Authors : Dr. Ivona .

Nowadays, it is very easy to make an aesthetic enhancement in the lower facial third. Before, very complicated plastic surgeries were done to improve the shape of the lower face in order to treat inappropriate mandibular growth and gummy smiles. Reconstruction of the lower facial third ten years ago, was possible only through invasive surgery, however now lot of things can be enhanced without surgery. Further, recent procedures result in no down time and the elimination of all risks and complications associated with surgery such as effects on swallowing, talking, breathing etc.

Silicon implants, as an option for correction of mandibular retrognathia maintains its indication, but it is less pronounced than before. Hyaluronic acid dermal fillers are now replacing silicon implants with no down time at all. In the new era of minimal invasive aesthetic medicine, surgical tools tend to be replaced with different type of injectables. The options and choices are temporary, semi permanent and permanent dermal fillers for volume replacement and Botulin toxins for chemo sculpting. The toxin which is used for functional and aesthetic enhancement is Botulin Toxin type A. Hyaluronic acid dermal fillers tend to take over the market as high as 95%(in Europian market). The choice of most practitioner preference is mono-phasic, cross linked hyaluronc acid dermal fillers.
 

Facial Reshaping, and/or facial Enhancement

We all agree that the best example of a young looking face is a "heart shape “or triangle face. With aging, the preferred young looking "heart shape" face transforms into an "inverted heart-shape”. This inversion is indicated by the accumulation of fat pats in the face around the mandibular line, creating “jowls”, “and/or “double chin". Due to aging, ligament enlargement and a lack of skin elasticity, malar fat pads “slide downwards” and change their youthful position. Further, the naso-labial folds become more visible and the volume of the middle face also disappears. Marionette lines also become easily noticeable as an early sign of an aging face. Through facial reshaping or enhancement, facial aging is slowed and the ideal heart shape is returned. Remodeling an aging face into a young and energetic face is literally equal to reverting the inverse heart face shape into heart face shape. How to achieve it?

The lower facial thirds can be enhanced in a very cosy and comfortable environment, instead of surgical theaters ,with easy, repetitive and painless procedures.

We perform Chemo sculpting using Botulin toxin type A and inject Botulin toxin into m. masseter from both sides of the face, creating a voluntary muscle atrophy . This results in more radiant lower facial third with sharp and clearly defined facial expression.
 

PHYSIOLOGY OF THE CHEMO DENERVATION OF THE M.MASSETER

After repetitive chemo denervation of m. masseter with Botulin toxin, a less temporary, and more permanent m. masster reduction is acchived. The bone matrix is effected too. When the muscle is inactive there is a certain bone atrophy going along. This is due to the Moss’ “Bone -Muscle-Matrix”theory and thus starts with chemo denervation of m.masster. Narrowing of the mandibular width over several month to years is a final outcome. By reducing the volume occupied with masseter muscle, the lower face is made narrower, with improved definition of the zygomatic arch and malaria eminence. The jaw line becomes sharper and better defined.

These and other results are part of a medical revolution, as previously these results could be achieved only with surgical reduction of the mandibular angle and /or muscle itself.

Chemo sculpting of lower face with Botulin toxin can result in a myriad of changes such as a slight width reduction to more visible changes which could be represented with defined zygomatic arch and infra zygomatic hollow which is now days sign of “supermodel-like ”appearance. Over-correction of the face, could result in a cachectic and unattractive face. We have to perform changes slowly and gradually , respecting the safe parameters of under-correction.

Another cause of a too wide lower facial third is hypertrophic parotid gland. Men do look overweight and not really energetic and women have the masculine appearance.It can be corrected with Botulin toxin injection directly into the parenchyma of parotid gland itself.

In most cultures in the world , be it Asia or Western world triangle or heart looking face is an attribute of beauty and youth.To reconstruct it we need to start with lower third which must be slim enough to live the middle and upper third visual domination.

Even young individuals ,specially Asians ,Chinese,Korean and Japonese do have hypertrophic masseter muscles, and there is a huge demand for the m.masseter reduction.

I started to use BOTOX(Allergan,Irvine)to treat patients with m.masster hypertrophy ,at first to treat functional indications.

The most common indication was grinding or bruxism.The strong forces implicated on the back teeth ,and involuntary action due to the strong and overly developed masseter muscle would result into decreasing of the quantity of hard dental tissues (Enamel and dentin)by dental abrasia. Decreasing of the vertical dimension , and tension in the temporo- mandibular joint(TMJ) and surrounding anatomical structures results headaches and tooth aches symptomatology because of the strong forces applied on the teeth.

The other, quite common, functional problem i would treat ,at my very beginnings, with Botulin Toxin type A was the facial pain syndrome caused by TMD syndrome.

Face and its surroundings are very complexed as we all know ,because of the complaxed innervation and vascularization of the region.The diagnosis for pain syndrome caused by TMD is quite complicated and not so far ago this patients would be treated at neurology departments or psychiatry departments diagnosed as idiopathic pain syndrome or even psychosomatic syndrome.With detailed medical history and CT involved we can easy find the organic cause of their pain in TMJ and its disorder.Injecting into masseter muscle can relive the tension of the region and help the pain.Also the temporal muscle can be injected in order to relief the symptoms.

It is seen that Botulin Toxin for pain lasts longer then for muscular contraction.Most muscles do return to a normal function into 4 month after injection while pain relief lasts for 6 month and longer.Botulin toxin has the effect on noci receptors of the pain pathway (c and A delta fibers),and also is shown its effect on inhibition of the neurotransmitters associated with pain like substance P ,calcitonin gene related peptide (CGRP)and vanillin receptorT9TRPV-1)All of those neuropeptides are causing the inflammation and pain. Blocking them we gain relief of significant inflammation and pain.

There is another ,speculative theory connected with Botuin toxin and pain.Releasing the muscular contraction with chemo-denervation,thus less local ischemia(associated with compression of vessels in that area)and therefore pain reduction.

The patients improved their status and they became less stressed and and pain and muscle tension free ,and the result for pain relief was lasting from 6-8 month.

Nowadays i still use Botox for medical and functional indications as for bruxism and increasing the vertical hight,but more popular indication became the cosmetic one-enhanceing lower facial third.
 

CASE REPORT

Patient walked into my clinic complaining of headache ,grinding and occasional TMJ related pain in the mornings and while wide opening the mouth.

She had a large asymmetric masseter muscles,”chubby" or “puffy” face and inspection in mouth showed obvious signs of bruxism - grinding facets on the frontal teeth as well as molars where grinding forces were the strongest .Her TMJ was painful on palpation wheil opening the mouth and simulating biting into the cotton roll.Mouth opening presented as an asymmetric , inconsistent and limited movement .
 

Botulin toxin is used for chemo denervation of m.masster, bilateral

But patient main concern was chubby and unattractive facial expression.

Initially , 40 U of Onabotulinum Toxin type A was injected into the one muscle and 45U into more hypertrophic muscle from the other side .

The injection points I decided on ,were 5 injection points in each muscle.

After two weeks patient was coming on the first recall.

Her symptoms of bruxism and headache were reduced but not disappeared completely.

Her face shape started to change .The face looked slimmer but still the desired features were not acchived.The muscles were softer but noticeably reduced in size.We scheduled a recall into two weeks time ,and gave more time for Boutlin toxin type A to finalize its action.

After one month,(4 weeks time from the chemo denervation), patient was feeling much better and her symptoms as grinding , headaches,mostly disappeared, but her muscles could still clutch weekly.

This time she was injected again with the same doses of 40 U and 45 U per side into the both muscles.

Recall after two month time brought the patient back to the clinic.

She was happy to announce that all her friends and family had remarked on her physical change.She had no medical symptoms which were happening occasionally, but overall she felt like a “new Born” after waking up in the morning without stiff muscles and tension and burning sensations due the TMD.

We injected her again with 40U and 45U per side to stabilize the result.After one more month(three month after first injection ) she was happy looking slimmer and all the medical symptoms disappeared.She was injected one more time with 40U and 45U per affected muscles, from both sides.

In three month time,the total dose of 255U U was injected bi -muscular,with the frequency of ones per month.

She was told to come back for another injection when she can feel her "back teeth again"or “face becoming puffy again" (face gaining the muscle on muscle mass).Then she was injected again the 32U-40U and U per side.

The patients remains in recall every 6 month or when she feels the muscle is growing again or can clunch on the back molars-what ever happens before.
 

The patients face appears slimmer after the bilateral chemo denervation treatment of m.masseter

 

MATERIALS ,INJECTION TECHNIQUE AND MEDICAL PROTOCOL-

I was using the Botox (allergen) deleted in 2,5 ml saline .Every 1 ml contained 40 U of Btx.

Botulin toxin was delivered mostly into the bulk of the master muscle with the 30 G Precision Glide Needle .
 

ANATOMY

the masseter muscle has three heads that arise from the three sections of the length of the zygomatic arch and are inserted fan like into ramus ,condyle ,angle and lower border of mandible.

The position where all the three muscle’s heads are overlapping is ideal as an injection point.

the muscle borders are zygomatic arch ,posterior edge of the ramus ,and the lower border of the mandible.The anterior edge we can easy feel and mark when clutching.Care should be taken of non injecting too deep in to ptherygoid muscles through coronoid notch.It will result on discomfort when chewing.
 

Asian “V shape” face is considered as a beauty standard. botulin toxin is injected into m.masseter bilateral, in m.levator labii superioris alecque nasi bilateral as well as into m.mentalis