Cosmetic
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The Use of Botulinum Toxin Type A in
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Aesthetic Mandibular Contouring
Nam-Ho Kim, M.D., Jee-Hyeok Chung, M.D., Rho-Hyuk Park, M.D., and Jong-Beum Park, M.D.
Seoul, Korea
The lower third of Asian faces is wider
than that of Caucasians and it is deter-
mined by the size and width of the man-
dibular bone and the thickness of muscles
and subcutaneous fat tissues surrounding
it. Efforts to create an aesthetically slim and
smooth facial contour line in nonobese
people have led the authors to focus on two
approaches: surgical resection of the mas-
seteric muscle and modeling ostectomy of
the square-angled mandibular bone. Be-
cause these procedures present some prob-
lems, the authors adopted a nonsurgical
concept that chemically denervates mus-
cles and reduces the bulk of the muscle.
The authors have conducted a total of 1021
clinical cases from March of 2001 through
September of 2002, in which patients were
treated with botulinum toxin type A (Dys-
port; Ipsen Ltd, Slough, United Kingdom)
for remodeling the lower facial contour
line; 383 of those cases were followed up for
at least 3 months after the initial injection.
A database was made by measuring the
change in the thickness of the injected mus-
cle with an ultrasonogram. Eleven patients
underwent resection of the mandibular an-
gle before injection. The preinjection os-
tectomy group was involved in the study as
a result of their dissatisfaction with the sur-
gical results; they had a rather thick mas-
seter muscle and not a bone problem.
Some had both bone problems and a thick
masseter muscle. Three months after the
botulinum toxin injection, the thickness of
the muscle was reduced by 31 percent on
From the Gyalumhan Plastic Aesthetic Clinic. Received for publication October 9, 2003; revised April 5, 2004.
DOI: 10.1097/01.PRS.0000153236.79775.A0
919
average. The atrophic effect of injection
was observed after 2 to 4 weeks for most
patients. Seventy percent of the 383 pa-
tients tracked were greatly satisfied with the
result, with another 23 percent generally
satisfied. No long-term side effects were re-
ported. Masseteric hypertrophy is frequent
in Asians because of racial characteristics
and dietary habits. Botulinum toxin type A
has made a new epoch in facial contouring
for Asians. Considering that Asians have a
prominent malar and a prominent mandi-
ble angle, the reduction in the thickness of
the masseter can provoke relative promi-
nence of the malar and mandible angle.
Therefore, precise indication and anatomy
of the facial muscle should be thoroughly
understood, which will decrease the inci-
dence of side effects and problems. Botu-
linum toxin type A (Dysport) injection is
simple in technique, has few side effects,
and promises a rapid return to daily life.
The authors conclude that the injection of
botulinum toxin type A can replace surgical
masseter resection. (Plast. Reconstr. Surg.
115: 919, 2005.)
Asians, unlike most Westerners, have a
rather round or square-angled face. This is why
there has been a steady and growing stream of
demands for mandibular contouring treat-
ments or surgeries among Asians to create a
slimmer and more oval face. Since Legg1 first
described bilateral masseteric hypertrophy as a
benign condition characterized by a bilateral
 920
enlargement of the masseter muscles in 1880,
conservative treatments, including systemic
medications, were used over a long period of
time. Gurney2 in 1947 performed the masse-
teric resection through skin incision, and in
1951, Converse3 used the intraoral route to
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resect the masseteric muscle together with the
bone. Since then, even in cases of bilateral
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masseteric hypertrophy, surgical resection of a
square-angled jawbone has been performed
more frequently.
The width of a lower face is determined by
the size of the mandibular bone, the volume of
muscles, and subcutaneous fat tissues sur-
rounding it. To make the contour line of this
area slim and smooth, various treatments, such
as resection of the angled bone and the mas-
seteric muscle or liposuction, have been ap-
plied. The overall effect of the angle resection,
which directly resects the bone, depends on
the shape of the jawbone, the three-dimen-
sional structure, and the status/conditions of
the soft tissues. Benefit from this surgery is best
realized when a patient has a protrusive angled
mandible or a flaring at the lower soft tissues or
when the soft tissue is appropriately thin or has
enough elasticity. In practicing this surgery in
an actual clinical scene, however, the full effect
from the mandibular angle resection is rather
restricted.
PATIENTS AND METHODS
Patients
We treated a total of 1021 patients from
March of 2001 to September of 2002 with bot-
ulinum toxin type A injections for aesthetic
purposes to reduce the volume of the masseter
muscle. We asked all treated patients to visit
the hospital again within 3 to 4 months after
injection. Follow-up depended entirely on pa-
tient will. Of 1021 patients, we were able to
track down 383 patients with a follow-up period
of longer than 3 months (28 males, 355 fe-
males) There were 10 teenagers, 293 patients
in their 20s, 70 patients in their 30s, and nine
patients in their 40s. Eleven of these patients
had already received surgical resection of the
mandible but were unsatisfied with the result.
Of patients treated with a first injection, 194
received a second injection after 3 to 12
months; the average time to second injection
was 5 months.
Lyophilized botulinum toxin type A (Dys-
port; Ipsen Ltd, Slough, United Kingdom) was
PLASTIC AND RECONSTRUCTIVE SURGERY, March 2005
reconstituted to a final concentration of 125
U/cc in sterile saline; one Dysport vial contain-
ing 500 U was reconstituted with 4 ml of sterile
saline. Aliquots of 1 ml (equivalent to 125 U)
were injected through a 30-gauge needle in an
even distribution.
After the first injection, we observed the
muscular volume at the time when the crunch-
ing power of the muscle reappeared and com-
pared the photograph taken before the injec-
tion with the photograph taken at that point.
After comparisons were made of the progress
in the outcome and patient desires, a second
injection was performed if necessary.
Pretreatment and Posttreatment Examinations
and Analysis
Patients were examined with inspections and
palpations before treatment, and a standard
frontal view photograph was taken to indicate
the change after injection. Muscle volume was
measured by ultrasonogram to determine the
right dose of the injection. The measured value
was used as a basis for an objective observation
of the change after treatment. To bring consis-
tency in measuring the change over the in-
jected area with ultrasonogram, all the patients
were measured from the ear lobe to each cor-
ner of the mouth. For example, there was a
difference of the size of masseter muscle be-
fore and after injection (Fig. 1). Radiographs
were also taken as necessary to evaluate the
relationship between muscle and jawbone.
In the same manner, after the injection, the
thickness of masseter muscle was measured by
ultrasonogram. The value between pretreat-
ment and posttreatment was compared. We
analyzed these data simply and obtained only
mean and range. We did not conduct further
statistical analyses.
Methods
The injection dose was 100 to 140 U of Dys-
port for each side based on the muscle volume
(Table I). The injection was given divided in
three to four areas depending on the width of
the muscle following the contour line of the
mandible (Fig. 2).
RESULTS
Change in the Muscle
The average thickness of the masseter mus-
cle measured by ultrasonogram before injec-
tion in the 383 responding patients was 13.36
 Vol. 115, No. 3 / AESTHETIC MANDIBULAR CONTOURING 921
percent on average 3 months after the injec-
tion, showing 9.27 mm (range, 6.5 to 13.5 mm)
on the right and 9.28 mm (range, 6.3 to 13.7
mm) on the left. These data are summarized in
Table II.
The muscular crunching power disappeared
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after 1 to 2 weeks, whereas the effect of muscle

volume decrease started to manifest after 2 to 4
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weeks, with the maximum effect showing after

10 to 12 weeks. Muscle strength started to re-
appear after 3 to 4 months. At 6 months after
the injection, we found that even when the
muscle strength was mostly on the increase, the
recovery in the muscle volume varied from case
to case.

Additional Injection

The second injection was usually given after

4 to 7 months. To have a long-term effect, the
time of the second injection was determined to
be the point at which muscle recovers its
crunching power. Approximately 70 percent of
patients could be followed up for a long-term

FIG. 1. Ultrasonogram results. (Above) Before injection,

the average size of the masseter muscle is 14.3 mm. (Below)
After injection, the average size is 10.0 mm.

TABLE I
Our Standard Scale for the Volume of Injection

Muscle Thickness (mm) Botulinum Toxin Units*

10 100
11 110
12 120
13 125
14 130
15 135
16 140
FIG. 2. Injection sites are the three to four points (yellow
* Total injected units for one side. circles) within 1.5 cm of the mandible angle border.

mm (range, 9.4 to 19.1 mm) on the right and TABLE II

13.69 mm (range, 9.5 to 20.1 mm) on the left. The Muscle Thickness of Responders and Nonresponders
The average thickness for the nonresponders
(638 of 1021 cases) before injection was 13.51
Nonresponders Responders
mm (range, 6.5 to 22.1 mm) on the right and (n ⫽ 638) (n ⫽ 383)
13.75 mm (range, 7.5 to 22.1 mm) on the left. Before Injection Before Injection After Injection
These results suggest that the left side of the Muscle thickness
muscle was significantly thicker than the right Right 13.51 (6.5–22.1) 13.36 (9.4–19.1) 9.27 (6.5–13.5)
side. The thickness of the muscle in the 383 Left 13.75 (7.5–22.1) 13.69 (9.4–19.1) 9.28 (6.3–13.7)
cases tracked and observed was reduced by 31 Values are mean (range).
 922
follow-up, of which approximately 50 percent
were treated with a second injection for a long-
er-term effect. When followed up for 2 years, it
was estimated that approximately 40 percent of
the patients would remain satisfied with the
result because muscle volume recovery was
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PLASTIC AND RECONSTRUCTIVE SURGERY, March 2005
they are more satisfied with the results because
they never returned for secondary treatments.
Satisfaction
We analyzed how the 383 patients who we
were able to track down were satisfied with the

small (Figs. 3 and 4). results after treatment. Seventy percent (268
We informed patients before the first injec- patients) were greatly satisfied with the better-
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tion that the treatment would have only a tem- than-expected result and 23 percent (88 pa-
porary effect such that they could require re- tients) were generally satisfied, showing a total
petitive treatments. With regard to the of 93 percent (356 patients) who felt positive
nonresponders, their nonresponse implies about the outcome.

FIG. 3. A 24-year-old woman first received a 120-U injection of Dysport; a second injection of 110 U was given after 3 months.
(Above, left) Before injection. (Above, center) Three months after injection (second injection). (Above, right) Six months. (Below,
left) Thirteen months. (Below, center) Fifteen months. (Below, right) Twenty-four months.
 Vol. 115, No. 3 / AESTHETIC MANDIBULAR CONTOURING 923
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FIG. 4. A 26-year-old woman received 130 U of Dysport in her first injection and then 120 U in her second injection 3 months
later. (Above, left) Before injection. (Above, center) Three months after injection. (Above, right) Six months. (Below, left) Twelve
months. (Below, center) Twenty months. (Below, right) Twenty-four months.

When we analyzed the change in the muscle
volume from the pictures taken before and
after the injection and the thickness measured
by ultrasonogram, we found that patients were
more satisfied with the result when they had
thick masseter muscles, an even facial contour
line with few curves, and a relative lack of fat
tissues in their face.
The remaining 7 percent (27 patients), how-
ever, complained about the outcome, with 14
patients indicating that the alteration was less
than they expected, whereas 14 said that the
alteration made them appear too lean or gaunt.
For those who have a round face owing to the
bone structure with little soft tissues, those who
have an overdeveloped parotid gland (Fig. 5),
those who have thicker fat tissues, or those who
have little skin elasticity, little change in the facial
contour line or in overall image was observed.
For three patients who showed little change
because of thick fat tissues, a liposuction was
separately performed later over the chin con-
tour area. Three patients who complained of a
gaunt/bony image with protrusive-looking
cheekbone were later treated with a microli-
poinjection together with zygomatic bone re-
section (Figs. 6 and 7).
We conclude that progress after botulinum
toxin type A injection passes through five steps,
as follows:
 924
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FIG. 5. A 30-year-old man (above, left) before injection, (above, center) 1 month after injection, and (above, right) 6 months after
injection. (Below) Ultrasonogram shows that the parotid gland is overdeveloped.
1. Muscle is softened within 1 week.
2. The patient feels that the muscle is thinner
in the jaw after 2 to 4 weeks.
3. Maximum effect appears at 10 to 12 weeks.
4. Action recurs after 12 weeks.
5. Muscle volume recurs after 16 weeks.
These steps are illustrated in Figure 8.
One patient experienced a change 6 months
after a mandibular resection, but she desired
further change. When treated with botulinum
toxin, she had an improved appearance from
the front (Fig. 9).
Complaints after Botulinum Toxin Injection
We asked the returning patients after the
treatment “How are you feeling since the injec-
tion?” Patients made some complaints after the
PLASTIC AND RECONSTRUCTIVE SURGERY, March 2005
injection. The most frequent complaint re-
garded diminished chewing power. The next
most frequent complaints concerned awkward-
ness when smiling, as was seen in seven cases,
and uneven bumpy muscular movements when
chewing, as observed in 14 cases. Approxi-
mately 50 percent of patients complained of
discomfort resulting from decreased crunch-
ing power after the injection. These symptoms
were typically reported after 2 to 4 weeks after
the injection and persisted for 1 to 2 months.
The degree of discomfort resulted in difficulty
chewing hard or tough foods but they were
able to have regular meals.
Uneven bulging of muscles in the contour
line was observed for 2 to 4 weeks after the
injection. This was particularly visible with
male patients who had a thin skin layer with
 Vol. 115, No. 3 / AESTHETIC MANDIBULAR CONTOURING
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FIG. 6. A 35-year-old man (left) before and (center) after injection. (Right) A zygomatic bone resection was performed because
of the protrusive-looking cheekbone.
thick muscle volume. Another complaint con-
cerned awkward facial expressions experi-
enced for a period after the injection, mostly
regarding the corners of the mouth not fully
going up, making it difficult for them to smile
or laugh in earnest. This usually occurred 2 to
4 weeks after the injection and continued for 1
or 2 months after onset. Complaints are sum-
marized in Table III.
Biopsy
We conducted a biopsy test on some patients
4 months after botulinum toxin injection and
noted muscle atrophy, necrosis, and hyaline
degeneration (Fig. 10).
DISCUSSION
Because Koreans belong to the Mongolian
race, they innately tend to have a wide jaw-
bone. Furthermore, the typical Korean diet al-
lows them to chew hard and tough food in
regular meals, resulting in well-developed mas-
ticatory muscles over the course of their life-
time. In Korea certain facial features and phys-
iognomy are believed to bring about luck or
good fortune. These are highly appreciated
and emphasized. This, along with social pref-
erence over a small and slim face, has resulted
in facial contour line remodeling treatments,
including surgical resections, rapidly increas-
ing recently.
What determines the overall image of a face
is harmony and balance of facial features.
From the front and the side, a face can be
925
divided into three portions: the upper, the
middle, and the lower parts. The vertical
length of these parts is approximately the
same, dividing a face into three similar-sized
vertical portions. The standard gap between
the masticatory muscles of a face should be
approximately the same as the gap between the
temporal lobes and approximately 10 percent
shorter than the gap between the zygomatic
bones.4
The average gap between the masticatory
muscles of Western women is 105 to 109 mm,5
whereas the average for Korean women is
117.80 to 125.25 mm,6 –9 suggesting that Ko-
rean women have an approximately 12 to 20
mm wider gap than Western women. In gen-
eral, Korean women tend to have a wider gap
between the masticatory muscles with a more
protrusive angled mandibula. Given these rea-
sons, it is quite natural that Korean women
wish to adjust or correct their mandibular con-
tour line into a slimmer and smoother one.
To achieve a slim and smooth contour line
of the lower face, conventional treatment has
concentrated on two approaches: surgical re-
section of the masseteric muscle or modeling
ostectomy of the square-angled mandibula.
In 1951, Converse3 finally announced for the
first time that the resection of both the bone
and the muscles could be done at the same
time through the intraoral incision. Whitaker10
reported in 1989 that the width of the lower
face could be reduced through the ostectomy
of cortical bone of the mandibula, together
 926 PLASTIC AND RECONSTRUCTIVE SURGERY, March 2005
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FIG. 7. A 34-year-old woman (above, left) before injection, (above, right) 6 months after
injection, (below, left) after micro-lipoinjection (7 months), and (below, right) at 12 months.

with the resection of the masseteric muscle.
Baek11 found that the masseteric muscle vol-
ume is reduced over time as the muscle tone
deteriorates when only the mandibula was re-
sected, whereas Hong et al.12 proved that after
the ostectomy of the mandibula, the nonused
masseteric muscle becomes atrophied over
time through the Gato experiment. The resec-
tion of the masseter muscle is likely to cause a
variety of side effects such as bleeding, hema-
toma, facial nerve injury, and asymmetric re-
section. Although the operation itself is rela-
tively simple, it is difficult to predict the
outcome. Moreover, muscle resection may re-
sult in unwelcome side effects such as bleeding,
asymmetry, and uneven contour lines.13 In this
respect, even in the case of muscular hypertro-
phy, surgical treatments for the square-angled
jawbone have been frequently applied. If mus-
cular dystrophy is not as much as expected,
however, the change in the lower face from the
front are minimal. Thus, the need to reduce
 Vol. 115, No. 3 / AESTHETIC MANDIBULAR CONTOURING 927
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FIG. 8. Diagram of progress after botulinum toxin type A injection.

FIG. 9. A 25-year-old woman (left) before operation, (center) 6 months after operation and 110 U were injected in each side,
and (right) 4 months after injection.

TABLE III that it also works to remove or ease wrinkles on

Temporary Discomforts the face. Later Carruthers and Carruthers15 be-
gan to use botulinum toxin type A in full-scale
Type No. of Cases treatments for aesthetic purposes. Recently the
Crunching power is decreased 192 (50%) use of botulinum toxin has been expanded to
In crunching, muscle is protruded 38 (10%) treat square-angled mandibula,14,16 hyperhidro-
Unnatural smiling appearance 8 (2%)
Disappearance of facial dimple 4 (⬍1%) sis,17 and even migraines.18
The effect of injecting botulinum toxin to
the lower facial muscular volume in a safe man- ease or remove wrinkles is believed to be, at
ner has been raised. best, temporary. Wrinkles are eased by block-
In 2001, von Lindern et al.14 announced the ing muscular contraction and reappear when
masseter muscle can be reduced using botuli- the muscular contraction is recovered. The use
num toxin A (Dysport) in the case of mastica- of botulinum toxin in reducing the masseter
tory hypertrophy. Since it was first used in 1976 muscle volume differs from the use to ease
for facial spasms, botulinum toxin A has been wrinkles. Wrinkles tend to increase with aging
widely used to treat muscle spasms by ophthal- whereas the muscular volume decreases over
mologists and in rehabilitation centers. While time. The older the patients are, the longer the
botulinum toxin A was being used for the time is required for recovery, with less volume
aforementioned disorders, it was discovered recovered.
 928
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FIG. 10. Biopsy results: (above) uneven cell size; (center)
myolysis, central and marginal necrosis, and centralization of
nucleus; (below) pseudocyst and liquefaction.
The positive facet is that there is a time gap
between the recovery of muscle function and
the muscle volume; the latter does not come
back in full.
From observations on the change in the mus-
cle volume measured by ultrasonogram, we
found that after 6 months, even when the mus-
cular function was recovered, the reduction in
the muscular volume still remained. In some
cases, it was observed that even a year or longer
after the injection, the reduced volume re-
mained the same. We believe it is possible for
the injected area to develop signs of fibrosis.
PLASTIC AND RECONSTRUCTIVE SURGERY, March 2005
Further studies are required with a histological
approach. In the case of re-injections, even
when a similar dose of the toxin was injected,
most patients did not complain of discomfort
in mastication. This may imply that compensa-
tions occur in temporal muscles and the inner
and outer pterygoids.
The degree of change after the botulinum
toxin injection parallels the thickness of the
masseter muscle. The result is not always man-
ifested as patients or doctors desired or ex-
pected. When a patient has large or strong-
featured facial bones other than muscles, the
injection may worsen the existing bony curves
of the face, resulting in a less desirable facial
appearance. The masseter muscle is a dia-
mond-shaped muscle that links the zygomatic
bone to the pointed part of the mandibula.
When atrophy of the masseter muscle occurs
after the injection, not only the muscles
around the chin but also the muscles right
below the zygomatic bone get atrophied; there-
fore the zygomatic bones may appear more
protrusive. Thus, when injecting botulinum
toxin to patients with large, wide cheekbones,
we should use caution and the zygomatic bone
resection or lipoinjection may also be consid-
ered, if necessary.
Patients who have an overdeveloped parotid
gland or excessive fat located on top of the
muscle with less skin elasticity may find their
muscular volume reduction is much less than
they expected. If a patient has excessive fat
tissues, a liposuction can be considered with
the injection, whereas for older patients with
less skin elasticity, caution should be taken be-
fore botulinum toxin is used.
The ideal applications of botulinum toxin
would be those with well-developed masseter
muscles without protrusive bones or a large
amount of fat tissue around the chin or the
cheekbones. Ideal patients for treatment with
botulinum toxin injections for an aesthetically
slim and smooth lower face contour line have
the following characteristics:
1. Square-angled mandibula as a result of over-
developed masseteric muscle.
2. Mandibula not angled but appearing wider
in comparison with other facial parts.
3. Well-developed masseteric muscle and the
desire to have a slimmer face.
4. A face for which a bone resection may not
bring about satisfactory results.
5. Less than desired effect achieved after the
 Vol. 115, No. 3 / AESTHETIC MANDIBULAR CONTOURING
angled mandibular resection because of a
minor decrease in masseteric muscle
volume.
There were no serious or worrisome side
effects reported to be caused by the treatment.
Discomfort in mastication resulting from weak-
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ened contraction of masseter muscle was re-
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ported in approximately half of the patients
treated. This happens as a result of weakened
muscle strength. This is inevitable because this
treatment is based on the mechanism that the
toxin will paralyze the muscle, resulting in de-
generating atrophy. It continued for 1 to 2
months, maintaining less than the period when
the muscle could not contract. Given the time
differences or gaps among the periods of no
complaints, the actual period when the muscle
contraction is reduced, and the period when
the discomfort continued, it is believed that
there are compensations from other muscles
(i.e., the pterygoid and temporal muscles).
Uneven muscular movements during masti-
cation manifest because botulinum toxin can
have influence over different time spans on
different parts of the muscle. Some parts of the
muscle may remain contracted while some
parts show a decreased contraction level. In
areas where the muscular movement remains
active, the movement can be seen much larger
as compared with areas where the muscular
movement has degenerated. This occurred in 5
to 10 percent of patients and persisted 2 to 4
weeks after the occurrence. This occurs when
the muscle volume is thick, the skin is thin, the
dose of the injection is not enough, or when
the point of injection is not appropriate. It
usually occurs when patients have thick muscle
volume and a thin skin layer. It disappears
naturally after 3 to 4 weeks and can be adjusted
with additional injections on the bumpy parts
of the muscle, if necessary.
Approximately 2 percent of the patients
complained that the tips of their lips did not
fully go up when they smiled or laughed, re-
sulting in awkward facial expressions. This oc-
curred at approximately 2 to 4 weeks after
injection and persisted for 4 to 8 weeks before
it naturally disappeared. The main causes of
this symptom are the weakened risorius muscle
that links the masseter muscle to the corners of
the mouth and a decreased tension of the su-
perficial musculoaponeurotic system as a result
of a drastic change in muscle volume. Injec-
tions near the zygomatic bones may result in
929
changes in facial expressions because of a di-
rect impact on the muscles around them. Von
Lindern et al.14 suggested the injections should
be given from the area right beneath the zygo-
matic bone to the linkage to the mandibula. As
we believe the injection to the area right be-
neath the zygomatic bone may bring a change
in facial expressions because it directly affects
the small facial muscles attached to the bones,
we primarily injected the muscles following the
mandibula contour line. The injection works
perfectly well, eliminating all muscular activi-
ties followed by muscular dystrophy. Further-
more, the awkward facial expressions can be
minimized by injecting the toxin within 1 cm of
the root area of the masseter muscle. Again,
this symptom may occur when the point of
injection was not precisely located but was lo-
cated on such areas that can directly affect the
minor and major zygomaticus.
Further studies are required with a longer
tracking period on the duration of the effect,
whether additional injections are required or
not, the appropriate timing for additional in-
jections, and the alterations in the muscles go-
ing forward.
CONCLUSIONS
Botulinum toxin type A (Dysport) injection
is simple in technique, has few side effects, and
promises a rapid return to daily life. Therefore,
botulinum toxin type A injection can replace
the masseter resection, which does not have
the advantages of botulinum toxin type A.
Nam-Ho Kim, M.D.
Gyalumhan Plastic Aesthetic Clinic
New York Company Building, Suite 1318-1
4th Floor
Seocho-Dong, Seocho-Gu
Seoul 137-070, Korea
gyalumhan@korea.com
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