Cosmetic Injection Techniques
A Text and Video Guide to Neurotoxins and Fillers
Cosmetic Injection Techniques
A Text and Video Guide to Neurotoxins and Fillers
Theda C. Kontis, MD, FACS
Assistant Professor
Johns Hopkins Hospital
Board-Certified Facial Plastic Surgeon
Facial Plastic Surgicenter
Baltimore, Maryland
Victor G. Lacombe, MD
Board-Certified Facial Plastic Surgeon
Santa Rosa, California
Foreword by Jean D. Carruthers, MD, FRCSC, FRC(Ophth)
Clinical Professor
Department of Ophthalmology
University of British Columbia
Vancouver, British Columbia
Sarah E. Faris, MA, CMI
Medical Illustrator
Thieme
New York · Stuttgart
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333 Seventh Ave.
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Executive Editor: Timothy Hiscock
Managing Editor: J. Owen Zurhellen IV
Editorial Assistant: Elizabeth Berg
Senior Vice President, Editorial and E-Product Development: Cornelia Schulze
Production Editor: Barbara A. Chernow
Medical Illustrator: Sarah E. Faris, MA, CMI
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Library of Congress Cataloging-in-Publication Data
Kontis, Theda C.
Cosmetic injection techniques : a text and video guide to neurotoxins and fillers / Theda C. Kontis,
Victor G. Lacombe.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-60406-712-5 — ISBN 978-1-60406-713-2 (eISBN)
I. Lacombe, Victor G. II. Title
[DNLM: 1. Cosmetic Techniques. 2. Face—surgery. 3. Biocompatible Materials—therapeutic use. 4. Face‚
anatomy & histology. 5. Injections, subcutaneous—methods. 6. Neurotoxins—therapeutic use. WE 705]
617.5′20592—dc23 2012036154
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Some of the product names, patents, and registered designs referred to in this book are in fact registered
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Printed in China
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ISBN 978-1-60406-712-5
Also available as an e-book:
eISBN 978-1-60406-713-2
I dedicate this book to David and Alexandra, for their love and support;
to my Mom, my greatest fan; and in memory of my father, my angel.
– TCK
I dedicate this book to my wife, Alice, and my children, Victoria and Max.
You all mean the world to me. Love, Victor.
– VGL
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Contents
denotes a chapter with additional video content on MediaCenter.thieme.com
Foreword by Jean D. Carruthers ....................................................................................................................... x
Preface ...................................................................................................................................................................... xi
Section I Introduction to Neurotoxins
1 Neurotoxins Overview ................................................................................................................................ 2
2 Neurotoxin Preparation ............................................................................................................................. 5
3 Instrumentation for Neurotoxin Injections ...................................................................................... 6
4 The Physicians Coalition for Injectable Safety .................................................................................. 8
Section II Neurotoxin Injection Techniques
5 Neurotoxin Injection for Glabellar Frown Lines ............................................................................ 10
6 Neurotoxin Injection for Forehead Wrinkles .................................................................................. 16
7 Neurotoxin Injection for Smile Lines and Crow’s Feet ................................................................ 22
8 Neurotoxin Injection for Lateral Brow Lift ...................................................................................... 26
9 Neurotoxin Injection for Chemical Brow Lift.................................................................................. 29
10 Neurotoxin Injection for Lower Eyelid Roll ..................................................................................... 32
11 Neurotoxin Injection for Bunny Lines ................................................................................................ 34
12 Neurotoxin Injection for Nasal Tip Lift .............................................................................................. 38
13 Neurotoxin Injection for Nasal Flare .................................................................................................. 40
14 Neurotoxin Injection for Elevating the Oral Commissures ....................................................... 42
vii
viii Contents
15 Neurotoxin Injection for Lip Lift .......................................................................................................... 45
16 Neurotoxin Injection for Smoker’s Lines .......................................................................................... 47
17 Neurotoxin Injection for Gummy Smile ............................................................................................ 50
18 Neurotoxin Injection for Dimpled Chin ............................................................................................ 54
19 Neurotoxin Injection for Platysmal Banding .................................................................................. 57
20 Neurotoxin Injection for Necklace Lines ........................................................................................... 60
21 Neurotoxin Injection for Nefertiti Neck Lift .................................................................................... 62
22 Neurotoxin Injection for Masseter Hypertrophy ........................................................................... 66
23 Neurotoxin Injection for Parotid Gland Hypertrophy ................................................................. 69
24 Neurotoxin Injection for Submandibular Gland Hypertrophy ................................................ 72
25 Neurotoxin Injection for Gustatory Sweating (Frey Syndrome) .............................................. 74
26 Neurotoxin Injection for Profusely Sweating Underarms ......................................................... 76
27 Neurotoxin Injection for Profusely Sweating Hands .................................................................... 80
28 Neurotoxin Injection for Profusely Sweating Feet ........................................................................ 82
29 Neurotoxin Injection for Migraines .................................................................................................... 84
30 Management of Neurotoxin Injection Complications ................................................................. 88
Section III Introduction to Fillers
31 Fillers Overview .......................................................................................................................................... 92
32 Anesthesia Techniques ............................................................................................................................. 96
33 Filler Injection Methods ....................................................................................................................... 100
Section IV Filler Injection Techniques
34 Filler Injection for Nasolabial Folds ................................................................................................. 104
35 Filler Injection with Polymethylmethacrylate (Artefill) ......................................................... 108
36 Filler Injection for Marionette Lines ............................................................................................... 111
37 Filler Injection for Lip Augmentation ............................................................................................. 114
38 Filler Injection for Elevating the Oral Commissures ................................................................. 118
Contents ix
39 Filler Injection for Vertical Lip Lines ............................................................................................... 120
40 Filler Injection for Glabellar Frown Lines ...................................................................................... 122
41 Filler Injection for Forehead Wrinkles ........................................................................................... 125
42 Filler Injection for Tear Trough Deformity .................................................................................... 128
43 Filler Injection for Sunken Upper Eyelids ...................................................................................... 131
44 Filler Injection for Lateral Brow Lift ................................................................................................ 134
45 Filler Injection for Sunken Temples ................................................................................................. 137
46 Filler Injection for Nonsurgical Rhinoplasty ................................................................................ 140
47 Filler Injection for Nasal Valve Stenting ......................................................................................... 146
48 Filler Injection for Medial Midface Hollowing ............................................................................ 149
49 Filler Injection for Cheekbone Augmentation ............................................................................. 152
50 Filler Injection for Sunken Cheeks ................................................................................................... 156
51 Filler Injection for Chin Augmentation .......................................................................................... 160
52 Filler Injection for the Mental Crease ............................................................................................. 164
53 Filler Injection for Jawline Rejuvenation ....................................................................................... 166
54 Filler Injection for Earlobe Rejuvenation ...................................................................................... 168
55 Filler Injection for Acne Scars ............................................................................................................ 170
56 Filler Injection for Aging Hands ........................................................................................................ 173
57 Filler Injection with Poly-L Lactic Acid for Facial Volumizing (Sculptra) ......................... 176
58 The “Liquid Facelift” ............................................................................................................................... 180
59 Management of Filler Injection Complications .......................................................................... 182
Appendices
A Neurotoxin/Filler Injection Techniques Arranged by Order of Difficulty
and Level of Experience Required ..................................................................................................... 190
B Sample Informed Consent Form for Neurotoxin Injections .................................................. 192
C Sample Informed Consent Form for Filler Injections ............................................................... 193
Index ...................................................................................................................................................................... 195
Foreword
Drs. Theda C. Kontis and Victor G. La- of injection technique are carefully
combe, two highly respected facial plas- explained and demonstrated. But none
tic surgeons, share their combined ex- of this efferent response is possible
periences in this practical handbook on without a secure afferent knowledge of
Cosmetic Injection Techniques. If “Seeing anatomy—both classical and as found
Is Believing,” the authors have done a with the subject themselves.
superb job in making the facial tissue This book is a labor of love written
“transparent” for everyone interested in by authors who represent variations in
this increasingly important subject area. techniques from the East and West coasts
Universal appreciation of the predict- of the United States. I recommend it to
able effectiveness and safety of cosmetic all readers who choose to review their
injections has opened up the possibili- treatment plans from start to finish and
ties of other medical treatments to the who value learning from experts who
benefit and health of millions. teach with passion as well as knowledge.
Cosmetic surgeons have the privilege
of using transcutaneous treatments to Jean D. Carruthers MD, FRCSC, FRC(Ophth)
restore patients’ faces to their natural Fellow American Society of Ophthalmic
best. Drs Kontis and Lacombe written Plastic and Reconstructive Surgery,
a text to assist with this process. The Clinical Professor, Department of
anatomy drawings are precise, clearly Ophthalmology
labeled, and well correlated with the University of British Columbia
clinical issues under discussion. Details Vancouver, British Columbia
x
Preface
I hear and I forget.
I see and I remember.
I do and I understand.
Confucius
Chinese philosopher (551 BC–479 BC)
The number of nonsurgical facial en- The authors are aware that there is
hancements has skyrocketed in the past certainly more than one way to treat a
10 years. As a consequence of patient certain anatomic region. It was our aim,
demand, many physicians, nurses, and by having authors from two very differ-
physician assistants have begun to treat ent locales (East Coast and West Coast),
such patients. This book is a guide and and different practices, that the “best”
quick reference for the many profession- injection technique would be described
als and paraprofessionals who have be- by comparing our techniques of injec-
come facial injectors. It is not, however, tion. In cases where our techniques
a training manual for the naive injector. markedly differed, alternate techniques
We highly discourage the novice injec- are presented.
tor from using this book as a primer on The products described in the book
injections. In our opinion, nothing can are all U.S. Food and Drug Administra-
replace training that is offered by courses tion (FDA)-approved fillers and neuro-
and by one-on-one preceptorships. toxins; however, most of the techniques
This book was designed to augment described are considered “off-label” uses
the knowledge of a beginner injector of the products. The doses of products
and to train the experienced injector in described serve as a general guide for
how to perform “finesse” injections. The injection. Although the utmost care was
face can be shaped and minor irregu- taken in ensuring the accuracy of the
larities and asymmetries improved by dosing listed, we urge the injector to use
performing the techniques we describe. his or her best judgment or experience
In addition, we hope to help the injector in the unlikely event that a misprint sug-
“look through” the skin to the under- gests an inappropriate dose. The com-
lying anatomy. This will help to identify ments we make about specific products
both the targets of injection and the are often our opinion derived from
important structures to avoid. clinical observation. Others may have
xi
xii Preface
different observations clinically, and we stylane, Perlane, Juvederm Ultra and
respect these variations in clinical prac- Ultra Plus, Belotero, Radiesse, Sculptra,
tices and results. and Artefill. These products are the
We realize that this book will be uti- most commonly used fillers and neuro-
lized by injectors with different skill toxins at the time this manual was writ-
levels. In an attempt to promote safe uti- ten. New products are being developed
lization of these products, we have de- and may be available at the time of
vised a rating scale for each technique. publication. However, because we have
Each injection technique is evaluated in no experience with these new products,
terms of difficulty for the trainer, risks they will not be described in this edi-
involved in performing the injection, tion. The experienced injectors, however,
and patient satisfaction with the results. will be able to extrapolate the tech-
Appendix A lists the chapters by degree niques and dosing strategies described
of difficulty, as a cross-reference for in- in this book to newer products, if they
jectors who would like to safely advance desire.
to more challenging injection techniques.
The rating system is as follows:
■ ■Disclosure
Degree of difficulty for the injector:
Easy T.C.K. is a speaker/trainer for Allergan,
Intermediate Medicis, and Valeant. V.G.L. is a speaker/
Advanced trainer for Allergan, Medicis, and Vale-
Expert injectors only should at- ant, and serves as a principal investiga-
tempt these injections tor for Juvederm Voluma.
Patient satisfaction with procedure: Disclaimer
Variable results; results may be subtle
Good results; patients usually The material presented is a compilation
pleased of the clinical experiences of the authors.
High patient satisfaction; predict- Off-label uses of FDA approved products
able results are described. A qualified health care
professional should be consulted before
Risks of complications: using any therapeutic procedure dis-
Low cussed. Readers should verify all infor-
Medium mation and data before treating patients
High or employing any therapies described in
this publication.
The products described in this book
include Botox, Dysport, Xeomin, Re-
Acknowledgment
The authors would like to thank the skill have made this volume one that is
people at Thieme Publishers for believ- not only thorough, but easy to read and
ing that a well-illustrated manual for understand. We would also like to thank
facial injectables was needed in the Kristi Fritz for scheduling patients for
medical literature. Specifically, we ap- injection technique demonstrations and
preciate the editorial assistance of for acting as videographer for such ses-
Timothy Hiscock and J. Owen Zurhellen sions. Finally, and most importantly, we
at Thieme. This quality of this book was thank our patients who have graciously
enhanced by the fabulous artwork of agreed to have their procedures filmed
our medical illustrator, Sarah E. Faris. so that medical professionals can learn
Her attention to detail and her artistic safe injection techniques.
xiii
■ SE C T ION I ■
Introduction to Neurotoxins
1
Neurotoxins Overview
■ ■Action • Vacuum dried
• Store in freezer until reconstituted;
Peripheral neuromuscular blocking refrigerate after reconstitution
agents.
Dysport: AbobotulinumtoxinA
■ ■Mechanism of Action (BoNTA-ABO)
• 300 DU (Dysport units) per vial (also
Botulinum toxins irreversibly bind to contains 0.125 mg human serum al-
the presynaptic terminal of the neuro- bumin, 2.5 mg lactose)
muscular junction and prevent release • Lyophylized
of acetylcholine, thereby preventing • Store in freezer until reconstituted;
muscle contraction. refrigerate after reconstitution
■ ■Botulinum Toxin A (BoNTA) Xeomin: IncobotulinumtoxinA
Formulations (BoNTA-INC)
• 100 XU (Xeomin units) per vial (also
Botox: OnabotulinumtoxinA contains 1.0 mg human albumin,
(BoNTA-ONA)
4.7 mg sucrose)
• 100 BU (Botox units) per vial (also • Lyophylized
contains 0.5 mg human serum albu- • Stored at room temperature; refrig-
min, 0.9 mg sodium chloride) erate after reconstitution
2
CHAPTER 1 ■ Neurotoxins Overview 3
Neuronox • The only botulinum toxin A regis-
tered with the Chinese government
• Approved in 2004 by South Korean • Lyophilized
Food and Drug Administration (FDA),
manufactured by Medy-Tox Inc. • Contains 5 mg bovine serum albu-
min, 25 mg dextran, 25 mg sucrose
(Seoul, Korea)
per 100 units
• Not U.S. FDA-approved in the United • Conversion ratio to Botox unknown
States
• 50, 100, and 200 U vials available • Store in freezer, refrigerate after
reconstituted
(100 U contains 0.5 mg human
serum albumin and 0.9mg sodium
chloride) ■ ■Botulinum Toxin B (BoNTB)
• Lyophilized Formulation
• Conversion ratio appears to be 1:1
with Botox Myobloc: BoNTB
• Stored in freezer until reconstituted; (rimabotulinumtoxinB)
refrigerate after reconstitution
• Solstice Neurosciences Inc., Mal-
vern, PA
Purtox • Minimal use cosmetically due to
• Pending FDA approval painful injection and limited
• Similar to Xeomin without complex- duration
ing proteins • FDA-approved only for cervical
dystonia
BTXA
• Not FDA-approved in the United
States
4 SECTION I ■ Introduction to Neurotoxins
Table 1.1 Comparison of Botulinum Toxin A Formulations
Dosing
Similar Ratio
Year of Product Compared
FDA Trade with
Product Approval Generic Name Composition Manufacturer Names Botox
Botox 2002 Onabotu- 900 kd Allergan, Inc., Botox NA
linumtoxinA Irvine, CA cosmetic,
Vistabel,
Vistabex
Dysport 2009 Abobotu- 500–900 kd Medicis Reloxin, 2.5–3:1
linumtoxinA Aesthetics, Azzalure
Inc., Scotts-
dale, AZ
Xeomin 2011 Incobotu- 150 kd Merz Aesthet- Xeomeen, 1–1.5:1
linumtoxinA No complex- ics, Inc., Bocouture
ing proteins Franksville,
WI
Neuronox N/A N/A 900 kd Medy-Tox Meditoxin, 1:1
Inc., Seoul, Cunox,
Korea Siax, and
Botulift
Purtox Pending N/A 150 kd Mentor Corp., 1–1.5:1
No complex- Santa
ing proteins Barbara, CA
BTXA N/A N/A 900 kd Lanzhou Prosigne ?
Biologics,
Lanzhou,
China
Abbreviation: N/A, not applicable.
■ ■Additional Reading Moers-Carpi M, Dirschka T, Feller-Heppt G,
et al. A randomised, double-blind compar-
Flynn TC. Advances in the use of botulinum ison of 20 units of onabotulinumtoxinA
neurotoxins in facial esthetics. J Cosmet with 30 units of incobotulinumtoxinA for
Dermatol 2012;11:42–50 PubMed glabellar lines. J Cosmet Laser Ther 2012
Nettar K, Maas C. Neuromodulators: avail- PubMed
able agents, physiology, and anatomy. Fa-
cial Plast Surg 2011;27:517–522 PubMed
2
Neurotoxin Preparation
Package inserts for the neurotransmit- • 2.5 mL preserved saline, which
ters state that they should be reconsti- produces a solution of 12 DU per
tuted with nonpreserved saline (0.9% 0.1 mL
sodium chloride). However, clinical prac- • 1.5 mL preserved saline, which
tice has determined that using preserved produces a solution of 20 DU per
saline results in much less patient dis- 0.1 mL
comfort. • 1.0 mL preserved saline, which
Botox, Botox Cosmetic—100 BU (Botox produces a solution of 30 DU per
units) may be reconstituted with: 0.1 mL
General conversion ratios:
• 1 mL preserved saline, which pro-
duces a solution of 10 BU per 0.1 mL • 1 BU = 1.0 to 1.5 XU
• 2 mL preserved saline, which pro- • 1 BU = 2.5 to 3.0 DU
duces a solution of 5 BU per 0.1 mL
• 2.5 mL preserved saline, which pro-
duces a solution of 4 BU per 0.1 mL ■ ■Additional Reading
• 4 mL preserved saline, which pro-
duces a solution of 2.5 BU per 0.1 mL Moers-Carpi M, Tan K, Fulford-Smith A.
A multicentre, randomized, double-blind
study to evaluate the efficacy of Onabotu-
Xeomin—100 XU (Xeomin units) may linumtoxinA (20 units) in the treatment of
be reconstituted and used similar to glabellar lines when compared to Incobot-
Botox, above. ulinumtoxinA (30 units). European Mas-
Dysport—300 DU (Dysport units) may ters in Aesthetic and Anti-aging Medicine,
be reconstituted with: September 30–October 1, 2011, Paris
5
3
Instrumentation for
Neurotoxin Injections
After reconstitution, botulinum toxin A When using these non-drip insulin
(BoNTA) can be injected using a 1-mL syringes, the needle is pre-attached.
syringe with a 30-gauge needle. Product The BoNTA must be reconstituted and
can be withdrawn from the vial with the vial stopper removed. Neurotoxin is
a 20-gauge needle, and a 30-gauge or drawn up into each syringe and the sy-
smaller needle can then be used for in- ringes labeled with the product name,
jection. A “No Waste” syringe with or lot number, and expiration date. The sy-
without a Luer lock (Acuderm Inc., Fort ringes are stored in the refrigerator. Be-
Lauderdale, FL, or Exelint International, cause the needles are so fine and fragile,
Los Angeles, CA) is also available that care must be taken not to hit the vial
pushes the last drop of product through with the needle tip while aspirating the
the needle hub. Alternatively, non-drip product. In addition, the utmost care is
insulin syringes (BD Ultra-Fine Needle, required during re-capping of the needle
Becton Dickinson, Franklin Lakes, NJ) (prior to patient use) to prevent damage
may be used. These syringes are avail- or blunting of the fine needle tip.
able in 0.3 and 0.5 mL and have an at-
tached 31-gauge, 8-mm needle.
6
CHAPTER 3 ■ Instrumentation for Neurotoxin Injections 7
Fig. 3.1 Dripless 0.5 mL (left) and 0.3 mL (right) Fig. 3.2 “No Waste” syringe pushes plunger
BD insulin syringes may be used for BoNTA in- into needle hub. (Left) Acuderm, (right) Exelint.
jections. These syringes have a pre-attached 31-
gauge needle.
4
The Physicians Coalition for
Injectable Safety
The increased popularity of injectable can Society for Aesthetic Plastic Surgery
procedures has been accompanied by an (ASAPS), the American Society of Plastic
unfortunate increase in the performance Surgeons (ASPS), the American Society
of these procedures by unqualified per- for Dermatologic Surgery (ASDS), the
sonnel. It is the authors’ concern that American Academy of Facial Plastic and
the use of this book by untrained indi- Reconstructive Surgery (AAFPRS), the
viduals could produce disastrous results. American Society of Ophthalmic Plastic
The Physicians Coalition for Injectable and Reconstructive Surgery (ASOPRS),
Safety (PCIS) was created to provide the the International Society of Aesthetic
public with information on qualified in- Plastic Surgery (ISAPS), the International
jectors, Food and Drug Administration Federation of Facial Plastic Surgery Soci-
(FDA)-approved materials, and informa- eties (IFFPSS), and the Canadian Society
tion on injectable training that can be for Aesthetic Plastic Surgery. We en-
obtained by qualified professionals. We courage professionals to utilize the PCIS
direct patients and injectors to the PCIS Web site for up-to-date information
Web site, http://www.injectablesafety about injectables and injectable safety,
.org, for appropriate information about laws and ethical guidelines pertaining
the safe use of injectable materials. to the purchase of injectables, research
The PCIS is represented by over 5,000 and statistics, and courses available for
board-certified members of the Ameri- training in the use of injectables.
8
■ SE C T ION II ■
Neurotoxin Injection Techniques
5
Neurotoxin Injection for Glabellar
Frown Lines
zontal lines are caused by contraction
Difficulty: of the centrally located procerus muscle.
Patient Satisfaction: The corrugators originate on the supra-
Risk: orbital ridge of the frontal bone and in-
sert on the skin above the middle third
of the eyebrow. The procerus muscle
originates on the nasal bone and inserts
■ ■Indications onto the skin of the glabella or mid-
forehead.
Neurotoxins are commonly used to treat Although this anatomy seems straight-
the vertical lines between the brows. forward, there are subtle anatomic
This is the only area currently Food and variations that can be visualized during
Drug Administration (FDA) approved facial animation. We have noted two
for treatment with botulinum toxin A distinct patterns of corrugator position-
(BoNTA). ing: either straight along the brow, or
more vertically oriented in a V shape.
For this reason, the injector should not
■ ■Anatomic Considerations rely on only one technique in this area.
The injector should “look through” the
The vertical lines of the glabella are pro- skin to imagine the location of the mus-
duced by contraction of the paired cor- cles and their contribution to the wrin-
rugator supercilii muscles, and the hori- kles produced during movement.
10
CHAPTER 5 ■ Neurotoxin Injection for Glabellar Frown Lines 11
■ ■Injection Technique tions decreases ptosis or improves re-
sults. However, some physicians ask their
Topical anesthesia may be used; how- patients not to bend over, push on the
ever, this injection usually can be toler- injection sites, or lie down for 4 hours.
ated without anesthesia. They also recommend the patient not
Prior to injecting the patient, have the exercise that day and to actively move
patient frown the brow. Attempt to look the injected muscles for 90 minutes.
through the skin to determine the size,
strength, and location of the procerus Alternate Post-Injection Instructions
and corrugator muscles.
Usual doses in this region are 20 to No exercise immediately after injection,
30 BU (Botox units) or 50 to 80 DU (Dys- as it may accentuate bruising.
port units), but injector experience with
these treatments has shown that some
patients can do well with as little as 10 ■ ■Risks
units, and others (often men) may need
substantially more. Diffusion of product into the eyelid
Injections must be placed 1 cm above may affect the levator palpebrae supe-
the superior orbital rim to reduce the rioris muscle and result in a transient
risk of upper eyelid ptosis. Injections are ptosis.
placed in the muscle belly. Try not to
“bump” the periosteum, as this occasion-
ally can be associated with post-injection ■ ■Pearls of Injection
headache.
Ask the patient to frown as you assess
the size and shape of the muscle. Tailor
■ ■Precautions the treatment to the anatomy. Filler
injections may be necessary for deep
Injection in this area can result in an rhytids in this region. Consistent re-
upper lid ptosis, which can be seen up to treatment of the glabella may result in
2 weeks after injection, and may last 2 the patient “unlearning” to move the
to 4 weeks post-injection. brow, and thus not only improve the
rhytids but also extend the time re-
quired between injections. Placing the
■ ■Post-Injection Instructions thumb along the orbital rim during in-
jection may reduce the likelihood of
There is no clinical data to suggest that diffusion toward the levator palpebrae
giving patients post-treatment instruc- superioris muscle.
12 SECTION II ■ Neurotoxin Injection Techniques
a
b
Fig. 5.1a, b Clinical photographs of the differing anatomy of corrugators muscles. (a) More hori-
zontal muscles. (b) More vertical V-like muscles. The injector should learn to “look through” the skin
to determine the anatomy.
CHAPTER 5 ■ Neurotoxin Injection for Glabellar Frown Lines 13
a
b
Fig. 5.2a, b Suggested patterns of injection for more horizontal corrugator supercilii muscles. De-
pending on the length of the muscle, the injections may need to be placed farther our laterally. (Open
circles denote optional injection sites.)
14 SECTION II ■ Neurotoxin Injection Techniques
a
b
Fig. 5.3a, b Suggested patterns of injection for the V-like corrugator supercilii muscles.
CHAPTER 5 ■ Neurotoxin Injection for Glabellar Frown Lines 15
a
b
Fig. 5.4a, b Suggested injection sites for predominantly horizontal glabellar rhytids with more con-
tribution from the procerus muscle and less contribution from the corrugator supercilii muscles.
■ ■Additional Reading a in facial aesthetics. Plast Reconstr Surg
2004;114(6, Suppl)1S–22S PubMed
Bassichis BA, Thomas JR. The use of Botox to Moy R, Maas C, Monheit G, Huber MB; Re-
treat glabellar rhytids. Facial Plast Surg loxin Investigational Group. Long-term
Clin North Am 2003;11:453–456 PubMed safety and efficacy of a new botulinum
Carruthers J, Fagien S, Matarasso SL; Botox toxin type A in treating glabellar lines.
Consensus Group. Consensus recommen- Arch Facial Plast Surg 2009;11:77–83
dations on the use of botulinum toxin type PubMed
6
Neurotoxin Injection for
Forehead Wrinkles
central position of the forehead is not
Difficulty: devoid of wrinkles. Therefore, treatment
Patient Satisfaction: of the forehead should include injections
Risk: in the central aspect of the forehead.
The upper face must be assessed both
in animation and at rest prior to injec-
tion. In women, the brow should lie at
■ ■Indications or just above the superior orbital rim. In
men, it should lie at the bony rim.
Transverse wrinkles of the forehead.
■ ■Injection Technique
■ ■Anatomic Considerations
Have the patient raise and lower the
Contraction of the paired frontalis mus- brow and assess the extent of muscle
cles raises the eyebrows and upper eye- movement. The frontalis muscles are
lids, which produces transverse creases located superficially, so the injections
in the forehead. These muscles originate should be placed in the superficial sub-
on the galea aponeurotica of the cra- cutaneous tissue. Treat the entire fore-
nium and insert into the skin of the eye- head from medial to lateral. As with all
brows. The frontalis muscles are often BoNTA injections, male patients may re-
described as paired muscles that do not quire a higher dose. The typical dose
meet centrally. However, clinically, the ranges from 10 to 20 BU or 30 to 60 DU.
16
CHAPTER 6 ■ Neurotoxin Injection for Forehead Wrinkles 17
■ ■Precautions sition to determine if the frontalis con-
traction was masking brow ptosis.
The forehead is often described as the Poor technique in this area can pro-
most difficult area to inject well. Al- duce an odd-shaped brow. Do not limit
though treatment of the forehead seems the injections to the central brow. Do not
intuitively simple, common errors in- assume that the injections cannot extend
clude overtreatment or poor injection laterally. If only the center of the brow
planning. The most important rule of is treated, the brow will drop medially
injection is to assess the position of the and elevate laterally, which produces an
brows at rest, prior to injection of neu- odd-appearing slanted look, sometimes
rotoxin. Two important conditions of referred to as the “Mr. Spock,” or “Me-
this region must be predetermined: the phisto (devilish) sign.” A lateral browlift
presence of brow ptosis; and increased can be obtained by using this technique,
resting tone of the muscles, which can but proceed with caution in this area to
mask brow ptosis. avoid an overly slanted medial brow.
In some patients, horizontal forehead
creases are the result of compensation
for brow ptosis. These patients often re- ■ ■Post-Injection Instructions
quest neurotoxins to improve their deep
forehead rhytids. It is important to re- Instruct the patient not to exercise im-
member that the frontalis muscles are mediately after treatment. Bruising may
the only muscles that elevate the brows. decrease the effect of the BoNTA by pre-
If the brow is ptotic, do not inject the venting diffusion to the neuromuscular
frontalis muscles, as this will worsen the junction.
brow ptosis. If injection must be per-
formed on a patient with brow ptosis,
plan the injections high in the forehead ■ ■Risks
so that the patient retains some brow
elevation movement, or consider under- Ptosis of the upper eyelid and unmask-
treating this entire area. ing brow ptosis are the major risks of
In addition, the frontalis muscles can this procedure. Minor risks include in-
sometimes show a resting tonic contrac- appropriate injection planning, which
tion that must be relaxed to determine may result in unnatural-appearing brows
the resting position of the brow. This or persistent rhytids.
may even require the injector to “smooth
out” the forehead manually to encour-
age relaxation of the muscles. Having the ■ ■Pearls of Injection
patient close his/her eyes can help relax
the frontalis muscles. Once the frontalis More than with any other area, it is im-
muscles are at rest, assess the brow po- perative to observe the patient contract-
18 SECTION II ■ Neurotoxin Injection Techniques
ing and relaxing the frontalis muscles creases will be seen just above the lat-
while the injector plans the injection eral brow. A unilateral forehead resting
sites. If the rhytids extend up to the hair- contraction may be compensation for
line, make sure the injections extend to upper eyelid ptosis. Assess these areas
this area, or it will result in a smooth carefully prior to injecting the patient.
forehead with a ridge of wrinkles supe- One dose of BoNTA (20–25 BU or
riorly. Also be sure to assess the lateral 50–70 DU) can occasionally be used to
brows; occasionally these rhytids are treat both the glabella and the forehead
undertreated, and deep crescent-shaped in selected patients.
a
Fig. 6.1a, b Frontalis muscle injection sites may extend up to the hairline in some individuals. Main-
tain a distance of 1 cm or more above the superior orbital rim. Alternate injection patterns are shown.
Tailor the injection pattern to the shape and action of the muscle.
CHAPTER 6 ■ Neurotoxin Injection for Forehead Wrinkles 19
b
Fig. 6.1a, b (Continued)
20 SECTION II ■ Neurotoxin Injection Techniques
Fig. 6.2 “Mr. Spock” brow produced by central injection of the forehead.
Fig. 6.3 In some patients, care must be taken to treat the crescent-shaped rhytids superolateral to
the brow.
CHAPTER 6 ■ Neurotoxin Injection for Forehead Wrinkles 21
■ ■Additional Reading Michaels BM, Csank GA, Ryb GE, Eko FN,
Rubin A. Prospective randomized compar-
Carruthers J, Fagien S, Matarasso SL; Botox ison of onabotulinumtoxinA (Botox) and
Consensus Group. Consensus recommen- abobotulinumtoxinA (Dysport) in the
dations on the use of botulinum toxin type treatment of forehead, glabellar, and peri-
a in facial aesthetics. Plast Reconstr Surg orbital wrinkles. Aesthet Surg J 2012;32:
2004;114(6, Suppl)1S–22S PubMed 96–102 PubMed
7
Neurotoxin Injection for Smile Lines
and Crow’s Feet
■ ■Anatomic Considerations
Difficulty:
Patient satisfaction: The orbicularis oculi muscle surrounds
Risk: the eye and is separated into three divi
sions: pretarsal, preseptal, and orbital.
The orbital portion extends laterally and
is intimately adherent to the overlying
■ ■Indications skin. Contraction of this muscle results in
lines extending radially from the lateral
Smile lines and crow’s feet are two of canthus. As the overlying skin thins and
the most commonly sought after areas ages, crow’s feet become visible in the
for treatment with BoNTA. To soften or skin from repeated muscle contractions.
eliminate wrinkles around the lateral
and inferior orbit, injection of the or
bicularis oculi muscles can prevent ■ ■Precautions
movementrelated creasing of the over
lying skin associated with expression and The periocular area often has many su
baseline muscle tension. Neurotoxin in perficial and deep venous structures that
jection will not improve static wrinkles may or may not be visible through the
or deep creases due to photoaging. surface of the skin. Trying to avoid them
22
CHAPTER 7 ■ Neurotoxin Injection for Smile Lines and Crow’s Feet 23
will keep the toxin from being washed firm pressure for a minute or two to
away and also prevent bruising. minimize bruising.
■ ■Injection Technique ■ ■Risks
Topical anesthesia may be used and ice Extending the injections too far inferi
may be applied, though neither is neces orly and too deep under the orbicularis
sary in most cases. Three to four injec can affect the zygomaticus major mus
tions of BoNTA are placed radially in the cle and result in an upper lip droop or
area of the crow’s feet. A total of 8 to asymmetric smile. Patients should be
20 BU or 20 to 60 DU may be placed in made aware that injections cannot be ex
each side. Care should be taken to inject tended too inferiorly in this area. Some
1 cm lateral to the bony orbital rim, es patients will note an accentuation of
pecially above the canthal angle, as upper lines in this region once the lateral lines
lid lag can occur. It is helpful to place a have been treated.
finger of the noninjecting hand at the
lateral orbital rim as a guide.
The muscle is superficial, so the nee ■ ■Pearls of Injection
dle does not need to be placed deep into
the subcutaneous tissue. Because of the It is acceptable to have some movement
wide zone of effect for BoNTA, a super with full expressive action of the mus
ficial dermal injection will minimize cle. Because of the wider zone of effect,
bruising without compromising clinical some practitioners prefer BoNTAABO
results. (Dysport) in this area.
■ ■Post-Injection Instructions
This is a highly vascular area, so bruising
is possible. If a vessel is injured, hold
24 SECTION II ■ Neurotoxin Injection Techniques
a
b
Fig. 7.1a, b Injections to treat the crow’s feet are traditionally placed subcutaneously into the orbi
cularis muscle in a radial fashion 1 cm outside the lateral orbital rim. Avoid injection into the super
ficial veins seen in that region.
CHAPTER 7 ■ Neurotoxin Injection for Smile Lines and Crow’s Feet 25
Fig. 7.2 For patients with wrinkles under the eyes, optional sites are shown, but care must be taken
to avoid diffusion of BoNTA into the zygomaticus muscles.
■ ■Additional Reading Kim DW, Cundiff J, Toriumi DM. Botulinum
toxin A for the treatment of lateral perior
Carruthers J, Fagien S, Matarasso SL; Botox bital rhytids. Facial Plast Surg Clin North
Consensus Group. Consensus recommen Am 2003;11:445–451 PubMed
dations on the use of botulinum toxin type
a in facial aesthetics. Plast Reconstr Surg
2004;114(6, Suppl)1S–22S PubMed
8
Neurotoxin Injection for
Lateral Brow Lift
superolateral orbicularis oculi is posi-
Difficulty: tioned at or just inferior to the level of
Patient Satisfaction: the lateral eyebrow hairs.
Risk:
■ ■Injection Technique
■ ■Indications The best effect occurs when the non-
injecting hand is used to elevate the
Hyperactivity of the lateral aspect of the brow and injections are kept approxi-
orbicularis oculi muscle can result in mately 1 cm above the orbital rim. Topi-
ptosis of the lateral aspect of the brow. cal anesthesia may be used and ice may
Vertically and obliquely oriented fibers be applied, though neither is necessary
of muscle, when activated or with base- in most cases.
line resting muscle tension, pull down BoNTA is injected into the muscle in
on the position of the tail of the brow two to three spots along the lateral
and oppose the lifting action of the fron- brow, each with 2 to 3 BU for a total of
talis muscle. 4 to 6 BU per side.
■ ■Anatomic Considerations ■ ■Precautions
The orbicularis oculi muscle is a strong Bruising is a risk in this area. The peri-
brow depressor. In most patients, the ocular area has many superficial venous
26
CHAPTER 8 ■ Neurotoxin Injection for Lateral Brow Lift 27
structures that may or may not be visible ■ ■Pearls of Injection
through the surface of the skin. Bruising
can be minimized by injecting into the • Not all patients will be able to
superficial subcutaneous tissue. achieve significant brow elevation.
• Because brow elevation results from
the upward pull of the brow by the
■ ■Post-Injection Instructions frontalis muscle, simultaneous in-
jection of the lateral aspect of the
Hold firm pressure. Bruising is possible frontalis and the lateral orbicularis
and more likely in this area than in many muscles will negate the upward lift
others. of the brow in this region.
■ ■Risks
There are few risks as long as the BoNTA
does not affect the levator palpebrae su-
perioris muscle.
28 SECTION II ■ Neurotoxin Injection Techniques
a
b
Fig. 8.1a, b Suggested patterns of BoNTA injection of the lateral aspect of the orbicularis muscle
can result in a lateral brow lift.
■ ■Additional Reading Maas CS, Kim EJ. Temporal brow lift using
botulinum toxin A: an update. Plast Re-
Ahn MS, Catten M, Maas CS. Temporal brow constr Surg 2003;112(5, Suppl)109S–112S,
lift using botulinum toxin A. Plast Recon- discussion 113S–114S PubMed
str Surg 2000;105:1129–1135, discussion
1136–1139 PubMed
Chen AH, Frankel AS. Altering brow contour
with botulinum toxin. Facial Plast Surg
Clin North Am 2003;11:457–464 PubMed
9
Neurotoxin Injection for Chemical
Brow Lift
pressors. Inactivation of the depressor
Difficulty: muscles permits the elevation of the
Patient Satisfaction: brow by allowing the frontalis muscle to
Risk: overcome their downward pull. Medial
elevation is obtained by placing BoNTA
in the corrugator and procerus muscles.
Lateral brow lift is achieved by treating
■ ■Indications the lateral orbicularis oculi muscles. It
is imperative to preserve muscle func-
Volume loss in the forehead, combined tion in the forehead by not overly treat-
with hyperactive corrugator, procerus, ing (relaxing) the frontalis muscle with
and orbicularis oculi muscles, is often BoNTA as the forehead will not be able
responsible for brow ptosis. Vertically to elevate the brow, and brow ptosis may
and obliquely oriented muscle fibers, occur.
when activated or with baseline resting
muscle tension, pull down on the posi-
tion of the brow relative to the upward ■ ■Injection Technique
pull of the frontalis muscle.
Topical anesthesia may be used; ice may
be applied though neither is necessary
■ ■Anatomic Considerations in most cases. Essentially, this lift is
created by combining the techniques of
The corrugators, procerus, and lateral treating the glabella and lateral brow
orbicularis oculi muscles are brow de- (see Chapters 5 and 8). A total of 20 to
29
30 SECTION II ■ Neurotoxin Injection Techniques
30 BU or 60 to 90 DU may be necessary Alternatively, patients are instructed
for this treatment. not to exercise immediately post-
injection.
■ ■Precautions
■ ■Risks
Place injections at least 1 cm away from
the bony orbital rim to reduce the risk of There are few risks as long as the neuro-
spread to the levator palpebrae superi- toxin does not affect the levator palpe-
oris muscle. brae superioris muscle.
■ ■Post-Injection Instructions ■ ■Pearls of Injection
Hold firm pressure. Bruising is possible • Not all patients obtain the same de-
and more likely in the temporal area than gree of brow elevation using this
in many others. Patient instructions may technique.
include the following: avoid exercise for • Over treatment of the frontalis
the day, do not bend over, lie flat, or push muscle will negate any possible
on the injection sites for 4 hours. It also brow elevation achieved with these
may be advisable to have the patients techniques.
move their brows for 90 minutes after • Patients with severe brow ptosis are
injection to potentiate uptake of the less likely to obtain a significant lift
BoNTA. However, there are no clinical from a neurotoxin.
studies to show that these instructions
improve the results or minimize ptosis.
CHAPTER 9 ■ Neurotoxin Injection for Chemical Brow Lift 31
a
b
Fig. 9.1a, b A chemical brow lift can be produced by treating the procerus and corrugator muscles
centrally and the orbicularis oculi muscle laterally. The frontalis muscle must not be treated so that it
can take over the upward pull of the brow. Alternative techniques are demonstrated.
■ ■Additional Reading Chen AH, Frankel AS. Altering brow contour
with botulinum toxin. Facial Plast Surg
Carruthers J, Carruthers A. Botulinum toxin Clin North Am 2003;11):457–464 PubMed
(Botox) chemodenervation for facial reju- Frankel AS, Markarian A. Cosmetic treatments
venation. Facial Plast Surg Clin North Am and strategies for the upper face. Facial Plast
2001;9:197–204, vii PubMed Surg Clin North Am 2007;15:31–39, vi
PubMed
10
Neurotoxin Injection for
Lower Eyelid Roll
■ ■Injection Technique
Difficulty:
Patient Satisfaction: Botulinum toxin (1 to 2 BU) is injected
Risk: at the midpupillary line approximately
3 mm below the lash line. A single injec-
tion is placed per eyelid. The injection is
■ ■Indications immediately subcutaneous.
Hypertrophy of the orbicularis oculi ■Precautions
muscle can cause a fullness of the lower ■
eyelid when smiling or squinting, but is Injection of the pretarsal orbicularis
not noticeable at rest. muscle will result in a widening of the
palpebral aperture. Do not inject pa-
■ ■Anatomic Considerations tients who have a preexisting lower lid
laxity or excessive scleral show.
The orbicularis oculi muscle surrounds
the eye and is divided into three parts: ■ ■Post-Injection Instructions
orbital, preseptal, and pretarsal. Hyper-
trophy of the pretarsal portion of the None.
muscle can result in a fullness of the
lower eyelid when the patient smiles.
32
CHAPTER 10 ■ Neurotoxin Injection for Lower Eyelid Roll 33
Fig. 10.1 BoNTA is injected at the midpupillary line into the superficial subcutaneous tissue to re-
duce the bulging of a hypertrophic orbicularis oculi muscle.
■ ■Risks muscle hypertrophy and treated appro-
priately. Because of the increased zone
Widening of the palpebral aperture may of effect for Dysport, Botox is preferred
result in dry eyes. Inject with caution in for these injections.
patients with lax lower eyelids, or with
dry eye syndrome. Bruising may occur
after injection. ■ ■Additional Reading
Carruthers J, Carruthers A. Aesthetic botuli-
■ ■Pearls of Injection num A toxin in the mid and lower face and
neck. Dermatol Surg 2003;29:468–476
PubMed
Check the tone of the lower eyelid prior Flynn TC, Carruthers JA, Carruthers JA.
to injection (snap test). Accurate diag- Botulinum-A toxin treatment of the lower
nosis is key in these patients, who com- eyelid improves infraorbital rhytides and
plain of lower lid “bags.” Patients must widens the eye. Dermatol Surg 2001;27:
be counseled on the differences between 703–708 PubMed
lower lid fat herniation and orbicularis
11
Neurotoxin Injection for Bunny Lines
incisor foramen and inserts into an apo-
Difficulty: neurosis on the nasal dorsum. At this
Patient Satisfaction: aponeurosis, the fibers meet those of
Risk: the opposite nasalis muscle and the mid-
line procerus muscle. When contracted,
these muscles create wrinkles or lines
■ ■Indications on the nose as well as pull the center
of the forehead down and contribute to
“Bunny lines” are wrinkles that radiate horizontal glabellar creases.
from the medial canthal region and run
inferomedially on each side of the nose.
Bunny lines are not found on every ■ ■Injection Technique
patient and are not universally disliked,
but can be unacceptable for some pa- Topical anesthesia may be used and ice
tients. Occasionally these rhytids con- may be applied, though neither is neces-
tribute to deep horizontal glabellar sary in most cases. The patient is usually
rhytids. In those cases, BoNTA injections asked to wrinkle his/her nose up “like
can be used to soften this region. a bunny.” This will indicate where the
muscle is located and the strength of the
nasalis fibers. A single injection of 2 to
■ ■Anatomic Considerations 3 BU is placed per side. The muscle is
not deep, so the injection need only be
The superior portion of the nasalis mus- placed in the subdermal subcutaneous
cle (pars transversa) originates over each tissue.
34
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