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64 Essentials of neuromodulation
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can be interrupted in an unnatural and displeasing way due to the insertion
point in the DAO.
Zygomatic minor—The zygomatic minor is yet another superficial
elevator muscle. The zygomatic minor muscle elevates the upper lip outward and upward, allowing to show the maxillary teeth. This muscle sits
beneath the orbicularis oculi on the medial portion of the zygomatic bone
just in front of the zygomatic major muscle and connects to the subcutaneous tissue of the upper lateral lip muscle. The zygomatic muscle is essential in
the function of smiling. This muscle can be inadvertently injected when the
lateral canthal lines are treated in the ill-prepared injector’s hands.
Levator anguli oris—The levator anguli oris raises the mouth’s angle in
smiling and contributes to the depth and contour of the nasolabial fold. This
muscle lies deep and lateral to the levator labii superiors. It originates in the
canine fossa of the maxilla and connects the modiolus of the lips. The levator
anguli oris is not typically a muscle that would be injected with neuromodulation. However, due to the proximity of other muscles treated, it is a
muscle to be mindful of while injecting.
Risorius—The risorius pulls the corner of the mouth laterally in numerous facial activities, including grinning and laughing. The risorius muscle
originates in the fascia over the parotid gland. This muscle is closely related
to the master muscle as it course along to the corner of the mouth just above
the master muscle.
Lower lip (elevators, retractors, and evertors)
Depressor labii inferioris (DLI)—The depressor labii inferioris draw the
lower lip downwards and a little laterally in the action of chewing or
otherwise known as a masticatory activity. It is further thought that the
DLI may assist in the eversion of the lower lip as well. The DLI is a muscle
that injectors want to avoid entirely. The DLI is responsible for the expressions of irony, sorrow, melancholy, and doubt, to name a few. When treating the DAO incorrectly, it can lead to the neuromodulator being
introduced to the DLI. Because it is a depressor muscle when it is injected
with neuromodulation, the lateral portion of the lower lip from the corner
to midline will be forced upward, and then action of the pink of the lip will
curl inwards. The result can look like a palsy event. Only time will heal this
mistake.
Depressor anguli oris (DAO)—The depressor anguli oris muscle
draws the angle of the mouth downwards and laterally in opening the mouth
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and in expressing sadness or questioning. With age, the DAO is responsible
for the volume loss and the development of creases in the marionette region.
This muscle always pulls downward and creates a shearing effect deepening
the crease in this area and disrupting the fat position. Treating this area with
neuromodulation will help to prevent the progression of a rapid breakdown
in this area.
Mentalis—The mentalis muscle raises the lower lip and is responsible
for the skin’s wrinkling on the chin. It raises the lower lip base and, therefore, helps in protruding and everting the lower lip in drinking and expressing doubt or disdain. In patients with a jaw that is thrusting forward as in an
overbite, this muscle often stays active and will result in a cobble stoning
effect on the chin.
Compound sphincter muscle group
Orbicularis oris—The orbicularis muscle consists of four quadrants the
upper, lower, left, and right. This muscle is responsible for oral competence.
The orbicularis muscle can create the kissing face or a puckering of the lips
and pull the lips toward the teeth to complement the expression of confusion
or disbelief. The orbicularis oris is a sphincter muscle, which is also confirmed to be a part of the depressor group of muscles. It aids in speech as
well as oral competence. If treatment with neuromodulation is done incorrectly here, it can create difficulty with speech, drinking through a straw, and
whistling. The injections should be superficial and always in the muscle’s
belly but not too deep to affect the deeper portion of the muscle, which
can affect a patients’ oral competence.
Three other muscles are a part of this group but do not play a significant
role in the art of neuromodulation; therefore, we will make a note of them
but will not spend much time on them. They are the incisivus labii superioris, incisivus labii inferioris, and the buccinator.
Muscles by facial groups and areas
Circumorbital and palpebral muscle group
Orbicularis occuli
Corrugatur supercilii
Buccolabial muscle group
Levator labii superioris alaeque nasi
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Zygomatic major
Zygomatic minor
Risorius
Levator labii superioris
Menatlis
Depressor labii inferioris
Depressor anguli oris
Buccinator
Pterygomandibular raphe
Orbicularis oris
Pars peripherals
Pars marginalis
Incisivus labii superioris
Incisivus labii inferioris
Platysma
Nasal muscle group
Procerus
Nasalis
Depressor septi
Skeletal structure
The skeletal structure is the support, or shall we say the framework for all
facial layers to rest. The craniofacial skeletal structure undergoes much stress
throughout the years, which produces many changes over time. Bone loss
and position changes are relative to the dynamics of expansion and loss,
along with musculoskeletal changes. As muscles atrophy over time, the craniofacial structures reposition as the muscle and ligaments act like anchors or
support systems for the skeleton. In aging, the mandible begins to drop forward, so the mentalis becomes hyperdynamic in an effort to hold it back in
position. Patients’ facial height, width, and depth all change with time. The
chin can widen, the gonial notch demineralizes and is pushed forward, the
maxilla changes aiding in the formation and accentuation of the nasolabial
folds. The orbits increase in size by widening and increasing the opening,
which leads to the dreaded dark tear trough. As the maxilla decreases in size,
this leads to a shift in the malar fat pad, accentuating the nasolabial fold.
There is also a loss of support of the upper lip, creating a lengthening of
Fig. 8.5 Vessels of the face.
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Fig. 8.6 Superficial nerves.
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Essentials of neuromodulation
Fig. 8.7 Bone and cartilage.
the upper lip with the maxilla bone reabsorption. As teeth start to decay, this
will also change the structure of the craniofacial structures, further creating
volume loss and shifts in facial features’ contours.
Further reading
Kolarsick, P., Kolarsick, M., & Goodwin, C. (2011). Anatomy and physiology of the skin.
Journal of the Dermatology Nurses’ Association, 3(4), 1–11.
Netter, F. (2014). Atlas of human anatomy (6th ed.). Philadelphia, PA: Elsevier.
Pessa, J. E., & Rohrich, R. J. (2012). Facial topography: Clinical anatomy of the face. St. Louis,
MO: Quality Medical Publishing.
Standring, S. (2016). Gray’s anatomy: The anatomical basis of clinical practice. Philadelphia, PA:
Elsevier Limited.
CHAPTER 9
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The esthetics of aging
The aging face
Now that the mechanism of action of BoNT-A, the nervous system, the soft
tissues, and the muscles of the face have been reviewed, let us begin to put
the pieces together by looking into how the face ages so that proficiency can
be developed in the art of assessment to develop unique yet effective treatment plans with the use of neuromodulation.
The onset and pace of aging are multifactorial and unique to different
individuals, and factors such as lifestyle, gender, and ethnicity play an essential role in the development of prescriptive treatment plans. Given the
dynamic relationship to each structure involved in the aging process (bone,
ligaments, fat, muscles, fasciae, and skin), it can be challenging to pinpoint
the culprit for most aging processes. It is essential to understand the underlying structures and how they age before offering esthetic advice to the
patient. Often the patient will have a budget that does not meet the reality
of a singular rejuvenating treatment. It is crucial to begin down the esthetic
journey with the patient by building trust. This way, a partnership can be
developed of equal trust resulting in a long term relationship. The patients
can learn from their provider, fostering confidence in their decisions based
on the treatment plan carved out for them. If the provider comes on too
strong, they will feel as if they are being sold. Also, pointing out too many
areas of concern can make the client feel hopeless. When a trusting relationship is created, providers can begin to educate them on their aging process
slowly. Patients will feel more comfortable with their decisions and less
focused on the dollar amount. All providers should produce a prescription
of treatments to the patients based on their needs, not based on their interpretation of the patient’s budget. Providers prescribe and then let the patients
decide if they want or can afford the plan for rejuvenation.
The effects of aging on the face are complex and multi-dimensional
(Fig. 9.1). Injectors must analyze this carefully and systematically ask the
questions; is the skin thick or thin, rough or smooth, dry or oily, how much
fat has shifted, and how do the muscles aid in the aging process? The facial
assessment will be unique to every patient. There is no way to provide a
Essentials of Neuromodulation Copyright © 2021 Elsevier Inc.
https://doi.org/10.1016/B978-0-323-89920-8.00034-5 All rights reserved.
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Essentials of neuromodulation
Fig. 9.1 The aging face.
cookie-cutter treatment plan based on the millions of unique presentations
of facial features that will present in the clinic for treatment. Address and
assess every patient individually. The way a novice injector injects will
not be the way they inject in 5 years from now. This concept is based on
the idea that as the novice injector injects more and more and analyzes more
and more faces, a more in-depth knowledge of the anatomic relationships
and the complex emotional view of the patient will develop. Having every
patient come back for a 2-week follow-up is best for many reasons. One
reason is so that proper after photos can be taken to showcase the work
performed. Another reason for the follow-up visit is to develop a real understanding of the treatment’s effect. Having the ability to review the treatments’ effect will allow for further growth in the industry and shorten the
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learning curve time frame. Before and after photos help in growing new
businesses. When a patient comes back at the 2 weeks follow up, it is an
opportunity to capture photos and see the results of the actions taken during
treatment in real-time.
Your assessment will evolve over time, and so will your skill and technique.
How does the face age?
(1) The dermis thins and tiny vessels become more visible with time.
(2) Bony structures can become more prominent as fat shifts or are lost.
(3) The cheeks and the mouth area hollow.
(4) The philtral columns will sink and or deflate. They, at times, will widen
as well.
(5) The upper lip lengthens.
(6) Corners of the mouth become sad appearing and create deficits in the
marionette region.
(7) The nasal tip drops.
(8) The lower 1/3 of the face drops and jowls form, enhancing a hollowing
of the pre-jowl sulcus.
(9) The lower mandibular region narrows and pushes forward.
Aging occurs in two ways; intrinsically and extrinsically
Intrinsic aging is due to our genetic makeup and ethnicity. Extrinsic aging is
due to sun damage, smoking, pollutants, and ultimately poor lifestyle
choices, all of which add to exposure.
Patients can help to curb the aging process by paying attention to extrinsic factors. Providers can manipulate the internal environment to help
patients reverse the hands of time with neuromodulators, fillers, lasers,
chemical peels, and various other non-surgical options. The exposome
influences skin changes. This refers to the internal and external factors
and the interactions with an individual from birth to death. Keeping in mind
that severe outside influences that rapidly progress the aging process are the
use of tobacco, pollutions, lack of sleep, stress, nutrition, temperature, radiation (sun and computers).
Aging is a vicious process of wear and tear over time while being exacerbated by the exposure to daily oxidants. Muscles create friction and shearing, which causes a breakdown and a loss of volume in the face. The force of
muscle activity also creates epidermal injuries such as static rhytids. Our
bones begin to shift and demineralize, which creates even more shifting
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of tissues. It is important to understand anatomy and then how that anatomy
ages over time.
Common aging features are drooping skin, flattened cheeks, fullness is
lost in the upper face, and resides in the lower face at the mouth and jawline.
A deepening of the nasolabial fold, enhanced jowls, harsh static rhytids are
also a part of the more commonplace aging features. The face can take on a
sad, tense, and tired appearance. We lose volume, and muscles weaken, connective tissue loosens and allows for more significant sag. Aging is part genetics and part lifestyle; prevention is more manageable than repair and
restoration.
Youthfulness is expressed through shape, structure,
and contour
Skin in the younger years is soft, plump, hydrated, and looks full. The cells of
the skin turn over rapidly, improving the overall tone and texture of the skin
(Figs. 9.2 and 9.3). However, once we age, we experience a loss in facial
glands, which in turn, we have a decrease in oil production, immediately
dehydrating the skin. We then lose collagen, hyaluronic acid, and elastin.
The loss of collagen, hyaluronic acid, and elastin depletes the skin’s building
blocks, minimizing the health and youthfulness of our skin.
The loss of the three building blocks will lead to the dynamic lines of
expression that become sad and angry emotions. Static lines will be created
due to the muscles’ abuse and forceful, repetitive action on the skin. With
time our expressions leave a story on our face of how our anatomy works.
Elastin is essential for our skin’s ability to recoil, and once we lose elastin, our
recoil ability is sharply stunted.
Facial esthetic treatments have evolved and now include correcting
age-related volume loss in the midface. Rejuvenation has shifted from the
two-dimensional approach to a three-dimensional approach. The typical
youthful face follows the shape of an ogee curve. The ogee curve is the central facial triangle or the double soft-S curves seen on the youthful face from
an oblique angle. However, with age, the mid-face flattens, and the skin
begins to sag. The deflation of the cheek makes the nasolabial fold much
more prominent. Then a concavity begins to form under the eye in the tear
trough. As gravity pulls these structures down the pre-jowl sulcus area is
hollowed, and the pre-jowl region becomes full and prominent.
Aging is happening on a variety of levels. The skin surface becomes discolored; the skin can become thicker or thinner. The texture changes, pores
become larger and more pronounced, and old scar tissue changes how the
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Fig. 9.2 Typical attributes of a youthful face include; a full upper face above a sloping
lower midface.
skin lies or puckers. Permanent lines and wrinkles are set into hyperdynamic areas. Gravity grips and begins the pull downward, causing fat pads
to deplete and drop into the nasolabial area and the jowls.
In more recent esthetic literature regarding aging has focused on the anatomical facial fat compartment. This has revolutionized the concept and
approach of adding volume to specific deflated soft-tissue compartments
with dermal filler. However, it has added depth to the muscle’s effect on
the facial fat compartments. Dermal fillers with the understanding of the
facial fat pads have allowed injectors to create a more individualized youthful
restoration to the face. The overall improvement in understanding facial fat
pads has compartmentalized the treatment strategies and prescriptive plans
for facial rejuvenation. Rejuvenation and restoration treatment plans should
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