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Aesthetic Botulinum A Toxin in the Mid and Lower Face and Neck


Address correspondence and reprint requests to: Jean Carruthers, MD, Department of Ophthalmology, University of British Columbia, 943 West Broadway, Suite 740, Vancouver, BC, Canada V5Z4E1, or e-mail:


Background. Botulinum toxin type A (Botox formulation) is used extensively for smoothing hyperkinetic lines in the upper face. The use of botulinum toxin for aesthetic indications in the mid and lower face and neck is now becoming increasingly popular.

Objective. To review our current approaches to botulinum toxin treatment for cosmetic indications in the mid and lower face and neck.

Methods. Procedures and outcomes are described for the primary and adjunctive use of botulinum toxin.

Results. Cosmetic treatment with botulinum toxin successfully changes the contour of the palebral aperture; smoothes lines, including “bunny” lines, perioral rhytides, and horizontal neck lines; softens creases, including the mental crease and melomental folds; and alleviates facial asymmetry and nasal flare. The doses of botulinum toxin used in the mid and lower face are generally lower than those used in the upper face. Caution must be used in injecting botulinum toxin in the perioral area to avoid an incompetent mouth.

Conclusion. Botulinum toxin treatment is valuable for aesthetic improvements in the mid and lower face and neck. In some areas, particularly the perioral region, the use of botulinum toxin in combination with other therapeutic modalities provides optimal results.