Platysma and the Nefertiti Lift®

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19 Platysma and the Nefertiti Lift®

Phillip M. Levy

Summary and Key Features

• The platysma acts as a major depressor in the lower face

• Anterior and posterior platysma bands can be treated with a total of 10–30 units of onabotulinum toxin A (BoNT-A) in women and with a total of 10–40 units in men (3–5 injection sites per band)

• The Nefertiti Lift® uses BoNT-A to redefine and sharpen the jawline whilst helping to lift the corners of the mouth. Dosage is 15–20 units onabotulinum toxin A per side injected intradermally

• Complications such as dysphagia and dysphonia can be avoided if injections are intradermal, there is no excessive toxin migration, and the total dose per session does not exceed 40 units

• Asymmetric smile, a rare adverse event associated with the Nefertiti Lift®, can be prevented through precise dosing (maximum dose of 20 units onabotulinum toxin A or equivalent per side, per session) and accurate intradermal injection

• Poor candidates for the Nefertiti Lift® include: patients with excessive submental fat, heavy jowls, or poor downward pull of the platysma with no prominent posterior platysma band

• Excellent candidates for the Nefertiti Lift® include: patients with prominent posterior platysma band and disappearing jawline with platysma contraction

Introduction

Botulinum toxin type A (BoNT-A) is now extensively used for the upper face to correct wrinkling of the glabella, forehead, and periocular regions thereby promoting rejuvenation and postponing the need for surgical intervention. A more youthful and attractive appearance is achieved when fillers are combined with BoNT-A to smooth rhytides and eradicate deep folds in the upper and mid face, but the lower face and neck should not be ignored or there could be a risk of creating an aesthetic imbalance.

As clinicians gain experience and confidence with BoNT-A, they should consider treating areas of the lower face and neck. It is becoming commonplace to treat the depressor anguli oris, orbicularis oris, chin, masseter, and platysma. These indications have the main objective of ‘lifting’ lower face features, sharpening the jawline, and thus creating the clinical effect of a ‘mini-lift’.

Brandt & Bellman were the first to document their clinical use of BoNT-A for the aging neck. The aging process causes rhytides to appear on the neck and the skin to become increasingly slack. The authors observed that these effects diminished and appearance improved when BoNT-A was injected directly into the platysma muscle. They also noted an improvement in platysma bands that procured ‘an overall tightening of the neck and recontouring of the jawline’ even though their primary objective was not to improve facial contouring. High doses (50–100 units onabotulinum toxin A) were used, with some patients receiving as many as 200 units in one session. When 50–200 units were employed, adverse events such as muscle soreness, neck discomfort, mild neck weakness, and headaches were reported by patients. This rather expensive high-dose regimen translated into non-specific aesthetic improvements and an important array of possible unwanted side effects.

In this chapter we discuss how to use BoNT-A to treat vertical platysma bands and horizontal neck folds, and then we will focus on the ‘the Nefertiti Lift®’ – a ‘low-dose’ technique described in 2007 that restores a sharper and more defined jawline while lifting the corners of the mouth.

The platysma: anatomy and dynamic aesthetic clinical implications

The platysma is a large, flat cutaneous muscle stretching from the upper décolleté to the mid cheek. It originates inferiorly from the pectoralis and deltoid fascia. The fibers ascend upwards and at the mandible some fibers insert directly into bone under the mandible, its only bony insertion. The other fibers blend into the modiolus, the depressor anguli oris, the lower lip, the depressor labialis inferioris and mostly continue to ascend above the mandible where they blend into the SMAS (superficial muscular aponoretic system). In the midline of the neck the platysma is absent except when the fibers from each side decussate (intertwine) with the other side under the chin (Fig. 19.1).

image

Figure 19.1 The platysma muscle.

When the platysma contracts it acts as a major depressor on the skin of the lower face and the medial fibers and posterior band contribute to lowering the corners of the mouth. When the upper and lower parts contract they pull the skin towards the center of the muscle like a compressed accordion. This creates prominent anterior and posterior vertical platysma bands at the two lateral borders of the muscle and forcefully pulls down the lower cheek, the corner of the mouth, and some of the lower lip.

Injection techniques for the neck

Vertical bands

After asking the patient to contract their platysma the practitioner should hold the band to be injected between the thumb and index finger. Deep intradermal injections of 2.5–5 units should be injected equidistantly in 3–7 sites per band. A maximum of 30 units for women and 40 units for men should be respected per session (Fig. 19.2).

image image

Figure 19.2 Anterior platysma bands: (A) before and (B) after treatment with BoNT-A.

Horizontal folds

To treat horizontal neck folds approximately 2 units should be injected in a superficial intradermal wheal raised equidistantly in the folds themselves, for a maximum of 30 units per treatment session.

Pearl 1

Overall total dose in the neck (all sites and indications included) per treatment session should not exceed 40 units of onabotulinum toxin A.

The Nefertiti Lift®

Nefertiti was an Egyptian queen famed for her beauty. A statue of her bust can be seen in the Neues Museum in Berlin. It is one of the most recognizable works from Ancient Egypt thanks to her perfect facial proportions, elegant neck, and sharp jawline and angle (Fig. 19.3).

image

Figure 19.3 Nefertiti: the perfect mandibular contour.

Courtesy of Raphäelle Levy.

The Nefertiti Lift® is a novel technique that is used for the specific recontouring of the jawline. It relies on modifying the elevator and depressor vectors in the zone encompassing the corner of the mouth and the mandibular border by weakening the platysma depressor action on this area. This effect amplifies the elevator muscle dynamics of the cheek and corner of the mouth resulting in sharper skin draping along the jawline and creating the visual effect of a ‘mini lift’.

The technique is straightforward; however, the complexity of the musculature of the lower face requires the physician to clearly identify injection points and use precise doses and intradermal tangential injections of BoNT-A to avoid adverse events such as asymmetric smile, dysphagia, dysphonia, and anterior neck weakness.

Patients should be carefully assessed for their suitability prior to treatment. To do this patients should be in a sitting position then asked to pull down hard on their platysma muscle to make the posterior vertical platysma band clearly visible. If this action causes the mandibular border to disappear it is a good indication that treatment is likely to be successful (Fig. 19.4).

image

Figure 19.4 Assessing potential efficacy of the Nefertiti Lift®. Vertical arrows illustrate downward pull of platysma muscle and disappearance of the jawline. Horizontal arrows illustrate prominent contraction of posterior platysma muscle band.

Prior to treatment, injection points under the mandible going posteriorly and into the contracted vertical posterior platysma band should be marked on the skin. Injection of 2–2.5 units of onabotulinum toxin A should be administered intradermally and tangentially in four points, 1–2 cm apart, under each mandible and into the upper half of the posterior vertical platysma band for a total of 15–20 units per side. In this way a double dose equating to 4–5 units should be administered at the point where the horizontal and vertical injection points meet (see Fig. 19.5).

image

Figure 19.5 Nefertiti injection points along the mandible and posterior platysma band.

Pearl 2

Total maximum treatment dose of 20 units of onabotulinum toxin A should be split 50% under the mandible and 50% into the posterior platysma band.

During treatment of the platysma band the patient should be asked to contract the platysma muscle and the band should then be grasped and injected at the previously marked points. For the four injections under the mandible the patient should, on the contrary, be told to relax the platysma.

Pearl 3

The submandibular jawline injections are most effective when placed under the mandible, the platysma is relaxed, and injections are intradermal and tangential to the skin. Inject in a posterior direction towards the mandibular angle.

Patients should experience only the minor discomfort during the procedure. As for any BoNT-A consultations, patients should be followed up approximately 2 weeks after their initial treatment and touch-ups performed if necessary.

The average duration of effect with the Nefertiti Lift® is 6 months and patient satisfaction is very high.

Case Study 1

‘I don’t want cosmetic surgery!’

A 50-year-old female patient with no previous experience of aesthetic procedures consulted for global facial rejuvenation. She emphasized that she did not want surgery but would consider minimally invasive treatment requiring no recovery time. Her main concern was how to avoid having to admit to her husband that she had had aesthetic treatment.

Clinical assessment showed that she would benefit from relaxation of the glabella and periocular regions as well as recontouring of the lower face. To test her suitability for the Nefertiti Lift®, she was asked to strongly contract her platysma muscle. Upon contraction the platysma bands were prominent and the jawline was completely effaced. This confirmed that she would be an ideal candidate for this procedure.

BoNT-A was used to treat the upper face according to standard protocols. For the lower face 20 units of BoNT-A were injected under each mandible and into the top part of the posterior platysma band on each side of the neck (Fig. 19.5).

Following treatment, the patient was invited to return for a follow-up visit 2 weeks later. At the second visit the patient expressed her delight with the results. She had suffered minimal discomfort during the procedure and reported no adverse events. She had received compliments on her ‘relaxed and glowing’ appearance from family and friends and said she felt more attractive.

The before and after photographs clearly illustrate the effect of the Nefertiti Lift® in redefining the jawline, reducing jowling, and improving skin laxity (Fig. 19.6).

image image image image

Figure 19.6 Platysma (A, C) before and (B, D) 2 weeks after Nefertiti Lift®; (A, B) at rest; (C, D) contracted.

Pearl 4

There is no aesthetic benefit in injecting lower than the top half of the posterior platysma band.

Potential complications of the Nefertiti Lift®

The Nefertiti Lift® is a site-specific treatment that is associated with minimum adverse effects. Problems with mild dysphagia and excess muscular contraction in the upper face can be avoided by using low total doses, injecting intradermally, and injecting in a direction tangential to the skin. A maximum dose of 20 units per side is recommended.

There is a risk of modifying the smile if BoNT-A is inadvertently injected into the depressor labialis inferior (DLI). Unless rectified by injecting the contralateral DLI, effects will last approximately 4 weeks (Fig. 19.7).

image

Figure 19.7 Nefertiti Lift®: modified smile caused by inadvertent injection into the depressor labialis inferioris (DLI). Treatment in this case consisted of injecting 1.5 units of onabotulinum toxin A into the contralateral DLI.

This risk of modified smile can be avoided by:

image starting the mandibular injections at a point 1 cm posterior to the junction of nasolabial folds and mandible

image always pointing the syringe towards the mandibular angle posteriorly

image injecting under the mandible (Fig. 19.8).

image

Figure 19.8 Nefertiti Lift®: injection points (blue arrows) situated under the mandible at least 1 cm posterior to the red arrow indicating the position of the posterior fibers of the depressor labialis inferior.

Pearl 5

To avoid the depressor labialis inferioris muscle (and an asymmetric smile) inject under the mandible in a posterior direction starting 1 cm posterior to the junction of the nasolabial fold and the mandible.

Conclusion

The aging process affects the skin on the jawline and neck in the same way as other areas of the face. These changes include skin thinning, loss of elasticity, increased laxity, and fat redistribution. The aesthetics of the lower face are greatly influenced by the platysma muscle, which pulls down the lower cheeks and the corners of the mouth. Over the years inaesthetic vertical neck bands and jowling develop whilst jawline definition is lost.

In a patient without excessive skin laxity in the midline of the neck, vertical banding can be markedly improved. The Nefertiti Lift® uses a low-dose specific injection pattern to sharpen the jawline and raise the corners of the mouth. Patient satisfaction is high and few patients experience adverse events, which are most often linked to excess dosage and inappropriate injection technique. Rare adverse events include mild dysphagia, an excess ‘lifting’ effect, and slight smile modification. All adverse effects are reversible and resolve rapidly. Treatment failure is often due to poor candidate selection and the presence of excess fat on the mandibular border. The Nefertiti Lift® offers clinicians an opportunity to sharpen the jawline and improve facial contours making it an excellent complement to other minimally invasive procedures when seeking to achieve global facial rejuvenation.

Further reading

Brandt FS, Bellman B. Cosmetic use of botulinum A exotoxin for the aging neck. Dermatologic Surgery. 1998;24:1232–1234.

Brandt FS, Boker A. Botulinum toxin for the rejuvenation of the neck. Clinics in Dermatology. 2003;21:513–520.

Carruthers J, Fagien S, Matarasso SL, the Botox Consensus Group. Consensus recommendations on the use of botulinum toxin type A in facial aesthetics. Plastic and Reconstructive Surgery. 2004;114(6 suppl):S1–S22.

Carruthers J, Carruthers A. Aesthetic botulinum A toxin in the mid and lower face and neck. Dermatologic Surgery. 2003;29:468–476.

Gassia V, Beylot C, Béchaux S, et al. Botulinum toxin injection techniques in the lower third and middle of the face, the neck and the décolleté: the ‘Nefertiti lift’. Annals of Dermatology and Venereology. 2009;136(suppl 4):S111–S118.

Hoefflin SM. Anatomy of the platysma and lip depressor muscles. Dermatologic Surgery. 1998;24:1225–1231.

Levy PM. The ‘Nefertiti Lift’: a new technique for specific recontouring of the jawline. Journal of Cosmetic and Laser Therapy. 2007;9(4):249–252.

Park MY, Ahn KY, Jung DS. Botulinum toxin type A treatment for contouring of the lower face. Dermatologic Surgery. 2003;29:477–483.

Rohen JW, Yokochi C, Lütjen-Drecoll E. Color atlas of anatomy, 4th edn. Philadelphia: Lippincott Williams & Wilkins; 1998.

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