The Art of the Full Face: Mapping Out a Neurotoxin Treatment
There's a philosophy I live by, especially when it comes to my own face. I practice what I preach. It has been four months since my last treatment, and I have waited until my full movement returned. No little touch-up doses in between. My full frontalis movement is back, my glabella and 11s are starting to show. Four months is the perfect time to treat. This is the standard I hold for every single one of my patients.
I always tell them, "Don't come back until your full movement has returned, or at least three to four months." This simple rule takes care of you as a patient and me as an injector. It minimizes the risk of possible resistance, and more importantly, it prevents an asymmetrical result. Layering old toxin with new toxin is a recipe for disaster, creating that patchy, uneven look. I tell them every time: an injector can only treat what they are seeing. If you come in with a frozen forehead and a moving glabella, I will treat the glabella appropriately. But I will only lightly treat the frontalis, because your full movement will return to that area. Then you might feel like I watered down the toxin, and that's simply not the case. Educate your patients on this, and they will get a beautiful, predictable result every single time.
So, let me map out my entire face. Let's get up close and personal. I want you to see my muscle movement. Every patient has unique anatomy. What works for me won't work for Susie, and it won't work for Jessica. My goal is to show you my thought process, the little tips and tricks I've learned along the way, the things you have to keep an eye out for. A pattern of injection is never a one-size-fits-all, but the process of evaluation is universal.
The Corrugators and the Glabella
I will start with the corrugators. The glabella is a complex dance between the procerus and the two diagonal muscles of the corrugators. These muscles work together to bring your brows inward and downward, creating those 11s. Some patients have a classic "11," others have a "1." You must look at their particular anatomy. For me, I have a pretty classic textbook 11, with those two faint shadows right there. I use about 20 to 25 units of neurotoxin for this area, but it is all about learning your specific product. Do not worry about what Betty is using down the street. Get experience with your neurotoxin. Get comfortable with its spread, its dosing, and how it performs in different types of tissue. I work with patients in their 20s and patients in their 90s. You must know how your toxin behaves in every single type of tissue.
In the glabella, I inject the procerus first. Mine is pretty classic textbook. But you must watch the tail of the corrugator. When I bring my brows together, you can see I am pulling from a specific spot right here. You do not want to go lateral to that tail because then you will be hitting the frontalis, and that's when you weigh down the brows. I keep those two pokes concentrated on the movement of the corrugator. I stay medial to the tail. The medial part of the corrugator is thicker, so you need to insert the needle deeper to get the belly of the muscle. The lateral tail is thinner, so you only need to go superficially. Medial corrugator: deeper. Lateral corrugator: more superficial.
The Frontalis and the Art of the Brow
Moving on to the frontalis, the only eyebrow elevator we have. There is the concept of the "line of convergence," a horizontal line where the frontalis has opposing functions. The upper part can drop the brows, while the lower part is an elevator. If you inject below that line, you get heaviness in the brows. For me, I don't think about the line of convergence on a daily basis. I simply understand that the closer I get to the brows, the heavier they will be. I am incredibly sensitive to keeping my brow arched. I love an exaggerated, feminine, pretty arched brow. I would rather have a little bit of movement and a nice arch than a frozen forehead and a heavy brow. That is my preference.
For my forehead mapping, I always remember if the patient is moving past the temporal fusion line—that ridge above the tail of the brow where the frontalis and temporalis meet. If you have movement lateral to that, you have to account for it, as the more lateral you go, the heavier the brow becomes. So for me, I go right above the tail of the brow, putting about a unit there. This prevents a Spock-like appearance. Then I create my pattern, working my way up. I have a wrinkle close to the brow, but I won't try to tackle it completely. I have learned the hard way that if I do not inject the central part of my forehead, I get this bulge effect. I call it my "boner frontalis." So I absolutely must place a poke right in the center to prevent that pucker.
I also have movement in my hairline. If I do not tox my hairline, I end up frozen everywhere except for one little wrinkle right there. Always take a look at the hairline. My typical dose for the frontalis is 12 to 14 units. As I am getting older, my dose is getting lighter because my frontalis is weakening. For brand new patients, I always say this: "Give me one treatment to really master your dose. I will inject you based on my experience, but you can respond differently than we anticipated. Be patient with me for one treatment so I can understand how you respond. After that, we will master and perfect your dose." This gives you leeway. If you aren't perfect, they understand. You are building a relationship. I always undertreat and am conservative on that first treatment, and then we build upon it.
The Crow's Feet and the Brow Lift
For the crow's feet, we have the orbicularis oculi muscle. You never want to go too medial to the orbital rim, or the toxin will track back inwards. You also don't want to go too lateral, or you won't get the right effect. I don't mark out the crow's feet. I just follow the patient's lines. But the tail of the brow is a special place. The orbicularis oculi draws the eye inward and downward. When you inject a little neurotoxin in the tail of the brow, you relax that function and get a beautiful brow lift. This is honestly my favorite poke of the entire treatment. It is the one thing that really stands out for patients. They come back and say, "Oh my God, please don't forget the brow lift!" Every female patient, unless they have some wild, aggressively arched anatomy, needs a brow lift. For my brows, I like a good raise. I am generous with the units—sometimes five or six, even seven if I am feeling frisky. I inject right under the hairline at the tail of the brow, about three pokes. Then I follow my crow's feet lines: poke, poke, poke, and one superficially right here. Sometimes I will even go into the medial canthus for one little poke. So on the other side, it's the same pattern. I am typically doing two units per spot, so maybe 12 to 14 units total for the crow's feet.
Now, for patients with heavy lateral cheek crow's feet, you have to educate them. If I freeze your crow's feet completely and you have all this movement in your lateral cheek—from the zygomaticus muscle—you will create a harsh, unnatural shelf whenever you smile. I have learned this the hard way. I tell them, "If we freeze this completely, it will create a weird ledge in your lateral cheek. I would like to gently dose your crow's feet so that it blends cohesively into your cheek, rather than creating a frozen shelf." They will thank you for pointing that out. Those little details separate you as an injector.
The Bunnies and the Gummy Smile
When I think about bunny lines, I don't have strong ones at rest. But when my entire face is treated and at its peak, I definitely recruit them. The face only has so many ways to express itself, and the muscles that aren't paralyzed will compensate. So I always treat my bunnies, even if they don't seem strong. I just put two to three units per poke on either side of the nose.
I do not do a gummy smile tox for myself, as I don't have one. But if I did, I would inject the levator labii superioris alaeque nasi muscle (LLSAN). That's the muscle that runs down the lateral side of the nose and elevates the upper lip. If you have a hyperactive LLSAN, it creates a gummy smile. You would inject right in the corner of the nose, about two to five units depending on the patient. I always start with the least amount of units and increase from there if needed.
The Perioral Area and the Chin
I don't do a lip flip. I personally hate the side effects of paralyzing the orbicularis oris muscle. Some of my patients live for it, but for me, I skip it. If I were to do it, I would go right at the vermilion border, about two units per site.
But I love the mentalis muscle. This muscle raises the chin and the lower lip, and it can be tricky. I have learned the hard way by creating the "chin boner." You must stay medial to the depressor labii inferioris (DLI) muscle. If you hit the DLI, the patient won't be able to draw their lower lip down, and their smile will look distorted. Lateral to that is the depressor anguli oris (DAO). For me, my DAOs are strong and getting stronger as I age. I do a superficial unit right where it pulls, and then I go all the way down, following the angle of my oral commissure, and inject a deeper unit there. Two units per poke. I keep it safe by watching the muscle pull the lip down into a frown.
The Masseters and the Jawline
For the masseter muscle, I give every patient a full lecture. I lay down the risks and benefits. The medical pros of masseter tox are weakening the muscle, which can drastically improve clenching, grinding, and associated headaches. The aesthetic benefit is jawline slimming. But with the aesthetic benefit comes a risk. When you weaken that hypertrophied muscle, you atrophy it. The skin that was draped over that thickened muscle loses its anchor. Where does that skin go? Forward. This can worsen or create the appearance of jowls. For a patient in their 20s, this is less of a concern. But for someone in their 40s with TMJ symptoms, you must explain this risk. I also explain the two common side effects. The masseter is divided into a superficial and a deep belly. You must inject both. If you only go down to bone and hit the deep belly, the superficial belly will overcompensate. That's an easy fix—just re-inject. But there is another side effect: the risorius muscle. This muscle lies over the masseter and attaches to the corner of your mouth, allowing you to pull your smile outward. If some neurotoxin bleeds into the risorius, you won't be able to pull out your smile. This is a watch-and-wait situation that usually lasts two to three weeks. I lay out these risks so that if it happens, my patient was educated and not blindsided.
When I map my masseters, I clench down to find the muscle. I mark the anterior border so I do not go medial. I typically do a triangle or square of dots. I use 20 to 25 units minimum. If a patient wants only 10 units, I usually say no. That girthy muscle will just absorb it, and they will be underwhelmed. I always stay below the ear lobe to avoid the risorius. I go all the way down to bone and perform a retrograde injection, pulling the neurotoxin back out to ensure I hit both the deep and superficial bellies. My masseters last about six months, so I treat them every other time, not every visit.
The Platysma: The Neck Connection
Finally, the platysma muscle. This is a thin, sheet-like muscle spanning the entire neck. It attaches to the jawline and, over time, creates a cumulative downward pull, contributing to jawline laxity. I am incredibly neck-heavy. I express with my neck. I smile with my neck. My platysmal bands are very strong. My gym girls who are constantly bearing down when squatting have these strong bands. For me, I am doing about 10 to 12 units on each band. I always explain to my patients, especially the "fit chicks," that they will feel weird during the first session. We are weakening that neck muscle. They might be doing sit-ups or a plank and feel like their head is a little heavy. I prepare them for this so they don't call me thinking their head is falling off. After the first treatment, it just becomes normal.
I focus my platysmal band injections on the superior part where it attaches to the jawline, to get the most bang for my buck. I don't focus down lower. I have four bands, but some patients recruit only three. Always look at your patient's anatomy. I inject right at the connection, about two centimeters apart, with two units per poke. The result really cleans up the smile and the expression. Our age shows in our neck. You can even ride up and do a Nefertiti lift, superficially injecting along the jawline for a cohesive jawline-neck treatment.
This is how I map my entire face. I cannot stress enough that this specific pattern won't work for your patient. My hope is that you took the tips and tricks on how to view muscle movement, how to look at the face, and how to avoid little complications. Softly dosing the crow's feet to avoid a shelf. Looking in the hairline. Educating on the masseter risks. These are the details that will help you stand out as an injector.