The Facial Platysma and Its Underappreciated Role in

Lower Face Dynamics and Contour

Ada R.T. de Almeida, MD,* Alessandra Romiti, MD,* and Jean D.A. Carruthers, MD,
FRCSC, FRC (OPHTH)†

BACKGROUND The platysma is a superficial muscle involved in important features of the aging neck. Vertical
bands, horizontal lines, and loss of lower face contour are effectively treated with botulinum toxin A (BoNT-A).
However, its pars facialis, mandibularis, and modiolaris have been underappreciated.

OBJECTIVE To demonstrate the role of BoNT-A treatment of the upper platysma and its impact on lower face
dynamics and contour.

MATERIAL AND METHODS Retrospective analysis of cases treated by an injection pattern encompassing the
facial platysma components, aiming to block the lower face as a whole complex. It consisted of 2 intramuscular
injections into the mentalis muscle and 2 horizontal lines of BoNT-A injections superficially performed above
and below the mandible (total dose, 16 onabotulinumtoxinA U/side). Photographs were taken at rest and
during motion (frontal and oblique views), before and after treatment.

RESULTS A total of 161 patients have been treated in the last 2 years with the following results: frontal and
lateral enhancement of lower facial contour, relaxation of high horizontal lines located just below the lateral
mandibular border, and lower deep vertical smile lines present lateral to the oral commissures and melo-
mental folds.

CONCLUSION The upper platysma muscle plays a relevant role in the functional anatomy of the lower face
that can be modulated safely with neuromodulators.

A.R.T. de Almeida has been a consultant to Allergan Inc. and Merz, and participated in clinical trials for Allergan
and Galderma. A. Romiti has been paid to give lectures for Galderma. J.D.A. Carruthers has been paid to do
research by Allergan, Inc., Medicis, Inc., Ipsen Pharma, Merz GmbH, and has been a consultant to Allergan,
Inc., Medicis, Inc., Ipsen Pharma, Merz GmbH, and Solstice Neurosciences.

T he muscular anatomy involved in the lower face

muscles of facial expression is complex and
includes the orbicularis oris (OO), depressor angulis
The use of botulinum toxin A (BoNT-A) in this region
is considered as an advanced technique and gained
acceptance after years of experience in the upper face.
oris (DAO), depressor labii inferioris (DLI), risorius As with the upper facial areas, it can be indicated for
(R), masseter (MA), mentalis (M), and platysma (P) the treatment of specific muscles alone or several
muscles. It is known that not only persistent muscles combined as a whole lower face complex.
contractions wrinkle the skin, but the increased Usually, to address mouth frown and melomental
platysmal resting tone is also implicated in the folds (Marionette Lines), the depressor anguli oris is
muscular role of senescence.1 Such changes can be injected. Mentalis is the target when correcting or
modified by neuromodulators, either alone or in alleviating a mental crease and/or a peau d’orange
combination with other treatment modalities (e.g., appearance over the chin,2 whereas injections into the
fillers, resurfacing with laser and energy-based devices, MA can alter the shape of the jawline by reducing
surgery). muscle thickness and bulk.3

*Dermatologic Clinic, Hospital do Servidor Público Municipal de São Paulo, São Paulo, Brazil; †Department of
Ophthalmology and Visual Science, University of British Columbia, Vancouver, British Columbia, Canada

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· ·
ISSN: 1076-0512 Dermatol Surg 2017;43:1042–1049 DOI: 10.1097/DSS.0000000000001135

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 DE ALMEIDA ET AL

Figure 1. Cadaver dissection showing the depressor angulis oris, and platysma pars mandibularis (left). The latter, when
contracted, produces high parallel lines and wrinkles located just below the lateral mandibular border (right).

The platysma is a broad flat muscle that covers the were horizontally injected along each mandible and
anterior and lateral aspects of the neck. It rises from into the upper portion of the posterior platysmal
the superficial fascia over the upper chest and ascends band.11,12 The result was a visible release of the
superior-medially from the neck to insert into 3 points: platysma muscle’s downward pulling and jawline
medially into the mentum; centrally into the perios- recontouring.
teum of the ramus of the mandible; and laterally to the
OO, DAO, and R muscles overlying subcutaneous On the other hand, whereas useful when adequately
tissue.4 Its anterior fibers from both sides may cross indicated, the Nefertiti Lift technique does not address
each other at the midline, forming various patterns of the anterior platysma fibers. Because only the lateral
decussation, whereas complete separation may also upper half and the posterior platysma band are trea-
occur.5,6 When the upper and lower portions of the ted, the untreated anterior fibers may be recruited
platysma contract, they pull the skin to the center of during neck contraction, resulting in local wrinkling,
the muscle like a compressed accordion, forming banding worsening, and loss of anterior facial con-
horizontal neck lines. tour. To avoid these problems, many BoNT-A experts
use their own technical variations of the method,
Most BoNT-A injection techniques have targeted the adapted to each patient’s individual needs.
platysmal bands and horizontal necklines (like
“laces”). First described by Brandt and Bellman, not Some described techniques are a single injection
only the tightening of the neck, but also some kind of sequence performed horizontally at 3 to 4 sites at the
jawline recontouring was noticed by these authors.7 mandibular line (Dr. A. Romiti, MD, personal com-
To achieve the results, though, high doses of BoNT-As munication, June 6, 2013), a technique using a single
were needed (up to 200 units of onabotulinumtox- injection site with 20U to 30U onabotulinumtoxinA
inA), and side effects related to the toxin diffusion to per side,13 or an entire neck treatment of minute
adjacent muscles were also reported. This fact made intradermal doses of BoNT-A, with a total dose of 60
experts recommend reducing the total dosage used, to to 80 onabotulinumtoxinA U (Dr. Woffles Wu
avoid complications.8–10 Microbotox technique).14

Focusing specifically on jawline redefinition, Levy The objective of this article is to review the functional
described the “Nefertiti lift,” where individuals anatomy and to evaluate the role of BoNT-A

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 FACIAL PLATYSMA AND BONT-A

treatment of the upper platysma muscle and its impact lateral to the DAO. Its contraction contributes to the
on the lower facial dynamics and contour. appearance of lower vertical deep smile lines located
laterally to the oral commissures and laterally to the
melomental folds.15 (Figure 3).
Upper Platysma Functional Anatomy

Although appearing in face and neck drawings in

Material and Methods
anatomic papers, especially about botulinum toxin,
the upper platysma location and function are fre-
Study Design
quently neglected or forgotten. It is classically
described as having 3 parts: This is a retrospective, open label study performed at 3
centers, which complied with the ethical rules of the
Platysma pars mandibularis, which inserts onto the 2000 Declaration of Helsinki. To achieve complete
lower border of mandible and onto the skin and sub- relaxation of the upper platysma area, the entire lower
cutaneous plane of the lower face, with some fibers face was considered as a single region and treated as
interdigitating with the DAO. Its contraction forms a “lower face complex.” For this reason, a standard
oblique and horizontal parallel lines and wrinkles that injection pattern was chosen and applied for all subjects.
appear high in the neck just below the lateral man-
dibular border and above the necklace lines (Figure 1).
Patient Selection and Documentation

Platysma pars labialis, which travels deep to DAO, re- Patients aged 18 years and older, seen at the Derma-
emerges medially to it, interdigitates and blends to tologic Clinic of Hospital do Servidor Público
OO, DLI, and mentalis muscles, and in some cases, Municipal de São Paulo and the private clinics of the
occupies the space between DLI and DAO. Its con- first 2 authors, were selected. Subjects were invited to
traction may be related to horizontal lines located participate if they had investigator identified, loss of
below the oral commissures and lower lip (Figure 2). lower face contour, and/or lower face and upper neck
wrinkles and lines, during lower face animation.
Platysma pars modiolaris, which includes all of the Upper neck was defined as the region located just
remaining fibers of upper platysma that are postero- below the mandibular border. There were no

Figure 2. Cadaver dissection showing the depressor angulis oris, depressor labii inferioris, platysma pars labialis, and its
intimate relationship (left). Contraction of pars labialis may be related to horizontal lines located below the oral commis-
sures and inferior lip (right).

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 DE ALMEIDA ET AL

physician and the treated subject only at the follow-up

visit, after 2 to 4 weeks. The analysis was standardized
as follows: For each photograph pair, improvement of
lower face contour was observed and compared. For
efficacy measures, subjects were asked if, during ani-
mation, the lower face contour appeared more defined
in lateral view (yes or no) and/or changed (more linear/
triangular than round, irregular) in frontal view.
Treated subjects were also asked if they were satisfied
and willing to repeat the treatment (yes or no). At that
moment, touch-ups could be performed if needed.

Treatment Technique

Botulinum toxin A vials were reconstituted as follows:

2 mL of normal saline solution were added to 100U
vials (Botox/Xeomin) for a final concentration of 50 U/
mL, whereas 3.2 mL were added to 500U Dysport
vials to reach a ratio of 1:3 with the other
neuromodulators.

To treat the lower face as a whole unit, 2 sites of the

mentalis muscle were intramuscularly injected, fol-
Figure 3. Cadaver dissection showing the platysma pars lowed by superficial BoNT-A injections in a pattern
modiolaris which fibers are posterolateral to the depressor
angulis oris (left). Its contraction contributes to the consisting of 2 horizontal lines in each side of the lower
appearance of lower vertical deep smile lines located lat- face. The first one was injected into 3 injection sites
eral to the oral commissures and lateral to melomental
folds (right).
with 2U each, at the mandibular border, starting at the
DAO level and spaced every 2 cm laterally, ending at
restrictions regarding sex or cutaneous phototype. the mandibular angle. The second horizontal line was
Patients were ineligible if they had received neuro- placed 2 cm below the mandibular border, starting at
modulator treatments in the preceding 120 days or if a site below and between the mentalis and DAO
they were planning in the upcoming month to have any muscles, spaced every 2 cm, running laterally to
procedure to improve lower face contour, including a point after the mandibular angle, laying between the
fillers, chemical lipolysis injections, and energy-based above ones (Figure 4).
devices and/or surgeries. Interested patients provided
written informed consent. This second line was treated with 2U each into 4
injection sites. The first 2 sites might be injected with
Photographs were taken at rest, during full smile, and higher doses (2.5U–3U) in selected individuals who
while contracting the lower face (upon request to say show a stronger platysmal band for a total dosage of
“eeeeee”) in frontal and oblique views before injection 14U to 18U BoNT-A per side. Every injected site was
and after treatment, scheduled to occur after at least 15 compressed for a few minutes right after withdrawing
and no more than 30 days, keeping the same camera, the needle to reduce the likelihood of bruising.
lighting, and distance parameters.

Results
Patients were instructed to report any side effects,
heaviness sensation, or asymmetries that might occur. A total of 161 patients, both men and women, were
The photograph pairs were evaluated by the injecting included. Table 1 shows detailed demographic patient

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 FACIAL PLATYSMA AND BONT-A

Figure 4. The injection pattern (left) and its corresponding location in the cadaver (right).

characteristics. Most individuals received 16U per side The second finding was relaxation, and in some cases,
(including 2U into the mentalis muscle). complete disappearance of several oblique and hori-
zontal parallel lines and wrinkles, which were seen just
When comparing before and after photographs dur- below the lateral mandibular border during platysmal
ing animation, the effects could be observed in all contraction. In some patients, these wrinkles may
patients at the follow-up visit. Physicians and subjects reach the lower face and are difficult to treat (Figure 6).
were all satisfied with the treatment, and patients
confirmed the will to repeat the technique in the The third and most surprising effect was relaxation,
future. and in some cases, effacement of the lower vertical
deep smiles lines, located just behind the oral com-
Three findings showing improvement could be missures (Figures 5 and 6).
observed. The first sign was enhancement of lower
facial contour, particularly during lower facial mus- Since improvement of lower face contour, and not
cular contraction. The skin under the mandibular effacement of rhytides, was the purpose of our study,
border seemed more closely apposed to the bone comparative facial wrinkles scales were not included
structure, and this effect could be noticed in lateral and in the evaluation.
in frontal views. Previously loose skin and the round
shape of the lower face were replaced by a more linear Regarding adverse effects, 1 patient described
(in some subjects, more triangular) and better defined a heaviness sensation after treatment, while in 2 oth-
contour. Some patients reported that their face looked ers, a very mild unilateral reduction in the lower lip
“thinner” in frontal view as if they had lost weight retraction was observed, probably because of slight
(Figure 5). weakness of the DLI. However, the latter was not
perceived by the patients and did not require any
correction. No complaints of dysphagia or voice
TABLE 1. Demographic Characteristics of alteration were noted.
Treated Subjects

Age Discussion
Range 28–73
Mean 56.5 The full role of the upper platysma muscle in the lower
Median 57.5 face is still poorly understood and explored. Never-
Gender theless, attentive observation may show that it can be
Female 142
very active in some patients, particularly with
Male 19
Botulinum toxin A senescence.
OnabotulinumtoxinA 131
IncobotulinumtoxinA 19 Although Benedetto15 described in detail its anatomic
AbobotulinumtoxinA 11 boundaries, the consequences of its contraction on the
Dose/side skin is still a complex issue because of its intimate
Mentalis (M)/platysma 2U/14U
relationship, interdigitation, and blending with other

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 DE ALMEIDA ET AL

Figure 5. Fifty-year-old lady before and after the facial platysma botulinum toxin A treatment in oblique (left) and frontal
views (right). Note the sharper, better defined lower facial contour with a more linear shape and effacement of lower face
wrinkles (red circle).

lower facial muscles. During contraction, muscles with DAO, OO, DLI and Mentalis, its contraction
follow force vectors that generally run from their may be related to the appearance of horizontal lines in
insertion (mobile portion of the muscle) to their origin the lower face—below the oral commissures—that can
(fixed portion of the muscle), determining hyperki- be identifiable even in young individuals (Figure 2).
netic lines perpendicular to the contraction’s direction
and resulting in horizontal, vertical, and/or oblique And last, but not less important, the upper platysma
wrinkles.16 Therefore, the horizontal lines that appear pars modiolaris is frequently forgotten in the facial
below the mandible and the chin may be secondary to motion. It includes all the remaining fibers of the facial
the contraction of the pars mandibularis of the upper platysma that are posterolateral to the DAO. Con-
platysma, since it inserts onto the lower border of the traction of these horizontally oriented fibers pulls the
mandible as well as in the skin and subcutaneous plane corner of the mouth laterally, thereby forming vertical
of the lower face, with some fibers interdigitating with lines and wrinkles located behind the DAO. In some
DAO (Figure 1). patients, it has considerable dermal insertions lateral
to the modiolus parallel to the NLF. In these cases,
On the other hand, as the pars labialis is considered a smile or grimace produces lateral creases in the skin,
a direct labial depressor, interdigitating and blending which may be difficult to treat (Figure 3).5

Figure 6. Thirty-eight-year-old male patient. Before (above) and after upper platysma botulinum toxin A treatment (below).
Note the amelioration of oblique and horizontal parallel lines located below the lateral mandibular border and lower face
deep vertical smile lines (red circle).

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 FACIAL PLATYSMA AND BONT-A

The idea is that the upper platysma region behaves like mandibular border. If necessary (a strong platysmal
a whole unit and has a diverse function than its lower band in one side), higher amounts of BoNT-A can be
part. Because it is a very superficial muscle, deep BoNT- placed below the mandible in the first 2 sites of the sec-
A injections are not recommended, to avoid affecting ond injection line, to prevent or minimize lip asymme-
underlying muscles of deglutition and causing dysphagia tries or reduction in the extent of the smile due to
and voice alterations.17 The described technique, using diffusion to R muscle (Risorius smile). Although not
superficial horizontal injections, aims to relax its entire observed in the authors’ cases, recruitment of lower
width, leaving fewer areas without treatment when platysma fibers may occur. If necessary, it can be cor-
compared with the technique where only the vertical rected at the follow-up visit after 2 to 4 weeks, with
bands were addressed. It will allow enhancement of additional BoNT-A doses to the corresponding location.
lower facial contour in profile as well as in frontal view,
in repose and during motion. Here, it differs from the Limitations of this study are its retrospective nature, the
Nefertiti lift because the Nefertiti lift technique addresses lack of comparative facial wrinkles scales before and
only the posterior fibers of the upper platysma, but not its after treatment that could estimate more accurately the
anterior portion at the cervicomental junction, improv- impact on deep smile lines and submandibular lines,
ing the mandibular contour mostly in lateral views. and the combined blockage of some lower face muscles
such as DAO and mentalis. A prospective trial in the
The botulinum toxin denervation of the anterior por- near future may be useful for this purpose.
tion of the platysma muscle, though, can produce
a gentle anterior neck lift.2 Some individuals treated by The upper platysma muscle plays a relevant role in the
the new technique, even when noticing the enhance- functional anatomy of the lower face, acting as a major
ment of the lateral mandibular contour, reported that depressor that can be modulated by neuromodulators.
their lower face looked thinner in frontal view. More- When addressed in combination with other lower
over, amelioration of horizontal wrinkles located at and facial muscles as a whole complex, enhancement of
below the mandibular line and chin was also observed. lower facial contour and relaxation of dynamic
The same effect could be noticed with deep vertical wrinkles of the lower face will be achieved.
smile lines that arose near the mandibular border.
Acknowledgments The authors thank Dr. Hee-Jin
Most patients received concomitant BoNT-A treat- Kim, DDS, PhD. Professor, Division in Anatomy and
ment in the upper face. In the lower face, the total dose, Developmental Biology, Department of Oral
including into the mentalis muscle, was lower than Biology, Yonsei University College of Dentistry,
20U per side, with most patients being treated with Seoul Korea, for the anatomical sample of Figure 2.
only 16U per side. For this reason, no sensations of
heaviness during motion of the lower face were References
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Address correspondence and reprint requests to: Ada
neck-jawline contouring/platysma bands/necklace lines. Plast Reconstr
R.T. de Almeida, MD, Dermatologic Clinic, Hospital do
Surg 2015;136:80S–83S.
Servidor Público Municipal de São Paulo, Rua Turiassu,
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Carruthers J, Carruthers A, editors. Procedures in Cosmetic 000, or e-mail: [email protected]

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