In recent times, facial rejuvenation
with minimally invasive procedures have become extremely popular and
accessible. These procedures can improve patient’s appearance with almost no
downtime and limited risk of adverse reactions.
Among the non-invasive treatments,
injections of botulinum toxins and fillers are the most popular and effective
procedures in order to reduce the appearance of wrinkles and restore the volume
we lose with ageing, respectively. While in the past years practitioners were
inclined to choose one of the two to improve patients concerns, nowadays they
recommend a combination of them to achieve a better aesthetic result, defined
by contemporary aesthetic concepts. In fact, to reach harmony and create an
attractive face, lines, proportions, and contours need to be analysed and
personalised for each patient.
The aim of any treatment is to perform
it safely and correctly to avoid complications and adverse reactions.
Unfortunately, also with pristine techniques, they may occur. Therefore, a deep
knowledge to understand and recognize these problems is mandatory, in order to try
to prevent their occurrence and to provide the suitable solution.
In particular, this article will
evaluate the use of botulinum toxins and derma fillers for the rejuvenation of
the lower face.
Generally, in aesthetic medicine, the
face is evaluated divided in three horizontal sections. The upper third starts
from the hairline to the glabella, the middle third from the glabella to the
subnasal area, and the lower third from the subnasal area to the menton. The
lower third can further be divided into its own thirds, outlining the upper
lip, the lower lip, and the chin.
The typical marks of a young-looking
lower face involve a smooth transition from the cheeks to the chin, with a
well-defined mandibular angle, an adequate jawline shape and volume, and a good
projection of the chin.
Ageing is associated with a shift of volume
from the upper to the lower part of the face. The loss of volume is responsible
for the main signs of the lower face ageing. The youthful face, typically
described with a “heart” shape, secondary to this loss, becomes rectangular. The
nasolabial folds start to become deeper, the prejowl sulcus appears, and
wrinkles are developed particularly in the perioral area. In addition, ptosis
of the labial commissure results in a depressed area at the corner of the
mouth. All these alterations, summed to bone resorption, sagging skin and
gravitational changes, give to the face a tired appearance.
Due to the multifactorial causes of the
facial ageing, a combination of treatments, such as toxins and hyaluronic acid
fillers, could be the best way to restore a youthful appearance. The balance of
these two treatments should be individualized after an accurate assessment of
The different types of botulinum toxins
are produced by Clostridium Botulinum, a Gram positive anaerobic bacterium. Distinctive
classes of this bacteria can produce up to eight serotype of toxins, classified
as A,B,C,D,E,F,G, and H. These toxins cause muscle paralyses through the
inhibition of acetylcholine release in the neuromuscular junction. The effect
is an improvement of the appearance of fine lines and dynamic wrinkles in the
overlying skin of the injected muscle.
Several studies have described the
safety and efficacy of this treatment, especially for the reduction of
forehead, glabellar, and periocular lines. However, the cosmetic use of
botulinum toxin in the lower face has become progressively popular due to the
safety profile of the toxin and the efficacy of the result. In addition, now
physicians are more aware that a combination of muscular hyperactivity and
volume reduction are coexistent elements in the appearance of the lower face.
Low doses of botulinum toxin should be
used in the lower face, as to produce just partial relaxation of the muscles
instead of paralysis. This aims to avoid side effects, which can be related to
the expected effect of the product (eg, excessive weakness), to the spread of
the toxin to nearby uninjected muscles, and to the systemic distribution of the
The most common side effects include
local reactions at the injection site like pain, bleeding, and ecchymosis,
which can be reduced with the right technique and knowledge of facial anatomy. Systemic
reactions, such as nausea, headache and flu-like syndrome, are rare but can
Derma fillers can achieve what other
products cannot: they restore volume. The most common fillers used in aesthetic
medicine are hyaluronic acid fillers. Hyaluronic acid is a linear
polysaccharide which is a component of the extracellular matrix in the normal
skin of all adult animal tissues. Normally, in its native form it is degraded in
24-48 hours. Consequently, in order to increase its longevity and viscosity,
hyaluronic acid is chemically crosslinked, making it one of the best products
for the rejuvenation of the lower face in terms of efficacy and safety.
Different techniques can be used for the
injection of derma fillers, such as threading, puncture and fanning, depending
on the area to treat.
As with all aesthetic procedures, the
patient expectations and desires should be carefully assessed to avoid
deformity due to an over injection of the product, and dissatisfaction as a
result of unrealistic demands.
The most common localized side effects after
hyaluronic acid treatment are: bruising, pain, tenderness, oedema, and erythema
at the injection position. Rare reactions include hypersensitivity, necrosis
and embolization. All these adverse reactions can be minimized with the right
injection technique and knowledge of facial anatomy.
Particularly in the lower face, ageing causes
modifications in the facial contour. These changes are produced mainly by the
loss of subcutaneous tissue, bone resorption, and sagging skin, which give to
the face an “old” appearance.
The major changes include (fig…):
of the labial commissure resulting in a depression of the corner of the mouth
of “marionette lines”
of “mentalis sulcus”
of the concavity between jaw and neck
In general, the facial contour is designed
by the jaw, the mentalis muscles, the masseter, the platysma and the depressor
anguli oris. The latter and the platysma, with their contraction, decrease the
concavity between the jaw and the neck and pull down the angle of the mouth.
The mentalis corrugates the skin of the chin. The masseter is important for the
lateral shape of the face, and its hypertrophy can produce a square profile
with a negative aesthetic impact.
Finally, lips and the perioral area are as
important as the facial contour for the rejuvenation of the lower face. Lips
are affected by the ageing process in their fullness, definition and shape.
They become flat, narrow and pale. The perioral area starts to develop lines due
to a volume loss which affects also the border of the upper lip, increasing the
flattening of the vermilion border.
Due to all these changes, botulinum
toxins and hyaluronic acids fillers, or a combination of them, can be used to rejuvenate
the lower face, taking into consideration the different anatomical parts that make
up the lower face as a unit.