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

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