CHAPTER 11 ■ Neurotoxin Injection for Bunny Lines 35
A single injection point can be placed ■ ■Risks
into the muscle on each side. Assessing
muscle location and activity during Undertreatment of one side will leave
contraction is essential in determining asymmetrical sniffing, which is usually
the proper placement of BoNTA in this not very noticeable and is easy to adjust
area. Another technique is to insert the with a small injection “boost.” Over-
needle across the belly of the muscle treatment is far more troublesome, as
and then inject retrograde. The injection it can result in a flattening of the cheek,
occurs at or perpendicular to the direc- nasolabial fold, or upper lip droop. It
tion of the actual bunny lines seen dur- is advisable to begin with conservative
ing muscle contraction. Alternately, for dosing and to keep the area of injection
larger muscles and extensive lines, more at or near the level of the nasal bones
injections can be placed, with care being and upper lateral cartilages of the nose.
taken not to extend too far laterally.
■ ■Pearls of Injection
■ ■Precautions
Some patients may not understand why
The treatment in this area needs to be you are treating this area or even realize
kept more medial, to avoid relaxing the that they move the area or that they
nearby levator labii superioris alaeque gesture during smiling. You may need
nasi muscle. Spread to that muscle could to demonstrate these creases to them in
lead to lip ptosis or flattening of the na- the mirror and explain that it is an im-
solabial fold. Injections also should be portant adjuvant in lifting the central
kept medial to avoid injection into the glabella and softening the frown lines.
angular vein.
■ ■Post-Injection Instructions
Because this is a highly vascular and vis-
ible area, bruising is possible. Firm pres-
sure should be applied after injection.
36 SECTION II ■ Neurotoxin Injection Techniques
Fig. 11.1 A single injection is used for each muscle, or, for larger muscles, several injections may be
placed, with care being taken to stay medial to the levator labii superioris alaeque nasi.
CHAPTER 11 ■ Neurotoxin Injection for Bunny Lines 37
■ ■Additional Reading Carruthers J, Fagien S, Matarasso SL; Botox
Consensus Group. Consensus recommen-
Carruthers J, Carruthers A. Botulinum toxin dations on the use of botulinum toxin type
(Botox) chemodenervation for facial reju- a in facial aesthetics. Plast Reconstr Surg
venation. Facial Plast Surg Clin North Am 2004;114(6, Suppl)1S–22S PubMed
2001;9:197–204, vii PubMed
12
Neurotoxin Injection for Nasal Tip Lift
inserts onto the medical crural foot-
Difficulty: plates. It pulls the nasal tip down with
Patient Satisfaction: smiling. Weakening of this muscle will
Risk: result in elevation of the tip or widening
of the nasolabial angle. The nasolabial
angle should be approximately 90 de-
■ ■Indications grees in men, and more obtuse in women.
Neurotoxin can be injected into the base
of the nasal columella to produce a sub- ■ ■Injection Technique
tle elevation of the nasal tip (increase in
tip rotation). This is indicated in patients Topical anesthesia may be used; how-
with a mild drooping of the nasal tip. ever, this single injection usually can
It will not improve a severely ptotic be tolerated without anesthesia. The de-
nose with thick, sebaceous skin. Consider pressor septi nasi muscle is located at
surgical treatment for severely ptotic the base of the columella and is the
noses. This procedure is a mild “finesse” muscle targeted with the injection. Use
technique. approximately 2 BU or 5 to 9 DU.
■ ■Anatomic Considerations ■ ■Precautions
The depressor septi nasi muscle is an This injection will not improve a se-
extension of the orbicularis muscle and verely ptotic tip. Use with caution in
38
CHAPTER 12 ■ Neurotoxin Injection for Nasal Tip Lift 39
Fig. 12.1 A single injection at the
base of the columella can produce a
subtle nasal tip elevation.
women who already have an elevated aware that this is a subtle improvement.
tip. Use with caution in men, who gen- Do not overtreat.
erally do not want an over-rotated tip.
■ ■Additional Reading
■ ■Post-Injection Instructions
Carruthers J, Carruthers A. Aesthetic botuli-
None. Bruising is unlikely. num A toxin in the mid and lower face and
neck. Dermatol Surg 2003;29:468–476
PubMed
Redaelli A. Medical rhinoplasty with hyal-
■ ■Risks uronic acid and botulinum toxin A: a very
simple and quite effective technique. J Cos-
Overtreatment of this area may cause a met Dermatol 2008;7:210–220 PubMed
drooping of the upper lip.
■ ■Pearls of Injection
Proceed slowly; try half the suggested
dose first. Make sure that the patient is
13
Neurotoxin Injection for Nasal Flare
■ ■Injection Technique
Difficulty:
Patient Satisfaction: Topical anesthesia may be used; how-
Risk: ever, this single injection usually can
be tolerated without anesthesia. One
injection point is used per side. Approx-
■ ■Indications imately 5 BU or 15 DU are used per side.
Inject into the immediate subdermal
Some individuals inadvertently flare tissue, with care being taken to avoid
their nostrils while speaking. the alar cartilage.
■ ■Anatomic Considerations ■ ■Precautions
The dilator nasalis muscle is the lower None.
portion of the nasalis muscle and at-
taches to the alar cartilage. Contraction ■Post-Injection Instructions
of the dilator nasalis muscle results in ■
alar flaring. This muscle lies superficial None. Bruising is unlikely.
to the lateral crura of the lower lateral
cartilage.
40
CHAPTER 13 ■ Neurotoxin Injection for Nasal Flare 41
Fig. 13.1 A single injection of BoNTA is placed in the superficial subcutaneous tissue (on each side)
to decrease nostril flare.
■ ■Risks may not be necessary as the patient may
“unlearn” to contract the muscle while
None. speaking.
■ ■Pearls of Injection ■ ■Additional Reading
Proceed slowly; try half the suggested Carruthers J, Carruthers A. Aesthetic botuli-
dose first. Make sure that the patient is num A toxin in the mid and lower face and
aware that this is a subtle improvement. neck. Dermatol Surg 2003;29:468–476
Do not overtreat. Results may last 3 to PubMed
4 months; however, frequent injections
14
Neurotoxin Injection for Elevating
the Oral Commissures
DAO muscle pulls down the corners of
Difficulty: the mouth. Weakening this muscle will
Patient Satisfaction: result in a compensatory upward pull of
Risk: the zygomaticus muscles, which results
in elevation of the oral commissures.
■ ■Indications ■ ■Injection Technique
Neurotoxin can be injected in the de- A single injection per muscle is suggested
pressor anguli oris (DAO) muscles to and well tolerated. The DAO muscle
elevate the oral commissures. This is should be palpated while having the
indicated in patients with downturned patient actively frown. If the belly of the
corners of the mouth. Neurotoxin alone muscle cannot be palpated, a rough es-
can be used in this area, but most often timate of its location can be made by
must be combined with filler injections going 1 cm lateral to the oral commis-
to the oral commissure (see Chapter 38). sure and then 1 cm inferiorly. Inject ap-
proximately 2 to 5 BU or 6 to 15 DU
deeply into each muscle.
■ ■Anatomic Considerations
Alternate Technique
The DAO muscle originates along the
oblique line of the mandible and inserts To avoid other perioral muscles, injec-
into the modiolus. Contraction of the tions may be placed into the inferior as-
42
CHAPTER 14 ■ Neurotoxin Injection for Elevating the Oral Commissures 43
pect of the muscle. A single injection is ment in the downturned oral commis-
placed just above the mandibular bor- sure is seen, especially in patients with
der, diagonally and inferior to the oral heavy surrounding skin. The major risk
commissure. is that BoNTA will affect the wrong peri-
oral muscles and affect the smile or
expression.
■ ■Precautions
This injection will not improve severely ■ ■Pearls of Injection
depressed oral commissures and will not
elevate the marionette lines. Neurotoxin alone may improve mild
down-turning of the oral commissures.
More resistant cases likely will require
■ ■Post-Injection Instructions hyaluronic acid filler injection to the
oral commissure in addition to BoNTA
None. Bruising is unlikely. injection of the DAO muscles. Be sure
to inform the patient that only a subtle
improvement is likely.
■ ■Risks
Overtreatment of this area is unlikely. It
is more likely that only a mild improve-
44 SECTION II ■ Neurotoxin Injection Techniques
Fig. 14.1 (Left) BoNTA can be injected into the depressor anguli oris muscle, which can be pal-
pated 1 cm lateral and inferior to the oral commissure. (Right) Alternate injection site of the de-
pressor anguli oris muscle is 1 cm above the mandibular border, on a line positioned diagonally
and inferior to the oral commissure.
■ ■Additional Reading Dayan SH, Maas CS. Botulinum toxins for
facial wrinkles: beyond glabellar lines.
Carruthers J, Carruthers A. Aesthetic botu- Facial Plast Surg Clin North Am 2007;15:
linum A toxin in the mid and lower face 41–49, vi PubMed
and neck. Dermatol Surg 2003;29:468–
476 PubMed
15
Neurotoxin Injection for Lip Lift
lips. This pull will result in more visible
Difficulty: pink lip and a slight “lip lift.”
Patient Satisfaction:
Risk:
■ ■Injection Technique
Botulinum toxin is injected at the base
■ ■Indications of the philtrum at the vermillion border.
The corresponding location of the lower
A small improvement in the visible pink lip may also be injected. Approximately
lip can be achieved by the use of BoNTA. 1 to 2 BU is used for each injection. (Be-
This can be used to enhance the upper cause of the increased zone of effect of
and/or lower lips. Dysport, the authors prefer to use Botox
in this area.)
■ ■Anatomic Considerations
■ ■Precautions
The orbicularis oris muscle is the sphinc-
ter that surrounds the mouth. The pull Injections around the mouth must be
of the muscle is toward the center; symmetric, to avoid asymmetry of the
therefore, weakening this pull will allow mouth when smiling or puckering the
the upper lip elevators and the lower lip lips. Avoid these injections in persons
depressors to increase their pull on the who play the flute, whistle, or do similar
45
46 SECTION II ■ Neurotoxin Injection Techniques
Fig. 15.1 BoNTA is injected at the base of the philtral columns on the upper lip and may also be
injected in similar locations on the lower lip to cause a subtle increase in pink lip, or a pseudo-
augmentation.
activities. Warn patients that they may 2 mm increase in pink lip visibility. The
initially experience difficulty drinking relative size of the lip increases but there
through straws. is no increase in lip volume. The patient
should not expect this procedure will
produce the same results as fillers; how-
■ ■Post-Injection Instructions ever, this procedure can be used in ad-
dition to fillers and is encouraged in
None. patients who have very thin lips.
■ ■Risks ■ ■Additional Reading
Asymmetry can be reduced by en - Fagien S. Botox for the treatment of dynamic
suring that the injections are placed and hyperkinetic facial lines and furrows:
symmetrically. adjunctive use in facial aesthetic surgery.
Plast Reconstr Surg 1999;103:701–713
PubMed
Semchyshyn N, Sengelmann RD. Botulinum
■ ■Pearls of Injection toxin A treatment of perioral rhytides.
Dermatol Surg 2003;29:490–495, discus-
This technique produces a very subtle sion 495 PubMed
augmentation in the lips, possibly a 1 to
16
Neurotoxin Injection for
Smoker’s Lines
■ ■Injection Technique
Difficulty:
Patient Satisfaction: BoNTA is injected at the vermillion bor-
Risk: der, usually 1 to 2 units per quadrant.
Not more than four injections are done
on each lip, and not more than two
■ ■Indications per side. (Because of the increased zone
of effect for Dysport, the authors prefer
Perioral wrinkles extend radially from Botox in this area.) The wrinkles them-
the lips due to the repeated puckering selves do not necessarily need to be in-
motion from speaking or smoking. In jected, as the mild paresis of the entire
women, lipstick may “bleed” into these muscle will improve the entire region
lines. In nonsmokers, these lines can be injected.
produced in patients who purse their lips
while talking.
■ ■Precautions
■ ■Anatomic Considerations Injections around the mouth must be
symmetric, to avoid asymmetry of the
The orbicularis oris muscle is the sphinc- mouth when smiling or puckering the
ter that surrounds the mouth. Repeated lips. Avoid these injections in persons
contraction of this muscle may result in who play the flute, whistle, or do similar
circumoral rhytids. activities. Warn patients that they may
47
48 SECTION II ■ Neurotoxin Injection Techniques
Fig. 16.1 To treat smoker’s lines, either 2 or 4 injections should be placed symmetrically on the
upper and/or lower lip. Do not attempt to inject every wrinkle.
initially have difficulty drinking through to inject near the oral commissure, and
straws. not to over-inject the lips, which poten-
tially could cause oral incompetence. The
concomitant use of fillers in this area can
■ ■Post-Injection Instructions improve results. For those who charge
by the unit, the benefit–risk ratio for
None. this area is not favorable, and only tiny
amounts are used, resulting in low re-
■ ■Risks imbursement yet the risk of asymmetry
and/or overtreatment is high because of
Asymmetry can be reduced by en- the small sensitive muscles being treated.
suring that the injections are placed The novice injector should beware.
symmetrically.
■ ■Pearls of Injection
This technique can be performed on one
or both lips, but care must be taken not
CHAPTER 16 ■ Neurotoxin Injection for Smoker’s Lines 49
■ ■Additional Reading ranging study for hyperdynamic perioral
lines. Dermatol Surg 2012;38(9):1497–
Carruthers J, Fagien S, Matarasso SL; Botox 1505 PubMed
Consensus Group. Consensus recommen- Romagnoli M, Belmontesi M. Hyaluronic
dations on the use of botulinum toxin type acid-based fillers: theory and practice. Clin
a in facial aesthetics. Plast Reconstr Surg Dermatol 2008;26:123–159 PubMed
2004;114(6, Suppl)1S–22S PubMed
Cohen JL, Dayan SH, Cox SE, Yalamanchili R,
Tardie G. OnabotulinumtoxinA dose-
17
Neurotoxin Injection for
Gummy Smile
lip snarl, and this muscle has been re-
Difficulty: ferred to as the “Elvis” muscle.
Patient Satisfaction:
Risk:
■ ■Injection Technique
■ ■Indications Topical anesthesia may be used; how-
ever, this single injection (per side) usu-
Some patients pull their upper lip up ally can be tolerated without anesthesia.
dramatically while smiling, which re- The levator labii superioris alaeque
veals a large part of the gingival tissue, nasi muscle travels just lateral to the
often referred to as a “gummy smile.” nose; 1 to 2 BU is used in this area. Ti-
trate to determine the necessary dosing
for the patient.
■ ■Anatomic Considerations
The upper lip is elevated during smile by ■ ■Precautions
the levator labii superioris alaeque nasi
muscles. These muscles originate on the This injection will elongate the upper
frontal process of the maxilla and insert lip. Use with caution in older patients
on the skin of the lateral aspect of the who may have long upper lips. Younger
nostril and upper lip. Unilateral contrac- patients may benefit more from this
tion of this muscle results in an upper procedure than do elderly patients.
50
CHAPTER 17 ■ Neurotoxin Injection for Gummy Smile 51
Use with caution for patients who ■ ■Risks
cannot tolerate a weakening of the
upper lip (e.g., wind instrument musi- Overtreatment of this area may cause
cians, actors). severe drooping of the upper lip.
■ ■Pearls of Injection
■ ■Post-Injection Instructions
Proceed slowly; try half the suggested
None. Bruising is unlikely. dose first.
Fig. 17.1 Injection of BoNTA into the inferior aspect of the levator labii superioris alaeque nasi
muscle will decrease the upward pull on the lip when the patient smiles.
52 SECTION II ■ Neurotoxin Injection Techniques
a
b
Fig. 17.2a, b (a) Patient with gummy smile pre-injection. (b) Post-injection BoNTA with patient
producing maximum smile excursion. Also note improvement in the horizontal crease below the
columella.
CHAPTER 17 ■ Neurotoxin Injection for Gummy Smile 53
■ ■Additional Reading Stephan S, Wang TD. Botulinum toxin: clini-
cal techniques, applications, and compli-
Polo M. Botulinum toxin type A (Botox) for cations. Facial Plast Surg 2011;27:529–539
the neuromuscular correction of excessive PubMed
gingival display on smiling (gummy smile).
Am J Orthod Dentofacial Orthop 2008;
133:195–203 PubMed
18
Neurotoxin Injection
for Dimpled Chin
ous fat and dermis overlying the mus-
Difficulty: cles can contribute to a dimpled appear-
Patient Satisfaction: ance. Because this dimpling somewhat
Risk: resembles the skin of an orange, this de-
formity is called “peau d’orange” chin.
■ ■Indications ■ ■Anatomic Considerations
Some patients inadvertently wrinkle The paired mentalis muscles originate
their chins either at rest or while talk- on the incisor fossa of the mandible and
ing. Usually it is not noticed by the insert directly onto the dermis of the
patient until it is pointed out by the cli- chin skin. Contraction of the mentalis
nician. Dimpled chins can also be seen muscles elevates the lower lip, produc-
after chin implants, or in patients with ing a “pout.” Contraction also contrib-
retrognathia. Atrophy of the subcutane- utes the mental crease.
54
CHAPTER 18 ■ Neurotoxin Injection for Dimpled Chin 55
■ ■Injection Technique ■ ■Risks
Botulinum toxin is injected deeply into Injection above the mental crease can
each muscle in three or four injection affect the orbicularis oris muscle and
sites. A total of 3 to 10 BU or 9–30 DU is may result in lower lip droop, or even
injected. drooling.
■ ■Precautions ■ ■Pearls of Injection
Place injections low in the chin, between • Inject symmetric amounts of neuro-
the mental crease and the lower edge of toxin into the muscle bodies.
the mandible. • This is a relatively painless injection.
• Show patients how their muscle
looks contracted, so that they un-
■ ■Post-Injection Instructions derstand the rationale for this
treatment.
None.
56 SECTION II ■ Neurotoxin Injection Techniques
Fig. 18.1 Suggested techniques for injection of BoNTA into the paired mentalis muscles to improve
dimpled chin.
■ ■Additional Reading dations on the use of botulinum toxin type
a in facial aesthetics. Plast Reconstr Surg
Carruthers J, Carruthers A. Aesthetic botuli- 2004;114(6, Suppl)1S–22S PubMed
num A toxin in the mid and lower face Wise JB, Greco T. Injectable treatments for
and neck. Dermatol Surg 2003;29:468– the aging face. Facial Plast Surg 2006;22:
476 PubMed 140–146 PubMed
Carruthers J, Fagien S, Matarasso SL; Botox
Consensus Group. Consensus recommen-
19
Neurotoxin Injection for
Platysmal Banding
icle and upper chest and inserts onto
Difficulty: the superficial musculoaponeurotic
Patient Satisfaction: system (SMAS), the skin of the lower
Risk: face, facial muscles, and the mandible.
Although in youth it is considered a con-
tinuous sheet, in the elderly this muscle
may splay centrally and produce promi-
■ ■Indications nent vertical bands. Platysmal bands
can be prominent in patients with thin
Platysmal bands are vertical bands in necks, thin skin, and without abundant
the neck that are seen at rest and are overlying fat.
accentuated with neck tightening and
forced jaw opening. This procedure
may be used in younger patients who ■ ■Precautions
are not yet ready for surgery, or in older
patients who do not desire surgery, and Over-injection in this region may affect
to treat recurrent bands in postopera- the muscles involved in swallowing.
tive patients. Bruising is not uncommon.
■ ■Anatomic Considerations ■ ■Injection Technique
The platysma muscle is a thin super- Having the patient grimace to tighten the
ficial muscle that originates on the clav- neck will often bring out the problem
57
58 SECTION II ■ Neurotoxin Injection Techniques
muscles and make the injection easier ■ ■Post-Injection Instructions
to perform. Ask the patient to sit upright
and lean forward slightly, with the chin Hold pressure to prevent bruising.
elevated just above the horizontal plane.
With the platysma muscle in full con- ■Risks
traction, the edge of the muscle band ■
is grasped with two fingers while the Patients with heavy necks may not be
muscle is injected. The needle is placed good candidates for this procedure, as
deeply into the muscle, between the fin- the results of injection may not be im-
gers and perpendicular to the muscle pressive. Over-injection of BoNTA in
fibers. Approximately 3 to 5 BU is in- this region can result in dysphagia or
jected into each injection site, for a total dysphonia.
of 15 BU per band or 20 to 40 DU per
band. A series of approximately three
injections is placed down the length of ■ ■Pearls of Injection
the band approximately 1.5 to 2 cm
apart. If lateral bands are prominent on Although very effective for some pa-
full contraction, then these can be in- tients, the results can be short lived and
jected in the same fashion, though they can require large doses. This technique
may need fewer units. Begin injections may need to be combined with subman-
at the cervicomental angle and work dibular gland injection for optimal neck
inferiorly, staying approximately 2.0 to contouring (see Chapter 24). Appropri-
2.5 cm below the mandibular border, so ate surgical can didates should be given
as not to affect the upper facial muscles the option for lower face and neck lift
of expression. surgery.
CHAPTER 19 ■ Neurotoxin Injection for Platysmal Banding 59
Fig. 19.1 A 1-inch (2.5-cm) or longer needle is usually required to place BoNTA well into the muscle
of each platysmal band. Grasp the muscle during injection to ensure intramuscular injection.
■ ■Additional Reading Matarasso A, Matarasso SL, Brandt FS, Bell-
man B. Botulinum A exotoxin for the
Carruthers J, Fagien S, Matarasso SL; Botox management of platysma bands. Plast Re-
Consensus Group. Consensus recommen- constr Surg 1999;103:645–652, discussion
dations on the use of botulinum toxin type 653–655 PubMed
a in facial aesthetics. Plast Reconstr Surg
2004;114(6, Suppl)1S–22S PubMed
20
Neurotoxin Injection for
Necklace Lines
■ ■Injection Technique
Difficulty:
Patient Satisfaction: This is an intradermal injection! One
Risk: or 2 BU is injected at 1.0- to 1.5-cm in-
tervals along the horizontal crease. There
should be a wheal of product in the skin.
Do not use more than 15 to 20 units per
■ ■Indications treatment session.
Horizontal lines of the neck are noted at
rest and can deepen with aging. ■ ■Precautions
Deep injection may affect the muscles
■ ■Anatomic Considerations involved in swallowing.
These lines occur due to the dermal at-
tachments of the superficial musculo- ■ ■Post-Injection Instructions
aponeurotic system (SMAS). They are
seen in the neck from birth, but can None. Bruising is unlikely.
increase and deepen during the aging
process. Treatment of these areas will
soften the lines in this area, but not com-
pletely remove them.
60
CHAPTER 20 ■ Neurotoxin Injection for Necklace Lines 61
Fig. 20.1 Superficial injections of BoNTA are placed at 1.0- to 1.5-cm intervals along the crease to
soften “necklace lines” of the neck.
■ ■Risks • Inform the patient that this is only a
subtle improvement.
Because the swallowing muscles are cho- • Do not overtreat.
linergic, overtreatment of this area can • Inform the patient of the risk of di-
result in a weak or diminished swallow. minished swallowing.
■ ■Pearls of Injection ■ ■Additional Reading
Carruthers J, Carruthers A. Aesthetic botu-
• Stay intradermal; do not inject linum A toxin in the mid and lower face
deeply. and neck. Dermatol Surg 2003;29:468–476
• Proceed slowly; try half the sug- PubMed
gested dose first.
21
Neurotoxin Injection for
Nefertiti Neck Lift
■ ■Anatomic Considerations
Difficulty:
Patient Satisfaction: The platysma muscle is a neck depres-
Risk: sor. It originates at the clavicle and fas-
cia of the upper chest and inserts onto
the mandible and skin of the chin and
cheek. Release of the downward pull of
■ ■Indications the platysma will allow the facial eleva-
tors to elevate the sagging skin over the
The Ancient Egyptian Queen Nefertiti lower face and more clearly define the
has been referred to as one of the most mandibular border.
beautiful women to have ever lived. Im-
ages of Nefertiti generally bring to mind a
graceful neck and sculpted jawline, based ■ ■Injection Technique
on the famed 3,300-year-old bust found
in Egypt in 1912 and now displayed in Patient selection is extremely important
Berlin. The “Nefertiti neck lift” procedure when performing this procedure. Pa-
uses BoNTA to increase the definition of tients who desire a more defined man-
the mandible, in selected patients. dibular contour should be assessed for
62
CHAPTER 21 ■ Neurotoxin Injection for Nefertiti Neck Lift 63
the extent of platysmal pull on their ■ ■Post-Injection Instructions
lower face. It is suggested that the pa-
tient be asked to contract the platysma None.
muscles; if the mandibular border be-
comes less visible, the patient is a good
candidate for this procedure. ■ ■Risks
Injections of BoNTA are placed along
the inferior aspect of the mandible and Over-injection of this area can result in
in the upper aspect of the strongest dysphagia, or an irregular smile. Exces-
lateral platysma band. Injections are sive pull upward on the lower face can
deep into the muscle; approximately result in irregular bunching of the tissue
14 to 20 BU (or 42 to 60 DU) is used per over the mandible.
side in equal injections.
■ ■Pearls of Injection
■ ■Precautions
This technique is difficult to perform
Extending these injections too far medi- well and should be performed only by
ally can affect the depressor labii inferi- experienced injectors. Patient selection
oris and cause a lip droop or asymmet- and meticulous technique is imperative.
ric smile. Do not inject medial to a line Stay low and lateral on the mandible to
drawn down from the nasolabial fold to avoid complications. Results may last up
the mandible. to six months.
64 SECTION II ■ Neurotoxin Injection Techniques
Fig. 21.1 Photograph of the famed Queen Nefertiti bust, crafted ca. 1345 BC in Egypt and un-
earthed in 1912. (Courtesy of Album/Art Resource, NY)
CHAPTER 21 ■ Neurotoxin Injection for Nefertiti Neck Lift 65
Fig. 21.2 Injections of BoNTA should be placed along the inferior aspect of the mandibular border
and into the strongest platysmal band noted during contraction. Stay lateral to avoid weakening the
depressor labii inferioris muscle.
■ ■Additional Reading
Levy PM. The “Nefertiti lift”: a new tech-
nique for specific re-contouring of the jaw-
line. J Cosmet Laser Ther 2007;9:249–252
PubMed
22
Neurotoxin Injection for
Masseter Hypertrophy
■ ■Anatomic Considerations
Difficulty:
Patient Satisfaction: The masseter muscle’s origin is along
Risk: the inferior aspect of the anterior zygo-
matic arch and it inserts into the angle
of the mandible along both the horizon-
tal (body) and the vertical portions of
■ ■Indications the mandible (ramus).
Square jaw lines and wide mandibular
borders are often desirable masculine ■ ■Injection Technique
characteristics but can be unattractive
for women and become exaggerated Two different techniques for injecting
when anatomic hypertrophy exists. the muscle can be attempted: intraoral
Bruxism (teeth grinding), anxiety, and or transcutaneous. In the intraoral tech-
clenching can lead to masseter muscle nique, the injector’s thumb is placed in-
enlargement and accentuate the hori- side the buccal mucosa until the angle
zontal width of the mandibular border. of the mandible is palpated and the pa-
Occasionally Asian patients note hyper- tient is asked to bite down (but not
trophic masseter muscles and may re- on the injector’s finger!). The anterior
quest improvement in this area. edge of the masseter muscle is palpated
66
CHAPTER 22 ■ Neurotoxin Injection for Masseter Hypertrophy 67
between the thumb and fingers of the ■ ■Post-Injection Instructions
same hand resting outside on the cheek.
A 1-inch (2.5-cm), 30-gauge needle is Holding pressure and gentle massage
passed intraorally anterior to the man- helps to prevent bruising. It can take up
dibular ramus and into the muscle belly. to a month for atrophy of the muscle to
This will be somewhat uncomfortable occur.
for the patient. BoNTA is injected in a
retrograde fashion as the needle is with-
drawn. Two to four passes are performed ■ ■Risks
in several tangential intramuscular injec-
tions for a total of 20 BU (or 60 DU) to the Improper injection into surrounding
muscle. muscles can result in swallowing and
In the transcutaneous technique, it is speech disorders. Over-injection of the
useful to place one finger along the masseter is unlikely to result in prob-
lower border of the mandible, one along lems with bite or chewing because the
the vertical border of the mandible, and temporalis muscle, one of the strongest
one as a reference at the inner aspect of primary muscles of mastication, is un-
the mandibular angle with the patient affected. Undertreatment can be re-
clenching as a way to mark out the pe- treated with more product and can be
rimeter of the muscle. With a half- or tested by asking the patient to clench
¾-inch (1.27–1.9 cm) needle or longer, while you palpate the masseter.
injection can be performed inside that
perimeter down to just above the bone,
and depot injections of 4 to 5 units can ■ ■Pearls of Injection
be placed per area. An average of 20
units should be used depending on the Reduction of muscle hypertrophy and
mass of the muscle being treated. mandibular width narrowing occurs
gradually and it may take 6 weeks to see
the full effect. If not adequately im-
■ ■Precautions proved, touch-up treatments may be
required approximately 6 weeks after
Care must be taken to keep the injections the initial treatment. Results can last 6
low and posterior, and centered in the to 12 months.
muscle itself. If placed too far anteriorly,
the smile may be affected by diffusion
into the zygomaticus major or risorius
muscles.
68 SECTION II ■ Neurotoxin Injection Techniques
a
b
Fig. 22.1a, b Possible injection patterns for transcutaneous BoNTA injection for the treatment of
masseter hypertrophy.
■ ■Additional Reading treatment of hypertrophic masseteric mus-
cle and parotid enlargement to narrow the
Choe SW, Cho WI, Lee CK, Seo SJ. Effects of lower facial width. Facial Plast Surg Clin
botulinum toxin type A on contouring of North Am 2010;18:133–140 PubMed
the lower face. Dermatol Surg 2005;31: Yu CC, Chen PK, Chen YR. Botulinum toxin a
502–507, discussion 507–508 PubMed for lower facial contouring: a prospective
Wu WT. Botox facial slimming/facial sculpt- study. Aesthetic Plast Surg 2007;31:445–
ing: the role of botulinum toxin-A in the 451, discussion 452–453 PubMed
23
Neurotoxin Injection for Parotid
Gland Hypertrophy
■ ■Anatomic Considerations
Difficulty:
Patient Satisfaction: The parotid gland rests anterior to the
Risk: ear, beneath the superficial musculoapo-
neurotic system (SMAS) and platysma
muscles, over the lateral mandible. The
external carotid artery and posterior fa-
■ ■Indications cial vein pass just posterior to the gland.
The five branches of the facial nerve,
Hypertrophy of the parotid gland can be which provides motor innervation to fa-
caused by many different factors. Ruling cial mimetic musculature, pass through
out neoplasms and other diseases should the middle of the gland.
be undertaken before beginning treat-
ment to shrink the gland with BoNTA.
Benign glandular enlargement from aging ■ ■Precautions
and xerostomia conditions are some-
times appropriate indications for neuro- Injection above the gland and through
toxin injection. HIV patients can develop the mandibular notch can lead to neuro-
lymphoepithelial enlargement of the toxin spread into the lateral pterygoids,
parotid, and bulimic patients can also which assist in jaw opening and contra-
develop benign parotid enlargement. lateral jaw thrust.
69
70 SECTION II ■ Neurotoxin Injection Techniques
■ ■Injection Technique 30% can be seen, often lasting 6 months
or longer. Repeat treatments can be ex-
A 30-gauge, 1-inch (2.5-cm) needle is pected. If cosmetic narrowing of the
inserted perpendicular to the gland and lower third of the face is desired, then
20 to 30 BU (or 60 to 90 DU) of BoNTA is injection of the masseter muscle should
injected as the needle is withdrawn via be undertaken at the same time (see
several passes through the parenchyma Chapter 22).
of the gland. It is definitely discernible
that the needle has entered the firmer
body of the gland after passing through ■ ■Risks
the SMAS/platysma muscle. Patients will
also be able to sense when the needle Improper injection into surrounding
is in the gland as they will feel an elec- muscles can result in swallowing and
tric or tingling sensation that is clearly speech disorders. Hematoma or major
different from what they felt before the bruising could result from injury to one
needle passed into the gland. It is neces- of the large vessels near the gland.
sary to use a longer needle (1 inch/2.5
cm) to reach the gland.
■ ■Pearls of Injection
■ ■Post-Injection Instructions Turning the patient’s head slightly up-
ward and away from the side of injec-
Holding pressure and gentle massage tion, and grasping either side of the
helps to prevent bruising. It can take up gland with the thumb and first finger
to a month for involution and shrinking to stabilize it, will help ensure proper
of the gland to occur. Shrinkage of 20 to placement of the neurotoxin.
CHAPTER 23 ■ Neurotoxin Injection for Parotid Gland Hypertrophy 71
Fig. 23.1 BoNTA is injected into the body of the parotid gland by using a fanning technique to re-
duce gland hypertrophy.
■ ■Additional Reading muscle and parotid enlargement to nar-
row the lower facial width. Facial Plast
Wu WT. Botox facial slimming/facial sculpt- Surg Clin North Am 2010;18:133–140
ing: the role of botulinum toxin-A in the PubMed
treatment of hypertrophic masseteric
24
Neurotoxin Injection for
Submandibular Gland Hypertrophy
midline, on each side of the neck. The
Difficulty: facial artery passes just posterior to the
Patient Satisfaction: gland, the marginal mandibular branch
Risk: of the facial nerve passes over the cap-
sule of the gland, and the facial vein
passes around the gland’s posterior as-
■ ■Indications pect. Deep to the gland are pharyngeal
muscles and muscles of the floor of the
Ptosis or hypertrophy of the subman- mouth and base of the tongue.
dibular glands can be seen with aging.
Post-necklift/facelift and liposuction pa- ■ ■Precautions
tients are often left with more elegant
jaw lines; however, ptotic submandibu- Injection into surrounding structures
lar glands can be unmasked, which can may result in significant side effects in-
produce an unsightly lump on an other- cluding bleeding, hematoma, intravas-
wise smooth neck. Benign hypertrophy cular injection, swallowing dysfunction,
of the submandibular glands can be and tongue movement disorders. Care
treated with BoNTA. must be taken to ensure that the BoNTA
is injected into the body of the gland.
■ ■Anatomic Considerations
■ ■Injection Technique
The submandibular glands are located
under the mandible, beneath the pla- Botulinum toxin (12 to 15 BU, or 36 to
tysma muscle, 2 to 3 cm posterior from 45 DU, per gland) is injected in a retro-
72
CHAPTER 24 ■ Neurotoxin Injection for Submandibular Gland Hypertrophy 73
grade fashion via several passes through ■ ■Risks
the parenchyma of the gland. The injec-
tor should “feel” that the needle has en- Improper injection into surrounding
tered the firmer body of the gland after muscles can result in swallowing and
passing through the platysma. Patients speech disorders or even aspiration. He-
will be able to sense when the needle is matoma or major bruising could result
in the gland as they will feel an electric from injury to one of the facial vessels
or tingling sensation that is clearly dif- near the gland.
ferent from what they felt before the
needle passed into the gland. It is neces-
sary to use a longer needle (1.0 to 1.5 ■ ■Pearls of Injection
inch/2.5 to 3.8 cm) to enter the gland.
Proper placement of BoNTA can be en-
sured by turning the patient’s head
■ ■Post-Injection Instructions slightly upward and away from the side
of injection. The gland should be grasped
Holding pressure over the injection site and stabilized during injection. Reflux
and gentle massage help to prevent bruis- on the syringe prior to injection pre-
ing. It can take up to a month for involu- vents intravascular injection.
tion and shrinking of the gland to occur.
Shrinkage of 30 to 60% can be seen.
Fig. 24.1 A long needle is used to inject BoNTA into the body of the submandibular gland to im-
prove submandibular gland hypertrophy.
25
Neurotoxin Injection for Gustatory
Sweating (Frey Syndrome)
glands. These patients notice sweating of
Difficulty: the cheek skin overlying the parotid bed.
Patient Satisfaction: The starch-iodine test is useful when
Risk: first treating these patients because the
pattern of sweating may not be predict-
able. On subsequent treatments, once
■ ■Indications the injector has developed an idea of the
affected sites, further treatments may be
Gustatory sweating can be seen after su- performed without repeating the starch-
perficial parotidectomy. These patients iodine test.
notice mild to profuse sweating of the The starch-iodine test can be per-
cheek during meals. formed prior to injection. Povidone io-
dine (Betadine) is painted over the cheek
on the side of the parotidectomy and
■ ■Anatomic Considerations is left for a few minutes to air dry. The
Betadine application should extend over
Acetylcholine, the neurotransmitter the mandible into the neck, onto the
blocked by botulinum toxin, is released ear, and into the temporal hairline. Corn
when eating, and it stimulates secretion starch (available from a food shop) is
of saliva by the salivary glands. When sprinkled lightly onto the cheek; a large
the gland has been partially resected, makeup brush works well for this appli-
such as in superficial parotidectomy, the cation. The patient may need to suck on
acetylcholine is released and diffuses to a sour candy to stimulate the salivary
the skin, where it stimulates the sweat glands. The areas of sweating will cause
74
CHAPTER 25 ■ Neurotoxin Injection for Gustatory Sweating (Frey Syndrome) 75
the cornstarch to turn black, and a grid uct is injected into the dermis in small
is drawn in the area of the sweating. The wheals separated by 1.0 to 1.5 cm. Each
starch-iodine testing can also be uti- injection is 0.05 to 0.1 cc, or approxi-
lized for touch-up treatments, and to mately 1 to 2 units per injection.
identify untreated areas that require
re-treatment.
■ ■Precautions
■ ■Injection Technique Care must be taken to maintain the level
of injection into the dermis.
This is a slightly uncomfortable proce-
dure, and generally well tolerated by pre-
treating with topical anesthetics. Usu- ■ ■Post-Injection Instructions
ally 30 to 50 BU or 100 to 150 DU may be
necessary for this treatment. The prod- None.
■ ■Pearls of Injection
Inject in a grid pattern and inject su-
perficially. Wait at least 2 weeks for
maximum response before considering
a touch-up. Weakening of the facial
mimetic muscles is unlikely and can be
prevented by not injecting anterior to the
anterior border of the masseter muscle.
■ ■Additional Reading
Arad-Cohen A, Blitzer A. Botulinum toxin
treatment for symptomatic Frey’s syn-
drome. Otolaryngol Head Neck Surg 2000;
122:237–240 PubMed
Fig. 25.1 A starch-iodine test is used to delin- Guntinas-Lichius O. Management of Frey’s
eate the areas of gustatory sweating, and BoNTA syndrome and hypersialorrhea with botu-
is injected intradermally in a grid-like pattern at linum toxin. Facial Plast Surg Clin North
the sites of maximum sweating. Am 2003;11:503–513 PubMed
26
Neurotoxin Injection for Profusely
Sweating Underarms
profuse underarm sweating. The starch-
Difficulty: iodine test can be performed prior to in-
Patient Satisfaction: jection. The axilla is painted with Beta-
Risk: dine and is left for a few minutes to air
dry. Corn starch (available from a food
shop) is sprinkled lightly onto the axilla;
■ ■Indications a large makeup brush works well for
this application. The areas of sweating
Profuse sweating of the armpits can be will cause the cornstarch to turn black.
treated with BoNTA. Results of treatment This is a messy procedure, and often
are impressive and can last up to a year. unnecessary because most sweating usu-
ally occurs in the hair-bearing skin of
the axilla. Touch-up treatments are oc-
■ ■Anatomic Considerations casionally required several weeks later
if not all areas were adequately treated.
Neurotoxins act by preventing release of A starch–iodine test can be helpful in
acetylcholine from nerve endings at the these cases.
neuromuscular junction, the effect of
which is to inhibit muscle contraction.
Acetylcholine is also the neurotransmit- ■ ■Injection Technique
ter for the sweat glands. Injection of
botulinum toxin into sweat glands will This is a relatively painless procedure,
prevent sweating and is an excellent well tolerated without the use of topical
treatment for patients who complain of anesthetics. Usually 100 BU or 300 DU is
76
CHAPTER 26 ■ Neurotoxin Injection for Profusely Sweating Underarms 77
used for this treatment, divided evenly ■ ■Post-Injection Instructions
for each axilla. The product is injected
into the dermis in small wheals sepa- None.
rated by 1.0 to 1.5 cm. Each injection is
0.05 to 0.1 cc, or approximately 1 to 2 BU
or 3 to 6 DU per injection. ■ ■Pearls of Injection
• Inject in a grid pattern, into the hair-
■ ■Precautions bearing areas of the axilla.
• The injector may make use of the
Care must be taken to maintain the level starch-iodine test for more accu-
of injection into the dermis. Deep in- rate injections or for touch-up
jection may weaken the muscles of the treatments.
arm. Deep injection also will not ade- • Wait at least 2 weeks for maxi-
quately treat the sweat glands, which lie mum response before considering a
in the dermis. touch-up.
Fig. 26.1 Injection of BoNTA in the axilla is intradermal and placed in a grid-like pattern with injec-
tions separated by 1.0 to 1.5 cm. If a starch-iodine test is not performed, injections should be placed
in the hair-bearing area.
78 SECTION II ■ Neurotoxin Injection Techniques
Fig. 26.2 Corn starch is lightly brushed on the area that has been painted with Betadine.
Fig. 26.3 The injection grid is placed in the areas of maximum sweating, denoted by the dark areas.
CHAPTER 26 ■ Neurotoxin Injection for Profusely Sweating Underarms 79
■ ■Additional Reading toxin. Aesthet Surg J 2012;32:238–244
PubMed
Cohen JL, Solish N. Treatment of hyperhidro- Naver H, Swartling C, Aquilonius S-M. Pal-
sis with botulinum toxin. Facial Plast Surg mar and axillary hyperhidrosis treated
Clin North Am 2003;11:493–502 PubMed with botulinum toxin: one-year clinical
Doft MA, Hardy KL, Ascherman JA. Treat- follow-up. Eur J Neurol 2000;7:55–62
ment of hyperhidrosis with botulinum PubMed
27
Neurotoxin Injection for Profusely
Sweating Hands
treatment for patients who complain of
Difficulty: profuse sweating of the hands.
Patient Satisfaction:
Risk:
■ ■Injection Technique
This is a painful procedure and some
■ ■Indications
type of anesthesia is required. Because
of the thick skin of the hands, topical
Profuse sweating of the hands may be anesthetics may not be well absorbed by
treated by BoNTA injections.
callused hands. Numbing the hands in
ice baths, using a regional block, or even
■ ■Anatomic Considerations sedation may be necessary.
Usually 100 BU (or 300 DU) is used for
Neurotoxins act by preventing release this treatment, divided evenly for each
of acetylcholine from nerve endings at hand. The product is injected into the
the neuromuscular junction, the effect of dermis in small wheals separated by 1.0
which is to inhibit muscle contraction. to 1.5 cm. Each injection is 0.05 to 0.1 cc,
Acetylcholine is also the neurotrans- or approximately 1 to 2 BU or 3 to 6 DU
mitter for the sweat glands. Injection of per injection. Because of the thickness
botulinum toxin into sweat glands will of the skin, a 30- or 26-gauge needle may
prevent sweating and is an excellent be necessary.
80
CHAPTER 27 ■ Neurotoxin Injection for Profusely Sweating Hands 81
■ ■Pearls of Injection
• Needles dull quickly when used on
hands and feet, so multiple needles
may be needed.
• Be careful to inject super ficially.
• Patients are likely to experience
some weakness of the hand muscles
during maximal grip, which can last
for several weeks post-injection.
• Results can last an average of 6
months.
■ ■Additional Reading
Cohen JL, Solish N. Treatment of hyperhi-
drosis with botulinum toxin. Facial Plast
Surg Clin North Am 2003;11:493–502
PubMed
Doft MA, Hardy KL, Ascherman JA. Treat-
ment of hyperhidrosis with botulinum
toxin. Aesthet Surg J 2012;32:238–244
PubMed
Fig. 27.1 BoNTA is injected in a grid-like pat- Naver H, Swartling C, Aquilonius S-M. Pal-
tern on the palmar surface of the hand to reduce mar and axillary hyperhidrosis treated
profuse sweating. with botulinum toxin: one-year clinical
follow-up. Eur J Neurol 2000;7:55–62
PubMed
■ ■Precautions Yamashita N, Shimizu H, Kawada M, et al.
Local injection of botulinum toxin A for
Care must be taken to maintain the level palmar hyperhidrosis: usefulness and ef-
of injection into the dermis. Deep injec- ficacy in relation to severity. J Dermatol
tion may weaken the hand muscles. 2008;35:325–329 PubMed
■ ■Post-Injection Instructions
None.
28
Neurotoxin Injection for Profusely
Sweating Feet
excellent treatment for patients who
Difficulty: complain of profuse sweating of the feet.
Patient Satisfaction:
Risk:
■ ■Injection Technique
■ ■Indications This is a painful procedure and some
type of anesthesia is required. Because
Profuse sweating of the feet. Results of of the increased thickness of the skin,
treatment can last up to a year. topical anesthetics may not be well ab
sorbed by callused feet. Using a regional
block (posterior tibial and sural nerve
■ ■Anatomic Considerations block) or even sedation anesthesia may
be necessary.
Neurotoxins act by preventing release Usually 100 BU or 300 DU is injected
of acetylcholine from nerve endings at for this treatment, divided evenly for
the neuromuscular junction, the effect each foot (occasionally more is neces
of which is to inhibit muscle contrac sary for larger feet). The product is in
tion. Acetylcholine is also the neuro jected into the dermis in small wheals
transmitter for the sweat glands. In separated by 1.0 to 1.5 cm. Each injec
jection of botulinum toxin into sweat tion is 0.05 to 0.1 cc, or approximately
glands will prevent sweating and is an 1 to 2 BU or 3 to 6 DU per injection. Be
82
CHAPTER 28 ■ Neurotoxin Injection for Profusely Sweating Feet 83
cause of the thickness of the skin, a 30
or 26gauge needle may be necessary.
■ ■Precautions
Care must be taken to maintain the level
of injection into the dermis. Deep injec
tion may weaken the muscles of the foot.
■ ■Post-Injection Instructions
None.
■ ■Pearls of Injection
Needles dull quickly on the hands and
feet, so multiple needles may be needed.
Be careful to inject superficially.
■ ■Additional Reading
Cohen JL, Solish N. Treatment of hyperhidro
sis with botulinum toxin. Facial Plast Surg
Clin North Am 2003;11:493–502 PubMed
Fig. 28.1 BoNTA is injected in a grid-like pat- Doft MA, Hardy KL, Ascherman JA. Treatment
tern on the soles of the feet to reduce profuse of hyperhidrosis with botulinum toxin.
sweating. Aesthet Surg J 2012;32:238–244 PubMed
29
Neurotoxin Injection for Migraines
aches. If feasible, try to inject directly
Difficulty: into the site of the trigger area. Most
Patient Satisfaction: often, the glabella, forehead, and lateral
Risk: brow as well as the temporalis muscle
and upper portion of the trapezius mus-
cle as it enters into the occiput are the
most common areas in which injection
■ ■Indications can relieve classic or common migraines
and tension headaches.
Symptoms of classic migraines may
include auras, photophobia, unilateral
foci, nausea, and pounding headaches. ■ ■Injection Technique
BoNTA has been used successfully in
some patients to reduce the frequency Topical anesthesia may be used and ice
or severity of their headaches. Similarly, may be applied, though neither is neces-
BoNTA may be used to treat patients sary in most cases. Injection techniques
with recurrent tension headaches in the as described herein for the treatment of
frontal and occipital regions. the glabella, forehead, and lateral brow-
lift are used for migraine headache as
well. In addition, BoNTA injections of the
■ ■Anatomic Considerations temporalis muscle may be performed
on the offending side.
Individual patients may be able to de- For the posterior type headaches, trig-
termine “trigger points” for their head- ger points are identified by digital pres-
84
The words you are searching are inside this book. To get more targeted content, please make full-text search by clicking here.
Discover the best professional documents and content resources in AnyFlip Document Base.
Search