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Botox Injection

Charles R Woodard, MD1; Alexandra L. Elder, BS2; C. Scott Brown, MD1
1Department of Head and Neck Surgery & Communication Sciences, Duke University
2Department of Dermatology, Thomas Jefferson University


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 dropped brow from over injecting the forehead or elevated brow from over injecting the periorbital muscles.

Case Overview


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 subcutaneous muscles, decreasing the patient’s ability to produce unwanted dynamic rhytids in the overlying skin. With early and consistent use of injectable neuromodulators such as Botox, patients can avoid the development of deeper static rhytids. The duration of paralysis varies but typically lasts for approximately 3 months. Commonly treated areas of the face include the glabellar and infraorbital lines, as well as the horizontal forehead lines.3

Focused History of the Patient

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 of family history of certain neurologic and autoimmune disorders. Patients should also be queried as to whether or not they are pregnant or breastfeeding.  

Physical Exam

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.

Natural History

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.

Options for Treatment

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. 

Rationale for Treatment

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.

Special Considerations

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.

Statement of Consent

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.


  1. Shin JW, Kwon SH, Choi JY, et al. Molecular mechanisms of dermal aging and antiaging approaches. Int J Mol Sci. 2019;20(9).
  2. Morita A. Tobacco smoke causes premature skin aging. J Dermatol Sci. 2007;48(3):169-175.
  3. Carruthers A. Botulinum toxin type A: History and current cosmetic use in the upper face. Disease-a-Month. 2002;48(5):299-322.
  4. 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.
  5. Fda Botox insert. HIGHLIGHTS OF PRESCRIBING INFORMATION.; 2010. Accessed August 23, 2020.
  6. Small R. Botulinum Toxin Injection for Facial Wrinkles. Vol 90.; 2014. Accessed August 23, 2020. 
  7. 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.
  8. Fda, Cder. MEDICATION GUIDE BOTOX ® BOTOX ® Cosmetic (Boe-Tox) (OnabotulinumtoxinA) for Injection What Is the Most Important Information I Should Know about BOTOX and BOTOX Cosmetic? BOTOX and BOTOX Cosmetic May Cause Serious Side Effects That Can Be Life Threatening, Including: • Problems Breathing or Swallowing • Spread of Toxin Effects.
  9. Brin MF, Kirby RS, Slavotinek A, et al. Pregnancy outcomes following exposure to onabotulinumtoxinA. Pharmacoepidemiol Drug Saf. 2016;25(2):179-187.
  10. 2019 Plastic Surgery Statistics, Cosmetic Procedure Trends COSMETIC SURGICAL PROCEDURES.; 2019.
  11. 2019 American Academy of Plastic Surgery Statistics. Accessed August 23, 2020.