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Dr. Barry Eppley

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Posts Tagged ‘masseter muscle reduction’

Botox Injections for Lower Facial Contouring (Masseter Muscle Reduction)

Monday, August 11th, 2014


The large masseter muscle (masseteric hypertrophy), unlike the prominent bony jaw angle, does not have a surgical solution. Surgical muscular reduction is associated with a high rate of complications and potental disability. As a result, the use of botulinum toxin type A injections (most commonly Botox) has become the standard of treatment to improve lower facial contour due to large masseter muscles.

There is little question that Botox into the masseter muscles can be effective but there is little standardization in dose and injection points of treatment. Dosage amounts vary amongst practitioners as well as treatment schedules. Long-term outcomes of a sustained effect remain wanting.

In the August 2014 issue of Plastic and Reconstructive Surgery, a paper on this topic was published entitled ‘Classification of Masseter Hypertrophy for Tailored Botulinum Toxin Type A Treatment’. In this  paper over 500 masseter muscles were classified into bulging types with three degrees of thickness. Over 200 patients were treated with Botox injections of 20 to 40 units per side with one to three injection sites per muscle. After injection, masseter muscle thickness decreased by an average of roughly 33% (13mms to 9mms approximately) as measured three months later. There was a corresponding improvement in the width of the lower face to the upper facial intercanthal distance. Overall patient satisfaction was 96% without any serious complications.

This study provides evidence in a large series of patients that an injectable approach to massteric muscle reduction is effective. Its maximum effect occurs by three months after treatment with a visible reduction is lower facial width. Dosages in units should be increased based on the muscle characteristics anywhere from 20 to 40 units per side. It is important to keep the injections into the bulk of the muscle closer to the jaw angle area to avoid a temporary weakening effect on the buccal branches of the facial nerve.

What this study does not address is how long this muscular facial thinning effect lasts and how many treatments it takes to achieve its maximal effects. It is still unclear as to whether Botox causes a permanent muscle atrophic result in the muscles of mastication.

Dr. Barry Eppley

Indianapolis, Indiana

Surgical vs. Non-Surgical Jaw Angle Reduction

Friday, October 3rd, 2008

Jaw reduction strives to narrow the lower-third of the face, particularly that of the lower jaw and its muscle attachments. There are several techniques for jaw reduction, some surgical and others non-surgical. Jaw reduction is most common in Asians where there is a societal preference for a slender jaw profile. This is in contrast to Causcasians which are more deficient in this area and augmentation is needed rather than reduction.

One form of jaw reduction involves surgical reduction of the mandible  or lower jaw angle area. Done through an incision inside the mouth, the jaw angle (junction of the back part of the jaw and the lower border of the jaw) is essentially sawed off. This changes the sharp acute angle of the jaw to a more round one. This softens the jaw angle and raises the line of the jaw from front to back. The bone cut can be extended from the jaw angle forward to about the middle of the body of the jaw for greater narrowing. Another bony reduction option is an outer corticotomy. Rather than just saw off the entire jaw angle, which can really blunt the angles and cause loss of soft tissue support, is to remove just the outer cortex of the angle area. Done lije a reverse sagittal split osteotomy, this will thin out the jaw angle are but without blunting the angle.

One thing that bony jaw angle reduction of any method does not do is correct for the thickness of the muscle over the bone.  It is not really possible (or desireable if you are the patient) to surgically thin out the muscle without causing a lot of pain and causing long-term restriction of mouth opening. Therefore, the effectiveness of jaw angle reduction will be more or less dependent on the how much the bone of the jaw causes the fullness of the jaw angle. That being said, bony jaw angle reduction will always make a visible external difference.

Non-surgical jaw angle reduction means Botox® injections. While this muscle paralyzing drug initially seems like it would not work for long-term muscle reduction (atrophy), it has been shown that it actually does. The dose of Botox® is fairly high for each side ( about 40 to 50 units), and it must be repeated every 4 months or so for up to a year or longer, but I have witnessed the masseter muscle actually get smaller over time. Why the muscle shrinks when it is partially paralyzed (chewing function is not affected)  is not known and the next question is….will it stay smaller long after the Botox® injections are stopped. Proponents of this injection technique say that it does but  long-term clinical studies have never been reported as of yet.

Dr. Barry Eppley

Indianapolis, Indiana


Masster Muscle Reduction with Botox Injections

Tuesday, May 27th, 2008

Botox, the world’s most popular injectable cosmetic treatment, works by providing a temporary muscle paralyzing effect reducing or eliminating unwanted facial expressions. The vast majority of Botox used for this purpose is done in the forehead and around the eyes. In the masseter muscle, however, repeated Botox injections over time can actually reduce the size of this large muscle improving external appearance and reducing muscle-clenching pain symptoms.
The use of Botox for masseter muscle reduction is well chronicled in the Korean medical journals. In this ethnic group, it is often desired to reduce the size of the muscles for the cosmetic purpose of making the face look less square. Botox done over time is so effective that the surgery historically used to achieve the same effect, masseter muscle reduction and mandibular angle reduction, is now reserved only for patients that demonstrate an actual bony prominence as the primary source of the problem.
Botox injections in the masseter muscle are easy to do. Have the patient clench their teeth together and the prominent bulging of the masseter muscle borders are easily seen. I usually inject right into the prominent bulging areas with 6 units per bulged area and stay closer to the angle areas of the jaw and its lower border to avoid injecting into the parotid gland. Plus, the thickest bulk of the masseter muscle lies low anyway. I have found that it takes about 25 – 35 units per side to get a good effect. So when I run out of bulging areas to inject, I will make sure I inject at the front and back of the muscle at the bottom of the jaw until I reach that number of units.
While effects can be usually been fairly quick, as judged by less muscle pain and headaches, it takes about 6 months before actual visible shrinking of the muscle is seen. Botox injections should be repeated every 4 months up to a years worth of treatment to see the best results. The decreased size of the muscle is impressive after a year of Botox therapy. I have been surprised to see that the results of masseter muscle reduction seem to be maintained even if no further Botox injections are done. I don’t have a good physiologic explanation as to why that would be so, as Botox does not cause any permanent atrophy in the muscles of facial expression. But I have seen it enough now to realize that it is real clinical finding with Botox use.
Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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