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CME

Current Use of Cosmetic Toxins to Improve Facial Aesthetics

Janes, Lindsay E. M.D.; Connor, Lauren M. M.D.; Moradi, Amir M.D.; Alghoul, Mohammed M.D.

Author Information
Plastic and Reconstructive Surgery: April 2021 - Volume 147 - Issue 4 - p 644e-657e
doi: 10.1097/PRS.0000000000007762

Abstract

Since the inception if its aesthetic applications during treatment of blepharospasm patients in the late 1980s,1 the use of cosmetic botulinum toxin has exploded, from 786,911 procedures reported by board-certified plastic surgeons alone in 2000 to 7,230,967 reported in 2017.2 Botulinum neurotoxin functions by blocking the docking and fusion of soluble N-ethylmaleimide–sensitive factor attachment protein receptor proteins at the neuromuscular junction.3,4 Given the mechanism of action, botulinum toxin is recommended for the treatment of dynamic wrinkles. There are eight known serotypes of botulinum neurotoxin (A, B, C1, C2, D, E, F, and G), of which types A and B are used clinically.5 The first three commercially available, U.S. Food and Drug Administration–approved formulations of type A botulinum neurotoxin are the most commonly known: onabotulinumtoxinA (Botox; Allergan U.S.A., Madison, N.J.), abobotulinumtoxinA (Dysport; Galderma Laboratories, LP, Fort Worth, Texas), and incobotulinumtoxinA (Xeomin; Merz Pharmaceuticals, LLC, Greensboro, N.C.). All three formulations are U.S. Food and Drug Administration approved for use in the glabellar region, and Botox is also approved for use on lateral canthal and forehead lines.6–8 Newer formulations include prabotulinumtoxinA (Jeuveau; Daewoong Pharmaceuticals, Seoul, Republic of Korea), which was approved by the U.S. Food and Drug Administration in February of 2019 for the glabella,9 and daxibotulinumtoxinA (Revance Therapeutics, Inc., Nashville, Tenn.), which has anticipated U.S. Food and Drug Administration approval in 2020 and claims to provide results lasting 28 weeks. Botulinum neurotoxin is a category C medication for both pregnant and breastfeeding patients.6–8 Patients with neuromuscular diseases (e.g., myasthenia gravis, Eaton-Lambert syndrome) are not suitable candidates for botulinum neurotoxin treatment, and medications such as aminoglycosides, penicillamine, quinine, and calcium channel blockers can potentiate the effects of botulinum neurotoxin and should be used with caution (Table 1).6,10

Table 1. - Quick Reference Guide for Injection of Botulinum Toxin
Indications Dosage Potential Complications Pearls
Upper face (glabella, frontalis, OO) • Brow lift/brow shaping
• Crow’s feet
• Eye shaping/widening eye aperture
Frontalis: 10–20 U
Glabella: 20–25 U
Lateral orbicularis: 6–12 U each side
Lower lid: 1–2 U each side
• Brow ptosis
• Upper eyelid ptosis
• Double vision
• Ectropion
• Should not treat frontalis in isolation, to avoid brow ptosis.
• Lateral OO injections should be shifted inferiorly in patients with already high lateral brows.
• Avoid injecting lateral OO too inferiorly to prevent diffusion to zygomaticus and inhibition of smile.
• Before performing lower lid injections, perform a snap-back test. Injections should be avoided in any patient with lower lid laxity. Do not perform these injections on patients with scleral show.
Perioral (OO, mentalis, and DAO) • Adjunct to filler and peels for significantly deep rhytides
• Pseudoeversion of lip and enhancement of vermillion contour
• Melomental folds, or “marionette lines; dimpling of the skin over the chin
OO:
4–6 U each lip
DAO: 2–5 U each side
Mentalis: 4–10 U
• Weakness with speech
• Oral incompetence
• Oral asymmetry
• Drooling
• Avoid lip corners/modiolus to avoid drooling and drooping of lateral lip.
• Avoid midline of upper lip to prevent the flattening of Cupid’s bow.
Mentalis • Alteration of face shape
• Bruxism
15–25 U per side in Caucasian women 30–50 U per side in East Asian women.
Male patients may need 10 U or so more than their female counterparts
• Weakness with chewing
• Loss of full smile because of diffusion of toxin to risorius and levator anguli oris
• Xerostomia

• Asymmetry
• Speech disturbances
• Dysgeusia
• The dose of Botox depends on the bulk of the muscle being treated. Caucasian patients may require less than East Asian patients.
• Male patients may need 10 BU or so more than their female counterparts.
Platysma • Platysmal banding
• Improved contour of jawline (Nefretiti lift)
10−25 U per band (2–5 U per injection administered into 5 evenly based sites per band). No more than 50 U should be injected at one time. Dysphagia and dysphonia (associated with doses greater than 50 U or deeper injection) To assess whether or not a patient is a good candidate for BoNT jaw contouring, the platysma should be contracted. If the mandibular border disappears with contraction, treatment is likely to be successful.
OO, orbicularis oris; DOA, depressor anguli oris; BU, botulinum units; BoNT, botulinum neurotoxin.

Intradermal or Subcutaneous versus Intramuscular Injection

In a split-face randomized prospective study of 19 patients who underwent botulinum toxin A treatment of the forehead, subcutaneous injection demonstrated equivalent efficacy to intramuscular injection as measured by eyebrow height and patient satisfaction surveys, with less patient-reported pain.11 Only three patients experienced bruising (two who received intramuscular injection and one who received subcutaneous injection), which is not sufficient to make a comparison. Intradermal injection of botulinum toxin has been reported to have similar efficacy in rhytide treatment as intramuscular injection with additional improvements in skin texture and midface lifting.12,13

Dilution

Product dilution often varies, with many practitioners anecdotally reporting that a more dilute volume leads to a softer appearance. Manufacturer recommendations are as follows: Botox dilution of 100 U in 2 ml, Xeomin dilution of 100 U in 0.25 to 5 ml, and Dysport dilution of 300 U in 0.6 to 3 ml.6–8 Larger volumes at lower concentrations do have a greater spread of product as would be expected, but many studies report equivalent outcomes with both higher and lower concentrations.14–16 Carruthers et al.15 injected 30 botulinum units into the glabellar region in 80 women at four different concentrations and demonstrated no significant differences in the Facial Wrinkle Scale scores as recorded by trained observers and by patients. However, the more dilute concentrations did have a higher incidence of adverse effects, including local swelling and brow ptosis. Thus, lower concentrations can be used for larger, broader muscles such as the frontalis or platysma, but higher concentrations should be used when more focused treatment is desired, such as for the lateral orbicularis oculi or the depressor anguli oris. Several studies have reported that higher doses of toxin produce longer lasting results17,18; however, this benefit must be weighed against the potential risk of adverse effects. An emerging technique, high-dose microfocused botulinum toxin injections, limits the field of effect by injecting higher doses in lower volumes.19 Although this technique may help safely extend the duration of action without adverse events, further outcomes research must be performed.

Dose Equivalence of Botox Units, Dysport Units, Xeomin Units

Dose equivalence between the main botulinum neurotoxin products, Botox, Dysport, and Xeomin, remains the subject of controversy even after almost 30 years of clinical use. In general, the Botox-to-Dysport ratio is most commonly reported at a conversion of 1:2 to 1:3, although though there are some reports of conversion at 1:6.20–22 The Botox-to-Xeomin ratio is reported at a 1:1 ratio.23 However, it has been increasingly noted that, based on treatment area, technique, dilutions, and injection patterns, the formulations are not interchangeable by any single conversion ratio.17,24–27 Thus, although 1:3 Botox-to-Dysport and 1:1 Botox-to-Xeomin ratios may be good starting points, each practitioner will likely modify their dosing as they become more experienced with each product and the areas treated.

Product Diffusion by Brand

Dysport is thought to have a greater range of diffusion for a given volume. In a study of 20 subjects with hyperhidrosis with half of the face injected with 0.06 cc of Botox and half with 0.06 cc of Dysport at a 1:2.5 ratio, Dysport produced a larger area of anhidrosis than Botox in 93 percent of mediomedial or laterolateral comparisons of the two products at individual time points.28

Reconstitution and Storage

The Botox, Dysport, and Xeomin prescribing information sheets instruct reconstitution in sterile, preservative-free 0.9% sodium chloride, administration within 24 hours of reconstitution, and single use only.6–8 However, implementing such use in practice generates significant cost and waste, which has led to several studies demonstrating similar safety and efficacy of preserved saline, multiple access using sterile technique, and storage as a reconstituted solution for at least 7 weeks.29–32 Xeomin is the only botulinum toxin that is free from complexing proteins and can be stored at room temperature.8

Upper Face (Forehead, glabella, periorbital)

Physical Examination and Facial Analysis

The upper face is one of the most commonly requested areas for nonsurgical facial rejuvenation. Before injection of botulinum toxin in the upper face, a full assessment of the patient’s face must be considered, including evaluation of the following:

  • Static versus dynamic rhytides should be considered carefully for potential combination treatment with laser, chemical peels, or fillers.
  • Brow shape and position, especially brow ptosis or asymmetries.
  • Muscle strength for different muscle groups should be assessed and the dose adjusted accordingly.
  • Constriction of the lateral orbital area.
  • Eye shape asymmetries and lower eyelid laxity.
  • Ethnicity.
  • Age.
  • Patient desire for retained facial expression.

Examination should be performed with the patient in the upright position. Evaluation of brow position, eye shape, and rhytide severity should be performed in these three areas together, as injection of one can affect the other areas and lead to unwanted effects if not placed carefully (Fig. 1). [See Video 1 (online), which demonstrates treatment of the forehead and periorbital area. (Courtesy of Mohammed Alghoul, M.D. Informed consent for publication of video/photographs was obtained.)] In older patients, it is critical to assess whether frontalis muscle contraction is compensating for levator palpebrae muscle weakness.

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Fig. 1.
Fig. 1.:
Before (above) and after (below) injection of botulinum toxin to the frontalis, glabella, and crow’s feet. (Courtesy of Mohammed Alghoul, M.D. Informed consent for publication of photographs was obtained.)

Anatomy and Technique

Forehead and Glabellar Rhytides, Brow Position, and Shaping

Successful treatment of forehead and glabellar rhytides requires understanding the force balance between the single brow elevator (frontalis), several medial brow depressors (corrugator supercilii, procerus, medial portion of orbicularis oculi), and the single lateral brow depressor (lateral orbicularis oculi). While treating rhytides, one should be mindful not to disturb the balance between these opposing muscle forces and create an unwanted effect such as brow ptosis or upper lid ptosis.

Treatment of forehead rhytides has been described with many patterns of injection, the most common of which are highlighted in Figure 2.33–39 In a randomized controlled trial, injection at the midforehead was shown to be more effective in rhytide reduction but induced greater brow ptosis than injection closer to the hairline.34

Fig. 2.
Fig. 2.:
Common patterns of injection for the upper face. BU, botulinum units.

Widely accepted treatment of glabellar rhytides involves five injection points in a V-shaped pattern targeting the procerus, oblique head of corrugator supercilii (medial eyebrow), transverse head of corrugator supercilia (mideyebrow), and depressor supercilii (Figs. 2 through 4). However, it has been observed that how patients use their glabellar muscles varies, and optimal results can be achieved by tailoring injection patterns to the patient.40-42 The corrugator is thickest in the medial portion above the medial canthus and becomes thinner laterally.43–46 The medial origin is on average 2.9 mm from the nasion and the lateralmost extension is on average 43.3 mm from the nasion and 7.6 mm from the lateral orbital rim.45 Medially, it lies deep to the frontalis, and therefore medial corrugator injections should be placed deeply within the substance of the muscle.

Fig. 3.
Fig. 3.:
Treatment of brow asymmetry with botulinum toxin. (Courtesy of Amir Moradi, M.D. Informed consent for publication of photographs was obtained.)
Fig. 4.
Fig. 4.:
Treatment of brow asymmetry with botulinum toxin. (Courtesy of Amir Moradi, M.D. Informed consent for publication of photographs was obtained.)

Botulinum toxin can also be used in these areas to address brow shape and position. A subtle chemical brow lift can be achieved through selective injection of brow depressors. Injection of superolateral orbicularis oculi with (1 to 4 botulinum units) has been shown to raise the brow up to 3 mm, which can also be used to even asymmetric brows.37,39,47–49 In addition to superolateral orbicularis oculi injection, enhancing the arch of the eyebrows can be achieved by injecting the lateral frontalis with a lower dose than the medial frontalis.49

Adverse events of treatment of forehead/glabella rhytides include asymmetry, bruising, and eyelid ptosis if there is migration of botulinum toxin to the levator palpebrae superioris. To avoid ptosis, the provider should (1) keep injection 1 cm above the brow and within the substance of the muscle; (2) use digital pressure over the supraorbital rim with the noninjecting hand to reduce the risk of diffusion; and (3) point the needle superiorly, away from the orbit. However, if ptosis occurs despite these strategies, 0.5% apraclonidine eye drops can be prescribed at a dosage of one to two drops three times per day. This is an alpha-adrenergic receptor agonist that causes contraction of the Müller muscle. There is a risk of causing miosis and closed angle glaucoma in susceptible individuals, and providers should assess the patient’s ophthalmic medical history before prescription.50

Lateral Canthal Lines (Crow’s Feet)

Lateral canthal lines are created by contraction of the lateral orbicularis oculi. In addition to elimination of lateral canthal lines, injection in this area can also be used to open up (vertically expand) the lateral orbital area to create a more youthful appearance of the eyes (Fig. 5). Treatment of this area has become a primary focus of treatment in the senior author’s (M.A.) practice, as it accomplished several goals in one treatment: (1) vertical expansion of the lateral orbital area, (2) elevation of the tail of the brow, (3) decreased lateral orbital constriction during animation (mainly smiling), and (4) improved lateral orbital lines (crow’s feet)

Fig. 5.
Fig. 5.:
Before (above) and after (below) injection of botulinum toxin into the lateral orbicularis oculi. Images show face relaxed (left) and with smile (right). Note the increased opening of the eye aperture with this treatment. (Courtesy of Mohammed Alghoul, M.D. Informed consent for publication of photographs was obtained.)

The muscle is very superficial in this area; thus, injections should be subdermal, producing a characteristic skin wheal. The injections should be 1.5 cm away from the lateral canthus to prevent spread of the product toward the extraocular muscles, leading to diplopia.38 Injection points can be shifted higher if the goal is also to raise the brow, or lower if the patient does not want their brow shape altered. However, injections should not be placed lower than the superiormost aspect of the zygomatic arch to prevent diffusion into the zygomaticus major and inhibition of smile.38

A double-blind, randomized, placebo-controlled study assessed the effects of 18, 12, 6, or 3 botulinum units of botulinum toxin type A or placebo injected into the lateral orbicularis oculi and found that higher doses had increased magnitude and duration of affect, with no significant improvement at doses higher than 12 botulinum units of botulinum toxin type A.17

Eye Shaping

In addition to opening of the lateral orbital area by injecting the lateral orbicularis oculi as discussed above, botulinum toxin can also be used to improve eye shape and lower eyelid position.35 Patients undergoing eye shaping with neurotoxin should be carefully screened for lower lid laxity, upper eyelid ptosis, and dry eye, as injection can worsen these conditions if not screened for appropriately. Epiphora can result from reduced lower eyelid tone that compromises the lacrimal “pump” function of the medial orbicularis oculi.51

For lower eyelid injections, the two potential locations are the pretarsal orbicularis oculi and the preseptal orbicularis oculi. The pretarsal orbicularis oculi functions mostly for involuntary eye closure and has a lesser effect on rhytide development or soft-tissue malposition.48 Injection of pretarsal orbicularis is typically used in patients with blepharospasm but can be used cosmetically in patients with lower lid orbicularis hypertrophy, injected at the midpupil. For lower lid rhytides, however, treatment should be directed more toward the preseptal orbicularis, with two injection points: lateral and midpupil. A single injection 3 mm below the lash margin with 2 botulinum units of botulinum toxin type A has been shown to increase the palpebral aperture at rest by 0.5 mm and 1.3 mm at full smile.36

Perioral (Orbicularis oris, mentalis, depressor anguli oris)

Physical Examination and Facial Analysis

The muscular anatomy of the lower face is complex and must be approached carefully to avoid oral incompetence and asymmetry. The goal of neurotoxin use in the lower face is generally reduced muscle strength, without complete inhibition. During aging, the lateral portions of the lips recede, the distance between the columella and upper lip vermilion border increases, and the substance of the vermillion rolls inside.52 Chronic contraction of these muscles leads to vertical perioral rhytides, or “smoker’s lines,” melomental folds, or “marionette lines,” and dimpling of the skin over the chin, giving the chin a peau d’orange appearance. Often, these areas are first treated with filler, using botulinum neurotoxin as an adjunct. Overview of injection technique is highlighted in Figure 6.53–61

Fig. 6.
Fig. 6.:
Common patterns of injection for the lower face. BoNT, botulinum neurotoxin; BU, botulinum units; DAO, depressor anguli oris.

Anatomy and Technique

Orbicularis Oris

It is critical to assess whether perioral rhytides are static or dynamic before treatment, as only dynamic rhytides can be treated with botulinum toxin. One should be cautious when treating the orbicularis oris in certain professions (e.g., musicians who play wind instruments and scuba divers). Static rhytides can be addressed with filler or skin resurfacing. Treatment of vertical perioral rhytides requires the patient to contract the orbicularis oris, puckering the lips. Toxin should be injected adjacent to the vertical rhytides, either intramuscularly or subcutaneously.52,53 Each site should receive approximately 0.5 to 1 botulinum units of toxin. Injection should occur along the vermillion border60 (Fig. 6).

For orbicularis oris, most cases reported in the literature use 0.5 to 1 botulinum units of botulinum neurotoxin at each injection site, with total doses of 4 to 6 botulinum units per lip.25,52,53,59,62 One study report success with higher doses up to 18 botulinum units, although doses above 7 botulinum units were associated with difficulty annunciating /p/ and /b/ sounds and eating foods such as soup.63 Cohen et al. conducted a randomized, double-blind trial comparing doses of 7.5 and 12 botulinum units to treat perioral rhytides. They showed that the lower dose was effective and caused fewer adverse events compared with the higher dose.64

Depressor Anguli Oris

Injection of the depressor anguli oris for treatment of melomental folds is difficult because its medial border overlaps with the depressor labii inferioris and its lateral border is adjacent to the risorius and zygomaticus major muscles. The majority of complications in this region occur because of an inadvertent effect on the depressor labii inferioris. Patients are most commonly asked to frown to aid in the location of the muscle (Fig. 6).52,53,62 [See Video 2 (online), which displays treatment of the depressor anguli oris. (Courtesy of Amir Moradi, M.D. Informed consent for publication of photographs was obtained.)]

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There are several anatomical articles that clearly demonstrate the location of the depressor anguli oris as it relates to the neighboring muscles.65–67 The depressor anguli oris originates close to the mandible inferiorly and inserts into the modiolus superiorly. The depressor labii inferioris crosses over laterally at the inferior half of the depressor anguli oris. The superior half has the least amount of exposure to the surrounding musculature. Using facial landmarks, a safe zone can be drawn (Fig. 6).56 Another useful landmark is the visible melomental wrinkle, which Trévidic et al. demonstrated occurs in the middle of the upper part of the depressor anguli oris muscular body.60

Mentalis

The easiest technique for the mentalis is injection of 4 to 10 botulinum units directly into the insertion point of both bellies centrally on the mandible.25,53,61,62 However, some practitioners prefer to inject each muscle separately, which can be accomplished by injecting 2 mm to 1 cm above the tip of the chin, 5 mm laterally from the midline on each side. It is important to stay at least 1 cm inferior to the mental sulcus to avoid oral incompetence caused by toxin migration to the orbicularis oris53 (Fig. 7).

Fig. 7.
Fig. 7.:
Before (right) and after (left) injection of botulinum toxin into the depressor anguli oris. (Courtesy of Mohammed Alghoul, M.D. Informed consent for publication of photographs was obtained.)

Gummy Smile

Excessive gingival display, or gummy smile, is defined as exposure of greater than 2 mm above the dental line when smiling. Muscles thought to be involved include the levator labii superioris, levator labii superioris alaeque nasi, zygomaticus minor, and zygomaticus major. Many variations with several injection points to these muscles have been reported,68 but more recent alternative approaches with a single injection have demonstrated success, with an average reduction in gingival display by an average of 3.04 mm55 (Fig. 6). More advanced practitioners could consider recommendations by Mazzuco and Hexsel that advocate classification and treatment of the gummy smile by four different types69: (1) excess show anterior to the canines, (2) excess show posterior to the canines, (3) mixed, and (4) asymmetric.

Depressor Septi Nasi

Patients presenting with dynamic tip ptosis and excessive upper lip shortening with smile can be treated with injection into the depressor septi nasi. The muscle fibers originate at the incisive fossa for the maxilla and insert onto the nasal septum just posterior to the medial crus of the lower lateral cartilage; thus, injection points have been described at both the nasal base and the nasal tip (Figs. 6 and 10).57,58,70

Masseter

Physical Examination and Facial Analysis

Patients presenting with strong jaw lines and/or a square face with a desire to change their face shape can benefit from injection of neurotoxin into the masseter (Figs. 8 and 9). Patients should be evaluated for parotid hypertrophy, as this can also contribute to the impression of a widened mandible.71 Patients should be asked about symptoms of headache, jaw clenching, or teeth grinding, as these patients may require more botulinum neurotoxin and have a shorter duration of action. Potential complications include jowling if high doses are used in an elderly patient with skin laxity, paradoxical bulging during mastication, loss of asymmetric smile caused by diffusion into the risorius, or difficulty with mouth opening.72

Fig. 8.
Fig. 8.:
Before (right) and after (left) injection of botulinum toxin into the masseter. Note the subtle change in facial shape. (Courtesy of Mohammed Alghoul, M.D. Informed consent for publication of photographs was obtained.)
Fig. 9.
Fig. 9.:
Before (right) and after (left) injection of botulinum toxin into the masseter. Note the more dramatic change in facial shape. (Courtesy of Mohammed Alghoul, M.D. Informed consent for publication of photographs was obtained.)

Anatomy and Technique

The masseter muscle arises as three heads from the length of the zygomatic arch. Key structures to avoid in this area include the parotid gland, the marginal mandibular nerve, and other branches of the facial nerve such as its buccal branch. Where the three heads cross each other represents the thickest part of the muscle that can be palpated when patients clench their teeth.71Figure 10 summarizes recommendations for injection landmarks based on prior anatomical studies.60,73,74 As shown in Video 3, injection in the masseter should occur below a line of safety drawn from the lateral commissure to the tragus. [See Video 3 (online), which displays treatment of the masseter. (Courtesy of Mohammed Alghoul, M.D. Informed consent for publication of photographs was obtained.)]

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Fig. 10.
Fig. 10.:
Common patterns of injection for the masseter.

Dosing Considerations

The dose of botulinum neurotoxin depends on the bulk of the muscle being treated. One study demonstrated that Caucasian patients required less than East Asian patients and women required less than men.75 Initial doses of 15 to 25 botulinum units per side are recommended in Caucasian women, whereas East Asian women may require 30 to 50 botulinum units per side. Men may need 10 botulinum units or so more than their female counterparts.75,76 In Western patients, aesthetic improvement has been demonstrated to last 9 to 12 months, whereas the functional improvement from bruxism lasted 6 to 7 months.75

Platysma

Physical Examination and Facial Analysis

Treatment of the platysma is indicated in patients who are seeking improvement in the contour of their jawline or softening of the anterior platysmal bands but do not need a lower face rhytidectomy. Jawline contouring with botulinum toxin is likely to be successful if the mandibular border disappears with platysma contraction on examination.77 In treatment of platysmal bands and horizontal neck rhytides, the degree of muscle flaccidity and hypertrophy are the factors that most influence success rates.78 The practitioner should carefully analyze whether the rhytides are caused by hyperactive platysmal action versus skin laxity. The patient with significant skin laxity will not gain improvement from botulinum toxin alone.

Anatomy and Technique

The platysma is a broad, thin muscle that originates in the deltopectoral fascia and first inserts along the inferior border of the mandible, and the remaining fibers continue upward, interdigitating with fibers of the depressor anguli oris, the lower lip, the depressor labii inferioris, and the superficial musculoaponeurotic system.78 With aging, the cervical skin loses elasticity, more submental fat becomes visible, and the platysma separates anteriorly to become two diverging vertical bands.77

Treatment requires the patient to contract the platysma muscle. The examiner then grasps each band between the thumb and index finger and injects 2 to 5 botulinum units at five sites approximately 1 cm apart, including down to where the platysma meets the clavicle.53 It is important to keep the injection in the superficial platysma and avoid deeper injection.

Alternatively, the Microbotox technique has demonstrated efficacy in this treatment area.79 Microbotox, first described by Wu in 2015, is the systematic injection of multiple microdroplets (at 0.8- to 1.0-cm intervals) of diluted onabotulinumtoxinA into the dermis or the interface between the dermis and the superficial layer of facial muscles.80 The intent is not to completely paralyze the underlying facial muscles but to weaken the superficial fibers that insert into the undersurface of the skin and lead to fine lines and wrinkles on the face and neck. Comparison of this technique with standard injection deep into the platysmal bands (Nefertiti lift) demonstrated that the Microbotox technique induced greater improvement in jowling and overall neck soft-tissue ptosis, whereas the standard injection provided greater improvement when banding was the primary concern.79

Dosing Considerations

Dosing in the platysma region should be approached to minimize adverse events such as dysphagia, dysphonia, and weakness of the sternocleidomastoid muscles. Most modern publications recommend avoiding these complications by using superficial injection techniques and by not exceeding more than 50 botulinum units in one session.52,60,81 Doses of 75 to 100 botulinum units have been reported to produce weakness in the neck flexors and dysphagia.82 Carruthers and Carruthers reported one patient treated with 60 botulinum units who developed such profound dysphagia she required a nasogastric tube for 6 weeks until she regained the ability to swallow.52,83 Higher doses should be approached with extreme caution and patient counseling.84

CONCLUSIONS

Injection of botulinum toxin is a safe and effective procedure for the treatment of dynamic rhytides. Careful facial analysis should be used to correct asymmetry and avoid unintended changes to facial harmony. This article serves as a reference for starting doses and patterns of injection to help the beginner provider successfully introduce cosmetic botulinum toxin into their practice.

PATIENT CONSENT

Patients provided written consent for the use of their images.

REFERENCES

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