WHAT is BOTOX?
Cosmetic BOTOX in the mid and lower face and neck has increased drastically over the past few years. Botox is the most effective tool in cosmetic medicine and should be used first and most often. BOTOX dosing and injection points should be based on assessing the patient’s anatomy, goals, preferences, and the physician’s own professional experience with prior treatments. Gender, cultural, and ethnic standards of attractiveness may significantly influence the patient’s preference. Each patient’s treatment should be individualized for the best results.
Indeed, there is now a greater appreciation that BOTOX-A is one part of overall facial rejuvenation therapy, in which all aspects of aging are addressed in the same individual. Finally, new esthetic indications emerge, including the treatment for scars, the horizontal upper lip line, musculus risorius excessive gingival display (“gummy smile”), and masseter reduction to improve facial shape. BOTOX is also beneficial with other aesthetic modalities, such as dermal fillers, laser, skin resurfacing, and surgery. More general applications push BTX-A toward an “art” rather than a clinical procedure.
Commercially Available BOTOX Formulations
As of 2012, four distinct BOTOX formulations are approved for human medicinal use in the United States. BOTOX formulations are the most widely used worldwide and are the only products with an approved indication for aesthetic purposes.
- OnabotulinumtoxinA (BOTOX, BOTOX Cosmetic) (BOTOX-ONA)
- AbobotulinumtoxinA (Dysport) (BOTOX-ABO)
- IncobotulinumtoxinA (Xeomin) BOTOX-INCO
- AbobotulinumtoxinA (Reloxin)
- IncobotulinumtoxinA (PurTox) BOTOX-INCO
- Topical for use in crow’s feet.
BOTOX has a remarkable efficacy and safety profile across many areas of medicine. However, its popularity may cause some health care providers and consumers to forget that it is still a deadly neurotoxin—the most powerful yet discovered.
Severe safety problems associated with the aesthetic use of BOTOX are rare. After procedures, complications and adverse events are typically mild, transient, and often preventable. Practical patient assessment and pre-treatment evaluation coupled with a precise injection strategy help ensure safe and effective outcomes.
What are Botox Injection Techniques?
BOTOX injections are usually performed on an outpatient basis with the patient seated in a chair with a raised head support. Physicians must evaluate the patient, analyze the facial anatomy, see patients at rest, contract their muscles, and pay attention to any preexisting asymmetry.
According to the earlier assessment, the injection sites are selected and marked with a skin-marking pen. Injections must be symmetrical concerning the sites, and the doses applied, except when patients show any asymmetries. Injections must be superficial and are usually performed with small syringes and fine-gauge needles.
You should remove makeup, and antisepsis of the skin is carried out using 70% isopropyl alcohol or iodine. I should minimize undesired side effects and increase patients’ comfort. It can reduce pain at the injected sites by applying topical anesthetics and frigid air or iced compresses or devices before each injection.
Common post-procedure recommendations are Patients must remain in the vertical position, avoid intense physical exercise, and manipulate the injected area for at least 4 hours after injections. These measures may prevent the action of BOTOX in the adjacent muscles, which is not desirable.
What is New in Botox Injection?
No use of BOTOX has garnered more attention than its use in aesthetic medicine. What started as a simple treatment of glabellar lines has grown into a flexible tool that dramatically changes every face area. Today, many procedures are performed in the middle and lower face rather than just on the upper face. BOTOX is also beneficial with other aesthetic modalities, such as dermal fillers, laser, skin resurfacing, and surgery.
The field of aesthetics is developing fast as clinicians refine their techniques to supply the best possible outcomes. The best technique includes considering several variables, including the treatment goal, skin thickness, and anatomic variation. Similarly, differences in skin type and color, facial shape, and esthetic and cultural ideals must be considered when planning esthetic procedures. Ongoing improvements in the esthetic procedures with BOTOX-A have led to greater acceptance and a widening clientele.
Each patient’s treatment should be individualized for best results. Taking careful medical notes and photography can aid the physician with personalizing treatment to meet patients’ needs. Indeed, there has been a move away from a “blanket” approach, which uses the same doses and injections for all individuals, toward a more individualized plan.
Furthermore, simultaneous treatment of multiple sites on the face can help achieve improved patient satisfaction. New techniques aim to avoid the “frozen” look associated with early BOTOX-A procedures. These more modern approaches aim to supply a more natural, harmonious, balanced effect and rely on an appreciation of the three-dimensional structure of the face.
Indeed, there is now a greater appreciation that BOTOX-A is one part of overall facial rejuvenation therapy, in which all aspects of aging are addressed in the individual: Finally, new esthetic indications are starting to emerge, including the treatment for scars, the horizontal upper lip line, musculus risorius and excessive gingival display (“gummy smile”), and masseter reduction to improve facial shape. These new targets will drive the development of future treatment approaches using BOTOX-A.
Eyebrow and Forehead (upper face)
The Forehead (Frontalis Muscle) treatment benefits that I should carefully evaluate these muscles. Treating the upper part of these muscles is the best option for some patients because treating the entire frontal region causes a significant loss of facial expression (masked appearance). Moreover, total paralysis of the frontalis m. can cause brow ptosis. The frontal region should always be treated in association with the Glabellar area for more satisfactory results, avoiding the excessive use of the glabella’s muscles, which are depressors.
The injections are typically given 2.5–5 units per injection site, depending on the extent of the area to be treated, whether totally or partially. Thus, the clinician should be conservative and allow some functional areas to remain intact to allow brow elevation. Patients with a narrow brow should receive fewer injections (four sites, compared to five) and lower doses than patients with broader brows.
Treatment aims to reduce the vertical and horizontal lines of the glabella (Frown Line). Contractions of the corrugators and, to a lesser degree, the medial orbicularis oculus and the depressor supercilii produce vertical lines between the eyebrows.
The contraction of the procerus produces horizontal lines over the bridge of the nose. Five injections, with two needles into each corrugator and one into the procerus, have been recommended for the cosmetic outcome. Clinical techniques should consider the variation in location, size, and use of the muscles among individuals. Injection of botulinum toxin into certain areas of the face that carry an elevated risk of ptosis (danger zone) needs caution.
The main cosmetic indications in the periorbital area include crow’s feet, hypertrophic lower eyelid orbicularis, narrow eye aperture, and eyebrow elevation. An example is a lateral forehead, particularly the lower part. Recently, however, the injection of BTX-A through the temporal hairline to correct supraciliary wrinkles seems to be safe and effective.
Patient assessment is critical to making an individualized treatment plan. The practitioner determines the source of the wrinkles- when assessing the lines while the patient animates and at rest. Evaluation should include a “snap test” to measure skin laxity along the lower lid margin. Skin that does not snap back into place after downward tugging may not respond well to neurotoxin treatment and be at higher risk for ectropion.
Nose and Gummy smile (mid Face)
Cosmetic BTX-A in the mid and lower face and neck has increased drastically over the past few years. More general applications push BTX-A toward an “art” rather than a clinical procedure. It is important to remember that each patient has individual features and musculature requiring an expert approach.
Only clinicians with a large base of clinical experience and those with a thorough understanding of facial anatomy (both dynamic and resting) and vasculature should try more advanced procedures for the incorrect application can result in catastrophic impairment of function and expression.
Even for experienced physicians, the mid-and lower face is a challenge because the gap between a perfect and a disastrous result over the treatment period is small. However, with adequate knowledge of anatomy and correct dosing, it is possible to obtain satisfactory results in most patients.
While smiling, the size of the eye aperture tends to be diminished, partly due to the contraction of the pretarsal orbicularis. Hypertrophy of the pretarsal portion of the orbicularis oculi can give a “jelly roll” appearance to the lower eyelid, enough that some individuals may complain that they look overweight.
We have found that two botulinum toxins injected into the lower pretarsal orbicularis will open the palpebral aperture both at rest and when smiling. This procedure should be used only for patients who respond well to a pre-injection snap test; treatment is contraindicated for patients with earlier lower eyelid ablative resurfacing or infra-lash blepharoplasty without infra-lash a coexisting canthopexy to support the normal position of the lower eyelid. Surprisingly, inferior eyelid injection is painless.
Injection of BTX-A for glabellar frown lines can cause mild medial brow ptosis, a lateral brow elevation, and a more pleasing contour to the eyebrow. Brow depressors include the glabellar complex, most notably the procerus and depressor supercilii. Clinicians can use the knowledge and understanding of how BTX-A works in the glabellar region to change the appearance of the brows in patients who want a more aesthetically pleasing look.
Treatment of the eyelids has become popular, especially among the two groups, those patients with fine wrinkling found on the lower eyelid and those who have a ptotic brow dropping down and adding weight to the upper eyelid. Treatment can be afforded using botulinum toxin, which improves the lower lid’s wrinkling and widening eye aperture.
I can achieve lateral brow elevation by treating fibers of the orbicularis oculi, which slightly lifts the lateral brow of the upper eyelid. Contractions of the orbicularis oculi muscle partly cause lower eyelid wrinkles. This muscle is intimately associated with the thin eyelid dermis and has multiple insertions around the peri-ocular skin. Contraction of the inferior pretarsal orbicularis produces inferior eyelid wrinkles.
This inferior part of the muscle serves to crinkle the lower lid and helps to suspend the lower eyelid. 2U of botulinum type A toxin placed in the mid-pupillary line of the lower eyelid, 3mm below the ciliary margin, was helpful in removing lower eyelid wrinkles. It was also noted to increase the palpebral aperture.
A more significant effect can be seen when the inferior eyelid is treated with the crow’s feet. A higher amount of orbicularis oculi muscle is relaxed, opens further, and widens the eye aperture. However, overtreatment can produce complications, including excessive drooping of the lower eyelid skin, photophobia, and the inability to close the eye entirely.
Although effective in diminishing the hyperkinetic lines, it is not recommended to treat the static wrinkles caused by photodamage or other causes, such as skin laxity. For this indication, lower doses and superficial injections should be used. I should avoid treating the lower eyelid with BOTOX in individuals with lower eyelid laxity or recent lower blepharoplasty. In these cases, I would recommend combination therapy.
Nasal wrinkles called “bunny lines” refer to the wrinkles on the lateral part of the nose, which result from the contraction of the transverse portion of the nasalis m. Several muscles contribute to bunny lines, but the nasalis is the most significant. Usually, bunny lines are not present in dynamic patients with a soft smile.
They only become apparent when smiling at maximum contraction. In hyperkinetic patients, bunny lines are found with a slight smile and worsen at maximum contraction. Patients should be asked to laugh, sniff, and squint intensely as if a very bright light is before their eyes.
Bunny line wrinkles, which appear on the lateral/dorsal aspects of the nose, but may extend to the lower eyelid, are naturally present during expression, especially in Asian and Hispanic patients and in patients with thin skin a fair complexion. Darker complexions and oily skin are more likely to produce wrinkles limited to the nasal dorsum.
Furthermore, they may become more pronounced after glabellar and periorbital BOTOX treatment. Lower doses are used in the transversal areas of the nasal bone. The procedure may be less effective in patients who recruit these muscles excessively or have had prior rhinoplasty.
The injections are 1–2 units per side of the upper nasalis and massage gently after the dose to help diffuse the toxin. On certain occasions, some people present dilated or rhythmic contractions of the nostrils (repeated nasal flare). BOTOX injections are shown on each side in the lower nasal fibers above the lateral nasal ala to treat this condition.
A drooping nasal tip can lead to a harsh and aged appearance. “When the nose is pointed up, it creates a much softer look. A droopy tip can also cause the area between the end of the nose and the upper lip to look short—small, thin lips are typical of an aged look.
Treatment of the nasolabial fold with BTX-A can result in ptosis of the upper lip and narrowing of the vermillion. Botulinum toxin type A injection could flatten the upper third of the nasolabial fold and elongate the upper lip. In patients with a naturally shorter upper lip, 1U BTX-A into each lip elevator complex in the naso-facial groove will collapse the high aspect of the nasolabial fold and elongate the upper lip.
A total dose of 3–6 U per injection site has shown excellent results. Lower doses should be injected initially, followed by equal doses after 7–15 days to avoid symmetries. We ask patients to return in two to three weeks for a follow-up examination to take photographs and assess treatment responses. For patients who still have deep furrows at two weeks, one may consider adding a filler.
Handling nasal deformities and those with “dropping” tips has always been a communal area of interest in surgery. BOTOX injections for a “dropping” nose (medical rhinoplasty) is a simple and highly effective technique with immediate results, which consists of using only hyaluronic acid to correct nasal angles and botulinum toxin in patients with hyperactivity of the muscle.
I can use it in those cases where patients are reluctant to undergo surgery or as a primary indication in correcting minor nose defects. Results are satisfactory, and no side effects have been reported so far. Results will last for a long time.
Mouth and Lips (lower face)
Botulinum toxin type A has been used less often for indications in the lower face. The depressor anguli oris (DAO) is an essential muscle that influences how other people see us. In addition, platysmal bands can increase this downward effect.
Constant hyperactivity might lead to deep furrows or Melomental Folds drawing down the corners of the mouth, leading to an overall sad, slightly depressed impression and has traditionally been treated with soft-tissue augmentation alone.
BOTOX can be used to weaken this muscle, elevating the mouth corners or returning them to a neutral position. We inject 3 to 5U at the level of the mandible but at its posterior margin, close to the anterior margin of the masseter, which will significantly weaken, rather than paralyze, the muscle to upturn the corners of the mouth. The combination of soft-tissue augmentation and BTX-A injected into the DAO will lengthen the duration of the enlargement and prevent the repeated molding and contortion of the soft-tissue augmenting agent.
The Perioral area has an essential role in the aesthetic balance of the face. The peripheral muscles act in concert to achieve the extraordinarily complex movements that control facial expressions, eating, and speech. The lips are central to the appearance of the lower face. During aging, the lateral portions of the lips recede, resulting in a “rosebud mouth.”
At the same time, the distance between the columella and the vermilion border of the upper lip increases, and the substance of the vermilion rolls inside, producing the thin and disappointing lips that are characteristic of old age. The orbicularis oris is the sphincter muscle that encircles the mouth, lying between the skin and mucous membranes of the lips, causing the lips to close and pucker. Dense vertical perioral wrinkles are often associated with the lengthening of the upper cutaneous lip during aging.
These vertical lines are labeled as “smokers” lines but can also result from heredity, photodamage, playing a musical instrument that requires embouchure or even whistling. Patients are often disturbed by the increased vertical length of the cutaneous lip and the radial upper lip lines that can cause lipstick to bleed upward from the lip and blur the outline of the lip. Vertical lines of the upper lip are a secure sign of aging. Even when using an injectable filler, some of these lines might remain.
The aim of treating the upper and lower lip is a reduction of these unsightly wrinkles. Appropriate patients must be chosen carefully, as those who play wind instruments or professional singers/speakers are not ideal candidates. BOTOX A Injection point should be made at the vermillion border, parallel to the lips, and at least 1.5 cm away from the mouth corners.
The total dose should be distributed in four to six points, four at the upper lip and two at the lower lip. Low treatments and superficial injections are preferred to avoid functional impairment of the lips. The patient is asked to pucker, and the areas of muscle contraction next to the lines are marked.
Small doses (1–2U per lip quadrant) are usually enough to weaken the orbicularis oris without causing a paresis that could interfere with elocution and suction, mainly when used with a soft-tissue augmenting agent. BTX-A injections must achieve the desired cosmetic result with the smallest dose without any functional discomfort.
Botulinum toxin chemo denervation of the risorius at once lateral to the corner of the mouth on the customarily innervated side will reenter the mouth when the face is in repose. Surgical or traumatic lesion of the orbicularis oris of the risorius muscle can result in the mouth being pulled off-center by the free action of the partner muscles on the customarily innervated side (asymmetric smile).
Moreover, some individuals have congenital or unilateral weakness of the depressor anguli oris muscle, resulting in an inability to depress the corner of one side of the mouth. In this case, botulinum toxin treatment of the partner muscle also restores functional and aesthetic balance.
I can achieve the softening of the mental crease by injecting the mentalis, just anterior to the point of the chin. We insert 3 to 5U into each side of the midline under the end of the button, just anterior to the bony mentum, rather than injecting centrally.
Care is taken not to insert at the level of the mental crease since this will also weaken the lower lip depressors and orbicularis oris and cause serious adverse effects that can persist for six months or more, depending on the dose. Again, as in the perioral area, weakening, rather than paralysis, is the aim of treatment.
A dimpled or “cellulitic” Chin (“peau d’orange”) is the result of the actions of the mentalis muscle coupled with the loss of collagen and subcutaneous fat in the chin. Treatment with BOTOX can be used to restore the smooth appearance of the button. This technique has also been used to correct abnormal contraction following chin implant or genioplasty with mental dysfunction following surgery; I may need deeper placement with a higher dose.
A usual number of BTX-A injection points is 1–2 points (start with one midline or two regular, lateral injections) and 2–8 units for a total starting dose. I should avoid the lip depressor muscle because lip incompetence can usually result in two injection points at the prominence of the chin resulting in a cosmetically proper outcome.
I should do the injections close to the mandibular bone to prevent mouth asymmetry or lower lip ptosis. The contraction of mentalis m. It can also promote lower lip projection. Thus, when the dimpled chin and drooping mouth corners are treated together, lower doses per point are recommended to prevent the overtreatment of this condition.
Of all the human facial expressions, the smile is the most pleasing and complex in terms of meaning. Although it has long been the motive for artistic and philosophical debates, the smile, from an anatomic and physiologic standpoint, is the result of the exposure of the teeth and gums during the contraction of the muscle groups in the middle and lower thirds of the face.
The smile itself and its aesthetics are influenced by three components: teeth, gums, and lips. An attractive smile depends on these three elements’ proper proportion and arrangement. The upper lip should symmetrically expose up to 3 mm of the gum, and the gum line must follow the contour of the upper lip.
The exposure of more than 3 mm of the gum during the smile is known as a gingival or gummy smile (GS). Excessive gingival exposure may be anterior (Major gum exposure ([3 mm) in the area between canine teeth, posterior (Major gum exposure ([3 mm) posterior to canines, with regular exposure (3 mm) in the anterior region, mixed (Excessive gum exposure in both areas (anterior and posterior), or asymmetric (Excessive or more apparent gum exposure on one side only) and each one has a variable degree of involvement of different muscles
GS represents an aesthetic disorder, and therefore, various correction methods are proposed, including gingivoplasty, orthodontic treatment, orthodontic surgery, and bone resection. They are overly complex procedures involving moderate to severe morbidity, prohibitive cost, and considerable time; they become less often recommended.
By contrast, botulinum toxin (BT) represents a simple, fast, and effective method for the aesthetic correction of GS. The use of BT for the treatment of GS can be considered remedial (when the cause of GS is exclusively muscular), adjuvant (when there is an association of reasons and an indication of additional treatments such as lip augmentation or orthodontic devices), or palliative (when definitive surgical treatment is recommended).
Careful case choice, BTX-A, may be an effective treatment alternative for patients with excessive gingival display caused by hyperactive lip elevator muscles. For this purpose, a dose of 2.5 units of BTX-A should be injected at two sites per side (four locations) in “Yonsei point” as an appropriate injection point for BTX-A.
The adverse events most reported after the application of BT to fix GS are ptosis or stretching of the upper lip (“joker-like” smile), asymmetric smile, and difficulty smiling or chewing. It is crucial to remember that the effect of BTX-A on one muscle often has an impact—positive or negative—on another.
An excellent example of this is the “mouth frown,” the permanent downward angulation of the lateral corners of the mouth, which is caused by the action of the DAO and the upward motion of the mentalis. We have found that attempts to weaken the DAO or mentalis alone, while proper in some individuals, are ineffective or associated with unacceptable side effects in others.
Injections of BOTOX are a simple, non-invasive, and safe way to correct asymmetric smiles. The number of points and total doses are defined individually according to the muscle involved. The results become clear in less than five days, and the effects last from 4 to 5 months after the first treatment. In later procedures, it is recommended to reduce the doses, and the results usually last longer.
Facial asymmetry may be caused by bone elements, soft tissue, or neurological or muscular causes. The two latter categories can be classified into hyper-functional (e.g., Hemifacial spasm) or hypofunctional (e.g., Facial palsy). BTX can be used to correct asymmetries of neurological or muscular origin. We recommend an injection through an EMG system for physicians not thoroughly comfortable with facial surface anatomy.
Masseter Hypertrophy, whether it is congenital or bought, is a developed master muscle that makes a face look fuller. This isn’t good for women because a square face gives a masculine image. From the view of an esthetic standard, it is more desirable for the bigonial distance (width of the lower face) to be narrower than the bizygomatic length (width of mid-face). The classical standard bigonial to bizygomatic ratio was 9:10, but a narrower bigonial distance has become preferred in recent years.
The size of the mandible, the volume of muscle that surrounds the jawbone, and the subcutaneous fat tissues determine the width of the lower third of the face. The overdeveloped jawbone can be corrected by bone resection, and excessive fat tissues can be removed by liposuction. However, if the main factor is masseter hypertrophy, treatment for the masseter muscle is needed.
The masseter muscle is divided into superficial and deep portions. The former is larger than the latter and found outside the last. In general, the injection is given to the thickest region of the masseter muscle.
However, it can be more efficiently delivered if a few reference lines are defined by palpation. Before injection, the anterior and posterior margins of the masseter muscle are found by palpation. Then, a rectangular area is appointed by linking the lower border of the mandible, the ear lobe–mouth corner line, and the anterior and posterior borders of the masseter.
Various degrees of success have been reported for some of the treatment options for masseter hypertrophy, ranging from simple pharmacotherapy to more invasive surgical reduction. Injection of botulinum toxin type A into the masseter muscle is considered a less invasive modality. It has been advocated for the cosmetic sculpting of the lower face Injection must be given to three different points that are 1.5cm away from the border of the mandibular angle, i.e., one aspect where the muscle is thick and two other locations that are found anterior and posterior to the center in a triangular manner.
If patients undergo the injection during clenching, they will feel more pain than during the resting state. Accordingly, I should relax patients before the treatment. I must give the center point 50% of the usual dose. Then, two points found anterior and posterior to the center must be given 25% each.
BOTOX injection can help Bruxism, a diurnal or nocturnal parafunctional activity that includes tooth clenching or grinding, resulting in several orofacial lesions, such as tooth wear, periodontal lesions, temporomandibular joint disorders, and muscle pain. Although several therapeutic modalities have been employed, including oral splints, medications, and behavioral approaches, none has been reported to be fully capable.
Botulinum toxin injections can reduce the frequency of bruxism events, decrease bruxism-induced pain levels, and satisfy patients’ self-assessment of the effectiveness of Bruxism. Botulinum toxin injections are equally as effective as a nocturnal oral splint for Bruxism. Furthermore, botulinum toxin injections at a dosage below 100 U of the masseter or temporalis muscles in otherwise healthy patients are safe.
Although there is well-documented evidence for the efficacy of BTX-A in the correction of platysmal bands, little work has been performed to explore its potential role in the rejuvenation of the jawline (Nefertiti Lift).
The effects in this area have been reported because of platysmal banding treatment and are inconsistent. Hesitancy to explore treatment maybe because of evidence of a higher, more durable response to the toxin in the lower facial muscles and reports of increased potential migration and later side effects. They conclude that the Nefertiti lift is a minimally invasive, effective, and acceptable alternative for those patients seeking an effective way to push back surgery.
Neck Botox Injection
The platysma, a large, thin sheet of muscle, originates from the pectoral and deltoid fascia. It extends upward, over the clavicle, and inward along each side of the neck and under the skin near the mandible. Anterior fibers of platysma may interdigitate with strands of the opposite side. The platysma depresses the lower jaw and pulls the lower lips and the corners of the mouth sideways and down, partially opening the mouth.
Banding occurs with aging and changes in the submental space. Its contraction may result in horizontal wrinkles and vertical bands, not only in the cervical region but also in the décolleté area. Although most neck wrinkles are related to photoaging and skin laxity, BOTOX can be an efficient and safe treatment for neck aging. It acts by producing a partial paralysis of the anterior part of the platysma m., softening the vertical platysmal bands. Ideal patients for this indication should have thin and good skin elasticity and little or no fat or sagging skin.
BOTOX should be applied on the platysma band with superficial intramuscular injections. Each band is grasped individually and held firmly between the thumb and index fingers. Needles are placed directly into the platysmal band at 1.0- to 1.5-cm intervals along with the band, starting at the jawline and descending to the clavicular border. Injections should be placed into the deep dermis and not subcutaneously. The risk of hitting deep venous perforations or other cervical muscles increases as injections are situated in more profound planes. A usual number of injection points is 2–12 bands and 10–30 units for a total starting dose. Using the correct technique and treatments, I can minimize potential adverse effects such as dysphasia, dysphonia, and neck weakness.
Horizontal Neck Lines
Two or three horizontal necklace lines of skin indentation often grace the slightly younger, chubbier neck. The superficial musculoaponeurotic system attachments cause these lines in the neck. We feel that the most straightforward approach is to “dance” along the lines of injecting small doses of botulinum toxin over multiple sites. Aliquots of 1 to 2U are inserted in the deep intradermal plane at 1-cm intervals along the horizontal necklines to soften and erase them. If the neck is gently massaged afterward, the skin usually does not bruise.
The physician is cautioned to do deep dermal rather than subcutaneous injections for two reasons: (1) There are deeper venous perforators that can bleed, especially lateral in the neck, and (2) the underlying muscles of deglutition are cholinergic and could potentially be affected. We usually inject no more than 15 to 20U of botulinum toxin for horizontal lines per treatment session.
The anterior mid-chest wrinkles result from extrinsic and intrinsic factors, such as the position adopted during sleep, photodamage, and action of medial fibers of the pectoralis major m. and the tail portion of the platysma m. BOTOX can be used when clinical examination shows the involvement of the mentioned muscles. Four to six injection points can be applied on each side, in a “V” shape, plus the treatment of the caudal part of the platysma muscle.
Botox Injection Skin Rejuvenation In Men
Botulinum toxin injection in men does not differ, and the basics are like procedures performed in women. However, they often require a larger dose; For example, men require larger doses of BOTOX-A than women, which is related to their higher muscle mass.
There are also differences in esthetic ideals in men; while women require an arched eyebrow, men prefer a lower, horizontal brow. We inject an added 4 to 5U into a point 1 cm above the supraorbital rim in the mid-pupillary line in men. It is helpful to halve the volume of saline used to reconstitute the vial when treating males, as this technique reduces the injected amount while merely doubling the injected dose.
Botox Injection Skin Rejuvenation. Others
Treatment of Hypertrophic scars is still a dilemma owing to the lack of adequate and excellent methods and agents. Recent reports show that BTX-A improves wound healing. BTX-A may be favorable for the improvement of hypertrophic scars. It can eliminate or decrease hypertrophic scars in clinical studies.
BTX-A cannot avoid the other age parameters, such as drying, pigmentation problems, vascular problems, and volume loss, but slow down muscle shortening and consequent structural aging when injected incredibly early in the aging process (preventing aging).
Botulinum toxin type A injections are not meant to replace upper, mid, or mandibular face and neck lifts; indeed, BTX-A injections may perfect results from these surgical procedures. It has been suggested that to maximize the effect of the medical procedures, BTX-A should be injected three weeks before surgery.
In addition, BTX-A injections may optimize and prolong the result of the skin resurfacing like lasers, peels, and fillers. Before laser resurfacing, hyperdynamic facial lines, pretreated with BTX-A, heal in a smoother rhytid-diminished fashion. These results were clinically most significant in the crow’s feet region. This process has two mechanisms: the blockade of solid facial muscles and neo-collagen synthesis. Pre-treatment of movement associated rhytids with BTX-A before laser resurfacing is recommended.
Continuing maintenance therapy with BTX-A postoperatively may perfect results. The acetylcholine receptor is present in neurons and can be found on the surface of melanocytes, keratinocytes, and other dermal tissue. It is reasonable to suspect that it may produce a versatile effect on adjacent tissue components after BTA injection.
BTA showed moderate but significant wrinkles soothing impact on the lower face for eight weeks without noticeable side effects through intradermal injection (mesobotox). The injection volume was 0.02 ml per spot. The endpoint of the injection was a subepidermal wheal-like swelling. The total dose of BTA for each person was 20–25 years.
Pre- and Post-Botox Injection Recommendations
The most effective tool in aesthetic medicine should be the one used first and most often. Quality patient communication encompasses many aspects of cosmetic practice and can significantly affect patient satisfaction through enhanced knowledge, realistic expectations, and proper treatment outcomes. Patients who are well-informed before their procedure will better understand outcomes and thus a better framework for assessing how the results reflect their pre-treatment vision.
Effective pre-treatment communication also enables physicians to understand unique patient-specific characteristics that determine the individualized treatment plan. Patients begin receiving information from the moment they first contact your office. Your staff, office, and other patients contribute to the patient’s expectations, comfort, and confidence in your abilities.
Understanding the prospective patient’s goals and aesthetic self-concept is critical for achieving satisfactory outcomes. Patients may express goals that fall outside the norm for their “group,” and physicians should be prepared to recognize and respond to those goals.
Gender, cultural, and ethnic standards of attractiveness may significantly influence the patient’s preference. Even subtle differences in outcome can change patient happiness to extreme dissatisfaction, so knowing as much as possible about the characteristics and motivations of the individual patient is essential.
In addition to assessing the patient’s goals and preferences, it is crucial to determine their medical and physical considerations before treatment. The first step in this process is to obtain the patient’s medical history. Any contraindications or cautions to therapy should be found and documented, as should the patient’s prior experience with aesthetic procedures.
Physicians should carefully assess and document observations of patients’ critical physical characteristics, including aging patterns, skin elasticity, surface landmarks, and muscle distribution and mass. Earlier cosmetic treatments can dramatically influence patient outcomes, and patient attitudes about earlier treatments may signal underlying psychological barriers to treatment satisfaction.
One of the most significant changes in modern aesthetic medicine has changed how we view the face. The approach to facial rejuvenation has shifted from a two-dimensional focus on lines and wrinkles to a three-dimensional viewpoint that recognizes the primary influence of volume on the appearance of facial aging.
This three-dimensional viewpoint is a cornerstone of aesthetic evaluation and treatment strategy. When we view the face in three dimensions, we can select the cosmetic tools better. Muscle pattern, size, and dynamic action will directly influence the BOTOX injection strategy for a specific treatment area. Although facial anatomy is similar in most individuals, anatomic muscle patterns can vary. Underlying muscular variances have been seen through differences in surface characteristics, such as various patterns identified in smiles, crow’s feet distribution, nasal wrinkles, and forehead lines.
Pre-treatment assessment should include careful evaluation of the musculature at rest and when dynamic and changes in facial landmarks as the muscles are activated. With the patient’s eyes open and closed and at repose, this should be done with moderate animation and maximum contraction.
Clinicians should also spend a few minutes seeing the patient speaking and document specific facial movements, mannerisms, smile patterns, and other individual animations. Facial muscles work in coordination to create expressions and control facial movement; treatment of a specific muscle group without considering its full-face effects can lead to less-optimal results.
I should repeat the patient assessment process at each visit because patient preferences, goals, and health status will change. Aging is a dynamic process, and the best treatment strategy for the patient at age 30 will undoubtedly be different from that of the same patient at age 60. I should also mention the effects and potential side effects on the patients. For a more detailed evaluation of the treatment outcomes, photographs should be taken at rest and contracting the target muscles before the procedure.
Another way the aesthetic industry evolves is by developing and using tools that enable standardized assessment of a patient’s appearance before and after treatment. It is challenging to “standardize” what is an inherently personal pursuit.
Still, the emergence of newer anatomic severity scales has improved our ability to objectively prove the degree of aging and severity of facial wrinkles before treatment and evaluate the improvement level. Standardized scales that visually and objectively show various aging pathologies are also valuable for in-patient communication.
Photographic documentation is mandatory before any aesthetic treatment. “Before” photos should ideally be shown to the patient and used as part of the pre-treatment assessment and communication process. Discussion of the upcoming treatment plan in the context of an objective view of critical facial landmarks, aging pathologies, and any preexisting asymmetry will strengthen the patient — understanding of realistic treatment outcomes.
Valid informed consent is essential and should capture any caution areas, including whether the treatment is off-label. In the event of legal proceedings with a dissatisfied patient, photographic and consent documentation will be critical.
Although BOTOX is safe, there are some contraindications to its use. Contraindications for BTX-A based on theoretical concerns include preexisting neuromuscular disorders; local infection at the expected injection site; known hypersensitivity to any part of the formulation; pregnancy; and lactation.
BTX-A should be avoided in patients taking concomitant aminoglycosides or other substances interfering with neuromuscular transmission (e.g., Curare-type non-depolarizing blockers, quinidine, magnesium sulfate, and succinylcholine. I should use caution in disorders that produce depletion of acetylcholine. The safety of BTX-A in pregnant or nursing women has not been evaluated in any study.
Foremost among the myriad factors in developing a BOTOX injection strategy for a patient are decisions about dilution, dosing, and injection placement. Only clinicians with enough education and experience to understand the potential clinical effects of that use should undertake any off-label use of BOTOX.
BOTOX dosing and injection points should be based on assessing the patient’s anatomy, goals, preferences, and the physician’s own professional experience with prior treatments. It is thus difficult to set up the total dose and injection point templates for specific facial areas— the possibilities are virtually endless.
- BTX-A cannot avoid the other age parameters, such as drying, pigmentation problems, vascular problems, and volume loss, but slow down muscle shortening and consequent structural aging when injected exceedingly early in the aging process (preventing aging).
- Botulinum toxin type A injections are not meant to replace upper, mid, or mandibular face and neck lifts; indeed, BTX-A injections may perfect results from these surgical procedures. It has been suggested that to maximize the effect of the medical procedures, BTX-A should be injected three weeks before surgery. In addition, BTX-A injections may optimize and prolong the result of the skin resurfacing like lasers, peels, and fillers. Before laser resurfacing, hyperdynamic facial lines, pretreated with BTX-A, heal in a smoother rhytid-diminished fashion.
- These results were clinically most significant in the crow’s feet region. This process has two mechanisms, including the blockade of solid facial muscles and neo-collagen synthesis. Pre-treatment of movement associated rhytids with BTX-A before laser resurfacing is recommended. Continuing maintenance therapy with BTX-A postoperatively may perfect results. The acetylcholine receptor is present in neurons and can be found on the surface of melanocytes, keratinocytes, and other dermal tissue. It is reasonable to suspect that it may produce a versatile effect on adjacent tissue components after BTA injection.
- BTA showed moderate but significant wrinkles soothing impact on the lower face for eight weeks without noticeable side effects through intradermal injection (mesobotox). The injection volume was 0.02 ml per spot. The endpoint of the injection was a subepidermal wheal-like swelling. The total dose of BTA for each person was 20–25 years.
Complications and How to Avoid It?
I can prevent many of the most common complications associated with BOTOX aesthetic use. The most powerful tools for preventing adverse events are the physician’s own artistic knowledge and injection competence. Before attempting cosmetic treatment with BOTOX, physicians should possess knowledge of the aging process and underlying causes of observed surface characteristics; facial musculature, its potential individual variations, and the interplay between muscles; essential attributes of the BOTOX formulation selected for use; and the effect of injection strategy decisions, including dilution, dosing, and specific injection sites.
Like beauty, adverse outcomes are in the eye of the beholder. If your patient does not like the outcome, the result stands for an adverse effect from the patient’s perspective—yet another reminder that aesthetic medicine is fundamentally patient-centered. The patient’s expectations, goals, and vision are foundational considerations in the treatment strategy, and how well these are fulfilled is an essential measure of success.
To take advantage of the exponential aesthetic possibilities inherent in combination therapy, physicians must have the requisite knowledge and experience with each part to use it to its best effect. The most common complications after BOTOX treatment relate to the injection strategy. Even minor missteps in dosing or injection placement can yield poor outcomes. The adverse treatment results will be temporary, but your patient’s dissatisfaction will be long-lived.
Erythema and edema these reactions are moderate and last only a few hours. They are dependent on the volume injected and, more importantly, on the diameter of the needle and require no specific treatment. Prevention Introduce a thin 30G needle carefully. Inject lesser amounts slowly. Do not massage the injection site and place a cold pack over it at the end of treatment.
Injection-site pain is typically transient, and most patients need little pain management. Using tiny gauge needles, changing needles often during intensive treatment sessions, and careful technique can help minimize pain during injection. Distraction strategies (e.g., talking to the patient, supplying a “stress ball” to squeeze, using a distraction device such as a massager) can be helpful. In patients who are pain-sensitive or apprehensive, pre-treatment application of ice or a topical anesthetic agent will lessen the discomfort and, at a minimum, will provide some psychological soothing. The use of preservative-containing saline as the diluent has been shown to reduce patient pain significantly during BOTOX injection.
Bruising is due to punctures of blood vessels, often because the latter have not been accurately found beforehand. Bruising after injection is common, especially in thin-skinned areas such as the periorbital area (crow’s feet. The patient must always be sitting; local veins must be found, especially in the periorbital area and areas at risk.
I may minimize bruising by avoiding anticoagulant medications or aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) for up to 2 weeks before treatment and using creams containing Arnica Montana or vitamin K. For patients who cannot stop taking anticoagulants because of medical necessity, pre-treatment patient information, materials, and counseling should involve caution about bruising as an outcome. Physician-applied pressure without massage and applying ice to the injection site can help minimize bruising.
Headaches and Nausea are the most common side effects. They disappear after a few treatments. They last from a few hours to 3–4 days. Local trauma, stress, and a history of migraines have been suggested as probable causes. They may require the use of pain killers or common anti-migraine drugs. Surprisingly, botulinum toxin type A injections also treat headaches and migraines due to muscle contractions.
A cockeyed Appearance can occur in the brow when the lateral fibers of the frontalis muscle have not been injected appropriately, and the untreated lateral fibers of the frontalis pull upward on the brow. To rectify this, a small amount of BTX-A is inserted into the fibers of the lateral forehead that are pulling upward.
Blepharoptosis, the severe only complication, is eyelid ptosis from a cosmetic point of view, but it has become increasingly rare. It is related to poor technique and underscores the necessity of understanding the effects of BTX-A on facial musculature. Injecting the glabella and the whole forehead in one session is also more likely to produce brow ptosis. It is caused by the diffusion of the product (injected into the procerus, depressor supercilii, or corrugator) through the orbital septum toward the levator palpebrae superioris muscle. It develops 2–15 days after the injection, is rarely transient, and lasts 2–8 weeks. It is, however, fully reversible.
Avoiding brow ptosis begins with proper patient choice and (avoid injecting patients with low-set brows, mild brow ptosis, and patients over the age of 50). Furthermore, exceptional care is recommended in patients with a history of glabellar trauma or surgery or patients, often elderly, with minimal ptosis due to a deficit in the Levator muscle, often masked by a resulting hyper-contraction of the frontalis.
It is therefore essential to take photos before the injection. It is vital to use a 30-gauge needle. A small volume and a higher concentration allow for more accurate placement, more significant duration of effect, and fewer side effects since there is an area of denervation associated with each injection point owing to toxin spread of about 1 to 1.5 cm (diameter, 2–3 cm).
More important is to inject the procerus and corrugator in the center of the glabella, away from the pupil line, and at least 1cm outside the orbital rim. Patients must be recommended to remain upright for two hours, exercise the treated muscles as much as possible for the first four hours, and strictly avoid rubbing or massaging the injected area for two hours following treatment.
Its treatment is exclusively symptomatic and does not shorten its course. Apraclonidine 0.5% (Iopidine®; Alcon) and phenylephrine hydrochloride (Neosynephrine ® 2.5%; Ciba or Chibret) may be administered 1–2 drops three times a day. Although they stimulate Muller’s muscle, an agonist of the levator, these potent mydriatic agents cause severe accommodation disorders, which limit their use.
Periorbital Complications Bruising, diplopia, ectropion, or a drooping lateral lower eyelid, and an asymmetrical smile (caused by the spread of the toxin to the zygomaticus major) are all reported complications of BTX-A in the periorbital area. To avoid the worsening of skin. Treatment for patients with skin laxity and eyebags, laxity of the canthal tendon, and lower eyelid retraction are contraindicated for patients with laxity of the canthal tendon and retraction of the lower eyelid.
It is also contraindicated when the wrinkles are due to the action of the zygomaticus major m. or when patients have been given ablation resurfacing or blepharoplasty of the lower eyelid without canthopexy. Patients with a significant degree of scleral show pre-treatment, dry eye symptoms, significant earlier surgery under the eye, a great deal of excess skin beneath the eye, or a slow snap test of the lower eyelid are not good candidates for infraorbital orbicularis injection.
BTX-A is inserted laterally at least 1 cm outside the bony orbit or 1.5 cm lateral to the lateral canthus. To avoid injections medially to a vertical line through the lateral canthus, neither close to the inferior margin of the zygoma. Ecchymoses are reduced by injecting superficially and avoiding blood vessels by placing each injection at the advancing border of the previous one. Although BTX-A for lateral canthal rhytids usually does not suppress tear production, this procedure’s dry eye is a complication. Treatment of a dry eye or exposure keratitis is symptomatic and includes lubrication.
Although poor injection strategy in the upper face, Lower Face, and Cervical Complications typically result in aesthetic inconvenience. BOTOX mistakes in the lower face can severely affect patients’ quality of life. The musculature of the lower face is highly integrated and integral to essential life functions such as speaking and eating.
Excessive dosing is the primary cause of complications in the lower front; misplacement of the injected product is the second most common Complication in the lower face and neck, such as drooling or asymmetry, which are usually owed to the over-enthusiastic use of BTX-A in large doses.
Starting with small doses and injecting more superficially rather than deeply limits the potential for complications, as do regular injections, to ensure uniform post-injection movement. Injections are avoided in singers, musicians, or other patients who intensely use their perioral muscles.
The left corner of the mouth drops in smiling after periorbital BTX-A injection because of zygomaticus major/minor paralysis. All injection sites should be situated above the zygomatic bone to avoid lip drooping. We recommend marking the injection points while the patient is smiling or squinting.
When injecting the DAO, areas too close to the mouth, the mental fold, and interaction with the orbicularis oris are avoided, resulting in a soft cheek, incompetent mouth, or asymmetric smile. Large doses (higher than 100 U) of BTX-A in the platysma have resulted in reports of dysphagia and weakness of the muscle.
Infections no case of infection has been reported at the injection site or other sites. The product is diluted with normal saline, irrespective of the brand, and I must keep the vial at four °C in a refrigerator. It showed no bacterial contamination 30 days after opening. However, I must apply aseptic techniques rigorously to avoid any risk. Cholinergic effects are rare and include primarily dry mouth and dry eye. These effects are more frequent and more pronounced with the type B toxin (NeuroBloc or Myobloc®).
We ask patients to return in two to three weeks for a follow-up examination to take photographs and assess treatment responses. For patients who still have deep furrows at two weeks, one may consider adding a filler. Consideration should be given to the time between the initial treatment and any touch-ups.
Because of the theoretical risks of an immunological response, a cautious approach would be to re-inject no earlier than two weeks post-injection. Consideration should be given to the time between the first treatment and any touch-ups. Because of the theoretical risks of an immunological response, a cautious approach would be to re-inject no earlier than two weeks post-injection.
We recommend further injections at three- to four-month intervals over one year in those with deep glabellar frown lines, which keeps the musculature paralyzed and allows the glabellar furrows to drop out. Many patients experience clinical benefits at higher doses lasting three to four months, and some continue to help for as long as six to eight months. After one year, the patients return when they want. All patients are instructed to contact their physician if anything unexpected occurs.
Non-Cosmetic Usage of BOTOX Injections
- Pompholyx among the recent developments, BTX-A is effective against pompholyx. This study shows that interruption of sweating by BTX-A improves the outcome and reduces relapses in patients with Dyshidrotic hand eczema. The major disadvantage of BTX-A is the need for injections, but efforts are being made to develop a topical form of application.
- Hailey–Hailey case reports comparing both sides of the axillary region with BTX-A revealed that it might be an effective and safe non-surgical alternative for treating benign familial pemphigus in intertriginous areas such as the axillae.
- Dermatochalasis, a randomized study comparing the efficacy and safety of two doses of BTX-A in treating dermatochalasis in forty patients with mild to moderate dermatochalasis, showed that single-site injection of two doses of BTX-A in the lateral infrared could offer effective treatment for mild to moderate upper eyelid dermatochalasis.
- Lichen Simplex Chronicus and Nostalgia Paresthetica, an open pilot study in three patients, was carried out to determine the therapeutic effect of blocking acetylcholine release with BTX-A in highly pruritic lichen simplex, showed that intradermal botulinum toxin alleviates pruritus associated with lichen simplex. In two cases of nostalgia paresthetica, a dose of BTXA was influential in improving symptoms after more than 18 months of follow-up. Acetylcholine is a dominant pruritic mediator in this condition.
- Granulosis Rubra Nasi in a case report, BTX-A was found to be useful for granulosis rubra nasi. After applying topical anesthetic cream with lidocaine and prilocaine to the nasal dorsum 30 min before the procedure, ten intradermal deposits of 0.1 ml (2 UI) of botulinum toxin were injected into each side of the nose. At one 1-month follow-up, there was a significant reduction in hyperhidrosis and erythema, an improvement that persisted six months later. One year after the single application of botulinum toxin, the patient showed gradual recurrence of hyperhidrosis
- Eccrine Polyhidrocystoma is one case report in which BTX-A was used successfully to treat multiple eccrine hidrocystomas. 26 A study on 18 patients to prove the efficacy of BTX-A on multiple facial eccrine hydrocystoma showed that a two-session injection of BTX-A intradermally around the lesions by 3–to 4 weeks apart could significantly flatten the lesions
- Epidermolysis Bullosa Simplex has one case report that proved the successful treatment of Epidermolysis bullosa simplex, Weber- Cockayne type, with BTX-A.
- Inverse Psoriasis a study on 15 patients with inverse psoriasis revealed that BTX-A therapy improved subjective patient symptomatology and objective reductions in erythema and maceration in the treated areas, according to photographic evidence.
- Pachyonychia Congenital is just one case report in which BTX-A was used successfully in three patients with pachyonychia congenital who had significant walking problems, especially during summertime.
- Raynaud Phenomenon reports in the literature describe the use of BTX-A for the treatment of vasospastic ischemia of the digits; in conclusion, BTX-A was found to be a safe and valuable treatment choice for vasospastic digital ischemia.
- Facial Flushing and Frey Syndrome is a case report of persistent facial flushing resistance to multiple pulsed dye laser treatments successfully treated with BTX-A. This result suggests that BTX-A can be used in small quantities to decrease persistent facial flushing temporarily. Intracutaneous injection of BOTOX is a practical, long-lasting, and well-tolerated treatment of Frey syndrome.
Medical Indications of BOTOX Injections
Botulinum toxin (BOTOX) is a fascinating compound proven to be a useful therapeutic tool for many human medical applications, and research is continually generating exciting new possibilities for future use. BOTOX is a foundational tool in treating eye disorders, pain, neuromuscular disorders, and urology, to name a few.
BOTOX has been used in the last 20 years in medical and cosmetic dermatology to treat facial wrinkles and has become one of the most popular cosmetic procedures. BOTOX is a powerful and flexible tool in the aesthetic physician’s armamentarium. Progress in aesthetic medicine has supplied contemporary insights into practices that maximize its use.
A range of product- and patient-specific factors influence the treatment plan, and genuinely optimized outcomes are possible only when the treating physician has the requisite knowledge, experience, and vision to use BOTOX as part of a unique solution for each patient’s specific needs. If history is any indication, demand for aesthetic BOTOX will continue to grow, and innovative approaches will further refine its use. The most successful physicians will be those who can develop and innovate at a pace with the industry.