Administering botulinum toxin injections is an essential skill for physicians and qualified healthcare providers who wish to incorporate aesthetic medicine into their practice.
According to statistics from the American Society of Plastic Surgeons, since its approval for cosmetic use by the U.S. Food and Drug Administration (FDA), botulinum toxin has become the most commonly performed minimally invasive cosmetic procedure, with over 3 million treatments performed annually.
To successfully perform botulinum toxin procedures, an understanding of relevant anatomy and an appreciation for facial aesthetics, in addition to injection skill, are necessary to achieve desirable results.
Wrinkling is a prominent feature of skin aging. Skin naturally thins and loses volume over time as dermal collagen, hyaluronic acid, and elastin gradually diminish.
This process of dermal atrophy is accelerated and compounded by sun exposure and other extrinsic factors such as smoking.
Hyperdynamic facial musculature also contributes to formation of visible lines and wrinkles. Initially,
lines and wrinkles are seen only during active facial expression such as frowning, laughing, or smiling and are referred to as dynamic lines (Fig. 1A). Over time, dynamic lines become permanently etched into skin resulting in static lines (Fig. 2B), which are present at rest.
Skin laxity, redistribution of facial fat, and biometric changes such as bone resorption, contribute to skin folds and facial contour changes. In addition, aged skin exhibits dyschromia such as mottled pigmentation, vascular ectasias such as telangiectasias and cherry angiomas, and undergoes benign and malignant degenerative changes.
Botulinum toxin is a neurotoxin protein derived from the Clostridium botulinum bacterium. When small quantities of botulinum toxin are injected into target muscles,localized chemical denervation occurs due to inhibition of acetylcholine release at the
neuromuscular junction (Fig. below). This temporarily reduces muscle contractions and smooths skin wrinkles in the treatment area.
Basic. Areas of hyperdynamic muscles in the upper third of the face (frown lines, crow’s feet and horizontal forehead lines) yield the most predictable results with the greatest efficacy, and fewest reported side-effects when treated with botulinum toxin.
These areas are ideal for providers getting started with cosmetic botulinum toxin injections and are referred to as basic treatment areas (Table 1) in this book.
Advanced. Botulinum toxin treatments in the lower face are considered advanced procedures (Table 1). This is a highly functional region and, in addition to facial expression, lower face muscles serve essential functions of mastication and elocution.
Treated muscles in the lower face must retain partial functionality which requires more practiced injection skill with precise placement of small doses of toxin. Botulinum toxin treatment of neck bands, hyperhidrosis and all facial areas other than the basic treatment areas, are considered advanced procedures in this book. These procedures have a greater risk of complications, and it is advisable for novice injectors to gain skill and confidence with basic procedures before proceeding to advanced botulinum toxin procedures.
Patients with dynamic wrinkles that have minimal to no static component demonstrate the most dramatic improvements with botulinum toxin treatments.
Results for patients with static wrinkles are slower and cumulative, and may require two to three consecutive treatments for significant improvements. Deep static lines may not fully respond to botulinum toxin treatment alone and may require combination treatment with dermal fillers or resurfacing procedures to achieve optimal results.
Severe static wrinkles and laxity, commonly seen in patients aged 65 years or older, may require surgical intervention.
Discussion regarding realistic expectations and results during the evaluation and consultation process is essential.
|Common Name||Medical Name||Muscles|
|Frown lines||Glabellar rhytids||Glabellar complex: corrugator supercilii, procerus, and depressor supercilii|
|Horizontal forehead lines||Frontalis rhytids||Frontalis|
|Crow’s feet||Lateral canthal rhytids||Lateral orbital orbicularis oculi|
|Lower eyelid wrinkles||Infraocular rhytids||Inferior preseptal orbicularis oculi|
|Eyebrow lift||Reduction of ptotic eyebrows and dermatochalasis||Superior lateral orbital orbicularis oculi|
|Bunny lines||Nasal rhytids||Nasalis|
|Lip lines (smoker’s or lipstick lines)||Perioral rhytids||Orbicularis oris|
|Marionette lines||Melomental folds||Depressor anguli oris|
|Downturned corners of the mouth||Depressed oral commissures||Depressor anguli oris|
|Nasolabial folds||Melolabial folds||Levator labii superioris alaeque nasi|
|Gummy smile||Gingival show||Levator labii superioris alaeque nasi|
|Chin line||Mental crease or labiomental crease||Mentalis|
|Chin puckering||Mentalis contraction||Mentalis|
|Neck bands||Platysmal bands||Platysma|
Botulinum toxin treatments are directed at specifically targeted muscles or regions of muscles to focally inhibit contraction and achieve intended effects such as smoothing the skin or elevating facial areas.
An optimal result yields a pleasing aesthetic effect with minimal to no functional impairment in the treatment area and, lack of other undesired effects and complications.
The degree of muscle inhibition achieved with botulinum toxin in a given treatment area is determined by patient preference and the need to preserve functionality in the treated muscles. For example, some patients may desire complete inhibition of the glabellar complex muscles with botulinum toxin treatment of frown lines, whereas others may desire partial muscle inhibition with retention of some ability to frown.
A greater degree of muscle inhibition is typically sought for treatments in the upper third of the face than in the lower face. In the lower face, partial muscle inhibition is the desired result as the treated muscles must still be able to perform essential functions, such as eating, drinking, and speaking.
Treatment goals listed in the following chapters are based on common patient preferences and considerations of muscle functionality in the treatment areas.
C. botulinum bacteria produce eight serotypes of botulinum toxin proteins (A, B, Ca, Cb, D, E, F, and G). Botulinum toxin serotype A is the most potent and is used for cosmetic indications. The FDA currently approve two botulinum toxin serotype A products for the treatment of the glabellar complex muscles that form frown lines: onabotulinumtoxinA (OBTX) (Botox® manufactured by Allergan, Inc, Irvine, CA) and abobotulinumtoxinA (Dysport® manufactured by Medicis Pharmaceutical Corp, Scottsdale, AZ), both of which were formerly known as botulinum toxin type
A. OBTX and abobotulinumtoxinA vary in formulation, diffusion capability, onset of action, efficacy, and complications and are not interchangeable. All references to OBTX in this book refer specifically to Botox.
Botulinum toxin is the only treatment for dynamic wrinkles currently approved by the
FDA. Other treatments for static wrinkles include chemical peels; microdermabra- sion; topical products such as retinoids, nonablative lasers for soft-tissue coagulation
and tightening such as infrared and radiofrequency; nonablative lasers for collagen remodeling such as 1320-nm, 1540-nm, and Q-switched lasers; ablative and fractional ablative lasers such as erbium and carbon dioxide lasers; and operative procedures such as dermabrasion and plastic surgery.
Botox Cosmetic is supplied as a powder, typically in vials of 50 or 100 units. For reconstitution, non-preserved saline is recommended by the manufacturer and the author.
Preserved saline is used for reconstitution by some providers because it may reduce discomfort with injection. There is no standardized volume for reconstitution. Botox efficacy is based on the number of units injected rather than the dilution. However, greater dilution volumes (of 10 mL or more) can increase diffusion and in turn the risk of complications.
The author’s reconstitution method, using a 100-unit vial of Botox, is outlined as follows:
Small volumes of reconstituted botulinum toxin solution are injected for cosmetic facial and neck treatments and a 1.0-mL syringe is used for injections. Providers must be aware of the exact dose associated with each 0.1-mL increment on the syringe for accurate dosing of botulinum toxin.
Botox is shipped frozen, on dry ice. Before and after reconstitution it may be stored in the refrigerator at a temperature of 2–88C (35.6–46.48F) for up to 24–36 months based on the vial size. While the manufacturer recommends using Botox within 24 hours of reconstitution, the American Society for Plastic Surgery Botox Consensus Panel recommends using Botox within 6 weeks after reconstitution and notes no loss of potency during that time.
Understanding the facial anatomy in the treatment areas is necessary before per forming botulinum toxin procedures (Anatomy section; Figs. 1–7). Most facial muscles have soft-tissue attachments to the skin through the superficial muscular aponeurotic system. When a muscle contracts, the overlying skin moves with it causing wrinkles (also called “rhytids”) to form perpendicular to the direction of the muscle contraction.
This allows for a diverse array of subtle facial expressions and functions.
Review the patient’s complete history, including medications, allergies, medical history including conditions contraindicating treatment, cosmetic history including minimally invasive aesthetic procedures and plastic surgeries as well as satisfaction with results and any side effects, and social history including occupations in which facial expression cannot be compromised.
Examine the areas of concern and, with the patient holding a mirror, have the patient prioritize the areas. Note any asymmetries, such as uneven eyebrow height, document in the chart and photograph. Discuss treatment options, number of recommended treatments, anticipated results, realistic expectations, and procedure cost. Review risks of complications associated with the procedure. Formulate a cosmetic treatment plan and record in the chart along with a consent form signed by the patient. It is advisable to use photographic documentation (referred to as photodocumentation) with aesthetic procedures and take dynamic and static photographs before botulinum toxin treatment and approximately 2 weeks post treatment to demonstrate results.
When discussing botulinum toxin or other injection treatments, it can be helpful to use non medical or “patient friendly” terminology to reduce patient anxiety. Examples of terms used include the following:
Anesthesia is typically not required for botulinum toxin treatments. If necessary, ice or a topical anesthetic may be used before injections (e.g., benzocaine, lidocaine, tetracaine).
Pretreat the anesthetic injection sites with a topical anesthetic such as benzocaine 20% : lidocaine 6% : tetracaine 4% (BLT) for 15–20 minutes prior to treatment.
Commonly used topical anesthetic products include:
* Over-the-counter product ** Prescription ***Compounded by a pharmacy See Appendix 6, Supply Sources.
BLT is one of the most potent and fast acting topical anesthetics and is preferred for use by the author. It is applied in-office, with a maximum dose of 1/2 gm applied topically for 15 minutes. Effects are enhanced for certain topical anesthetics by occluding the product under plastic wrap once applied to the skin. Occlusion under plastic wrap is not necessary with BLT due to its potency.
On the day of treatment, instruct the patient to avoid lying down for 4 hours immediately after treatment, manipulating the treated area (e.g., a facial or massage), and activities that can cause facial flushing (e.g., application of heat to the face, alcohol consumption, exercising, and tanning) to reduce the likelihood of product migration and risk of side effects. If bruising or swelling occurs, a soft ice pack may be applied for 10–15 minutes to each bruise site, every 1–2 hours until it is improved.
Complications and side effects can be categorized into injection-related or botulinum toxin related issues. Botulinum toxin–related complications listed below may be associated with treatment of the face and the neck. Complications associated with treatment of specific areas, as well as suggestions for management, are discussed in their respective chapters. General Injection-Related Complications
Pain with botulinum toxin injections is minimal as small-gauge needles are used for treatment. If necessary, injection pain can be reduced using ice, or topical anesthetics. Pretreatment anesthesia, especially with topical anesthetics, can prolong treatment times.
Bruising is commonly seen with botulinum toxin injections, particularly with treatment of crow’s feet.. Bruises can range in size from pinpoint needle insertion marks to quarter-sized ecchymoses or, rarely, hematomas. The time for resolution of a bruise depends on the patients’ physiology and the size of the bruise, where larger bruises can be visible for up to 1–2 weeks. Prevention of bruising is preferable and several suggestions for bruise prevention are listed in the Pre-procedure Checklist above. Immediate application of ice and pressure to a bruise can minimize bruise formation. Bruises can be camouflaged after treatment with makeup.
Erythema and edema are seen with almost all injections and usually resolve within a few hours after treatment. Firm compression of injection sites, particularly on the forehead, can effectively reduce edema. Icing is not typically necessary for these issues.
Headaches can occur with upper face injections and usually resolve within a few days after treatment without medication. There are reports of idiosyncratic severe headaches lasting 2–4 weeks. Nonsteroidal anti-inflammatory medications are usually adequate for management of headaches.
Infection is rare with botulinum toxin injections but can occur with any procedure that breaches the skin. The most common etiologies are bacterial or reactivation of herpes simplex. Prolonged pain, tenderness, and erythema, of more than a few days’ duration can signal infection and necessitates evaluation, with infection-specific treatment.
Numbness or dysesthesia in the treatment area is extremely rare and could result from nerve injury with injections.
Anxiety with injection procedures is common. Most patients have mild procedural anxiety, which can be reduced by ensuring that injection equipment is not visible during treatment and can be managed with breathing techniques. Rarely, patients with more severe anxiety may require preprocedural medications (e.g., tramadol 50 mg, 1 tablet 30 minutes prior to procedure).
Vasovagal episodes associated with severe anxiety are possible, and it is advisable for offices to have emergency protocols when performing injection procedures.
These complications have been reported in patients hours to weeks after receiving large doses of botulinum toxin for noncosmetic indications (e.g., 300 units in the calf muscles).
They have not been reported with cosmetic use of botulinum toxin at the labeled dose of 20 units (for glabellar lines) or 100 units (for primary axillary hyperhidrosis).
Some complications can be improved with botulinum toxin treatment of muscles that antagonize the affected muscles. However, for most complications, there are no corrective treatments and they spontaneously resolve as botulinum toxin effects diminish.
Utilizing precise injection technique into targeted muscles and minimizing diffusion of botulinum toxin with low reconstitution volumes, reduce involvement of adjacent muscles and decrease the likelihood of undesired effects and complications.
Botulinum toxin treatments in the upper third of the face can be safely and easily com-bined with treatment in the lower face during a given visit.Concomitant botulinum toxin treatment of multiple areas in the upper face may be performed; however, this can decrease expressivity. Some patients may, therefore, prefer to space out treatments in the upper face. For example, two areas may be treated together, such as the crow’s feet and frown, and 1–2 months later, treatment of the forehead and an eyebrow lift may be performed.
The lower face is a highly functional region, responsible for speaking, eating, and drinking. Excessive weakening of the muscles in this region can result in significant complications from functional impairment and it is advisable to use caution when treat ing multiple areas in the lower face and the neck. A conservative approach is to rotate treatment areas every 3–4 months such that only one area is treated with botulinum toxin at any give time. For example, if botulinum toxin treatment of upper lip lines and mental crease are desired, then the orbicularis oris muscle may be treated initially, followed by treatment of the mentalis muscle 3 months later once the upper lip botulinum toxin effect has resolved.
IncobotulinumtoxinA (Xeomin® manufactured by Merz Pharmaceuticals, Greensboro, NC), and PurTox® (manufactured by Mentor Corporation, Santa Barbara, CA) are new injectable botulinum toxin products currently undergoing FDA approval for cosmetic use in the United States.
RT001 or ReVance (ReVance Therapeutics, Newark, CA) is a physician-applied topical botulinum toxin under investigation for cosmetic applications including treatment of the crow’s feet and axillary hyperhidrosis.
Cosmetic botulinum toxin treatments are not covered by insurance. Fees for botulinum toxin injections are usually based on the number of units used, or on the treatment site.
Prices vary widely according to community pricing in different geographic regions and range from £250–£500 per site. The Current Procedural Terminology (CPT) designation for botulinum toxin procedures of the face is chemodenervation of muscles innervated by the facial nerve (CPT code 64612).
Facial aging is a multifaceted process involving not only the formation of facial lines and wrinkles but also contour changes, skin laxity, formation of dyschromic and vascular lesions, undesired hair growth, as well as benign and malignant degenerative changes.
Achieving optimal rejuvenation results often requires a combination of treatments to address these different aspects of facial aging. Botulinum toxin can be easily combined with other minimally invasive aesthetic procedures such as dermal fillers to treat static lines and volume loss; lasers and intense pulsed light for hair reduction, skin resurfacing, and treatment of benign pigmented and vascular lesion; exfoliation procedures like microdermabrasion and chemical peels; and topical skin care products.
Minimally invasive aesthetic procedures like botulinum toxin offer patients a means to enhance their appearance in a subtle, natural way and maintain a healthy youthful appearance. From the provider’s perspective, these procedures can be readily incorporated into practice to provide office-based aesthetic care.