BoTox Injection Technique.15
BoTox Injection Technique.15
BoTox Injection Technique.15
T E C H N I Q U E
Volume 1, Issue 1 45
N. Tucker
Optimal use of BoTox to improve facial esthetics re- wrinkles. These patients will often achieve a better result
quires finesse, experience, and a keen understanding of with surgery and/or laser in combination with BoTox. As
the interplay of individual muscles on facial rhytides, ex- patient awareness and education improves, I hope we will
pression, anatomic position, and symmetry. Facial asym- see a trend toward initiating BoTox treatment in the 30s
metry is often related to differences in the strength of the and 40s rather than the 50s and 60, achieving better, more
underlying muscles of facial expression. Careful inspec- natural results with smaller doses. In younger patients, ex-
tion in most patients will reveal some degree of facial cessive facial expression (particularly in the forehead and
asymmetry, evident by either a difference in the anatomic glabellar regions) can be softened and future rhytides pre-
position (most commonly appreciated in the brows) or by vented with appropriate BoTox treatment.
the depth and pattern of facial wrinkles (most commonly There are few contraindications to the use of botu-
seen in the forehead, glabella, and perioral regions). This linum toxin. Both BoTox and Myobloc are classified as
is often easier to appreciate in older patients with more ob- category C medications, meaning that there are not
vious lines. Asymmetries can be diminished or eliminated enough data available to advocate their use during preg-
by adjusting the injection site and treatment dose. Pre- nancy or lactation. Treatment should be avoided if infec-
existing asymmetries should be discussed with the patient tion is present at the planned injection site. It should be
and documented carefully. Photographs of each area at used cautiously in patients with neuromuscular disorders
rest and with maximal facial expression are an important and with coadministration of aminoglycosides or other
part of the patient record. This helps avoid any confusion agents interfering with neurotransmission. Due to the
or misunderstanding that can arise if asymmetries are first presence of human albumin, there is an extremely remote
noticed only postinjection. risk of viral disease transmission, although no cases have
The optimal dose of BoTox in each area depends on been identified.
the strength of the underlying muscles and the amount of
weakening desired. In general, more prominent rhytides
require higher doses of BoTox. The goal is to achieve the TECHNIQUE
desired effect using the smallest dose possible. The pa- There are many variations in injection technique, with re-
tient is made aware that the initial dose may be adjusted ported outcomes that are generally excellent.20–24 I usu-
on subsequent injections to achieve the best result. The ally mark the planned injection sites using a fine marking
patient should be actively involved in this decision- pen with the patient seated, particularly when treating
making process. I generally see patients in follow-up 2 multiple areas (Fig. 1). Although some authors have ad-
weeks postinjection to discuss the results in each area; ad- vocated injecting into the mounds on either side of the
justments can then be planned for the next treatment in 3 rhytid, I prefer injecting directly into the line itself. This
to 4 months. I prefer not to reinject at the 2-week follow- is based on the fact that BoTox diffuses up to 1 cm from
up because of the potential risk of antibody formation. the injection site;1,2 the underlying muscle anatomically is
Neutralizing antibodies have been reported as a complica- continuous; and it facilitates adjusting the dose and injec-
tion of BoTox treatment in approximately 5% of patients tion site when treating facial asymmetry. In general,
with cervical dystonia.17 It has been shown to be dose- therefore, I treat the lines, except in areas that are likely to
related18 and occurs more frequently with shorter injection influence the brow position, in which case I treat sym-
intervals.19 There have been no reports of reduced BoTox metrically, regardless of any pre-existing asymmetry in
activity related to antibody formation in patients treated the length or depth of the wrinkle line, to avoid unwanted
for facial esthetics. asymmetry in the position or shape of the brow.
BoTox has two important benefits. The initial benefit, After marking the injection sites, the patient is re-
seen at 4 to 7 days following injection, is a reduction in dy- clined to a supine position. A cool compress is placed over
namic wrinkles. The second effect is a long-term benefit the planned treatment areas for 3 to 5 minutes. A separate
in reducing static wrinkles, best seen when BoTox is used ice compress is kept handy to apply directly to each area
regularly for a prolonged period of time. The extent to for 5 seconds prior to injection. BoTox is prepared by
which lines will disappear depends on the initial depth of adding 2 cc nonpreserved sterile saline to each vial (50
the wrinkle, the amount of dermal restructuring that has al- U/cc), being careful to avoid denaturing the protein by let-
ready taken place prior to BoTox treatment, and the depth ting the saline enter forcefully under vacuum pressure.
of paralysis achieved. BoTox is best for relatively young The desired volume is drawn up in a 1-cc TB syringe with
patients with early wrinkles, who can enjoy excellent re- a 20-gauge needle and injected using a 30-gauge needle.
sults with small doses of BoTox that interfere minimally Alternatively, Flynn et al. have recommended a 0.3-cc in-
with facial expression. Older patients with deeper furrows sulin syringe (short Ultra-Fine II needle) to minimize
will require larger doses that are certain to reduce facial wastage.25 This design is also available in a 1-cc size. In
expression in order to reduce the static component of the areas with thick skin (such as the brow, forehead, and pe-
46 Techniques in Ophthalmology
BoTox: Ironing Out the Wrinkles
Crow's Feet
Treating crow’s feet requires more consideration. The un-
derlying muscle causing rhytides in this area is the orbic-
ularis oculi. Not only does this muscle cause crow’s feet,
but more importantly it is responsible for complete eyelid
closure with each blink and when sleeping. Significant
FIG. 1. Suggested sites for BoTox injection in the follow-
ing areas: glabella *, crow’s feet and lower eyelid , fore-
impairment of orbicularis function may cause or worsen
head , brow position •, perioral area dry eye symptoms and even result in lagophthalmos. In-
jection of crow’s feet above the lateral canthal tendon
(LCT) can be complicated by eyelid ptosis. For crow’s
feet, I start with 1 to 2 U per injection (in four or five sites),
rioral areas), I inject directly into the muscle, as these ar- injecting in each major crow’s feet line 1 to 1.5 cm lateral
eas do not tend to bruise, even when there is bleeding at to the orbital rim. Injecting above the LCT can cause lat-
the needle puncture site. In areas with thinner skin (such eral brow elevation. Even minimally asymmetric brows
as the crow’s feet, lower eyelid, under the lateral brow, can be very noticeable. For this reason, injections above
and nose), I inject subcutaneously, being careful to avoid the LCT should be performed symmetrically regardless of
any visible vessels. I warn the patient about the possibil- any asymmetry in the number or depth of the crow’s feet
ity of a small bruise when I am treating these areas and lines. The dose can then be incrementally increased on
recommend stopping aspirin for 7 to 10 days preinjection subsequent injections until the desired effect is achieved
in patients who wish to minimize this small risk. Follow- or until dry eye symptoms obviate higher doses. When dry
ing BoTox treatment, I replace the cool compress (or ap- eye symptoms develop and are not associated with reflex
ply pressure over areas of bleeding) for 2 to 3 minutes. For tearing, punctal plugs can be inserted to allow further dose
frontalis and mentalis injections only, I massage the area increase if necessary. Although diplopia has been re-
immediately following injection. When injecting above
the lateral canthal tendon, for either high crow’s feet or to
adjust brow position, I keep the patient supine for 15 to 20
minutes to minimize the risk of inducing lid ptosis by TABLE 1. Glabella
gravity-related inferior tracking of BoTox to the levator • Usual starting dose 10–25 U (5 U per injection site)
or Muller’s muscle. • Look for preexisting Asymmetry
• Treat conservatively Smaller lines (deeper, longer
glabellar lines require more
Glabella BoTox)
The glabella is the easiest area to treat and often the most • Caution Treatment of glabellar lines that
extend below brow, and above
rewarding. The underlying muscles causing wrinkles in
medial brow can cause lid
this area are the procerus and the corrugator supercilii, ptosis
which produce horizontal and vertical furrows respec-
Volume 1, Issue 1 47
N. Tucker
48 Techniques in Ophthalmology
BoTox: Ironing Out the Wrinkles
Volume 1, Issue 1 49
N. Tucker
produce a protective ptosis. Clin Experiment Ophthalmol 20. Carruthers JA, Lowe NJ, Menter MA, et al. A multicenter,
2001;29:394–399. double blind, randomized, placebo-controlled study of the
13. Garcia A, Fulton JE Jr. Cosmetic denervation of the mus- efficacy and safety of botulinum toxin type A in the treat-
cles of facial expression with botulinum toxin. A dose- ment of glabellar lines. J Am Acad Dermatol 2002;46:
response study. Dermatol Surg 1996;22:39–43. 840–849.
14. Benedetto AV. The cosmetic uses of botulinum toxin type 21. Frankel AS. BoTox for rejuvenation of the periorbital re-
A. Int J Dermatol 1999;38:641–655. gion. Facial Plast Surg 1999;15:225–226.
15. Foster JA, Wulc AE, Holck DE. Cosmetic indications for 22. Alan M. Botulinum A Exotoxin for hyperfunctional facial
botulinum A toxin. Sem Ophthalmol 1998;13:142–148. lines: Where not to inject. Arch Dermatol 2002;38:
1180–1184.
16. Brashear A, Lew MF, Dykstra DD, et al. Safety and efficacy
of Neurobloc (botulinum toxin type B) in type A-responsive 23. Carruthers A. Botulinum Toxin A: History and current cos-
cervical dystonia. Neurology 1999;53:1439–1446. metic use in the upper face. Dis Mon 2002;48:229–322.
17. Zuber M, Sebald M, Bathien N, et al. Botulinum antibodies 24. Carruthers J, Carruthers A. BOTOX use in the mid and
in dystonic patients treated with type A botulinum toxin: Fre- lower face and neck. Sem Cut Med Surg 2001;20:85–
quency and significance. Neurology 1993;43:1715–1718. 92.
18. Rollnik JD, Wohlfarth K, Dengler R, et al. Neutralizing bot- 25. Flynn CF, Carruthers A, Carruthers J. Surgical Pearl: The
ulinum toxin type A antibodies: clinical observations in pa- use of the Ultra-Fine II short needle 0.3-cc insulin syringe
tients with cervical dystonia. Neurol Clin Neurophysiolo for botulinum toxin injections. J Am Acad Dermatol 2002;
2001;3:2–4. 46:931–933.
19. Dressler D. Clinical features of antibody-induced complete 26. Matarasso SL. Complications of botulinum A exotoxin
secondary failure of botulinum toxin therapy. Eur Neurol for hyperfunctional lines. Dermatol Surg 1998;24:1249–
2002;1:26–29. 1254.
C L I N I C I A N ’ S C O R N E R
WHAT IS YOUR CURRENT preinjection cold compresses, I have them come in a half-
INJECTION TECHNIQUE? hour early (this is rare). I carefully wipe the area to be
treated with alcohol swabs. I suggest the following pearls
Dr. Anderson: I feel that it is important to inject patients for injection: Mark injection sites with a fine-tip marker;
in a sterile area. I inject my patients in a minor room in a use a 30-gauge 1/2-inch needle; pinch up skin at the in-
surgery chair at around 30. If patients desire topical or jection site; use loupes or reading glasses to detect and
avoid vessels; relax muscles during injection; direct the
Address correspondence to Richard L. Anderson, Center for Facial Ap-
needle nearly horizontal through pinched skin (don’t jab);
pearances, 1002 East South Temple, Suite 308, Salt Lake City, UT inject just under the skin in most sites (this helps avoid
84102; or Jean Carruthers, 943 W. Broadway, #740, Vancouver, British pain and hematoma from hitting muscle, blood vessels,
Columbia, V5Z 4E1 Canada.
Dr. Anderson is a paid consultant for Allergan (manufacturer of BoTox).
nerves and periosteum. Neurotoxins diffuse into the mus-
Dr. Carruthers is a paid consultant for Allergan (manufacturer of BoTox) cle); hold firm pressure immediately on any hematoma. If
and Elan (manufacturer of Myobloc). hematoma occurs, suggest avoiding aspirin and so forth
50 Techniques in Ophthalmology
BoTox: Ironing Out the Wrinkles
immediately prior to the next injection. Chart injections in Dr. Carruthers: In the last year I have injected more
a diagram for future reference. I feel that asking patients and more patients in the depressor anguli oris and men-
to contract muscles injected or not contract or avoid ac- talis. The mouth frown is a potent negative facial expres-
tivity is unnecessary. sion, and I think that this injection, along with the injection
Dr. Carruthers: If patients are taking nonsteroidal, as- of filler and nonablative resurfacing, really does help re-
pirin, or anti-inflammatory medications, we do routinely store the mouth area in a way that gives no downtime. I like
use preinjection cold compresses as well as topical Beta- to be sure that I inject just anterior to the anterior border of
caine anesthetic ointment. We always have our patients the masseter at the angle of the jaw so that BoTox gets into
sitting and we use the Becton-Dickinson superfine II 7- the depressor anguli oris by diffusion. If you inject more
mm 30-gauge needle on a 0.3-cc syringe. Serendipitously, anteriorly, in other words right into the muscle, what you
my husband Alastair discovered that if you dilute the see is diffusion into the depressor labii, and this gives
BoTox 1 cc of preserved saline in the vial, one Botox unit lower lip elevation, which is an impediment to speech and
is the same as 1 diabetic unit. Our injection technique is also cosmesis. This is photographically documented both
to go into the muscle in the brow, to be intradermal in the in our upcoming book (ready at the American Academy of
horizontal forehead lines and lateral crow’s feet areas if Dermatology March 2003) and also in our video series,
the skin is rather thin and there is a big plexus of veins that which can be accessed at [email protected].
need to be avoided.
We use frozen peas as our postinjection cold com-
presses, and then we have the patients stay upright for at WHAT DO YOU DO WITH UNUSED
least 4 hours after the injection. We make a joke of it and BOTOX AT THE END OF THE DAY?
say, “No shoe shopping!” Dr. Anderson: I have used BoTox on my family and my-
In addition, we ask the patients to repeatedly contract self after several days of refrigeration with little loss of
the muscles we have injected for 30 minutes, as this has strength. I usually use the daily unused on staff or family.
been shown to improve the binding and thus to improve Dr. Carruthers: Unused BoTox at the end of the day is
the results. We usually see the patients back in 2 weeks injected into my staff members and into individuals such
and then evaluate them and photograph them again and as receptionists in other doctors’ offices who send us a lot
see if there is any need to enhance their results. of patients. We have kept the vial over the weekend with
the plug in to prevent evaporation, but largely we try to use
it as a promotional event rather then leaving it in the fridge.
IS THERE ANYTHING ABOUT YOUR We have used it up to 1 month after recomposition and not
CURRENT TECHNIQUE THAT HAS found there to be any significant decrease in the potency.
EVOLVED OVER THE LAST YEAR?
Dr. Anderson: In the last year I have tried to establish a
more natural, youthful appearance in patients. I still treat IN WHAT CLINICAL SETTING
the glabellar region heavily but have in general lessened ARE YOU CURRENTLY USING
the forehead total dose and spread it over more sites to al- MYOBLOC?
low minimal but even forehead function. I have in general Dr. Anderson: I use Myobloc for touch-ups on BoTox pa-
treated crow’s feet with higher doses. I am injecting nasal tients. If one area doesn’t take or wears off before the sur-
scrunch lines, lips, mentalis scrunch, and melolabial folds roundings, I use Myobloc. Myobloc has advantages in this
much more frequently. My suggested doses are noted in situation: No fear of immunization to botulinum A toxin
Table 1. from short repeat dosing; more rapid onset to smooth out
uneven areas; shorter duration of action so it wears off be-
fore the next BoTox injection; stable in solution so a vial
can be kept in the refrigerator for touch-ups for long time
periods. As a primary treatment, Myobloc has the disad-
TABLE 1. Average Botox Cosmetic Requirements
vantages of a much shorter duration, more painful injec-
Forehead 20–30 units in 4–7 sites tions, dry mouth, and 50 to 100 times unit dosage re-
Glabella 20–40 units in 5–6 sites
Crow's feet 15–25 units in 6 sites quired.
Nasal scrunch lines 4–8 units in 2 sites Dr. Carruthers: I use Myobloc when I am looking for
Upper lip 3–5 units in 2 sites a very fast effect—within 7 to 8 hours after injection the
Lower lip 3–5 units in 2 sites process starts. Myobloc is a fabulous alternative. I partic-
Melolabial fold 4–8 units in 2 sites ularly like it for the extra diffusion it gives in the forehead
Mentalis scrunch 4–10 units in 2 sites
Platysmal bands 20–100 units in multiple sites and in the crow’s feet areas. In addition I find it very help-
ful in the axilla and palms for hyperhidrosis.
Volume 1, Issue 1 51
N. Tucker
WHAT OTHER PEARLS require more than females and old more than young. Tell
WOULD YOU OFFER FOR patients that you would prefer not to overtreat at the first
THE OPHTHALMOLOGIST injection, and if they require more you can increase the
JUST STARTING TO USE BOTOX? dose at the next visit.
Dr. Carruthers: The ophthalmologist starting to use
Dr. Anderson: I feel that ophthalmologists beginning to BoTox should understand global facial anatomy and not
use BoTox should start with glabellar folds until they are just that of the periorbital region. I think it is a good plan
comfortable with the injections. Patients note the greatest to go to your local university department of anatomy and
response in this area and there are fewer negative effects. review the anatomy and physiology of the muscles prior
Stronger muscles require more BoTox. In general, males to starting cosmetic injections.
52 Techniques in Ophthalmology