Botox Facial Slimming/Facial Sculpting: The Role of Botulinum Toxin-A in the Treatment of Hypertrophic Masseteric Muscle and Parotid Enlargement to Narrow the Lower Facial Width

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History

The author started this novel approach to reducing lower facial width in 1998, in response to the need for a nonsurgical and easy solution to treat patients with wide, “boxy” faces or “square jaws”. These patients complained of a masculine, aggressive appearance, lack of feminine face shape, and protruding angles of the jawline. Many patients who could not articulate the problem merely felt they looked fat in pictures. Some patients, on questioning, also suffered from headaches or migraine and

Anatomical considerations

The masseter muscle arises as 3 heads from the length of the zygomatic arch, with the superficial head arising anteriorly; the intermediate head, from the middle; and the deep head, more posteriorly. The 3 heads fan downwards in reverse direction to become attached to the angle and the ascending ramus of the mandible, with the superficial head attached more posteriorly and the deep head more anteriorly (Fig. 1). Thus, there is an overlap zone where the 3 heads cross each other, and this

Injection technique and scheduling

Although other types of botulinum toxin-A can be used effectively, the author prefers Botox. A dilution of 2.5 mL nonbuffered saline is used for 100 units of Botox, 1 mL thus containing 40 units of Botox. If 20 or 32 units are to be injected, 0.5 mL and 0.7 mL are drawn up, respectively, after which the syringe is topped up with the requisite amount of saline to make a 1-mL volume for ease of administration of the drug.

Two factors to consider when administering botulinum toxin-A to the masseter

Complications

The most frequent complications of botulinum toxin for masseter reduction are as follows:

  • 1.

    Loss of a full smile or an asymmetric smile due to diffusion of the botulinum toxin-A forward to the risorius and levator anguli oris;

  • 2.

    Weakness and an aching sensation on chewing; typically, the patient finds difficulty in opening the mouth wide and initiating biting, as needed to eat a hamburger or thick, juicy steak;

  • 3.

    Jowling due to overrapid volume reduction and sagging of the overlying skin envelope;

  • 4.

Results

The author has treated more than 600 patients with this technique and most patients have been extremely pleased with the results. Very few patients discontinue treatment; cost is the main reason for stopping treatment. Most patients are young and fashion conscious; some may not have the financial resources to maintain the result long-term. The longest follow-up seen was 11 years. The Botox was as efficacious in the last dose as in the first. No antibodies or resistance has been seen or

Botox and the parotid glands

Patients who complain of a widened, lower face have also to be examined carefully for parotid hypertrophy, because this can also contribute to the impression of flared mandibular angles. The parotid gland is identified by observing and palpating a diffuse swelling that extends beyond the posterior border of the mandibular angle. The parotid also pushes the earlobe outwards giving patients a “bull necked” look. Occasionally, this may be missed in patients with thick skin and overlying soft

Discussion

Before the use of botulinum toxin-A to treat the “square jaw” phenomenon, surgery was the only option. The procedure was often bloody, especially if part of the masseter muscle was resected and in some cases, it was quite difficult if the mandibular angle spur projected posteriorly. Achieving symmetry always posed challenges, because most of these patients exhibit facial and jaw asymmetry to some degree. Fractures of the mandibular ramus due to unfavorable splits of the bone during the

Summary

Botulinum toxin-A is a highly efficacious and cost-effective, nonsurgical option for reducing the width and shape of the lower face and jawline. The results can vary from the subtlest thinning of the face to an extremely thin, cachectic appearance. Many nuances can be achieved. The administration is simple, and the process takes barely 5 minutes in an office setting. Botulinum toxin-A can also be effectively used to reduce the bulk of an enlarged parotid gland without affecting saliva

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