Botulinum Toxin Injection

Introduction

 

Hello. In this series of videos, I’m going to talk to you about full face treatment with Botulinum Toxin. The brand of Botulinum Toxin I use is Botox, and therefore I will now refer to it as such. Remember, Botox only has licensed indication for treatment of glabella frown lines, horizontal forehead lines, and lateral canthal rhytids. I am going to talk to you about treatment of other areas, which are off-license and off-label, so do please bear in mind that if you are going to perform these treatments you do need to inform your patients that you are performing treatments which are off label and off-license.

 

Let me now introduce you to our lovely model, Diane. Diane is 44 years young, and I will just tell you that I have previously treated her in the masseter for bilateral masseteric hypertrophy, which was a little bit more dominant on her left side, but she has had a very nice contouring result from that, as you can see in this photo. Following that Botox treatment to the masseter, we are now going to discuss Botox treatment to the upper third, middle third, and lower third of her face. Let’s begin by doing an assessment of all the muscles that we propose to treat. I’ll begin by just evaluating her frown. When I get Diane to frown by bringing her eyebrows together, you will notice that all the lines we see are predominantly vertical, and this tells us that she has almost exclusive contraction of her corrugators. If I get you to relax now, remember that the lines formed by a muscle contraction are perpendicular to the orientation of the muscle fibres. The corrugator is horizontal and therefore these lines are vertical, so when she contracts we can see that she will form vertical lines. If there was a lot of procerus action, we would expect to see some horizontal lines on the bridge of the nose. When I look at the frontalis now, I will ask her to elevate her eyebrows, and when she elevates we can see that she has diffuse horizontal forehead lines, and now I want to check for two things.

 

The first thing I want to do is assess her risk of getting a Spock brow or Mephisto, and this is due to excessive elevation of the tail of the brow due to residual activity of the lateral fibres of the frontalis. To check for this, I can use my fingers just to press down on the middle of the forehead, and I’m blocking her frontalis from elevating in the central part, simulating the effect of Botox. Now I get her to elevate the brow, and you can see that if we were only to block the central part of her frontalis, she might get excessive brow elevation laterally, or the Mephisto look. It tells us that we have to ensure we adequately treat the lateral fibres. The second thing it’s always worth checking for, even in young patients, is to see if the patient has any degree of compensated brow elevation, and what we mean by this is that in some patients, either due to eyelid laxity, dermatochalasis, etc., what happens is as the eyelids start getting a little bit heavier, the patients compensate by activating the frontalis to keep the eye more open. Therefore, if we inadvertently overtreat the frontalis with the toxin we can get not only brow ptosis but also sometimes lid ptosis as well, just purely due to weakening the elevator of the brow. To look for this there are two things we can do. The first thing I will do is get Diane to close her eyes, and when she has done so I place my hand on her forehead to really relax her because some people continue to contract the muscles even when the eyes are shut. Then, when I’m happy she’s relaxed, I will get her to open her eyes, and you will notice that she manages to open her eyes without any elevation of the brow. Now, I will get her to track my swab by keeping her head still but following it with her eyes, and you will notice that in the initial part of upward gaze she can do so without elevating the brow. Watch what happens when we go a little bit higher, though. As we go higher you start noticing that she has to elevate her brow, so she’s got a very mild compensated brow elevation, and therefore we just have to be careful not to overtreat in the forehead. In some patients, they won’t be able to do upward gaze without elevating the brow to some degree, and in patients with very severe compensated brow elevation, they can’t open their eyes without getting a compensatory elevation of the brow. This is just worth looking out for.

 

Next, I want to check her for lateral canthal rhytids. I used to get people to smile, and in her case, it’s absolutely fine; she smiles with her eyes and therefore we can quite clearly see these lateral canthal rhytids. However, some people will smile predominantly with their mouths, so a better way for checking for these is to get patients to scrunch their eyes up. In Diane’s case, it really didn’t make any difference, but it’s always worth getting people to scrunch their eyes up rather than just smiling to check for this region, and we can see that the rhytids extend from the tail of the brow down to about a line just below the lateral canthus, and therefore we will treat in the upper arch, and I am going to leave this area untreated just so that it doesn’t impair her smile.

 

Now, let’s have a look at the lines around the nose. If I turn her slightly to the side and I get her to scrunch up her nose, you will notice that there aren’t too many lines over the bridge of the nose, but at the side, we have these obvious lines on the sidewall. These lines are due to contraction of the levator labii superioris alaeque nasi. This is a muscle that originates in the sidewall of the nose and the frontal process of the maxilla and inserts into the nasal alar and also the orbicularis oris. Its action is to widen the nose but also elevate the central part of the lip, and you can see the muscle very clearly lifting the central part of the lip but also accentuating the nasolabial fold. In patients like Diane, it can be worth treating this muscle just so that the nasolabial fold doesn’t deepen too excessively on animation.

 

The next thing I want to do is assess the perioral region, so if I just get her to pout for me, we notice that she doesn’t really have any perioral rhytids so we can avoid treating this area. If I did see excessive rhytids, I would treat her in this region to reduce the amount of lines that she was forming. The next muscle that I want to look at for her is the depressor anguli oris. You can see quite clearly here that she is able to downturn the mouth corners and at the same time she is contracting the mentalis, so it’s worth treating this in combination, and I will talk you through my injection points when I mark her out. You notice that when she smiles, she has excessive gingival display, especially in the anterior part, so if we look between the canines, we can see at least 3mm or more than 3mm of the gum. Therefore, she has an excessive gingival display, and we can treat this by targeting the levator labii superioris alaeque nasii muscle, which is responsible for central lip elevation.

 

Finally, I want to look at the neck, and you can see very clearly this platysmal band here and on the other side. She luckily only has very minimal banding at the front so we will probably focus our treatment just on the very obvious bands more laterally. One thing to bear in mind is that if we only treat very focally, we may accentuate other muscles, so if I get her to do that last movement again, we notice that not only is she straining her platysmal bands, but at the same time she is also contracting the orbicularis oris and also the risorius, so remember that all expressions are due to multiple muscles working together. If I get her to frown, you notice that there is certainly a contraction in the eyebrow region, but she’s also tensing up the orbicularis oris as well at the same time. If I get her to smile, remember the smile is coming from the perioral muscles but also from the eyes. Accordingly, when we treat the patient, I believe that we should treat the full face rather than just targeting single muscles.

 

Marking up

 

Now I want to share with you how I mark the patients prior to injecting. Botox treatments for me are all about precision; precision in how we dilute, precision in how we draw the product up, but also in how we mark the patients. I have seen some colleagues inject without marking but I think that’s quite risky because you just have to be a few millimetres up or down on different parts of the face to get an asymmetrical result.

 

So let’s look at the boney landmarks which can be useful. First of all, I’m going to mark out Diane’s temporal crest. Because Diane is quite lean, we can almost see where the temporal crests are, however, if you can’t see them and need to palpate them, always palpate lower down rather than higher up in the forehead because at this point the temporal crests actually fuse with the rest of the periosteum, whereas lower down you can see it as a palpable ridge where it inserts into the orbital rim. The importance of the temporal crest is that in the majority of patients, up to 98% it is estimated, this is the lateral aspect of the frontalis muscle. However, in at least 2% of people, the frontalis will go beyond the temporal crest, and if these fibres are undertreated, they’re the ones that can be responsible for an unnatural elevation of the eyebrow. Now, let me mark her out for treatment of the frown complex. To get my procerus injection point, I take a line from one medial canthus to the contralateral head of brow, and the other medial canthus to the contralateral head of brow. Where these two diagonals intersect is my injection point for the procerus. To get my injection point for the head of corrugator, I go vertically up from the medial canthus, and I want to have my injection point low down because remember the corrugator originates from the superciliary ridge on the superior orbital rim. For the tail of the corrugator, I want to go laterally, but only just medial to the mid-pupillary line, and I’m palpating as I mark because I want to be just slightly above the orbital rim, and I will do this on both sides. In terms of injection depth, it’s important to remember that the procerus injection is deep, the head of corrugator injection is also deep, but the lateral tail of corrugator injections are superficial. If I get Diane to contract and tense her brows, you will notice that the lateral injection points coincide with what we call the corrugator dimple, and this is essentially where the tail of the corrugator inserts into the dermis, and we can see the pull more medially.

 

To mark off the frontalis, I will get her to elevate so I can see the action, and I will mark a central injection point and then two further injection points, and you will notice that I’m going relatively lateral to make sure I can catch those lateral fibres of the frontalis. It may be the case that after treatment she still needs a top-up, and what I always explain to my patients is that if I undertreat you on my first treatment, I can always add some more in, but if I overdo it I can’t take it out, so it’s better to underdose than overdose, especially in the upper face and particularly with the frontalis. If I turn her to this side and get her to scrunch her eyes, you can see that she is contracting from a region here all the way down to here. Accordingly, I will put three injection points like so to catch these fibres of the orbicularis oculi. The idea is that this will just open up the orbital aperture laterally, and again on this side we’ll have three injection points to capture those fibres.

 

If I get Diane to scrunch her nose, you will notice that she has got very strong muscle action, but she also has good strong elevation of the upper lip as well, and because I want to treat her for excessive gummy smile, or excessive gingival display, rather than treating the fold, I am going to treat her just lateral to the nasal alar, and that will have more of an effect on the lip and perhaps less of an effect on the nasolabial fold. Aesthetically, I suspect it will give us a better result, so my treatment point is going to be lateral to the nasal alar. Remember, I’m missing out the orbicularis oris because she doesn’t have any rhytids there, but I really want to discuss now the treatment of the DAO, or the depressor anguli oris. If I turn Diane slightly oblique and I get her to downturn the corners of her mouth, you’ll notice that as she brings the commissures down, she has this contraction in this region here. The surface topography of this muscle is that if we take this modiolus, which is typically found just lateral to the oral commissure. The fibres of the DAO sweep anteriorly in the anterior border, and it has a posterior border as well, so it’s a triangular-shaped muscle which inserts into the mandible, and this is the shape of the muscle. However, as you can see it is riskier treating the muscle superiorly because there are fewer fibres and it broadens out at the base. In some people with very strong contraction, we do need to treat inferiorly and superiorly, so it’s worth remembering that if we are not accurate with the placement, we could influence other muscles, such as the orbicularis oris, the depressor labii inferioris, the risorius, or the zygomatic major. This is why I tend to err on the side of caution and inject a little bit more inferiorly and a little bit more laterally because we are less likely to impact other muscles. My injection point for her DAO will be found by palpating the muscle, and I can palpate it very obviously – you will notice that I am inferior, posterior, and when I inject my needle I will also angle backwards to avoid impacting the depressor labii inferioris, which is more anterior. For the DAO, I always think that you should be able to palpate the muscle. Some people like to treat the chin with two injections either side of the midline. I prefer a single injection in the middle because I feel there is less chance of diffusing to neighbouring muscles.

 

Finally, you can see this platysmal band rising all the way from its origin on the clavicular fascia and inserting right up into the mandible. What I will do is grab the band and use four injection points in the upper half of the muscle, and that ought to be enough to relax it. When we relax the top part of the muscle, we typically find that the bottom part of the band settles as well. I will repeat this marking on the other side.

 

Treatment

 

When I’m treating patients with Botox, I like to use a syringe with the needle attached, and the one I’ve got here is a 0.3ml syringe, so each gradation is 0.01 ccs, and my dilution is 1ml of normal saline to 100 units of Botox. With that dilution, the reason I like it is because each notch represents 1 unit of Botox. When I’m treating the procerus, I like to just pinch the skin, and the other thing I always tell novice injectors is that it’s good to stabilise your hands on the patient because that way if the patient moves, you move with them. I’ve seen some delegates inject with their hands completely away, and the problem with that is that if the patient moves they could inadvertently get injured with the needle. So, the first thing to do is stabilise your hands, and then you will notice I will turn her slightly towards me and pinch the skin here. I’m stabilising my hand with my little finger on her cheek, I pinch the skin, and then when I am ready I inject just below my mark, not through the mark. I’m injecting deep and I’ll inject the first 4 units of Botox in the procerus. Remember, in this region, there are lots of blood vessels, so it’s not unusual to get a bit of bleeding, and if you get bleeding all you have to do is apply compression until it stops.

 

To treat her right head of corrugator, I use my thumb just to protect the orbital rim and stop diffusion downwards. Again, I’m pinching here and I’m injecting just to the side of my dot, deep for the head of the corrugator, and I will inject 4 units here. The depth is deep onto the bone here, but for the tail, we have to be superficial because the insertion is into the skin, so you will notice that the angle of my needle is totally different, I’m very horizontal. I inject, and you will notice that I just insert the bevel and inject 2 units. There will be a bit of resistance because we’re intradermal, and it’s not unusual to see a little wheel like that. If you get that wheel, it tells you that the product has been injected perfectly. To treat the other head of the corrugator, I will use my index finger to protect the orbital rim. Again, I stabilise, pinch, and then inject just beyond the dot, deep, 4 units. For the other tail of the corrugator, I’ll come around to the other side of Diane, and you will see that I am injecting just beyond the dot, just below, horizontal until I lose the bevel, then a further 2 units. Her frown wasn’t particularly strong and that’s why I’ve decreased my dose to 2 units for the tail of the corrugator, but you will know that the conventional recommended dose is 4 units in the procerus and 4 units in both the head and tail of the corrugator. Some colleagues advocate treating the depressor supercilii separately, but I find that it’s perfectly reasonable to begin just with the 5 injection points and then treat any residual muscle activity if required afterwards.

 

I’m going to move on to treat the frontalis. I’ve decided to use 2 units in each of these 5 places, giving a total of 10 units. The recommended dose is 20 but for a lot of patients that may lead to a very dramatic effect and patients who want a natural result with a bit of movement will favour a slight dose reduction. Some people prefer to inject this muscle deep, others prefer to inject subcutaneously, and I like to inject subcutaneously. I’m going to roll her head towards me and I will start laterally and work medially, so you notice I am just above the mark. I insert the bevel of my needle and I inject 2 units. Remember, in this region the fat below the skin is very, very thin and therefore the product doesn’t have far to diffuse to the muscle, and this is why a subcutaneous placement is reasonable. In terms of treating the frontalis, I don’t think there is any recipe that will work every time, so I always consent my patients and let them know that the first time I see them, I will need to see them for review just to make sure that the injection has been successful. If I find that there is any residual frontalis activity which the patient doesn’t like, or they feel that the amount that has been injected is too little, I can then top it up at the review. I tell them that I usually need to do that for the first appointment, and maybe the second, but after that, we can make a note of all our injections and we have a blueprint for how to treat them in successive appointments.

 

When I’m treating her left orbicularis oculi, I will be on her right side so I can inject away from her eye. Again, my depth here is very superficial, so you notice that I am holding my needle and syringe almost parallel to the skin. I stretch the skin, I’m intradermal here, and I will inject 3 units. I then move down and I’m injecting the second point, again intradermal, and I inject another 3 units. Finally, for the last injection, 3 units again. Remember, just where I’m injecting the last injection, in the inferior part of the orbicularis, we have the origin of the zygomatic major. If I was to inject too much product or be too deep, I could influence the zygomatic major, which would give her a smile asymmetry. To inject this eye, I could bend my wrist this way, but what’s easier, and the way I teach, is to move to the patient’s other side and I’m now working away from her eye again, which I think is safer and far more advisable. Again, I’m injecting the superior point with 3 units, the middle point with 3 units, and the inferior point another 3 units.

 

I’m now going to move to treatment of her gummy smile. Remember, the muscle I’m targeting is the levator labii superioris alaeque nasi or LLSAN. To get the lower fibres of this muscle, I’m going just lateral to the nasal alar, I’m going about mid-depth with my needle, and I’m just injecting 2 units. I will move to the other side for the contralateral muscle, and again I go through the nasal alar, mid-depth with my needle and another 2 units of toxin.

 

Moving on to treatment of the DAO, I will turn Diane towards me so I can inject her left DAO. My needle is going to be superficial because the muscle is above the DLI, and I’m going slightly inferior and slightly lateral, and I inject 2 units. To inject her right DAO, I will come to her other side, turn her face towards me, and again I’m inferior and lateral, with a superficial placement of 2 units. Finally, to inject her mentalis, I will inject from below, and I am injecting deep, almost hitting the periosteum, withdrawing partially, and injecting 4 units.

 

That’s the treatment of her upper face, midface, and lower face done, so I will now target the platysmal bands. If I just get her to bring her chin up slightly, turn her face slightly away, and then say “ee”, as she does so, I can see the band very clearly and I can pinch it between thumb and finger, and inject 2 units. Moving down the band at periodic intervals, I inject another 2 units. I can also inject from the side, so I can hold the band and inject from the lateral approach. Especially with a very obviously defined band, this can be easier than grasping it between the fingers. Each of those injection points was 2 units, and I can now move to her other side. It’s less obvious on this side, so I need to pinch at the top part. If you can’t see the muscle very clearly, it’s worth manoeuvring the patient until you can. There we have the full treatment of Diane, face and neck, and I will review her in 2 weeks to see the impact, take some photos, and at that point, we can discuss exactly how successful the treatment has been and how we may add any additional units.