Introduction
Treatment of facial lines and wrinkles with botulinum toxin type A has become the most frequently performed cosmetic procedure in the United States today, according to the American Society for Aesthetic Plastic Surgery. It is also one of the most common entry procedures for primary care professionals seeking to incorporate aesthetic procedures into their practice.
By definition, facial wrinkles formed during muscle contraction are dynamic lines. Over time, dynamic lines may become etched into the skin resulting in permanent or static lines. Botulinum toxin reduces unwanted dynamic and static lines by relaxing overactive facial muscles and smoothing the skin. It is a potent neurotoxin protein derived from the Clostridium botulinum bacterium, and exerts its effect at the neuromuscular junction by inhibiting release of acetylcholine. Localized, temporary chemical denervation is achieved through injection of small quantities of botulinum toxin into specific overactive facial muscles.
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Botulinum toxin was first noted for its toxic properties, as were atropine and digitalis, but is now routinely used as a medicine to treat clinical conditions such as blepharospasm, strabismus, cervical dystonia, hyperhidrosis, migraines, and muscle spasticity associated with cerebral palsy and strokes. Botulinum toxin was approved by the U.S. Food and Drug Administration (FDA) in 2002 as BOTOX for cosmetic use to treat the glabella complex muscles, which contribute to frown line formation. All references in this chapter to treatments with botulinum toxin type A refer specifically to Botox, manufactured by Allergan.
Botulinum toxin is used for numerous cosmetic indications; however, treatment to the upper one-third of the face offers the most predictable results, greatest efficacy, and fewest side effects. The three essential medical aesthetic rejuvenation treatments (ARTs) for primary care professionals using botulinum toxin are injections of the: (i) glabella complex muscles, which form frown lines; (ii) frontalis muscle, which forms horizontal forehead lines; and (iii) lateral orbicularis oculi muscles, which form crow 's feet (see 01412520).
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Functional Anatomy
A thorough understanding of facial anatomy in the treatment areas is essential prior to performing botulinum toxin procedures. The muscles of facial expression are unique in that they have soft tissue attachments to the skin through the superficial muscular aponeurotic system, unlike most muscles, which have boney attachments. When a muscle contracts, the overlying skin moves with it and wrinkles are formed perpendicular to the direction of the muscle contraction.
Glabella wrinkles, or frown lines, are vertical wrinkles that occur between the medial aspects of the eyebrows. The muscles that contribute to formation of frown lines are the glabellar complex of depressor muscles, which pull the brows medially and inferiorly and include the corrugator supercilii, procerus, depressor supercilii, and medial orbicularis oculi.
Horizontal forehead lines result from contraction of the broad frontalis muscle, which spans the forehead between the temporal fusion lines (see 01412520). The muscle fibers are vertically oriented, and contraction of this elevator muscle raises the eyebrows, with the lower 2-cm portion having the most marked effect on eyebrow height and shape. The goal of treatment in this area is to partially inhibit activity of the frontalis to reduce horizontal forehead lines while maintaining a desirable eyebrow shape.
Lateral orbital wrinkles commonly known as crow 's feet, result from contraction of the lateral portion of the orbicularis oculi, a thin, superficial muscle that encircles the eye. Contraction of the palpebral portion of the orbicularis oculi results in closure of the eyelids. The goal of treatment in this area is to focally inhibit the lateral orbicularis oculi to reduce crow 's feet without complete orbicularis oculi inactivation.
Many of the muscles of facial expression interdigitate with one another. While providing treatment with botulinum toxin to one area in isolation will often provide adequate results, in some cases an adjacent area may require concomitant treatment to achieve the desired results. For example, the glabella complex muscles interdigitate to a greater or lesser degree with the frontalis, and treatment of the frontalis in addition to treatment of the glabellar complex may be required to smooth frown lines in some cases.
General Injection Guidelines
- Position the patient comfortably in a reclined position for the procedure, at about 65 degrees.
- Cleanse the treatment areas with alcohol prior to injection and allow alcohol to dry, as alcohol may denature the botulinum toxin.
- Typically no anesthesia is required for botulinum toxin treatments. If necessary, ice may be used prior to injections in all treatment areas except crow 's feet, as this makes identification and avoidance of veins more difficult.
- Injections should be made into the "hill " of the contracted muscle.
- Botulinum toxin is injected as the needle is withdrawn and should flow very easily, requiring only a light touch. If resistance is encountered, fully withdraw the needle and reinsert.
- Avoid intravascular injection. Intravascular injection is apparent when the surrounding skin blanches during injection. If this occurs, withdraw the needle partially from the blanched site, reposition, and inject.
- Avoid hitting the periosteum, particularly with frontalis treatments, as this is painful and dulls the needle.
- If bleeding occurs, apply firm pressure directed away from the eye and achieve hemostasis before proceeding to subsequent injection points.
Dosage
The doses and diagrams in this chapter are general treatment recommendations for starting doses and refer exclusively to botulinum toxin type A (Botox) from Allergan. Optimal results are achieved through individualization of treatments based on the patient 's observed muscle function and muscle bulk in the treatment areas.
Results and Follow-up
- Some reduction in muscle function is typically seen by the third day after botulinum toxin treatment. Maximal reduction in function of the targeted muscles is visible 1 to 2 weeks after treatment. Botulinum toxin effects are most dramatic for the treatment of dynamic lines. Static lines are slower to respond, usually requiring 2 to 3 consecutive botulinum toxin treatments and deep, static lines may not fully respond even after multiple treatments.
- If muscle activity persists in one or more parts of the treated area, a touch-up procedure may be performed 2 weeks after treatment. The dose is based on the degree of movement remaining in the treated muscle and may range from 2.5 to 10 units. Reassess the treatment area 1 week after the touch-up procedure.
- Return of muscle function in the treatment area is gradual. Patients should follow-up for subsequent treatment when muscle function is regained, prior to facial lines returning to their pretreatment appearance.
Preprocedure Checklist
- Perform an aesthetic consultation and review patient 's medical history (see Aesthetic Procedures Introduction).
- Obtain informed consent (see Aesthetic Procedures Introduction).
- Take pretreatment photographs with the patient actively contracting the muscles in the intended treatment area and with the muscles at rest.
- Document and discuss any notable asymmetries prior to treatment.
- Minimize bruising by discontinuation of aspirin, vitamin E, St. John 's wort and other dietary supplements including ginkgo, evening primrose oil, garlic, feverfew and ginseng for 2 weeks prior to treatment. Discontinue other nonsteroidal anti-inflammatory medications 2 days prior to treatment.
Equipment
Botulinum Toxin Reconstitution
- 5.0-mL syringe
- Botox 100-unit vial
- 10 mL vial 0.9% sterile nonpreserved saline
- 18-gauge, 0.5-inch needle
Botulinum Toxin Treatment
- Reconstituted Botox
- 1.0 mL Luer-Lok syringe
- 30-gauge, 1-inch needle
- 30-gauge, 0.5-inch needle
- 32-gauge, 0.5-inch needle
- Gauze, 3 3 inches, nonwoven
- Ice pack
Reconstitution
Using an 18-gauge needle and a 5.0-mL syringe, draw up 4.0 mL of 0.9% nonpreserved sterile saline diluent. Insert the needle at a 45-degree angle into the Botox vial and inject saline slowly, maintaining upward plunger pressure so that the diluent runs down the sides of the vial. Gently swirl the reconstituted Botox vial, and record the date and time of reconstitution on the vial. Note that alcohol can denature Botox and therefore, bottle stoppers must be fully dried.
Concentration
Botox is supplied as a vacuum-dried powder with 100 units per vial. Reconstitution of Botox powder using 4.0 mL of nonpreserved saline results in a concentration of 100 units botulinum toxin per 4.0 mL (100 units/4 mL) or 2.5 units botulinum toxin per 0.1 mL.
Handling
Botox is shipped frozen on dry ice. Prior to and after reconstitution, it should be stored in the refrigerator at a temperature of 2 °C to 8 °C (35.6 °F to 46.4 °F). Prior to reconstitution it may be stored for 24 months, per the Botox package insert. After reconstitution, the American Society for Plastic Surgery Botox Consensus Panel recommends using Botox within 6 weeks and notes no loss of potency during that time. The Botox package insert however, recommends using Botox within 4 hours of reconstitution.
Aesthetic Indications
- Temporary improvement in the appearance of dynamic facial lines and wrinkles.
- FDA approved for treatment of frown lines due to contraction of the glabellar complex muscles. Used off label for all other cosmetic indications, including treatment of lateral orbicularis oculi and frontalis muscles.
- Patients aged 18 to 65 years old. May be used in patients older than age 65, but treatments are less effective if severe static wrinkling is present.
Contraindications
Absolute Contraindications
- Pregnancy (category C)
- Nursing
- Active infection in the treatment area
- Gross motor weakness in the treatment area, for example, due to a history of polio or Bell 's palsy
- Neuromuscular disorder or current evaluation for neuromuscular disorder, including but not limited to: amyotrophic lateral sclerosis, myasthenia gravis, or Lambert-Eaton syndrome
Relative Contraindications
- Inability to actively contract muscles in the treatment area prior to the procedure
- Blepharoplasty or laser-assisted in situ keratomileusis (LASIK) surgery within the past 6 months
- Body dysmorphic disorder or unrealistic expectations
- Medications that inhibit neuromuscular signaling which may potentiate botulinum toxin effects, such as: aminoglycosides, penicillamine, quinine, and calcium channel blockers
The Procedure
Frown Lines
Frown lines often convey anger, frustration, and irritation and may be perceived negatively. Improvement of frown lines has therefore become one of the most common aesthetic complaints for which patients seek botulinum toxin treatments.01412520 shows a 38-year-old woman with frown lines resulting from active contraction of the glabellar complex muscles. 01412520 shows the same patient 1 month after her first botulinum toxin treatment attempting to frown. Notice the dramatic posttreatment improvement in frown lines and the elevated medial brow position, due to the lack of depressor muscle function. The duration of botulinum toxin effect in the glabella complex muscles is typically 3 to 4 months.
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The glabellar muscles require deep intramuscular injection, and a 30 gauge, 1 inch needle is preferable. Alternatively, a 30 gauge, 0.5 inch needle may be used. Botulinum toxin should be placed within the glabellar complex Safety Zone to minimize the risk of blepharoptosis and eyebrow ptosis. The glabellar complex Safety Zone (shaded gray) is bounded by the vertical lines extending up from the lateral irises (see 01412520). It is approximately 1 " 2 cm above the orbital rim and extends inferiorly to a point just below the glabellar prominence.
- Pearl: In some patients with broad musculature, the lateral margins of the corrugators may extend outside of the Safety Zone. Avoid injecting the portion of the corrugator that is outside of the Safety Zone.
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An overview of botulinum toxin injection points and doses for the treatment of frown lines is shown (01412520). The starting dose for women is 20 units botulinum toxin (0.8 mL of reconstituted Botox with 100 units/4 mL) and for men is 25 units botulinum toxin (1.0 mL Botox with 100 units/4 mL).
- Pearl: The doses listed in this chapter are recommendations for starting doses and refer exclusively to Botox from Allergan.
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Step 1
The first injection point is at the lateral margin of the corrugator within the safety zone. Identify the lateral margin of the corrugator by directing the patient to actively frown. Inject 2.5 units of botulinum toxin 1 to 2 cm above the superior margin of the orbit, at the visible lateral margin of the corrugator. If using the 1-inch needle, insert it part way to about half of its depth.
- PITFALL: Do not initiate treatment to the glabella complex if the lateral corrugator margin is not clearly visible.
- PITFALL: Inject at least 1 cm above the orbital margin to minimize the risk of blepharoptosis (droopy upper eyelid).
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Step 2
The second injection site is in the body of the corrugator, approximately 1 cm medial to the first injection site and more inferior, closer to the eyebrow. Direct the needle toward the procerus, inserting the 1-inch needle to the hub, and inject 5 units of botulinum toxin. Repeat Steps 1 and 2 for the contralateral side of the face.
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Step 3
The third injection site is in the procerus, which is approached inferiorly with the needle directed toward the forehead. With the patient frowning, inject 2.5 to 5 units of botulinum toxin with the 1-inch needle inserted into the procerus to about half its depth.
- Pearl: This site tends to bleed, so apply pressure firmly after withdrawing the needle.
- Pearl: This third injection site may not be needed if the procerus is adequately injected from the lateral corrugator injection points using the 1 inch needle in the Second Step.
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Horizontal Forehead Lines
Patients with deep horizontal forehead lines must be assessed for eyebrow ptosis and upper eyelid laxity with the frontalis muscle at rest prior to treatment with botulinum toxin. Avoid treating patients with low-set eyebrows or upper eyelid skin laxity, as frontalis muscle contraction is compensatory to alleviate these issues. The duration of botulinum toxin effect in the frontalis muscle is typically 3 to 4 months. 01412520 shows a 38-year-old woman with horizontal forehead lines resulting from active contraction of the frontalis muscle.01412520 shows the same patient 1 month after botulinum toxin treatment attempting to contract the frontalis muscle.
- Pearl: Elicit frontalis muscle contraction by having the patient raise his or her eyebrows as if surprised.
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The majority of botulinum toxin is placed within the vertical lines of the frontalis Safety Zone (shaded gray) to minimize the risk of eyebrow ptosis. The frontalis Safety Zone is the area between the vertical lines extending up from the lateral irises, at least 2 cm above the orbital rim, and includes a small area lateral to the vertical lines 2 cm inferior to the hairline (see 01412520). A 30 gauge, 0.5 inch needle should be used for all injections. The needle tip should be placed in the "hill " of the contracted muscle.
- Pearl: As a general rule, do not inject inferior to the lowest horizontal forehead wrinkle.
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An overview of botulinum toxin injection points and doses for the treatment of horizontal forehead lines is shown in 01412520. The starting dose for women is 16 to 22.5 units of botulinum toxin (0.6 to 0.9 mL of reconstituted Botox with 100 units/4 mL) and for men is 20 to 25 units of botulinum toxin (0.8 to 1.0 mL of Botox with 100 units/4 mL).
- Pearl: The doses listed in this chapter are recommendations for starting doses and refer exclusively to Botox from Allergan.
Figure 7 View Original Figure 7 View Original
Step 1
While the patient actively raises their eyebrows, inject 2.5 units of botulinum toxin into the "hill " of the frontalis muscle with the needle angled at 30 degrees to raise a wheal. Have the patient relax once the needle is withdrawn.
- PITFALL: Avoid injecting too deeply and hitting the periosteum.
- Pearl: Change needles after six injections to maintain a sharp needle.
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Step 2
The second injection point should be approximately 1 cm lateral to the first. Inject it with 2.5 units of botulinum toxin.
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Step 3
Continue along each "hill " of the frontalis muscle and proceed superiorly up the forehead. Inject 2.5 units of botulinum toxin at each injection point.
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Step 4
The last injection should be placed at the maximal point of eyebrow elevation, typically located just lateral to the Safety Zone line, approximately 2 cm inferior to the hair line. Inject 1.25 units of botulinum toxin (0.05 mL of reconstituted Botox, with 100units/4 mL). Perform botulinum toxin injection symmetrically on the contralateral side of the forehead.
- PITFALL: Omission of this injection may result in a peaked or quizzical eyebrow shape and subsequently require a touch-up.
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Step 5
Patients receiving botulinum toxin treatments for horizontal forehead lines for the first time should be seen 2 weeks after treatment to evaluate eyebrow symmetry and shape. Assess the eyebrow shape at rest and with active elevation. If a peaked eyebrow shape is present with frontalis contraction, inject 1.25 to 2.5 units of botulinum toxin at least 3 cm above the orbital rim, at the most peaked portion of the eyebrow. Reassess in 1 to 2 weeks. Step 5 shows the patient 1 week after receiving 22.5 units of botulinum toxin to the frontalis muscle with mildly peaked eyebrows. She was treated with 1.25 units of botulinum toxin above each peaked eyebrow, and her final result is shown in 01412520.
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Step 6
Eyebrow ptosis can result from botulinum toxin injected laterally, outside of the safety zone or, in the inferior portion of the frontalis, too close to the eyebrows. Eyebrow ptosis can be improved or reversed with injection of botulinum toxin in the orbicularis oculi under the affected eyebrow. Inject 1.25 units of botulinum toxin (0.05 mL of reconstituted Botox with 100 units/4 mL) lateral to the iris in the orbicularis oculi, just beneath the level of the orbital rim as shown in Step 6. Reassess in 1 week.
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Crow 's Feet
The pattern of crow 's feet resulting from contraction of the lateral orbicularis oculi muscle varies, with some extending superiorly toward the eyebrow and others extending inferiorly toward the cheek. Optimal results with botulinum toxin treatments in the crow 's feet area will be achieved by adapting the injection technique outlined here to the individual 's pattern of crow 's feet.
The duration of botulinum toxin effect in the lateral orbicularis muscle is typically 2.5 to 3 months.01412520 shows a 37-year-old woman with crow 's feet resulting from active contraction of the lateral orbicularis oculi muscle. 01412520 shows the same patient 1 month after botulinum toxin treatment attempting to contract the lateral orbicularis oculi muscle.
- Pearl: Elicit orbicularis oculi muscle contraction by having the patient smile and squint as if sun is in his or her eyes.
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All injection points should be within the crow 's feet Safety Zone (shaded gray), the area 1 cm lateral to the orbital rim, above the level of the zygomatic arch, which extends under the eyebrow to the lateral iris. The orbicularis oculi muscle is a thin, superficial muscle, and botulinum toxin should be placed just subdermally using a 30 gauge, 0.5 inch needle to raise a wheal at each injection point. Alternatively, a 32 gauge, 0.5 inch needle may be used to minimize bruising. After each injection, apply firm pressure away from the eye to compress the wheal.
- Pearl: Bruising is the most common side effect in the crow 's feet area. Look for and avoid veins, which are best seen with oblique lighting.
Figure 9 View Original Figure 9 View Original
An overview of botulinum toxin injection points and doses for treatment of crow 's feet is shown in 01412520. The starting dose for women is 16 to 20 units of botulinum toxin (0.6 to 0.8 mL of reconstituted Botox with 100 units/4 mL) and for men is 20 to 25 units botulinum toxin (0.8 to 1.0 mL Botox, with 100 units/4 mL).
- Pearl: The doses listed in this chapter are recommendations for starting doses and refer exclusively to Botox from Allergan.
Figure 10 View Original Figure 10 View Original
Step 1
The first injection point is superior to the lateral canthal line, 1 cm outside of the boney orbit. With the patient contracting the orbicularis oculi, inject 2.5 units of botulinum toxin subdermally into the "hill " of the contracted muscle to raise a wheal.
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Step 2
The second injection point is approximately 0.5 cm superior to the first injection point, and 2.5 units of botulinum toxin should be injected subdermally into the "hill " of the orbicularis oculi.
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Step 3
The third injection point is approximately 0.5 cm inferior to the first injection point. The needle should be angled inferiorly and threaded superficially to the hub, with 2.5 to 3 units of botulinum toxin injected as the needle is withdrawn. Repeat injections for the contralateral orbicularis oculi muscle of the other eye.
- PITFALL: Avoid injecting too deeply and too inferiorly below the level of the zygomatic arch, so as to avoid the zygomatic muscles. Relaxation of the zygomatic muscles can result in cheek ptosis and upper lip ptosis, which may affect oral competence.
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Complications
Common
- Localized burning or stinging pain with injection, bruising, erythema, infection, tenderness, temporary swelling, and mild headache.
- Blepharoptosis (3%) with or without diplopia. Blepharoptosis results from migration of botulinum toxin through the orbital septum, a fascial layer, to the levator palpebrae superioris muscle. Lateral to the Safety Zone line at the boney supraorbital margin, some of the levator palpebrae superioris fibers pass up through the orbital septum, and botulinum toxin can more easily migrate into and relax the levator palpebrae superioris, resulting in blepharoptosis. Blepharoptosis is infrequent and almost always unilateral. It is typically seen as lowering of the affected eyelid 2 to 3 mm, which is most marked at the end of the day with muscle fatigue. It typically resolves spontaneously within 6 weeks. Blepharoptosis may be treated with over-the-counter alpha-adrenergic eyedrops such as Naphcon-A, 1 drop four times per day, or prescription apraclonidine (Iopidine) 0.5% solution, 1 to 2 drops three times per day. These eyedrops cause contraction of an adrenergic levator muscle of the upper eyelid, the Mueller muscle, resulting in elevation of the upper eyelid.
- Eyebrow ptosis.
- Facial asymmetry, including but not limited to smile and eyebrows.
- Oral incompetence with crow 's feet treatment.
- Rarely, auto-antibodies against botulinum toxin may be present or develop after treatments, rendering treatments ineffective.
Rare and Idiosyncratic
- Numbness or dysesthesia at the treatment site
- Focal tonic movements
- Periocular swelling
- Extremely rare: immediate hypersensitivity reaction with signs of urticaria, edema, and a remote possibility of anaphylaxis
Pediatric Considerations
This treatment is contraindicated for cosmetic uses in pediatric patients.
Postprocedure Instructions
On the day of treatment, instruct the patient
- Not to massage the treated areas.
- Avoid lying down for 4 hours immediately after treatment.
- Avoid activities that cause facial flushing, including application of heat to the face, alcohol consumption, exercising, and tanning.
- Ice each site for 10 to 15 minutes every 1 to 2 hours for 1 to 3 days if bruising occurs.
Coding Information and Supply Sources
These procedures are not reimbursable by insurance.
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 64612 Chemo-denervation of muscles or muscles innervated by the facial nerve. $482.00 10 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
Supply Sources
Allergan, Inc., 2525 Dupont Drive, Irvine, CA 92612. Phone: 1-800-377-7790.
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Klein AW. Complications, adverse reactions and insights with the use of botulinum toxin.
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Sommer B, et al. Satisfaction of patients after treatment with botulinum toxin for dynamic facial lines.
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