In the last column I described the order that body sculpting follows: clear what hides the line before building the shape. If a thick layer lies over it, even a well-made shape will not show, so clearing comes first.
There is one more way an upper-body line gets broken, though. Not something hidden under a covering, but something standing up too high, so that the line is interrupted. That is not a problem that clearing solves, and not one that adding more solves either. It is a place where the answer is to take force away.
The places that need filling and the places that need taking down sit side by side in the same shoulder. Attend to only one of them and the line is only half finished.
Why the shoulder does not come down after filler has set the angle
Some patients say this after shoulder filler: the angle is definitely there, but in the mirror the shoulders still look raised. The tip of the shoulder drops cleanly, and yet the overall impression is still hunched.
Looking again at the tip of the shoulder is usually not the answer here. The place to look is between the neck and the shoulder, along the stretch where the trapezius runs. When that muscle is thick and bunched up, the line from the neck down to the shoulder cannot fall straight; it bulges upward partway along. However precisely the angle has been set at the tip, if the stretch above it stands up, what the eye catches first is the rise rather than the angle.
In other words the shape has been built, but the line that should carry it has not yet been sorted out. The reason more filler does not help here is the same as in the last column: the problem sits in a different place.
Two treatments that work in opposite directions
This is easiest to see with filler and botulinum toxin laid side by side. Botulinum toxin injection, the treatment most people know by the brand name Botox, reduces for a period the force with which a muscle contracts in response to its nerve signal. Where filler adds volume that was not there, this takes away force that was. The materials and the mechanisms are different, but on the line itself the two do precisely opposite jobs.
| Aspect | Filler | Botulinum toxin |
|---|---|---|
| What it does | Adds shape that is missing | Takes down what stands too high |
| Direction | Pushes outward to build a form | Reduces muscle force so the area settles |
| What it treats | Areas short of volume | Areas where muscle stands thick and high |
| When change shows | From immediately after treatment | Gradually, over days to weeks |
| Its stretch of the shoulder | The angle from the shoulder tip down into the arm | The slope from the neck down to the shoulder |
The last row of that table is the point of this column. What we call the shoulder line is not one line but two stretches: the angle where the tip of the shoulder drops into the arm, and the slope running from the neck out to that tip. The first is built by adding; the second is tidied by subtracting. Only when both stretches are resolved together does it read as a single line.
Why the neck looks longer when the trapezius comes down
The trapezius is a broad muscle that spreads from the back of the neck across the shoulders and down the back. Its upper part, the section that runs between neck and shoulder, works in the direction of pulling the shoulder upward. Carry a heavy bag on one side for years, hunch the shoulders whenever you are tense, or sit at a monitor with the shoulders raised for long stretches, and this section thickens, so that the area between neck and shoulder easily starts to look domed.
Treat this area with botulinum toxin and the force with which the muscle pulls the shoulder up is reduced. The raised stretch then settles, the slope from neck to shoulder becomes gentler, and that line looks longer. The neck has not actually lengthened; it looks that way because the line from neck to shoulder now runs down in one sweep instead of being interrupted partway. Because many people seek it before wearing something that shows the neck and shoulder line, such as a dress or an off-the-shoulder top, it is sometimes called "wedding dress Botox".
One thing has to be said alongside this. The trapezius is a muscle you actually use, to lift the shoulders and to carry heavy things. So how far its force may be reduced is not decided from the line alone; I also ask how much you exercise and whether your work uses the shoulders a great deal. How quickly the change appears and how long it lasts also differ from person to person with the thickness of the muscle and how it is used, which is why in consultation I give those only as ranges.
Raising the units versus finding the place
The first number that comes up in a toxin consultation is units: how many will go in. In a large, thick muscle like the trapezius, though, there is something that matters as much as the units and arguably has to be settled first. Where they go.
Every muscle has a point where the nerve signal enters it, commonly called the motor point. Placed accurately close to that point, the same amount reduces the force of the whole muscle evenly; placed away from it, only part of the muscle weakens and the rest stays as it was. The result then disappoints, and the usual next choice is "so let's raise the units". It is the same structure as "so let's add more" was with filler, and it was not the answer there either.
So when I look at a trapezius I look at the place before the units. Where the muscle stands thickest, and which point firms up first when force is applied: these I check by hand, and only then is the amount decided. When the place is right, the amount needed is often less than expected; when it is wrong, increasing the amount rarely produces the line that was wanted. The shape of the muscle and the position at which the nerve enters differ a little from person to person, of course, so this is settled by examination rather than from a diagram.
Increasing the amount is a choice anyone can make. Finding the place is a choice that requires an examination.
"Fill here, take down there" — why it is designed as a set
By this point it should be clear why a shoulder consultation is not only a conversation about filler. The shoulder line is made up of two stretches, and one is built by adding while the other is made by taking away. So from the start we draw, on one picture, where to fill and where to take down.
The mismatches I most often meet in the consulting room come down to these.
| A common assumption | What actually happens |
|---|---|
| The shoulder line is made with filler alone | If the trapezius stands high, the line breaks even with the angle set |
| If the angle does not show, add more filler | When the problem is in the upper stretch, more only makes it heavier |
| The more units, the better toxin works | Only with the right placement does a small amount reduce force evenly |
| Have the two treatments separately and the result is the same | They have to be designed together on one picture to become one line |
A set does not mean the two treatments must always be had together. To someone whose trapezius is not raised I do not recommend toxin, and to someone whose shoulder tip already has enough angle I do not recommend filler. Designing them together does not mean bundling prescriptions; it means making the judgement in one go, deciding in the same sitting what is needed and what is not.
If you are in a shoulder consultation and the conversation is only about filler, there is one more thing worth asking: where in your shoulder needs filling, and where needs taking down. If the answer covers both stretches, the shoulder is being seen as a single line.
So much for setting the line by adding and subtracting. Once what hides the line has been cleared, the shape built and the direction tidied, one thing remains: the surface that covers it all. In the next column I will explain why setting a line and tightening the skin are two different jobs, the final stage of body sculpting.
