43 Neuromodulation for Perioral Rejuvenation

Steven Fagien and Yash J. Avashia

Abstract

Neuromodulation for perioral rejuvenation requires a particular understanding of the function and complexity of the perioral muscular anatomy and function. Unlike the upper face where muscle groups can be more easily isolated, the lower facial region muscles are uniquely intertwined making specific isolation to a target area more challenging. Optimum technique and dosing as well as appropriate patient selection are therefore required to deliver predictable and consistent results.

Perioral rejuvenation – orbicularis oris – depressor anguli oris – botulinum toxin type A – neuromodulation – perioral rhytides

43 Neuromodulation for Perioral Rejuvenation

Key Points

Lips are the central focus to lower face aesthetics.
Vertical perioral rhytides can be a result of aging, smoking, and frequent mimetic expressions.
Fine wrinkles of the perioral region are often addressed with filler, but controlled use of neuromodulators can be used separately or in combination.
Complex functions of the perioral region deserve careful attention. Neuromodulation in the lower facial regions should be practiced by experienced injectors.

43.1 Anatomy

Perioral musculature includes the orbicularis oris, depressor anguli oris, and the mentalis.
The orbicularis oris is the sphincteric muscle of the mouth.
The origin of depressor anguli oris is in the lower jaw and it inserts into the angle of the mouth. The function is to depress the angle of the mouth and pull it backwards (posteriorly).
The mentalis raises the skin over the chin and can create surface dimpling.

43.2 Perioral Injection Technique

43.2.1 Orbicularis Oris (Fig. 43.1)

The average number of injection points is a total of two to seven for the upper and lower lips.
The average total starting dose for the perioral area is 2 to 6 U with 1 U per injection point.
Conservative techniques recommend 0.5 to 0.75 U per point and will be dictated by the number of injection points and desired results.
Areas to avoid injection include the midline upper lip at the philtrum and both commissures.
Injections usually should be kept superficial and symmetrical. Symmetry is a critical component to perioral neuromodulation unless one is attempting to treat pre-existing asymmetry.
Injections should be just above the vermilion border, and no higher than 5 mm above the border to avoid inversion, eversion, or lip ptosis.
The use of ice for topical anesthetic effect is beneficial for enhanced patient comfort.
The initial approach is to begin with one site per quarter lip (quadrant) and reassess in 2 weeks. Lower doses usually have shorter duration and this as well as the potential for temporary lip dysfunction (overly weak “pursing” or “difficulty using a straw”) should be explained to the patient prior to treatment (Fig. 43.1).
Injection sites should be 0.5 to 1 mm above the vermilion border. Injections are superficial.

Fig. 43.1 Perioral neuromodulator injection.