Botulinum Toxin Injection



I would like to introduce my next patient, Zoe. As you can see, Zoe is young and accordingly she will have very little treatment indication. She has told me that she is worried about lines in her upper face, so let’s just review her upper face from the trichion to the glabella. The first thing we notice is that she has a very nice convexity of her forehead, both in the vertical plane, and she is also convex horizontally across her forehead. This portrays youth and beauty. We can see from this distance that there does not appear to be any static lines in her face. Let’s now see what happens if we ask her to move her muscles – if now I ask Zoe to frown, you will notice she gets 2 vertical glabellar lines between the heads of brow. When she relaxes this action, you notice you can still just about see the lines for a few seconds, so she is in that transition period from when her lines are going from purely dynamic to becoming a little bit more static. She is therefore in the ideal period to start having Botox treatment.


We will now ask Zoe to raise her brows, and when she does, you can see she has very minimal dynamic lines, mainly in the centre of her forehead. However, just pay attention to her right brow, which is slightly higher than the left one at rest and when she elevates the brow, it remains higher. Spotting little asymmetries like this in patients is vital for treatment, because if you do not spot them and amend your treatment accordingly, you can exacerbate the asymmetry, and it would be easy to make her right brow higher than her left after treatment.

Injection site markings and treatment

Let’s review the surface markings for the injection points in the upper face on Zoe. After cleaning her face, we will proceed to make the injection point marks (I continue to mark the patient even after 18 years of clinical practice). I get Zoe to frown, and I can see that she is recruiting laterally so we will use 5 units to treat the glabella. The first point is the injection for the procerus – to find where to inject this, take a line from one medial canthus, crossing the nose bridge to the opposite head of brow and repeat on the other side. Where these two diagonal lines intersect will be the location of our first injection point.


Next, we have to make a point for the head of corrugator – to do this, take a line vertically up from the medial canthus, palpate the corrugator above the orbital rim, and slightly above the orbital rim – about a centimetre – make a mark for the head of corrugator, then repeat this on the left side. For the tail of the corrugator, we can continue along the orbital rim, just medial to the mid-pupillary line, and make a second point. Because the orbital rim is curved, we will find that this second point will be somewhat superior and lateral to the injection point for the head of corrugator, and we will repeat this on both sides.


We will now make the markings for the frontalis – if you recall, Zoe’s right brow is elevated compared to the left, and she has a lot of lines in the middle compared to the lateral aspect. We will therefore place the injection point relatively lower and I will place the second injection point higher to preserve the brow shape. The third point is lower again in the middle of the forehead, then we come up again for the fourth point, and then the final injection point on her left will be a little higher than the first point on the right. This is to balance out the brow shape. The five dots here will make an ‘m,’ a shape frequently used in female patients when we want to preserve the curve of the brow. You can see that by adjusting the first and final points, we can influence brow position.


To treat the procerus, I pinch the skin and insert my needle deep to inject the first 4 units in this location. I then move to treat the corrugator, I use a finger in the orbital rim to prevent diffusion of the toxin inferiorly, pinch the muscle between my thumb and finger, insert my needle deep and aim posterolaterally to inject a further 4 units into the head of corrugator. I repeat this on her right side, this time using my thumb in the supraorbital rim. Again, I am injecting deep because the origin of the corrugator is on the superciliary arch of the orbital rim. When I want to inject the tail of corrugator, I have to be superficial, this is because its insertion is into the skin. Accordingly, I come in laterally and just inject into the dermis in the location of the tail of the corrugator. If I was to be deep in this location, I could inadvertently inject toxin behind the corrugator, which could diffuse down, affecting the levator palpebrae muscle, and quite possible causing lid ptosis. We inject 2 units into the tail of corrugator. Injecting her forehead, the preference is to use an intradermal approach, because I find this more comfortable for the patient. Because the muscle is so adherent to the skin, toxin will easily diffuse through the skin into the muscle. I am injecting 1.5 units in each of the 5 injection points in Zoe’s forehead. If I find that this is not enough, and then she needs more treatment at a second follow up, I can always add in more units at that stage, however, if I inject her with too high a dose it could cause a lid or brow ptosis, which would be unforgivable in a female patient.

Treatment outcome at 6 weeks

We now welcome back Zoe, approximately 6 weeks after her Botox treatment. We can see at rest that she appears very soft and smooth, and we notice that when she is trying to frown, the area between her eyebrows is now smooth, without any obvious vertical glabellar lines. Likewise, when she raises, we see that she is smooth, however, she still does have a little bit more elevation of her right brow compared to her left, as she did before treatment. This is amenable to treatment, and we can treat this in the same way as we would treat a mephisto, by injecting 1 unit into the apex of that brow. I am now marking the position that I will inject in as she has requested correction of this region. She also has just a little bit more movement in her upper forehead than she would like so we will treat this region for her as well. I am injecting one unit in the mephisto region, and then I will proceed to inject 3 areas in the central forehead with 1 unit each in addition. This ought to give Zoe the exact look she was looking for. Again, I will follow up with her at 2 weeks just to make sure that she is happy with her result.