresses the nostril and dilates the
aperture. Nasalis synkinesis manifests as nasal obstruc-
tion (CN) or flaring (DN). Synkinetic activation can
contribute to locking down, or tethering, of the medial
cheek affecting upper lip elevation.
i. Origin: CN from maxilla superior to the incisive fossa;
the DN, or alar portion, originates from maxilla near
the lateral incisor
ii. Insertion: CN at nasal dorsum with the fibrotendinous
extension of the contralateral nasalis; the DN inserts
into the skin of the ala and lateral crus of the lower
lateral cartilage.
b. Injection: deeper SMAS injection at inferior lateral nasal
sidewall, above the alar crease
c. Dose: 0.5 to 1.25 U (Fig. 7)
75
4. Levator labii superioris (LLS)
a. Anatomy lip elevator best treated with soft tissue
mobilization and stretching; difficult to treat and
uniquely assess. Authors only treat when there is
described pain or contraction refractory to first-line
therapy; for select patients, single BT injection per-
formed lateral to nasal sidewall followed by therapy to
attempt to prevent the return of hypertonicity.
i. Origin: nasal maxilla and zygomatic bone inferior to
the orbital rim
ii. Insertion: blended superficial confluence with other
elevators of the upper lip and intrinsic upper lip
musculature
b. Injection: will affect the smile and limit lip elevation; if
patient willing to accept smile asymmetry, inject at the
site of a pressure point or spasm for relief, lateral to the
nasal sidewall
c. Dose: 0.5 to 1.25 U (Fig. 8)
5. Levator labii superioris alaeque nasi (LLSAN)
a. Anatomy: 2 limbs; nasal limb elevates and dilates nostril
(alaris). Labiocolumellar limb is lip elevator best treated
with soft tissue mobilization and stretching; synkinetic
LLSAN strongly contributes to the tethering of soft tis-
sues of the medial cheek.
i. Origin: frontal process of the maxilla
ii. Insertion: nasal limb at cephalic border of the lateral
crus; the labiocolumellar limb wraps around the alar
crease to the nasal base, decussating into the phil-
trum, columella, and other soft tissues of lip
76
Fig. 6 Orbicularis oculi injection. (A) Injection of superior lid. (B) Injection of inferior lid. (C) Injection at lateral canthus. (D) All 3 sites
of typical initial injection pattern marked by red circles.
b. Injection
i. Medial, alar limb of the LLSAN: superior to the nasal
ala at the distal nasal sidewall (same as nasalis
injection)
ii. Lateral or labiocolumellar limb of LLSAN: deep in-
jection to the insertion site into the soft tissues at
the base of the columella; injection lateral to nasal
sidewall or lateral to the ala superficially will affect
the smile and limit lip elevation
c. Dose: 0.5 to 1.25 U each limb
VandeWater & Hetzler
6. Levator anguli oris (LAO), zygomaticus major, zygomaticus
minor
a. Anatomy: lip elevators best treated with soft tissue
mobilization and stretching; difficult to treat and
uniquely assess
b. Injection: avoided; neuromuscular retraining and
stretching are recommended, because chemo-
denervation is difficult to titrate and even small doses
can affect smile. Similar to LLS, authors will perform
rare instances of direct injection related to refractory
Botulinum Toxin in Facial Reanimation
Fig. 7 Top photo demonstrating nasalis muscle injection along the nasal sidewall superior to nasal ala. Bottom photo demonstrating
depth and location of injection for deep alar injection (muscle confluence attaching to bone).
contraction or painful spasm at the patient’s direct
request.
7. Depressor septi (DS) (Videos 7e9)
a. Anatomy: depresses the nasal tip and septum, working
with the dilator nares laterally
b. Origin: maxilla at the incisive fossa
c. Insertion: region of the nasal septum medially and the
posterior dilator nares laterally
d. Injection: inject at superior, medial white lip at the base
of the columella and deep to the orbicularis oris, into
the deep soft tissues (same injection as labiocolumellar
LLSAN)
e. Dose: 0.5 to 1.25 U (Fig. 9)
Perioral
8. Risorius
a. Anatomy: contributes to the lateral vector in the
normal smile
i. Origin: fascia overlying the parotid and zygoma
ii. Insertion: the modiolus
b. Injection: avoided as its insertion to the modiolus will
invariably affect other modiolar muscles
9. Buccinator (Video 10)
77
a. Anatomy: lateral to the buccal mucosa within the cheek,
working to compress the cheek during mastication
i. Origin: alveolar process of the maxilla superiorly,
the buccinator ridge of the mandible inferiorly, and
the pterygomandibular raphe posteriorly
ii. Insertion: the modiolus
b. Injection: palpate bilaterally during smile and eye
closure prior to injection; target intraorally, deep to
the buccal mucosa, posterior and inferior to Stenson
duct, typically inferior to a visible occlusal line
c. Dose: 1 to 1.25 U (Fig. 10)
10. Orbicularis oris
a. Anatomy: sphincteric muscle surrounding the oral
commissure
i. Origin: the central upper and lower lips
ii. Insertion: perioral skin, muscles, and modiolus
b. Injection: more amenable to stretching; injection is
rarely and cautiously performed because of its close
proximity to the oral dilators, and even small doses can
compromise oral motor function. Some success with in-
jection on the wet lip surface medial to the commissure.
c. Dose: 0.5 to 1 U (Fig. 11)
78
Fig. 8 Oral gaposis related to hypertonic activity of upper lip
elevators and depressors leading to oral incompetence.
11. Mentalis (Videos 11e13)
a. Anatomy: centrally paired muscle in the chin, causing
deformity of the lower lip and chin while smiling; hy-
pertonicity contributes to the peau d’orange, skin of
the orange, or golf ball appearance of the mental skin
and elevation of the lower lip resulting in asymmetric
lower dental show
i. Origin: incisive fossa of the mandible
ii. Insertion: the skin of the chin
b. Injection: centrally or paramedian to avoid DLI
c. Dose: total 2.0 to 7.5 U (Fig. 12)
12. Depressor anguli oris (DAO) (Videos 14e16)
a. Anatomy: depressor of the oral commissure; routinely
injected for the limitation of oral commissure excursion
i. Origin: broad from the mental tubercle and oblique
line of the mandible
ii. Insertion: narrowly at the inferior modiolus
b. Injection: one can palpate this synkinetic muscle during
strong smile; ipsilateral injection is performed lateral
to the marionette line (to avoid the DLI) and just
inferior to the modiolus. For contralateral overpull in
the setting of marginal nerve weakness, inject at its
origin near the contralateral mandibular border, 5 to
10 mm medial to the marionette line.
c. Dose: 2.0 to 5 U (Figs. 13 and 14)
13. Depressor labii inferioris (DLI) (Video 17)
a. Anatomy: the primary lip depressor
i. Origin: oblique line of the mandible between the
symphysis and the mental foramen
VandeWater & Hetzler
Fig. 9 Injection of depressor septi muscle. Arrow points to site
of injection; note the depth of the needle for this deep injection,
aimed into the base of the columella.
ii. Insertion: skin of the lower lip, orbicularis oris,
decussating to the contralateral DLI
b. Injection: not recommended unless being treated in
conjunction with DAO for overpull in the setting of
contralateral marginal nerve weakness; inject at its
origin near the mandibular border, 5 mm medial to DAO
injection (Fig. 15)
Neck
14. Platysma (Videos 18 and 19)
a. Anatomy: superficial, sheet-like muscle; synkinesis re-
sults in visible banding, skin creep, and subsequent
tethering of the oral commissure
i. Origin: skin and fascia above and below the clavicle
ii. Insertion: lower mandible, the lower lip and mod-
iolus, the orbicularis oris, and the skin of the inferior
cheek
b. Injection: patients will typically verbally report the
area of greatest tightness, including jaw spasm, where
the muscle reflects over the lower border of the
mandible; for injection, manually distract the muscle
between 2 fingers for direct injection of the platysma
c. Dose: 10 2.5 unit injections (25 U) across the entire
surface of the platysma with varying extension over the
jawline (Fig. 16)
Fig. 10 Buccinator injection is performed intraorally. Arrow indicates the visible occlusal line. Red circle shows target of injection
inferior and posterior to occlusal line.

Fig. 11 Left orbicularis oris synkinesis injection. Injection intraorally allows submucosal position to avoid affecting other muscles
including lip depressors, lip elevators, and zygomaticus complex.
80 VandeWater & Hetzler

Fig. 12 Left photo with arrow pointing to peau d’ orange of skin created by mentalis with smile. Right photo with red circles marking
mentalis injection targets.

Potential complications may occur because of injection inadvertently affecting the

Chemodenervation is contraindicated during pregnancy, if
breastfeeding, during local infection, when there is a known
allergy to injection components, and with underlying
neuromuscular disorders. Lagophthalmos or blepharoptosis
levator palpebrae superioris. Dry eye symptoms may occur
even with optimal outcomes for relief of decreased ocular
aperture. Lip drop or reduced oral commissure excursion
related to lip elevator or zygomaticus complex injection may
occur.

Fig. 13 Left photo demonstrates palpation of ipsilateral synkinetic DAO at area of marionette line with smile. Right photo shows in-
jection of the DAO just lateral to marionette line, below the modiolus at red circle.
Botulinum Toxin in Facial Reanimation 81

Fig. 14 Patient with left facial synkinesis with continued limited left lip depressor function leading to right/contralateral overpulling of
the depressors. Left photo demonstrating contralateral activation of lip depressors, including DAO. Right photo with arrow showing
injection site of the contralateral DAO.

Pearls and pitfalls
Evaluation of photographic documentation prior to interven-
tion and approximately 3 weeks after injection is useful in
establishing a comfort level with BT injections, and helps drive
individual titration of injection maps. Document precise loca-
tions and dosage of each injection (Fig. 17).
Not every patient is bothered by all of the synkinetic man-
ifestations found on physical examinations. Allow the patient
to articulate what he or she finds distressing.

Fig. 15 Patient with left facial synkinesis with continued limited left lip depressor function leading to right/contralateral overpulling of
the depressors. Picture on left with arrow pointing to patient’s marionette line. Red circle highlights target of contralateral injection,
approximately 5 mm medial to DAO injection. Image on right demonstrates injection.
82 VandeWater & Hetzler

Fig. 16 Photo on left with red circles highlighting potential targets for unilateral platysma injection. Photo on right demonstrating
pinching of platysma muscle during injection.

Asymmetry or poor cosmesis may be caused by unmasking

other muscular vectors, although it should be noted that these
effects are temporary.
Botulinum toxin-A, onabotulinumtoxinA, or BotoxÒ is the
most commonly used treatment for patients with synkinesis;
however, antibody development has been reported. If BT in-
jection is unsuccessful secondary to antibody production, other
preparations of botulinum, including incobotulinumtoxinA
(XeominÒ) and abobotulinumtoxinA (DysportÒ), are also
approved by the US Food and Drug Administration (FDA) for this
indication.
Surgical intervention such as selective neurectomy or
myectomy, targeting the DAO and platysma, can be performed
in the synkinetic setting as an adjunct to chemodenervation.
If possible, the authors prefer to refer a new synkinetic
patient to a specially trained facial nerve physical therapist for
soft tissue mobilization, stretching, and facial retraining prior
to chemodenervation. Proceeding to BT therapy follows a
plateau in therapeutic progress.

Immediate postoperative care

The patient is instructed to avoid stretching or rubbing the

injected areas for 3 days after the injections, especially in the
periocular region.

Rehabilitation and Recovery

Fig. 17 Example of detailed injection map of actual synkinesis Patients are educated that maximum effects of BT will be 2
patient for reference. Circles are color coded by dosage. weeks after injection. The duration of the effect is variable,
Botulinum Toxin in Facial Reanimation
and patients often require repeat injections every 3 to 4
months initially. Serial injections may eventually be spaced out
to every 6 months or more. The goal of BT injections is not to
perform them lifelong. BT injections are seen as an adjunct to
facial retraining therapy.
Summary
Effective treatment of the facial synkinesis patient requires
global knowledge of facial musculature anatomy and the
ability to extrapolate the synergistic and antagonistic effects
of the globally hyperkinetic face. Initial treatment patterns
may be titrated for individualized treatment plans unique to
each patient. Successful treatment for synkinesis includes
facial retraining therapy by a specially trained physical or
occupational therapist in conjunction with chemodenervation.
Supplementary data
Supplementary data related to this article can be found online
at https://doi.org/10.1016/j.cxom.2022.09.007.
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