Treatment of a downturned smile

Treatment of a downturned smileManrina Rhode presents an award-winning dermal filler case study.

This 51-year-old lady came to see me because she said she was a happy person but her mouth looked ‘sad’.

In particular, she pointed to her marionette lines asking what I could do about these.

She had her forehead and around the eye ‘smile lines’ treated with toxin six months ago with another practitioner and wanted this topped up also. As she had started dating again, she wanted to feel at her best.

The aim she was hoping to achieve was a smoother appearance to her forehead and smile lines on movement. She said, prior to toxin treatment in the forehead area, she felt she looked like a Shar Pei dog and was nervous about these deep lines returning. She also wanted to correct her mouth area so it did not look downturned at rest.

It was important to her that as she is an expressive lady that she looked natural and still had movement. She also emphasised that she did not want to look like a 20-year-old, but rather a fresh 50-year-old.

She was otherwise fit and well with no history of previous surgical procedures.


I carried out an initial consultation. This confirmed the patient’s expectations were realistic and achievable.

I assessed her full face, took photos and discussed treatment options. This included discussion of surgical and non-surgical interventions.

The patient did not feel ready for surgical intervention and decided on a combination of toxin and dermal filler on a basis of less downtime, no scarring, no general anaesthetic and reversible results.

On assessment, it was noticed in the upper facial third she had some line formation returned on movement of her eyebrows, crow’s feet and nasal rhytids on smiling (Khanna, 2007). The muscles on the left side seemed stronger than those on the right causing some asymmetry. This was all discussed by pointing out the areas on the patient’s photos.

The patient felt quite ‘full’ in the facial mid third and wanted to leave that area as it was.

Lower facial third showed a down turned smile at rest causing dimpling of the chin and marionette lines. She also had some jowls at rest that she was not keen to treat at the moment, as she felt she had put on some weight she was in the process of losing and wanted to reassess this area after she had lost her weight.

  • Figure 1: Preoperative eyebrows raised

Upper third face treatment plan

The patient had frontalis, procerus, corrugator and orbicularis oculi treated with toxin six months ago. She had not had her nasal rhytids treated previously.

She had full movement in all of these areas and the aim was to reduce wrinkles without preventing movement. I decided to treat both sides equally despite the asymmetry and decide at review whether to add more toxin to the left side (Kim, 2013).

Brow preservation protocol was used for toxin placement in frontalis. Three areas of five Speywood units were placed 4cms from the orbital rim plus five units on either side.

Procerus was treated as a single 10 Speywood unit injection given and 1×10 Speywood units either side for corrugator.

Obicularis oculi was treated with 3×10 Speywood unit injections on each side and finally nasal rhytids were treated with 3×5 Speywood unit injections, all in accordance with Professor Bob Khanna’s protocol, as taught at his training institute.

Lower facial third treatment plan

The patient had her marionette lines filled with Restylane Kysse with another practitioner seven months ago. She had not treated mentalis or depressor anguli oris previously.

Restylane Refyne was used to fill marionette lines with 0.2ml each side using a 25 gauge cannula and a fanning technique. Five Speywood units of Azzalure were placed in depressor anguli oris on either side to minimise the ‘frowning’ appearance and 10 units in mentalis to prevent pitting of the chin (Mess, 2017).

The patient was prepared for treatment, skin cleansed and free from makeup. A 30G needle was used for Azzalure placement and 125 IU vial mixed with 0.70ml bacteriostatic sodium chloride (saline) (0.9%). Injection points were marked on the patients face prior to treatment using a white eyeliner pencil.

A review was carried out at three weeks.


For the upper third of the face we discussed that the left side still had some eyebrow asymmetry at rest, although it seemed less and the nasal rhytids were still more apparent on the left side when smiling. Although overall wrinkles were less.

The patient noted she was now not able to frown with her mouth. Other than that she was happy with the movement she had retained and happy not to frown. She was also happy with the improvement in her wrinkles and marionette crease. She noted the chin now looked smoother.

Generally, she felt she looked fresh and as she wanted. She was very happy with the treatment overall and happy to leave the asymmetries as they were prior to treatment and she liked to look natural. She requested no changes at review. No more downward smile!

  • Figure 9: Postoperative eyebrows raised

This article first appeared in Aesthetic Dentistry Today magazine. You can read the latest issue here.

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Coleman SR, Grover R (2006) The anatomy of the aging face: volume loss and changes in 3-dimensional topography. Aesthetic Surg J 26: S4-S9

Khanna B (2007) The use of botulinum toxin in facial rejuvenation. Aesthetic Dentistry Today 1(2): 50-6

Khanna B (2008) The use of BTX in bruxers and clenchers for facial aesthetics. Aesthetic Dentistry Today 2(2): 49-54

Kim J (2013) Contralateral botulinum toxin injection to improve facial asymmetry after acute facial paralysis. Otol Neurotol 34(2): 319-24

Mess SA (2017) Lower face rejuvenation with injections. Plast Reconstr Surg Glob Open 5(11): e1551

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