DAO, Nefertiti lift and platysma bands

A tug of war in the lower face

Facial expression is a balance between muscles that lift and muscles that pull down. In the lower face and neck, the main depressors are the depressor anguli oris (DAO), which pulls the corners of the mouth down, and the platysma, a thin sheet of muscle that runs from the jawline over the neck to the upper chest. With age, skin and connective tissue lose elasticity, and the downward pull of these muscles becomes more visible: mouth corners that turn down even at rest, a softer jawline, and vertical cords on the neck.

Botulinum toxin can reduce the activity of these depressor muscles. The lifting muscles then have less resistance to work against. The principle is the same in all three treatments described here; the target areas differ.

DAO: downturned mouth corners

The DAO is a small triangular muscle below the corners of the mouth. When it is very active, the mouth can look sad or tense even when you are relaxed. In a DAO treatment, small doses are placed in this muscle, typically near the jawline. The aim is a more neutral resting expression.

Precision matters here: right next to the DAO lies the depressor labii inferioris, which moves the lower lip. If product reaches this muscle, the smile can look uneven for a while. This is why dose and placement in the lower face are planned carefully and conservatively.

Nefertiti lift: the jawline

The term goes back to a technique published by Levy in 2007 (Journal of Cosmetic and Laser Therapy), named after the clearly defined jawline of the Egyptian queen. Small doses are placed along the lower jawline and in the upper part of the platysma. The Nefertiti lift aims to reduce the downward pull on the jawline so that the contour appears more defined.

The effect is subtle and depends strongly on the starting point. If the jawline is mainly softened by muscle pull, results tend to be more visible. If loose skin or fat in the lower face is the main factor, a muscle treatment has clear limits, and an honest consultation will say so.

Platysma bands: the neck

Platysma bands are vertical cords on the front of the neck that become more prominent when speaking or straining. They are caused by the edges of the platysma muscle and become more visible as the overlying skin thins. Injections along the bands can soften them (see platysma bands).

Of the three areas, the neck has the best clinical trial data. Randomized placebo-controlled phase 3 trials of onabotulinumtoxinA for moderate to severe platysma prominence led to approval for this indication in the United States in 2024, and a 2026 meta-analysis of randomized trials described the treatment as effective and well tolerated.

Why the lower face is more demanding

The upper face is relatively forgiving: the forehead and frown muscles are large and their function is easy to read. Around the mouth and neck, many small muscles work together for speaking, eating, drinking and swallowing. Doses are therefore lower and placement more precise. In the neck in particular, higher doses carry a risk of weakness in the neck muscles or, rarely, difficulty swallowing, which the product information lists as a possible effect. An experienced physician plans with this in mind.

Approval status: In the EU, botulinum toxin products for aesthetic use are approved for lines in the upper face. Treatments in the lower face and neck are an established part of aesthetic medicine but are used outside the approved indications (off-label). Physicians may do so after informing you about it.

Combining areas

The DAO and the platysma are connected anatomically and functionally, so the areas are often assessed together. Not every face needs every treatment, and some concerns in the lower face are better explained by skin quality or volume changes than by muscles. Which approach suits you is decided in a physician consultation. If you are new to the topic, our guide to the first Botox appointment is a good starting point.

References

1. Raspaldo H, Niforos FR, Gassia V, et al. Lower-face and neck antiaging treatment and prevention using onabotulinumtoxin A: the 2010 multidisciplinary French consensus--part 2. J Cosmet Dermatol. 2011;10(2):131-149. PMID 21649819.
2. Moradi A, Shirazi A. A Retrospective and Anatomical Study Describing the Injection of Botulinum Neurotoxins in the Depressor Anguli Oris. Plast Reconstr Surg. 2022;149(4):850-857. PMID 35139057.
3. Choi YJ, We YJ, Lee HJ, et al. Three-Dimensional Evaluation of the Depressor Anguli Oris and Depressor Labii Inferioris for Botulinum Toxin Injections. Aesthet Surg J. 2021;41(6):NP456-NP461. PMID 32232427.
4. Levy PM. The 'Nefertiti lift': a new technique for specific re-contouring of the jawline. J Cosmet Laser Ther. 2007;9(4):249-252. PMID 18236245.
5. Kane MA. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A. Plast Reconstr Surg. 1999;103(2):656-63; discussion 664-5. PMID 9950557.
6. Fabi S, Humphrey S, Biesman B, et al. Improvement of platysma prominence with onabotulinumtoxinA: Safety and efficacy results from a randomized, double-blinded, placebo-controlled phase 3 trial. J Am Acad Dermatol. 2025;92(2):285-291. PMID 39442886.
7. Syed R, Khan AA, Shah S, et al. Efficacy and Safety of OnabotulinumtoxinA for the Treatment of Platysma Prominence: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Cosmet Dermatol. 2026;25(2):e70701. PMID 41612547.
8. Obagi S, Golubets K. Mild to Moderate Dysphagia Following Very Low-dose Abobotulinumtoxin A for Platysmal Bands. J Drugs Dermatol. 2017;16(9):929-930. PMID 28915289.