articLe | BOTulInumTOxIn A | and narrowing and diminishing the fullness of the
upper lip vermillion — an appearance that is not often accepted by most. Overzealous treatment of this area can result in an asymmetric smile and a ptotic upper lip, causing drooling and fluid incontinence when drinking from a glass or cup. In most patients, these nasolabial lines are best treated with soft tissue fillers, implants, or surgical rhytidectomy, and not with onabotulinumtoxinA (3).
Injecting onabotulinumtoxinA any lower than the
upper alar facial border (i.e. closer to the alar labial sulcus or along the nasal sill) can produce a weakening of the central upper lip levators and the orbicularis oris that can produce an inability to elevate the upper lip, elongating its overall dimensions. This is a common technique used to drop the upper lip and correct a gummy smile, but is not appropriate in most patients simply seeking a reduction in the fullness of nasolabial folds. Injecting
1–2 u of the aesthetics of ideal tooth
onabotulinumtoxinA intradermally away from the mouth, and near the origins of the zygomaticus major and minor, and levator labii superioris at the inferior border of the lateral orbital orbicularis oculi, can both diminish the nasolabial fold and efface the lower lateral canthal wrinkles and lower lateral cheek rhytides. This technique is usually accompanied by a reduction in the strength of the upper lip sphincter competence and smile symmetry (3,5). It is paramount, however, that minimal volumes of onabotulinumtoxinA are injected precisely into the fibres of the targeted muscles, to lightly weaken and not paralyse them. Even with a light weakening of the levator labii superioris and the zygomatic complex, a certain amount of lip ptosis will occur, and is actually expected. This should be discussed with the patient before treatment, and should not be considered a true adverse outcome or complication. In older patients who have a large amount of excessive fat deposition or ptotic malar fat along with redundant
exposure when smiling varies according to structural and topographic anatomy, but has been loosely calculated to be
exposure than 1-2 mm of upper gum mucosa.
three quarters of the dental crown height of the upper incisors and no more
skin lateral to the nasolabial sulcus, weakening the central upper lip levators will have no effect on the extent and depth of the nasolabial folds. The nasolabial folds might even be enhanced if the lateral upper lip levators are weakened, causing a reduction in the lateral muscle support, which will allow the ptotic fat and redundant skin to sag even further. On the other hand, in younger patients with good cutaneous elasticity and soft tissue support (i.e. those in their early 30s to late 50s), much of the appearance of the nasolabial fold is caused by mimetic muscle contraction, the bulk of which can be attributed to the levator labii superioris alaeque nasi. When this muscle is weakened in younger persons, the nasolabial fold is diminished, usually uneventfully. Attempting to weaken some of the other upper lip levators may cause undesirable sequelae, such as upper lip ptosis, buccal asymmetry, and even oral sphincter incompetence. However, for those patients displaying an excessive amount of gingiva when smiling or laughing, weakening of the central upper lip levators may actually be desirable because it can reduce the full upward movement of the upper lip that overexposes the crown and gums of the upper incisors and canines. Attempting to reduce mid-cheek
wrinkling and nasolabial folds with injections of onabotulinumtoxinA can not only result in a flattening of the nasolabial fold, but also an overall flattening of the cheek and an elongation of the upper lip or lip ptosis, as well as lip asymmetry and lack of oral sphincter control (22). For these reasons, it is advisable not to treat this area of the mid face with onabotulinumtoxinA unless the patient is willing to endure the expected and inadvertent sequelae. Subcising deeply adherent nasolabial sulci, injecting them with a soft tissue filler and resurfacing the cheeks by chemical peeling, dermabrasion, or laser ablation is probably a more dependable way to address these problems and produce consistent, longer-lasting results (5).
Treatment implications when injecting nasolabial folds 1Successful treatment of the nasolabial fold is
dependent on proper patient assessment of what is actually causing and exaggerating the nasolabial fold and sulcus.
muscle primarily responsible for the creation of the upper medial portion of the nasolabial sulcus and fold.
2The levator labii superioris alaeque nasi is the 3Nasolabial folds are best reduced by injections of
soft tissue fillers, implants, and surgical rhytidectomy and subcision, rather than with injections of onabotulinumtoxinA.
of onabotulinumtoxinA should be given in the nasofacial or upper alar facial sulcus.
28 ❚ May 2011 |
prime-journal.com 4In the properly selected patient, injections of 1–2U
5Injections of onabotulinumtoxinA
too low along the alar facial angle will produce an elongation or ptosis of the upper lip; asymmetric smile; and functional incompetence of the oral sphincter.
to the nasofacial angle will produce an overall flattening of the mid-cheek and a drop in the soft tissue support of the malar fat pad.
6Injections of onabotulinumtoxinA too lateral 7In the properly selected patient, a combination of
injections of onabotulinumtoxinA and either soft tissue fillers or some form of surgical intervention—or both—will produce longer-lasting results than if the nasolabial folds were treated solely with either alone.
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