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Botox injection is one of the most common cosmetic procedures performed. Botox temporarily paralyzes targeted skeletal muscles of the face, reducing the patient’s ability to produce unwanted dynamic wrinkles. Commonly treated areas of the face include the procerus and corrugator supercilii muscles to treat glabellar frown lines, the frontalis muscle to treat horizontal rhytids of the forehead, and the orbicularis oculi muscle to treat “crow’s feet” wrinkles along the lateral aspect of the orbit. A thorough facial analysis is necessary to develop a treatment plan for each problem area, particularly by engaging the patient to determine what his or her goals for treatment are. Providers must take care when injecting into the face to avoid complications of overtreatment, such as brow ptosis from over-injecting the forehead or elevated brow from over-injecting the periorbital muscles.
The dermal layer of the skin is primarily composed of the extracellular matrix (ECM) and fibroblasts.1 Collagen fibers are the main component of the ECM, providing strength, support, and resilience to the skin. The production of new collagen decreases with age, and the existing collagen becomes fragmented and coarsely distributed due to the production of destructive reactive oxygen species. Major factors that contribute to the destruction of dermal ECM include age, UV damage, and exposure to tobacco smoke.2 These factors, along with hyperactive facial muscles, contribute to the formation of facial wrinkles.
Botulinum toxin A, made by the bacteria C. botulinum, is a neurotoxin that causes paralysis in target muscles by blocking the release of the neurotransmitter acetylcholine from pre-synaptic cholinergic nerve endings.3 While botulinum toxin was first used therapeutically as a method to alleviate focal muscle hyperactivity in disorders of the eye such as strabismus, it is now used as a treatment for a variety of conditions including focal dystonia, chronic headaches, hyperhidrosis, and gastrointestinal motility disorders.4, 5
The intramuscular placement of botulinum toxin into the face relaxes the muscles, decreasing the patient’s ability to produce unwanted dynamic rhytids in the overlying skin. The duration of paralysis varies but typically lasts for approximately 3 months. Commonly treated areas of the face include the glabellar and lateral canthal lines, as well as the horizontal forehead lines.3
This female patient presented for the cosmetic treatment of dynamic rhytids of the face. There were no known allergies or contraindications to treatment including personal or family history of certain neurologic and autoimmune disorders. Patients should also be queried as to whether or not they are pregnant or breastfeeding.
Physical examination revealed a healthy-appearing woman in no acute distress. Facial analysis is performed by instructing the patient to contract and relax the muscles of the face, taking note of the movement of the face. Dynamic rhytids appear as creases in the skin as the patient contracts the facial muscles, which disappear as the patient relaxes. As mentioned previously, it is important to engage the patient to the motivation for obtaining treatment.
No imaging is required prior to injecting Botox. Facial photography at rest and during facial movements may be obtained, though this is not common in our practice unless additional procedures are to be performed (rhinoplasty, blepharoplasty, etc.).
Facial rhytids develop due to loss of collagen and elasticity from age-related processes and ultraviolet light exposure. The age at which they appear depends on factors such as the amount of cumulative sun exposure as well as genetic predisposition. Patients may begin to notice dynamic rhytids in their mid-to-late second decade, at which point they can begin treatment with Botox injection to prevent the formation of static rhytids.
Botox injections are primarily used to treat dynamic rhytids of the face. Dynamic rhytids differ from static rhytids in that they either become more prominent or are only visible, during contraction of the muscles of the face. Patients with prominent rhytids at rest may consider treatment with a neuromodulator along with additional treatments such as dermal fillers.
The injection of Botulinum toxin products for cosmetic purposes aims to soften the appearance of dynamic rhytids of the face, which are typically located around the eyes or mouth, and on the forehead.
Care must be taken by the physician to not overtreat the patient to avoid unwanted side effects such as temporary blepharoptosis or eyebrow ptosis. These complications are rare and are avoidable with good technique. Botox injection is contraindicated in patients with keloidal scarring, neuromuscular disorders such as myasthenia gravis, allergies to constituents of Botox products, and body dysmorphic disorder.6 There are currently no controlled studies of the effects of Botox injections during pregnancy. Similarly, it is unknown if Botulinum toxin A passes into breast milk.7 Recommendations by the US Food and Drug Administration, as well as product labeling, state that Botox injection should only be used during pregnancy if the benefits outweigh the potential risks.8, 9 It is recommended that patients who are planning to become pregnant, are currently pregnant, or are breastfeeding not undergo injections with Botox until further information is gathered.
The procedure began with a careful examination of the patient’s facial anatomy, with an analysis of dynamic rhytids and movement of the face with contraction. It is important that the physician inspects the patient prior to the procedure with a relaxed facial expression as well as while frowning, smiling, squinting, and with brow elevation to determine the best treatment approach. Individualized treatment is given to each patient depending on the findings of the physical exam, the patient’s goals for treatment, and patient age. This patient was unique in that she is beginning Botox treatment at an age where her treatments are aimed at preventing wrinkles from becoming permanent. This allows the physician to use smaller aliquots of neuromodulator for each treatment session.
As shown in the video, this patient presented for her first treatment with Botox injectable. The physician placed a total of 40 units of Botox at a standard concentration of 5 units per 0.1 ml. The physician performed a physical exam, explaining his rationale for treatment in this specific patient. He also explained the mechanism of action of the Botox and set expectations as to the length of time until full effects of the treatment are realized.
According to the American Society of Plastic Surgeons, the number of Botox injections in the US has increased 4% from 2018–2019, and 878% from 2000–2019, with over 7.5 million procedures performed in the US in 2019.10 In addition, 94% of the patients who received Botox injection were female,11 and the number of patients in the 20–29 age range seeking out Botox treatment increases each year. The effects of Botulinum toxin develop over 3–5 days posttreatment, with the full effect seen at 7–10 days. Botox treatment may last between 2–6 months, depending on the patient. Best results are achieved with injections at regular intervals.
1 cc sealer Luer lock TB syringe
Prepared Botox dilution: 5 units per 0.1 ml sodium chloride
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Shin JW, Kwon SH, Choi JY, et al. Molecular mechanisms of dermal aging and antiaging approaches. Int J Mol Sci. 2019;20(9). doi:10.3390/ijms20092126.
- Morita A. Tobacco smoke causes premature skin aging. J Dermatol Sci. 2007;48(3):169-175. doi:10.1016/j.jdermsci.2007.06.015.
- Carruthers A. Botulinum toxin type A: History and current cosmetic use in the upper face. Disease-a-Month. 2002;48(5):299-322. doi:10.1053/mda.2001.25138.
- Frampton JE, Easthope SE. Botulinum toxin A (Botox® cosmetic): a review of its use in the treatment of glabellar frown lines. Am J Clin Dermatol. 2003;4(10):709-725. doi:10.2165/00128071-200304100-00005.
- FDA Botox Insert. Highlights of Prescribing Information.; 2010. https://www.fda.gov/medwatch. Accessed August 23, 2020.
- Small R. Botulinum toxin injection for facial wrinkles. Am Fam Physician. 2014;90(3):168-175. https://www.aafp.org/pubs/afp/issues/2014/0801/p168.html. Accessed August 23, 2020.
- Morgan JC, Iyer SS, Moser ET, Singer C, Sethi KD. Botulinum toxin A during pregnancy: a survey of treating physicians. J Neurol Neurosurg Psychiatry. 2006;77(1):117-119. doi:10.1136/jnnp.2005.063792.
- FDA, Cder. Medication Guide Botox® Cosmetic (Boe-Tox) (OnabotulinumtoxinA) For Injection.; 2016. https://www.fda.gov/media/77359/download. Accessed August 23, 2020.
- Brin MF, Kirby RS, Slavotinek A, et al. Pregnancy outcomes following exposure to onabotulinumtoxinA. Pharmacoepidemiol Drug Saf. 2016;25(2):179-187. doi:10.1002/pds.3920.
- 2019 Plastic Surgery Statistics, Cosmetic Procedure Trends.; 2019. https://plasticsurgerycal.com/wp-content/uploads/2021/08/plastic-surgery-statistics-full-report-2019.pdf. Accessed August 23, 2020.
- 2019 National Plastic Surgery Statistics. American Society of Plastic Surgeons.; 2019. https://www.plasticsurgery.org/documents/News/Statistics/2019/plastic-surgery-statistics-report-2019.pdf. Accessed August 23, 2020.
Cite this article
Woodard CR, Elder AL, Moses HA, Brown CS. Botox injection. J Med Insight. 2023;2023(177). doi:10.24296/jomi/177.
Table of Contents
We’re going to talk a little bit about facial analysis and how we determine where we put product, when we're doing treatment for Botox for dynamic rhytids of the face. So when you're analyzing a patient the first thing you want to do is a full facial analysis. After you identify the problems that they are concerned about, you want to make sure that you can offer an appropriate correction for those issues. So as we look at Helen here, and try to identify a couple of things that we could potentially improve upon with a neuromodulator, such as Botox, we wanted to try to identify a couple of different physical exam findings. So just ask her to elevator her brow. So recall that the elevation of the brow is primarily by the frontalis, and it's the only muscle that allows appropriate brow elevation. So if a patient comes in, particularly an older patient, complaining of horizontal rhytids in their face, one of the things you have to discuss with them is their expectation of a smooth forehead.
Remember neuromodulators are used primarily to treat dynamic rhytids of the face. If somebody has rhytids at rest, it's unlikely that neuromodulator alone is going to be able to appropriately treat those areas, so you have to manage their expectation accordingly. Also in an older individual what you have to worry about with treatment, aggressive treatment of neuromodulator in the upper face is the potential risk for brow ptosis, so you could potentially drop the brow as a result of placing too much product in the upper face in an attempt to treat their primary complaint. As we move toward the midline of the face, let's ask Helen to just furrow her brow.
Okay, so you can see that she's got probably perhaps a little more activity in her procerus region. The procerus is the muscle that's going to create the horizontal rhytid, in along the upper third of the nose. And then also in many key patients you will see them complain of something called “the elevens”, which are the vertical rhytids that exist along the medial aspect of the brow that are caused by the corrugator muscle. So, typical Botox treatment will focus in this area, and in fact that was the first FDA-approved use of this for cosmetic use.
Squint your eyes like it's bright outside. So she's got fairly significant crow's feet, and those are the extended rhytids along the lateral aspect of the orbital region caused by contraction of the orbicularis oris muscle, excuse me, the orbicularis oculi muscle. And so treatment of these areas around the lateral aspect of her brow will produce something called the Botox brow lift. Essentially if you think about the seesaw effect of the elevation of the brow with the frontalis and the depression of the brow with the lateral aspect of the orbicularis, if we are treating and knocking out the depressor function along the lateral aspect of the brow, we're going to have corresponding elevation of the tail of the brow.
In a female the peak of the brow is ideally located at the lateral aspect of the limbus or the lateral aspect of the canthus. So if we can get a touch of elevation of the brow, not only are we placing it in an ideal position, but you'll also notice that we're relieving some of the excess skin along the upper aspect of the eyelids. So you really are treating two issues. You’re placing the brow in the appropriate position, and you're also relieving some of the excess skin of the upper eyelid. So for Helen, I would recommend a treatment along the lateral aspect of the orbit. A light treatment in the glabellar region focused on the procerus, and then a small amount of product in the forehead to reduce the risk of dropping the brow.
So I've mixed the product up. What we're currently using today is Botox. And what I’ve placed this in is a 1 cc Luer lock TB syringe. The product comes freeze-dried, and you have to provide your own dilution. The typical dilution for these products in Botox would be 5 units per 0.1 ml. So I had a 50-unit vial, and I used 1 cc of sodium chloride to dilute the product. So we have 5 units of the Botox per 0.1 ml.
So now I'm going to get a couple of alcohol swabs and just clean off the areas that we’re looking at injecting. So again the glabellar region, the lateral orbicularis region, and then the forehead region. When you talk to patients about their expectations, another important thing to point out is when is the onset of action of this product. And in general, I tell folks that you're going to start to see some activity around day 3, day 4, but you're not going to have full correction until a week after administration of the product. So you can reassure them that while they may see a few changes in the first couple of days, it's not going to be the final result.
So typical treatments in the glabellar region - we're probably going to not need as high a concentration for her, because we didn't have a whole lot of corrugator activity - would be approximately 20 to 25 units. I tend to inject those in 5 unit aliquots in the central region of the face. And so what I’ll tend to do is just pinch the brow in this region and remind the patient that they need to breathe and then a small stick here. As close to possible, you want to put the product in at around 90°. You don't want to come in at a tangential angle, because you're trying to place this product directly in the muscle you're trying to affect. So we’ll do some symmetric injections of product in this region, and what I'm going to do, is I'm going to treat each of the corrugators with 5 units of Botox. And then I'm going to put 5 units of Botox in the procerus region, because I think her procerus activity was a little higher, and again we didn't see as much activity in her corrugator region.
Are you okay? Mm hmm. All right, So I’ll do pressure there for just a second and let her catch her breath. And then we'll treat in the lateral orbicularis oculi region. I tend to do injections in 2.5 unit aliquots on the lateral aspect of the orbit. It’s important to remind you that if you are in the orbital skin, that the skin deep to the skin you're going to find the muscle. There's not subcutaneous tissue there, so you're going to raise wheal akin to what you would for a TB test. So you're going to want to try to stay very superficial in the skin when you're addressing the area over here.
Push your head against my hand a little bit, good. So that just creates a little bit of tension. And I’m putting in just 2.5 unit aliquots in this area here. Good. You okay? Mmm, yeah. All right, now we’re going to come to the other side, rinse and repeat. Do you need a break or are you doing all right? No, I’m fine. Okay. Again a little elevation of the brow, head against my hand just a touch, but I'll point out also in this region is that you have branches of the zygomatic facial vein or the sentinel vein that can come down and be fairly superficial. So you want to be mindful of that so you reduce the risk of bruising in that area. Okay, a little pressure on this side. Good. And then just a touch in her forehead. And what we're doing that for is to counteract - we've taken away a lot of depressor function, so the frontalis is potentially going to be overactive and potentially peek her brow up a bit, so we're just going to relieve that by putting a small amount in her forehead. And I think it would be adequate to put 5 units on each side, and we’ll be done.
And I’ll do that in 2 injections of 2.5 units each. You’ll notice that I’ll use my contralateral hand to steady the injection site. And watch out for any underlying veins. All right, that's pretty much it, and so now we’ll have the patient ice. And that was a total of 40 units we used for her, which I think is appropriate. Since we reduced the amount of product that we put in the glabellar region relative to our typical patient, who would be perhaps a little bit older prior to this injection, and that should do it. Thanks.