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54 Essentials of neuromodulation
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With a keen eye, providers can begin to pick up the deflation when
observing the face from the side. The deflation in the lateral face mimics
bonnet straps. If a bonnet was placed on the patient and the ties for the bonnet would represent deflation areas. This deflation is noticeable at about age
40, and then the medial portion starts to deflate about 10 years later. However, it is common to see a malar fat pad split earlier in life as the fibrous bands
holding the fat in place become weak and allow the fat to shift even though it
may not have deflated just yet. Patients are aging on a global scale, and it is
not homogenous. Therefore, the esthetic rejuvenation process should mirror the process in order to create soft, natural, and beautiful results. The fat
deflates in regions instead. The malar fat pad split is often confused by novice
injectors and patients by feeling that they need to have their tear troughs
inflated. When in reality it is a need for cheek augmentation with fillers
instead of tear trough filler. As injectors progress into dermal filler implementation, the subcutaneous layer, the superficial muscle aponeurotic system, and the parotid masseteric fascia will play a more significant role in
importance. At the beginner level of injecting neuromodulators, it is nice
to be familiar with these planes as it will help injectors better assess and properly consult patients about developing effective anti-aging treatment plans. If
we are chasing the patient’s complaint, it will often lead to dissatisfied customers as they are indeed analyzing their face as a whole and do not understand the restorative process in depth as trained professionals. They cannot
articulate their needs. At this point, the injector steps up to the plate and
becomes the expert understanding the relationship of assessment, goals,
and the product’s ability to perform the task the patient desires.
There are three building blocks to the health and age of a patients skin;
elastin, collagen, and hyaluronic acid. Much of the esthetic industry talks a
lot about elastin, collagen, and hyaluronic acid as the foundation concepts
regarding restorative esthetic treatment and procedures. What are these
three building blocks in the skin, and how do they help injectors assess
and treat the patient?
1. Elastin is a 70 kDa elastic protein found in the body, mainly in the skin
and connective tissue, characterized by its elastic qualities. It provides the
skin with the flexibility and elasticity necessary to regain form when
stretched, contraction, or compression. Elastin aids in the skin’s ability
to get back to baseline after being placed under stress, such as pinching
or animation. Elastin-rich structures calcify over time, decreasing their
ability to recoil. In terms of skin, it is harder for the skin to maintain
it is elastin or, in lay terms, its recoil ability. It is a protein that is very
55Anatomy
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similar to collagen. Collagen is the primary structural support system in
elastic fibers. Elastin, hyaluronic acid, and collagen are all equally important to one another.
2. Collagen is defined as the tough fibrous protein. This protein is found in
bone, cartilage, and, most notably, for injectors, the skin. It can also be
found in other connective tissues within the body. Collagen provides the
body’s structures with the ability to withstand forces that stretch or
lengthen them. It is a natural structural protein in a fibrous form, found
in a mammal’s body, including humans, in abundance: around 30% of all
body proteins are collagen. These are responsible for keeping the body
tissues connected and supported and, therefore, commonly found in our
body’s strong structures like bones, tendons, ligaments, and, of course,
skin. Specifically relevant to the skin, collagen provides strength, flexibility, and resistance. In other words, it is the presence of collagen that
gives skin its firmness. To better understand collagen in action, when the
skin is cut, the skin produces collagen to repair the damaged tissues and
replaces the old tissue with new collagen. It is the body’s natural form of
stitches. Due to its specific properties, collagen’s medical uses extend to
treat joint mobility problems, severe burns and even create lab skin
substitutes.
Collagen and elastin work together to keep the skin smooth, supple,
and flexible. Fibroblasts produce both proteins in the dermis, and, as we
grow old, the body loses the ability to produce them, so cell structures
weaken. As it loses strength and elasticity, the skin grows thinner and less
resistant to damage, while it tends to sag, stretch, and wrinkle; this is
aging. A proper diet is vital in helping to maintain youthful collagen
and elastin levels. Sources rich in vitamin A, zinc, vitamin C, and other
oxidants have a preventive function in aging, helping the body to retain
or produce these proteins.
3. Hyaluronic acid seems to be the new big hit in town with the onset of
reversible hyaluronic acid filler treatments. However, technically it is not
new since this carbohydrate is also produced naturally by our body. Hyaluronic acid is found mostly in the eyes, joints, and skin (50% of hyaluronic acid in the body is found in the skin, both in deep underlying areas
and visible epidermal layers). This substance plays a huge role in cell
growth and renewal. It is responsible for retaining water and lubricating
the body’s movable parts: hyaluronic acid molecules can retain up to
1000 times its weight in water. Therefore, hyaluronic acid’s secret is
keeping the skin moisturized and hydrated.
56 Essentials of neuromodulation
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It is the dual action of HA and collagen that maintains the skin’s layers
and structure fresh and healthy. While collagen works on skin firmness,
hyaluronic acid nourishes and hydrates the collagen to keep it supple and
flexible, filling the skin matrix (formed by collagen and elastin) with
water and giving it a fuller, firmer, and youthful appearance. Hyaluronic
acid has been used mainly to treat joint disorders, but its water-retaining
and hydrating properties have generated a growing interest in the cosmetic industry. Nowadays, it is used in an injectable form (Juvederm,
Vollure, Volbella, Restylane; to name a few) to smooth fine lines and
wrinkles and create fullness around the injected location (for example,
to create volume in fine lines in the lips). As we age, hyaluronic acid
levels in the body decrease since our bodies are incapable of maintaining
the same concentrations of this substance.
Consequently, our body loses the ability to hold water and maintain hydration levels. Ultraviolet radiation and pollution play a dramatic role in the
reduction of this ability. Our skin becomes drier and, therefore, more susceptible to wrinkling and loss of natural radiance. Hyaluronic acid has gained
much attention in the last years due to its regenerative properties, especially
when combined with vitamin C.
Fat pads
The fat pads create contour and fullness in the facial features. As we age, the
fat pads become thin and begin to make the great descent to the lower face.
Hollows begin to form under the eyes as fat pads fall from the cheeks.
Drooping skin will create unwanted pressure on fragile tissues and enhance
a deep line due to the new pressure and shift change from the falling fat pad.
The fat from the upper face moves to the lower portion of the face-pulling,
everything downward. Most clients will describe this as they look sad and
tired. There are two separate subcutaneous fat pad layers; one is the superficial, and one is deep. The superficial fat pad layer is right below the dermis.
The deep subcutaneous fat is located below the superficial fascia (SMAS). As
we age, some superficial subcutaneous fat will be redistributed to visceral
organs; other superficial subcutaneous fat compartments descend. The deep
fat does not change position.
There is notably seven superficial fat compartments
1. Superficial nasolabial fold
2. Medial cheek
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57
3. Middle cheek
4. Lateral cheek
5. Superficial superior temporal
6. Superficial inferior temporal
7. The jowl fat compartment
Deep fat compartments are located deep to the SMAS and arranged around
muscles, nerves, and ligaments
Lateral soof
Medial soof
Deep medial cheek fat
Deep lateral cheek fat
Fig. 8.2 Superficial fat pads.
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Essentials of neuromodulation
Muscles of the face
The muscles of the face are our most significant concern when injecting
neuromodulators. It is essential to understand where they lay within the tissue and where they connect, as this is how injectors understand how to prevent adverse outcomes instead of managing them (Table 8.1). Our last focal
point is, of course, how they make a face animate and which position are
structures pulled in, up, down, medial, or lateral. With each neuromodulator injection, there is an indirect effect on a surrounding or opposing
Fig. 8.3 Muscles of the face.
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59
Fig. 8.4 Deep muscles of the face.
structure. In the next section, as we describe the muscles function and its
connections, it will be a concept beginners will want to go back to repeatedly. By grouping the muscles, the reader should be able to begin to understand areas of neuromodulator treatment better. This way, learners can begin
to see the unique and intricate relationship between the groups. With every
muscle that is injected, another muscle group will be either directly or inadvertently affected. Truly comprehending what muscle groups work together
is the difference between being injectors and being a great injector. Each
patient will respond differently to treatment, making the anatomy extremely
important in creating beautiful and natural results.
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Table 8.1 Depressor and elevator muscles.
Depressor and elevator muscles
Depressor
muscles Action Elevator muscles Action
Corrugator
supercilii
Pulls brow down
and medially
Procerus Lowers brow
Pulls the medial
angle of the
brow down
Orbicularis
oculi
Depressor
labi
inferioris
Forcefully closes
eyes
Depresses the
lower lip and
pulls it outward
lateral
Platysmal Lowers lateral
lower lip and
tenses the neck
Depressor
nasii septi
Pulls down the tip
of the nose
when smiling
Depressor
anguli
oris
Orbicularis
oris
Lowers corners of
the mouth
(frown)
Purses/puckers
lips
Contracts the
lips
Depressor
Lowers brow Zygomaticus
supercilii
Frontalis Elevates brows
Levator anguli
oris
Levator
Elevates the angle of
the mouth
Elevates upper eyelid
palpebrae
superioris
(Muellers
muscle)
Masseter Elevates and
protrudes the
mandible
Menatlis Elevates and dimples
chin and protrudes
the lower lip
Nasalis Elevates nasal skin,
draws the ala of the
nose to the septum
Levator labii
superioris
alaeque nasi
Raises the upper lip
and dilates the
nostril
Orbicularis oris Raises lower lip
Pulls the angle of the
major
mouth up and back
to aid in smiling
Zygomaticus
Elevates the upper lip
minor
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Circumorbital group
Orbicularis oculi—The orbicularis oculi muscle is a sphincter muscle of
the eyelids. It is a broad and flat muscle spreading into three regions.
A sphincter muscle closes circumferentially. Therefore, the orbicularis oculi
muscle plays a vital role in facial expression and various ocular reflexes such
as frowning, squinting, and eye closure. There is a palpebral portion that can
be contracted actively and passively. There is an upper and lower section of
the palpebral fibers. The upper portion acts as a depressor, and the lower
portion acts as an elevator. Due to the sphincter nature of this muscle, it
is considered a depressor muscle.
Corrugator supercilii—This muscle works in combination with the
orbicularis oculi muscle to draw the eyebrows in medially and downward
to shield the eyes in bright sunlight when squinting. Because the corrugator
supercilii muscle is responsible for the frowning and squinting action, it is
directly related to the development of static vertical wrinkles in the glabellar
region. The corrugator supercilii is a depressor muscle as it draws the tissue
downward.
Levator palpebrae superioris—The levator palpebrae superiors muscle is responsible for elevating the upper eyelid. The levator muscle is part of
the elevator muscle group. Not only is this muscle responsible for elevating
and lowering the upper lid, but it also aids in the expression of fear. The
palpebral apertures widen in the prescience of fear or excitement when
the eyes are widened. The widening of the apertures is a direct result of
the increased sympathetic nervous system.
Nasal muscle group
Procerus—The procerus muscle pulls down the medial portions of the eyebrows and results in wrinkling over the bridge of the nose. Due to the downward pull of this muscle, it is part of the depressor muscle group. If this
muscle is hyperactive, a static rhytid will develop over time directly on
the bridge of the nose at the insertion point. The procerus is an active muscle
in the emotion exhibited in frowning, squinting, and or concentration.
The glabellar complex is a leading treatment area in esthetic treatments.
The depressor supercilii sits on both sides of the procures and aids in
pulling the brows outward, creating a widening in between the brows.
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The depressor supercilii can be unintentionally and intentionally injected. In
the right candidate, it can be a fantastic treatment. However, in the wrong
patient, it can create a very disfiguring treatment. Understanding the
patient’s goals and how the tissue will react when the muscles have been
treated with BoNTA is essential in creating superior outcomes.
Nasalis—The nasalis muscle comprises two components, the transverse
section and the alar portion. The transverse section merges with the procerus
at the bridge of the nose and sits on the cartilaginous part of the nose. As the
transverse muscle extends down the sides of the nose, it attaches to the maxilla just above the lateral incisive fosa. The transverse part is responsible for
compressing the nasal aperture. It is also responsible for the expression that is
illicit in the face of a bad smell. Some refer to the wrinkling of the nose in an
upward fashion as the “bunny lines.” The alar part of the nasalis draws the
nares and posterior part of the columella down and laterally. It results in widening the nares and elongating the nose. When the alar portion of the nasalis
is treated with BoNT-A, it can slim the flair of the alar.
Depressor septi—This muscle sits deep within the tissues. It attaches to
the periosteum and connects with the nasal spine. The depressor septi pull
the columella, the tip of the nose, and the nasal septum downwards. The
depressor septi is a depressor muscle as it may be recognized as such by its
name. As the septi is activated, it can aid in the flailing of the nasal alar.
As this happens, the tip of the nose dips. A common aging problem is to
see the nasal tip begin to droop with age. Adding a few units of BoNTA
to the base of the nasal spine can elevate the tip to a more youthful
appearance.
Levator labii superioris alaeque nasi (LLSAN)—This muscle is the
target for treatment in the gummy smile. The LLSAN is a superficial elevator
muscle of the nose and the upper lip utilized in oral-facial expression. Its
origination point is on the upper portion of the maxilla and then inserts into
the alar cartilage and levator labii superiors (LLS). It starts on the sides of the
noses and runs lengthwise down the sides to the upper medial to the lateral
portion of the lip. The constant pull on this muscle will deepen the nasolabial
folds with time. It is an excellent treatment spot for the prevention of the
nasolabial folds. The LLSAN pulls the upper lip up to display teeth, and
sometimes, with a hyperdynamic muscle, the gums will also show. When
the lip is pulled upwards wards with activation of this muscle, the nares will
flare. It is sometimes accidentally injected when treating the bunny lines.
63Anatomy
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In the wrong candidate, the patient will have their upper lip hang over their
top teeth. The patient section is of most importance.
Buccolabial muscle group
Upper lip (elevators, retractors, and evertors)
Levator labii superioris alaeque nasi (LLSAN)—This muscle is the target for treatment in the gummy smile. This is a superficial elevator muscle
of the nose and the upper lip utilized in oral-facial expression. Its origination point is on the upper portion of the maxilla and then inserts into the
alar cartilage and levator labii superiors (LLS). It starts on the sides of the
noses and runs lengthwise down the sides to the upper medial to the lateral
portion of the lip. The constant pull on this muscle will deepen the nasolabial folds with time. It is an excellent treatment spot for the prevention of
the nasolabial folds. The LLSAN pulls the upper lip up to display teeth, and
sometimes, with a hyperdynamic muscle, the gums will also show. When
the lip is pulled upwards with activation of this muscle, the nares will flare.
It is sometimes accidentally injected when treating the bunny lines. In the
wrong candidate, the patient will have their upper lip hang over their top
teeth. The patient section is of the utmost importance when treating
this area.
Levator labii superioris (LLS)—This superficial muscle works in conjunction with the upper lip’s other muscles to elevate and evert the upper lip.
This muscle is an elevator muscle of the upper lip. The levator labii superior
is much like the LLSAN modifies the nasolabial fold. This muscle is responsible for making an expression of sadness or seriousness. The LLS starts on
the maxilla and inserts into the upper lip’s skin between the levator anguli
oris and the LLSAN.
Zygomatic major—The zygomatic major muscle is another superficial
elevator muscle that inserts on the lateral aspect of the zygomatic bone posterior to the zygomatic minor muscle. This muscle inserts into the orbicularis oris, the DAO, and the levator anguli oris. The zygomatic major
muscles draw the angle of the mouth up and outward laterally when smiling
or laughing. It attaches to the lateral portion of the zygomatic arch, and at
times it will snuggle under the orbicularis oculi muscle. The zygomatic
major muscle is another vital muscle to avoid when injecting the lateral
canthal lines. We also need to be careful when treating the DAO as the smile
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