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When you hear the word Botox, what springs to mind? Frowning for your injector, to accentuate your eleven lines? The tiny blebs that decorate your brow for a bit post-shot? The quick pinch of the needle piercing each crease of your crow’s-feet? For most of us, neuromodulators represent an upper-face fix—a way to prevent expression lines from digging in over time, by sedating the muscles that move when we’re surprised, worried, or genuinely joyful.
But botulinum toxins can be used in the lower face as well—across the entire face, really—to ease age- or stress-related changes, boost the longevity of filler, and literally turn frowns upside down. Since the FDA-approval studies for toxins focus solely on the upper face, however, all other areas are considered off-label. Still, according to New York City board-certified dermatologist Dr. Jennifer MacGregor, many doctors have been injecting Botox around the mouth, into the chin and chewing muscles (aka masseters), under the jawline, and across the neck for more than a decade now.
“Techniques evolve and improve over time, but the basic principles haven’t changed much,” she says. “The main things that have changed are that a lighter hand, using fewer units, is now the norm, and we’re better at balancing multiple areas, to harmonize the entire face and neck instead of just freezing the frown, for instance.” Those smaller doses, which are especially critical for the lower face, allow muscles to maintain some mobility. And by not knocking them out entirely, injectors prevent stony expressions and keep untreated muscles from overcompensating and forging new wrinkles. (“Bunny lines” on the sides of the nose are a prime example of this, she notes—when someone can’t move their upper face, they’ll often start scrunching their nose when striving to show emotion.)
Despite neurotoxin’s tried-and-true versatility, many patients don’t know what a game changer the drug can be for the lower face. Dr. MacGregor theorizes this may be because changes in this area “are more insidious and hard to recognize, so people may not realize it’s the muscle pulling that’s causing their skin texture to change—or that treating it with neurotoxin can smooth things out.” Ahead, dermatologists share strategies for injecting the dynamic southern hemisphere of the face—and the near magical effects a few drops of toxin can achieve here.
What happens to the lower face over time?
Much of the stuff we obsess over in the mirror (or Zoom grid)—the burgeoning smile lines, the subtly downturned mouth, the golf-ball-textured chin, the blunted jawline—can be blamed on our facial muscles, which tend to get larger and stronger over time, Dr. Macgregor tells us. We know that by repeatedly contracting and by simultaneously folding the overlying skin again and again, muscles contribute to wrinkle formation—but there’s actually more to it than that. People frequently store tension in the lower face, actively holding certain muscles in unnatural poses—clenched jaws, pursed lips—for much of the day and, sometimes, night. (The pandemic has heightened this phenomenon, our doctors say, accelerating the aging process for many.) These unwitting expressions not only dimple and crease the skin; they can gradually alter our features, causing jaws to become wide and boxy or chins to tighten and recede.
Some of the muscles we’re unconsciously activating are known as depressors—they exert a downward pull and give off grumpy vibes. While this can happen at any age, “our facial muscles become more and more active as we get older, to kind of counterbalance some of the volume loss we experience,” adds Dr. Amelia Hausauer, a board-certified dermatologist in Campbell, California. (They’re essentially working harder, to help hold up depleted tissues.) “We try to replace some of that structural foundation [with fillers] but also soften the muscles [with toxin] so you’re not having this tension that’s continually causing changes.”
Oftentimes, she finds that by minimizing contractions and allowing muscles to resume their intended shape and position, wrinkles and folds will naturally settle out—or, at least, become easier to finesse by other means. (More on this coming up.)
What aspects of the lower face can neuromodulators treat?
The beneficiaries of lower-face toxin are numerous—and somewhat surprising. And since the muscles being targeted—with the exception of the masseters, in the jaw, and the platysma, in the neck—are smaller and thinner than those of the upper face, injectors can use very conservative doses, notes Dr. Hausauer. Just remember, all neuromodulators (Botox, Dysport, Xeomin, and Jeuveau) can take up to a week to kick in and their effects are often cumulative—best appreciated over time or, in some cases, after several treatments.
The tip of the nose
If the tip of your nose droops down when you smile, distorting your profile, “two to four units [of neuromodulator] can be injected right under the septum of the nose, to relax the depressor septi nasi muscle and lift the tip,” explains Dr. Lina Kennedy, a board-certified dermatologist in Long Beach, California.
Around the mouth
For the so-called barcode or smoker’s lines around the mouth, “several injections of two units of toxin can be placed along the upper and lower lip to minimize lip furrows,” Dr. Kennedy says. The dose is similar to that used for a lip flip, which, by releasing the orbicularis oris muscle, allows the top lip to turn out a bit, showcasing more of the pink part.
The DAOs, or depressor anguli oris muscles, are “fanlike muscles that extend from the corners of the mouth down to the jawline,” Dr. Hausauer says. “Releasing their constant tug can subtly lift the corners of the mouth,” giving a more contented expression at rest and alleviating marionette lines. She typically injects two to four units of toxin per side, depending on the strength of the DAOs.
The chin
Cobblestone. Golf ball. Peau d’orange. Doctors have many descriptors for the dimpling that chins can develop due to the combo of volume loss and excess muscle movement in the area. But whatever you call it, neurotoxin—two to six units, in the mentalis muscle—can usually erase it.
Tempering the muscle also allows the chin to ease forward a smidge, notes Dr. MacGregor, improving its projection in cases where age and tension are causing it to draw down and back.
The jawline and masseters
When carefully injected along the underside of the jawline, Botox targets the top portion of the sheetlike platysma muscle that wraps around the mandible and stretches up into the face. “As we age, the platysma loses tone, pulling surrounding tissues down and leading to the development of jowls, loose skin, and an undefined jawline,” explains Dr. Kennedy. “Toxin can decrease the downward pull caused by these muscles.” She typically injects 10 units to each side, along the border of the mandible, commonly combining these shots with injections to the DAOs, to “give a nice lift to the jowls and tighten the neckline.”
At the back of the jaw sit the masseter muscles. With overuse—chewing, clenching, grinding— “they can get bigger and stronger, giving the face a bottom-heavy, thicker, or wider appearance,” Dr. MacGregor says. Relaxing these muscles—with 25–50 units of toxin per side—can restore a slimmer, more youthful face shape while simultaneously relieving bruxism. “I tell patients, ‘You may notice decreased tension [in the jaw], but you may not see a slimming effect right away’—that tends to take time, because the muscle has to atrophy,” says Dr. Hausauer. “With repeat dosing, that’s where I find you tend to see more and more slimming.”
Related: 8 Times When Your Injector Might Suggest Getting Botox Before Filler
Neck bands
Two broad sheets of muscle spanning the length of the neck comprise the platysma. In youth, its discrete sides lie seamlessly together, smooth and tight, but over time, the muscle weakens and separates and its edges become more pronounced, forming sinewy bands that protrude beneath the thin skin of the neck. These bands also “pull down on our lower face, contributing to sagging,” notes Dr. Kennedy. To lessen that drag and smooth the neck, she injects neurotoxin directly into the most prominent part of each band, spacing shots one to two centimeters apart. “This typically results in four to six injections per band, with a maximum of 20 units per band.”
The risks associated with lower-face toxin injections
With muscles abutting or even overlapping—their delicate fibers intertwining in spots—“the anatomy of the lower face is a lot more intricate than [that of] the upper face,” Dr. Kennedy explains. An imprecise needle stick, too big a dose, or the unintended spread of neurotoxin “can result in an uneven smile or unwanted limited motion,” she adds. Beyond animation issues, Dr. MacGregor adds drooling and difficulty pronouncing the letters B and P to our list of possible complications. “This is why most seasoned injectors start with low doses and add in stages,” she says—especially when working around the nose, mouth, and chin.
While the brawny masseters can require generous injections, doctors are still careful not to overdose. “One of the potential risks of masseter injection—the one that’s most worrisome for me—is decreased bone mass,” says Dr. Hausauer. She likens the bone-muscle interaction in play here to that which occurs in the body with exercise: “The more you have muscle contraction pulling on bone, the greater the bone density you get.” But if you quiet the muscles with toxin and no longer have that intense contraction, the bone could theoretically weaken. However, she points out, a new study in the Journal of Oral Rehabilitation, involving subjects with TMJ, did not detect any bony changes following repeat masseter injections using 20–25 units of Botox per side. “I think that tells us that a lot of this may be dose-related,” she says. “You have to pick the right patient [for this treatment] and use the right dose, adjusting it as the patient’s face changes.”
Another uncommon complication of masseter Botox is paradoxical bulging of the muscle. As Dr. Hausauer explains, the masseter has both a deep and a superficial compartment. In most people, a ligament partially divides the two, so toxin injected into one area seeps into the other, affecting the entire complex, to give the desired result. But in folks who have a rare anatomic variation, the ligament completely separates the two chambers, blocking the flow of toxin. In these cases, “if you inject into the deep portion of the muscle, the [unaffected] superficial portion can take over and you get a bulging effect,” Dr. Hausauer says. Fortunately, there’s an easy fix: “You just drop a little tox into the superficial portion, and the bulge will go down.”
Neuromodulators in the neck rarely cause trouble when appropriate amounts are used—but “excessive or inaccurate dosing in the platysmal bands could cause serious problems, such as dysphagia [difficulty swallowing] or airway compromise,” warns Dr. Kennedy.
Combining Botox with filler, for lower-face aging
While neuromodulators alone can influence the shape and mood of a face, pairing them with fillers can be even more transformational—particularly for those seeing a loss of fullness due to the inevitable erosion of bone, fat, and collagen. Generally speaking, “you can get better and more natural results by treating both the volume loss and relaxing the muscles that are responsible for wrinkles,” Dr. Kennedy says. Another perk of the partnership: “Toxin can make filler last longer—as the toxin relaxes the muscles, [nearby] filler is less likely to break down as quickly—and also reduce the amount of filler that’s needed,” she notes. Keen to this symbiosis, experienced injectors aim to deliver maximum payoff with as little product as possible.
