6. Facial Sculpting and Facial Slimming with Neurotoxins

10.1055/b-0036-141954

6. Facial Sculpting and Facial Slimming with Neurotoxins

Woffles T. L. Wu

6.1 Introduction

Although botulinum toxin type A became available in some parts of Asia only during the mid-1990s, the region has been responsible for introducing several of the latest and most advanced toxin injection techniques, one of which uses it for nonsurgical shaping or slimming of the lower face. ¹ ^, ² In part, this may have been due to the unrestricted freedom in Asia to use the drug in off-label situations. Another reason has been that many of the creative uses of botulinum toxin type A in Asia have been developed in response to patients’ desires to change some of the characteristic features of the Asian face (Fig. 6.1) that are considered undesirable, including the following:

A flat, square face, often with masseteric hypertrophy
Low-set brows with strong glabellar frown lines
Narrow, almond-shaped eyes with distinct epicanthic folds
Low nasal bridge with deficient anterior projection of the face
Midface retrusion with deficient infraorbital support
Bulging eyes and prominent eye bags
Deficient vertical height of the face with a retruded, popply chin
Bimaxillary protrusion
Thick, oily skin with visible pores and a greater tendency to form hypertrophic and keloid scars

Fig. 6.1 Asian man at (a) age 50 and (b) 75 years showing typical Asian features and volumetric depletion with aging.

6.2 The Globalization of Beauty

The principles of beauty are governed by harmony, balance, and proportion. At the lower end of the facial aesthetic spectrum, people possess stronger ethnic features and look distinctly different from other races.

At the upper end of the facial aesthetic spectrum, however, “beautiful people” of all races look similar and yet retain sufficient unique features to identify their origins. In some cases, the ethnic differentiation can be blurred. This observation suggests that there is a globalization of beauty and that all beautiful faces possess similar characteristics. Racial intermarriage, which often produces the most attractive faces, has undoubtedly contributed to the concept of a universal beauty.

Although distinct differences between Asian and white facial features, skin thickness, and fat content exist, ³ ^, ⁴ ^, ⁵ ^, ⁶ ^, ⁷ what Asians want in a beautiful face is not dissimilar to what other races desire. Most Asian patients do not wish to look white, a fact often overlooked by non-Asian physicians. Rather, their preference is to be at the upper end of their own ethnic facial aesthetic spectrum. The request for a “prominent” nose implies a prominent nose that can be found within their own Asian ethnicity, ⁸ not a white nose, which would look inappropriate in an Asian face. One of the most common requests in Asia is to have a narrower lower face with a sharply projected petite chin, conferring an oval to heart-shaped face, which is considered refined and elegant. A square face is undesirable, especially in women, as it is considered coarse and masculine. In particular, because the average Asian face is already flat, lacking vertical height and three-dimensionality, the addition of bulky masseter muscles makes the face look even more square, squat, and unattractive.

6.3 Botox Facial Sculpting and Facial Slimming

I coined the terms Botox facial sculpting and Botox facial slimming in 1999 to describe a purely cosmetic nonsurgical injection technique in which the lower facial width could be narrowed or triangulated to create a more aesthetic and youthful facial shape. ⁹ ^, ¹⁰ Previously, the only method to reduce a “square jaw” or “boxy” face was surgical resection of the mandibular angles. ¹¹ ^, ¹² ^, ¹³ This surgical technique is excellent in the hands of trained surgeons, but complications can occur, and the downtime from swelling and bruising can be considerable. It is not a technique the average aesthetic physician or dermatologist can use.

In the mid-1990s, several reports described Botox injection into the masseters to stop grinding and improve temporomandibular joint problems ¹⁴ ^, ¹⁵ ^, ¹⁶ but there was no description of Botox as a purely aesthetic sculpting tool. I had started injecting the masseter muscles in 1997 using as a scientific basis the bone–muscle matrix theory of Moss, Enlow, and Rankow, which states that the overlying muscles influence the thickness and density of the underlying bones to which they are attached. ¹⁷ ^, ¹⁸ ^, ¹⁹ ^, ²⁰ This theory is clearly demonstrated by the reduction in density and circumferential thickness of the tibia after prolonged immobilization in a plaster cast for a fractured lower leg as a result of disuse atrophy. Conversely, elderly people are encouraged to exercise regularly so that the continued muscle influence on the bones prevents them from becoming brittle and fracturing easily. In short, muscles and muscle activity control the density and strength of the bones to which they are attached. In Botox facial slimming, my intention in administering the Botox to the masseters was not only to reduce the bulk of the masseteric muscles to create an immediate aesthetic result but also to create such a degree of atrophy that the bone would begin to remodel and long-term facial slimming would be achieved.

Over the last 15 years, Botox facial slimming in my practice has evolved to embrace two distinct techniques: a reduction of masseteric hypertrophy as well as reduction of hypertrophic parotid glands, which can create an undesirable facial shape and contour.

6.3.1 Reduction of Masseteric Hypertrophy

Masseteric hypertrophy can occur in all races, but it is seldom seen in blacks and is more commonly seen in Asians, especially those from Korea, northeastern China, and parts of Japan. Because the Asian face is naturally short vertically, flat, and wide, the addition of masseteric hypertrophy makes the face even more squat and unattractive, giving rise to the terms square jaws or boxy face, and may explain the popularity of this simple technique in Asia to alter the facial shape dramatically. ²¹ ^, ²² ^, ²³ ^, ²⁴ ^, ²⁵ Patients can see results within 2 weeks, and continued periodic use of the toxin can allow bony remodeling of the mandible with long-term changes.

The current aesthetic consideration in most Asians is to have a narrow, oval face with a sharply projected chin. Asian women abhor having a wide lower facial width, as it makes them look too masculine and older. Masseteric reduction has a powerful effect in making the face look slimmer, longer, and younger.

Interestingly, in white patients, whose faces are naturally longer and thinner, with greater vertical height and anterior projection than those of Asian patients, masseteric hypertrophy can be attractive because it balances the facial shape, giving it structure and harmony. In men, it can make the face more masculine and strong and is a common feature in many movie personalities, especially those who act in action hero roles. Certain women can be extremely attractive with a mild degree of masseteric hypertrophy, as is seen in some models and actresses, because it gives them a more determined, athletic appearance. This may explain why the technique of masseteric reduction has not been as popular among whites as in Asians. ²⁶ Many white patients, both young and old, however, desire a slimmer face and well-defined jawline and thus could benefit from the reduction of masseteric or parotid hypertrophy (Fig. 6.2 and Fig. 6.3).