ARticle | boTulInuM ToxIn A | and below an imaginary horizontal line that passes
through the centre of the oral commissure. The subtle, three‑dimensional movements of the
modiolus enable one to integrate routine movements into daily activities, and control changes in oral vestibular contents and pressure. The modiolus facilitates the innumerable subtle variations in the fine movements involved in speech and word formation. Many of the movements of the modiolus seem to involve most, if not all, of its associated muscles, the actions of which are predicated on the amount of separation between the upper and lower teeth. As the interlabial and interdental distances approach their maximum separation of around 4 cm, the modiolus occupies the interdental space, moves anteriorly 1 cm closer to the oral commissure, and becomes immobile. With the mouth wide open, the nasolabial sulci elongate, becoming straighter and more vertical, and the inferior labiomandibular sulci (marionette lines) are less deep and curved. With the lips in contact and teeth in tight approximation, the modiolus can move only a few millimetres. The mobility of the modiolus is maximised when the upper and lower teeth are separated by 2–3 mm, similar to its position when speaking.
Dosing Place properly selected patients in the upright sitting or semi‑reclined position and inject 1–2 u of onabotulinumtoxinA into each pars peripheralis of the upper and lower lips intradermally, and no deeper than the dermo‑subcutaneous junction. At this level the superficial fibres of the orbicularis oris can be found. The appearance of fluid‑filled weals confirms the injections were performed at the correct depth. Injections can be placed into the border between the pars peripheralis and pars marginalis. It is recommended that at the initial treatment session, both quadrants of the pars peripheralis of the upper and lower lips be treated with no more than 2 u of onabotulinumtoxinA at each site and applied symmetrically into one to three sites. The upper lip should not be injected with more than 8 u of onabotulinumtoxinA at any time. botulinum toxin A should not be injected directly into
the centre of the philtrum, so as not to flatten the philtral columns. If the lower lip does not possess very deep rhytides, then it should be treated with only minimal amounts. It is advisable to treat the lips symmetrically, injecting the four quadrants of the pars peripheralis to weaken the orbicularis oris in a relatively proportional and symmetric manner. Treating both the upper and lower lips at the same time will maintain the necessary perioral function with a symmetric weakening of the overall sphincteric action of the lips. The dose in each quadrant can vary depending on the number and depth of rhytides. Some physicians use different patterns to inject the lips
. However, this large amount is not appropriate
can evaluate him/her for any asymmetry or aberration in lip function3
. for those who also have their lips injected with soft
tissue fillers, it has been found that injections of botulinum toxin A may prolong the effect as the constant muscle contraction and stress on the filler material by normal, routine lip movement is reduced4, 5
. When other cosmetic Botulinum toxin A should not
be injected directly into the centre of the philtrum, so as not to flatten the philtral columns. if the lower lip does not possess very deep rhytides, then it should be treated with only minimal amounts.
that include as many as 10 or 11 sites between the upper and lower lips, usually at the points of maximal muscle contraction3, 4
for most patients. It is important that the patient returns 2–3 weeks after a treatment session so that the physician
32 ❚ July 2011 |
prime-journal.com
procedures are performed during the same treatment session in which botulinum toxin A is injected, then this treatment should be given first. This will allow the muscles to become saturated with botulinum toxin A before a filler, laser or surgical procedure is performed.
Outcomes When injections of the lips are effective, a pleasing effacement of the depth of the vertical lip lines occurs, which can dramatically improve the overall physical appearance and emotional outlook of the patient. In addition to relaxing the superficial fibres of the orbicularis
oris and diminishing the wrinkles on the cutaneous surface of the lip, there can also be a widening of the philtrum and a slight eversion of the vermillion, producing an attractive ‘pseudo’ augmentation of the lips3, 6, 7
. Many feel that this
pseudoaugmentation and eversion of the lips are best produced when botulinum toxin A is injected directly into the cutaneovermillion border.
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