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Injections for DAO Muscle / Downturned mouth

Author: Dr Naomi / 28 Oct 2015

As we age the mouth can take on a downturned appearance. This causes a very negative and sour /sad appearance to the face.  Some patients subconciously regularly overuse the DAO muscle to pull down the mouth corners.

A downturned mouth can be treated with muscle relaxing injections. The injections stop the DAO (depressor anguli oris)  muscle pulling down the corners of the mouth. Treatment will cause the corners of the mouth to be slightly lifted, giving the mouth a more relaxed, happy, youthful and pleasing appearance.

TREATMENT OF DOWNTURNED MOUTH
A great  treatment for downturned mouth is antiwrinkle injections (due to Australian regulations, we are not allowed to name the drugs used) , the area may be improved even further by injecting dermal filler.
Small injections using a very fine needle are performed  into the muscles which cause the mouth corners to pull down . Typically about 2 injections  will be performed.

The consultation for antiwrinkle injections for DAO / downturned mouth
History-taking  is very important in the treatment of DAO / downturned mouth. The following should be explored:
Is there a genetic component? ie are there others in the family who have a downturned mouth? How has this progressed?
Has the patient had treatment before?
Were they happy every time?
Did the effect of the antiwrinkle injections last well?
Which area came back first?
How is the patient’s metabolism? Do they exercise? Are they very muscular? Do they have trouble putting on or losing weight?
Have they every had any complications with previous treatment, eg strange smile, asymmetry of the mouth etc

The examination
The doctor will examine the face and mouth area. In particular, she will look at many features, such as:
How the mouth looks at rest.

She will watch the patients use of the DAO muscles during the consultation to see if they are overused
Whether there is an asymmetry.

The severity of associated marionette lines/folds

How is the projection of the chin area

Choosing the dose of toxin
The doctor will assess the face and decide on the best dose after taking a history and examining the patient.
If the patient has a history of poor longevity, or needing high doses or wanting maximal effect, then a higher dose may be suggested
If a patient has a history of complications with muscle relaxing injections, or if their budget is small or if they want a more subtle result, then a smaller dose might be chosen.

Pain relief during treatment
A numbing cream (eg EMLA or LMX ) may be applied to the area prior to the treatment (45 minutes prior is ideal) Glad wrap may be used over the numbing cream to increase its effect.
Most patients do not bother with numbing cream because it takes so long to work and because the treatment isn’t very painful anyway.
Ice is always used to decrease pain and to reduce the risk of bruising.
Very rare patients will use Penthrox for frown line treatments

Nitrous oxide / Happy gas is available to patients
If the patient requires dermal filler, then typically local anaesthetic may be injected in the area of the chin first

What happens during the frown line treatment itself?
The face will be cleaned with alcohol.
Ice will be applied to the area briefly before treatment
The doctor will inject approx 2 sites around the lower face, injecting the DAO muscles which are responsible for pulling the mouth corners down. Then pressure with gauze will be applied.
The procedure itself takes less than 5 minutes.
How do I look afterwards?
Sometimes there is nothing to see. Sometimes there can be redness, small lumps, which can look like mild acne and usually resolve quite quickly.
Most people could come during their lunch break during work and go back without their coworkers noticing anything

Side Effects and risks of antiwrinkle injections for chin dimpling
In general, treatment DAO is very low risk.
Headache happens in around 10% of new users.
Bruising occurs in a significant number of cases.
Asymmetry: Sometimes one side is better treated than the other, this is usually because the patient is asymmetrical to start with.
Infection is a very rare complication, but always a possibility when the needle goes into the skin.
It is possible that speech or the smile may be affected with treatment in the lower face. However at the typical doses used this is very uncommon. The risk increases with larger doses

Instructions for care afterward
No makeup for 4 hours
No massage that day
No heavy exercise that day
No lying down for 4 hours
Lay off the acid face products for 24 hours

What to expect after DAO treatment?
The effect of the injection will start to occur after 2-8 days.
The maximal effect of the drug will be at 3-4 weeks, so a review should be booked in at 3 weeks (only after the first treatment, for subsequent injections, a review appointment shouldn’t be required)

What if I get asymmetry at some time before the 3 week point? Do I call the doctor?
No. No need to call the doctor. Sometimes asymmetry will occur because one side just comes on quicker than the other. Usually it will right itself by the time of the review appointment. If it doesn’t, then it can be treated at the review appointment. There is no point in coming in early for treatment of asymmetry. Treating asymmetry too early could lead to droop or further asymmetry

What do I do if at 3 weeks post treatment I think the DAOs could be further improved?
The doctor will assess this

A top up dose may be performed at the review appointment.

Dermal filler may also be considered

How long will the treatment last?
The answer to this is very individual and depends on the patient’s metabolism, the dose, the placement etc.
Typically this is what happens:
At 3-4 weeks, there is a maximal effect
at 8 weeks, movement starts to return
at 12 weeks, 50% of movement should be back
at 16 weeks 80% of movement should be back.
With an adequate dose, for most patients, this is very close to what occurs.

When should I have my next treatment for DAO?
Patients should be retreated when the movement is between 50%-80% back ie sometime from 3-4 months.

Some patients have treatment every 8 weeks because they do not like any movement at all

Price for antiwrinkle injections in DAO
Typically $260-$360. If other areas being treated then it will be cheaper

Other procedures which would be suitable to combine with DAO antiwrinkle injections
* Microlaser Peel
* Fractional laser
* Dermal Fillers
* Skin Boosters
* Antiwrinkle injections  in other areas

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