The Toxin Lift

According to the annual statistics report of the American Society of Plastic Surgeons (ASAPS), in 2024 close to 10 million Onabotulinumtoxin type A injection procedures were conducted in the US alone. For reference, in the same year only 300,000 breast augmentation procedures were performed. These numbers speak for themselves when it comes to the cosmetic use of this neuromodulator product which is considered to be the strongest poison on the planet. Nothing is more lethal than Onabotulinumtoxin type A, not even the extremely toxic radioactive isotope Polonium-210.

Despite its toxicity, humans enjoy injecting toxins into their faces to reduce facial rhytids, to look younger, to look less angry, or to look happier. Of the various cosmetic possibilities where Onabotulinumtoxin type A can be utilized, the upper face is most frequently targeted. However, in recent years a new indication was introduced to the scientific community: The Toxin Lift

Review of Lower Facial and Neck Injection Algorithms

Before explaining what the Toxin Lift is and when to best use it, let me give you a quick review of the scientific literature on this topic. Below you can find a summary of the most relevant lower facial and neck injection algorithms published by year:

• In 2007, the Nefertiti lift injection algorithm for treating platysmal bands and for improving lower jawline contour was published. See diagram for injection points.

• In 2017, the modified Nefertiti lift injection algorithm was published addressing the upper platysma and its impact on lower face dynamics and contour. See diagram for injection points.

• In 2022, the classic Toxin Lift was published for increasing midfacial volume (not for addressing platysmal banding). See diagram for injection points.

• In 2022, the modified Toxin Lift was published to increase the midfacial volume even more. See diagram for injection points.
• In 2023, the modified Toxin Lift was evaluated for improving infraorbital hollows (and it worked). See diagram for injection points.

Mechanism Behind the Toxin Lift Injection Technique

The Toxin Lift injection technique is based on the knowledge of the interplay between facial elevators and facial depressor muscles. The largest and strongest facial depressor muscle is the platysma muscle followed by the depressor anguli oris muscle. Relaxing these two muscles during neuromodulator treatments will temporarily reduce the downwards pull of the facial depressors and will give more (relative) strength to the facial elevators like the zygomaticus major, levator labii superioris, levator anguli oris, and orbicularis oculi muscles. Recognizing that the elevator muscles assume temporary functional dominance for the duration of the pharmacologic effect helps explain the observed elevation of the oral commissure, the apparent increase in midfacial volume, and the improvement in infraorbital hollowing, despite the intervention consisting solely of neuromodulator injections administered along the jawline.

Potential Effects of the Toxin Lift Injection Technique and Why They Occur

Increase in midfacial volume explained:

The increase in midfacial volume can be explained by the conformational changes of the transverse facial septum (another blog article here on www.cotofanaanatomy.com). This septum is connected to the undersurface of the zygomaticus major muscle and can push the midfacial fat compartments upwards when tensed. When the platysma is relaxed, the zygomaticus major muscle can pull more cranially, resulting in increased tension of the transverse facial septum, which in return pushes the midfacial fat compartments upwards. This will increase the midfacial volume and will improve infraorbital hollows.

Gummy Smile adverse event explained:

An understandable adverse event of the Toxin Lift technique is the increase in the Gummy smile. The latter effect is plausible when understanding that the levator labii superioris muscle is the culprit muscle in the Gummy smile. This muscle can suddenly pull the upper lip upward because the respective depressors are temporarily weakened following the Toxin Lift injection algorithm.

Improvement of infraorbital hollows explained:

Regarding the beneficial effect on infraorbital hollows, it is widely known and accepted that infraorbital hollows are best treated starting in the midface by increasing midfacial volume. This is now done via the Toxin Lift injection technique which is why toxin injections along the jawline can improve the tear trough deformity.

Limitations of the Toxin Lift Injection Algorithm

• Not every patient will benefit from this treatment: Patients with a high degree of skin laxity as well as mature patients will have a different aesthetic outcome than younger patients without laxity. The reason is that the underlying musculature might reposition following the Toxin Lift, but this effect might not be visible on the skin surface due to skin laxity and age-related soft tissue descent.
• Outcome duration: the Toxin Lift clinical outcome will last only as long as the neuromodulator product is in effect. When the toxin effect is gone, the clinical effectiveness is gone.
• Magnitude of lifting: The term ‘lifting’ is always critically seen by those who perform face lift surgeries (and understandably why). But any change in the position of the facial soft tissues that is greater than zero (even if its 0.1 mm) in a cranially oriented vertical direction is by definition a lift. Of course, the Toxin Lift will not replace a surgical face lift, a thread lift, or the temporal lifting technique with soft tissue fillers. But multiple independent studies conducted with different methodologies have provided evidence that it works.

Who Will Benefit from the Toxin Lift

• Patients who do not want to undergo surgery or have any foreign materials like fillers or threads implanted into their faces
• Patients that want to dip their toes into the aesthetic world and experience a non-permanent treatment
• Patients whose budgets are limited and do not have the funds to pay for surgery or filler treatments

Conclusion

Every medical treatment has its pros and cons, and the Toxin Lift is no exception. Fortunately, multiple studies have demonstrated its effectiveness, and many of you have likely already incorporated it into your clinical practice.