Arnold W. Klein, MD (in memoriam)

I have been using Botox since before 1997 for the frown and never have had seen it not work. The original injection pattern was 20 Units in 5 places  and I would combine it with 1/2 a forehead of 9-12 units. Bigger people needed slightly higher doses and at times I combined it with fillers but it always worked. This is about you being treated with to few units----go elsewhere.Dysport diffuses more than Botox and the 3:1 ratio does not always work. Also it does not last as long. While Xeomin diffuses like Botox it has a shorter duration of Action. AWK

Can we establish any rules for augmenting the  lower third of  the face?In looking at the aging lip, there are two important areas
to observe.
1) One is the shape of the lips themselves, and, i
2)the importance of the support provided to the lower third of the face by dentition,grinding and also 
bone structure.
These are all features which require restoration.
Not only  injection of the lips themselves but also on volumetric
restoration of the lower third of the face. The lips
should be full and well defined. They should be injected
without blunting the edge of the vermilion border of the
lips or unnatural fullness above the lips. A physician must
also focus on the restoration of the ends of the lips, as well
as the building of buttresses at these ends to restore height
to the lower third of the face, correcting the labiomandibular
grooves and oral commissure. Although dermatologic
and esthetic journals deal with substances for
implantation, these journals do not, in themselves, hold
information regarding the proper goal of lip enhancement.
Instead, the answer is found in the dental literature, in
which many articles have addressed the proper height,
size, and location of the lips as produced by dental restoration.

With the patient in the sitting  position, the lips
should be parallel to a line drawn between the pupils of
the eyes. In regard to spatial location, the upper lip should
be 18 to 20 mm from the nose and the lower lip should be
36 to 40 mm from the chin. As the dental support is lost over time the lips move farther from your lips with the visual concept your nose is getting larger. The concept of this loss of dental support is commonly referred to as "Long on the Tooth!

From the blanching on the left side of your lip it appears there is intravasculer occluson or blockage of the blood supply to your lip due to the thick or concentrated Succeev. This is serious side effect in the acute phase of hyaluronic acid  injection  that  can ultimatedly cause  localized tissue necrosis or death  by mechanical interruption of local blood supply. It has been reported with hyaluronic acids (HA) and can quickly be reversed if one observes blanching with a swift injection of Hyaluronidase to dissolve the HA. Succeev,while not available in the US,  is said to be  one of the most concentrated forms of hyaluronic acid available which may account for your reaction.  Succeev three is the most concentrated and used in the lip.Hyaluronidase must be used as soon as possible within 24 hrs to reverse this reaction.Succeev One for fine lines such as laughter lines around the eyes and the smoker lines or peri-oral lines above the top lip.

Succeev Two for medium lines and wrinkles such as naso-labial (nose to mouth) lines, glabellar lines (vertical lines between the eyebrows) and oral commisures (corner of mouth).

Succeev Three for lines and wrinkles such as naso-labial folds and for chin and cheek augmentations. It is also used for enhancing the border on the lips.

iBotox can be used in several ways to help the perioral area. For lip lines you can use 1-2 units per quarter. 
usually will draw up the Botox and then dilute it to get a better spread of  the toxin.

in regard to the down turned corners of your mouth 3 units can be injected at the edge your jaw to get the Depressor Anguli Oris muscle. The location can be determined two ways. Turn the corner of your mouth down and muscle is injected at the level of the jaw right  behind the downed turned corner on each side. tor draw a line by resting a pencil on the nasolabial fold to the edge of your jaw.

If you have an apple dumpling chin 10-15 units right under your chin will fix that 

The Corrugator Muscles make the frown. They  are both below the inner part of your brow and must be treated. Also the frown injections include an injection in the Procerus muscle which is below  the area between the brows at the top of your nose. Finally you need  2 injections above your brow 1.5-2cm above the brow lateral to the iris to  get the tale of the Corrugator Muscle. To prevent the Spock Brow inject over the lateral iris not the pupil. When you do not go lateral enough on these two  injections the the lateral part of of your forehead muscles will lift your brow create Dr. Spock! In summary

Glabellar lines or  frown lines used for FDA approval: 2.5 cc dilution- Inject 4 units (0.1 mL) into each of 5 sites, 2 in each corrugator muscle and 1 in procerus muscle for a total dose of 20 units - by the way these are my injection sites and dilution the used for approval