Các Kỹ Thuật Tiêm Thẩm Mỹ (Cosmetic Injection Techniques)

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Cosmetic Injection Techniques
A Text and Video Guide to Neurotoxins and Fillers
'Thieme

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Cosmetic Injection Techniques
A Text and Video Guide to Neurotoxins and Fillers
Theda C. Kontis, MD, FACS
Assistant Professor
johns Hopkins Hospital
Board-Certified Facial Plastic Surgeon
Facial Plastic Surgicenter
Baltimore, Maryland
Victor G. Lacombe, MD
Board-Certified Facial Plastic Surgeon
Santa Rosa, California
Foreword by jean D. Carruthers, MD, FRCSC, FRC(Ophth)
Clinical Professor
Department of Ophthalmology
University of British Columbia
Vancouver, British Columbia
Sarah E. Faris, MA, CMI
Medical Illustrator
Thieme
New York · Stuttgart

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library of Congress cataloging-in-Publication Data
Kontis, Theda C.
Cosmetic injection techniques : a text and video guide to neurotoxins and fillers I Theda C. Kontis,
Victor G. Lacombe.
p.;cm.
Includes bibliographical references.
ISBN 978-1-60406-712-5- ISBN 978-1-60406-713-2 (eiSBN)
I. Lacombe, Victor G. II. Title
[DNLM: 1. Cosmetic Techniques. 2. Face-surgery. 3. Biocompatible Materials-therapeutic use. 4. Face,
anatomy S. histology. 5. Injections, subcutaneous-methods. 6. Neurotoxins-therapeutic use. WE 705 [
617.5'20592-dc23
2012036154
Copyright ©2013 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected
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not responsible for any errors or omissions or for the results obtained from use of such information. Readers
are encouraged to confirm the information contained herein with other sources. For example, readers are
advised to check the product information sheet included in the package of each drug they plan to administer
to be certain that the information contained in this publication is accurate and that changes have not been
made in the recommended dose or in the contraindications for administration. This recommendation is of
particular importance in connection with new or infrequently used drugs.
Some of the product names, patents, and registered designs referred to in this book are in fact registered
trademarks or proprietary names even though specific reference to this fact is not always made in the text.
Therefore, the appearance of a name without designation as proprietary is not to be construed as a represen-
tation by the publisher that it is in the public domain.
Printed in China
5 4 3 2 1
ISBN 978-1-60406-712-5
Also available as an e-book:
eiSBN 978-1-60406-713-2

I dedicate this book to David and Alexandra, for their love and support;
to my Mom, my greatest fan; and in memory of my father, my angel.
-TCK
I dedicate this book to my wife, Alice, and my children, Victoria and Max.
You all mean the world to me. Love, Victor.
-VGL

To access additional material or resources available with this e-book, please visit
http:l/ After completing a short form to verify your e-book
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any bonus content.

Contents
1"'1 denotes a chapter with additional video content on MediaCenter.thieme.com
Foreword by jean D. Carruthers ....................................................................................................................... x
Preface ...................................................................................................................................................................... xi
Section I Introduction to Neurotoxins
1 Neurotoxins Overview ................................................................................................................................ 2
2 Neurotoxin Preparation ............................................................................................................................. 5
3 Instrumentation for Neurotoxin Injections ...................................................................................... 6
4 The Physicians Coalition for Injectable Safety .................................................................................. 8
Section II Neurotoxin Injection Techniques
r.,.
5 Neurotoxin Injection for Glabellar Frown Lines ............................................................................ 10
r •
6 Neurotoxin Injection for Forehead Wrinkles .................................................................................. 16
r•
7 Neurotoxin Injection for Smile Lines and Crow's Feet ................................................................ 22
r• 1 8 Neurotoxin Injection for I.ateral Brow Lift ...................................................................................... 26
r• 1
9 Neurotoxin Injection for Chemic:al Brow Lift .................................................................................. 29
(• 10 Neurotoxin Injection for Lower Eyelid Roll ..................................................................................... 32
r • 11 Neurotoxin Injection for Bunny Lines ................................................................................................ 34
r• 12 Neurotoxin Injection for NaSill Tip Lift .............................................................................................. 38
13 Neurotoxin Injection for NaSill Flare .................................................................................................. 40
r• 14 Neurotoxin Injection for Elevating the Oral Commissures ....................................................... 42
vii

viii
Contents
1• 15 Neurotoxin Injection for Up Lift .......................................................................................................... 45
r. 16 Neurotoxin Injection for Smoker's lines .......................................................................................... 47
17 Neurotoxin Injection for Gummy Smile ............................................................................................ 50
r. 18 Neurotoxin Injection for Dimpled Chin ............................................................................................ 54
r• 19 Neurotoxin Injection for Platysmal Banding .................................................................................. 57
r• 20 Neurotoxin Injection for Necklace Unes ........................................................................................... 60
r• 21 Neurotoxin Injection for Nefertiti Neck Uft .................................................................................... 62
1• 22 Neurotoxin Injection for Masseter lfypertrophy ........................................................................... 66
23 Neurotoxin Injection for Parotid Gland Hypertrophy ................................................................. 69
24 Neurotoxin Injection for Submandibular Gland Hypertrophy ................................................ 72
25 Neurotoxin Injection for Gustatory Sweating (Frey Syndrome) .............................................. 74
r. 26 Neurotoxin Injection for Profusely SWeating Underarms ......................................................... 76
27 Neurotoxin Injection for Profusely SWeating Hands .................................................................... 80
28 Neurotoxin Injection for Profusely SWeating Feet ........................................................................ 82
29 Neurotoxin Injection for Migraines .................................................................................................... 84
30 Management of Neurotoxin Injection Complications ................................................................. 88
Section III Introduction to Fillers
31 Fillers Overview .......................................................................................................................................... 92
,. 32 Anesthesia Techniques ............................................................................................................................. 96
33 Filler Injection Methods ....................................................................................................................... 100
Section IV Filler Injection Techniques
r• 34 Filler Injection for Nasolabial Folds................................................................................................. 104
35 Filler Injection with Polymethybnethacrylate (Artefill) ......................................................... 108
r-. 36 Filler Injection for Marionette lines............................................................................................... 111
r• 37 Filler Injection for Up Augnientation ............................................................................................. 114
r-. 38 Filler Injection for Elevating the Oral Commissures ................................................................. 118

Contents
ix
1• 39 Filler Injection for Vertical Up lines............................................................................................... 120
r. 40 Filler Injection for Glabellar Frown lines ...................................................................................... 122
41 Filler Injection for Forehead Wrinkles........................................................................................... 125
r. 42 FillerlnjectionforTearTrough))eformity .................................................................................... 128
43 Filler Injection for Sunken Upper Eyelids ...................................................................................... 131
r• 44 Filler Injection for Lateral Brow Uft ................................................................................................ 134
45 Filler Injection for Sunken Temples................................................................................................. 137
46 Filler Injection for Nonsurgical Rhinoplasty................................................................................ 140
47 Filler Injection for Nasal Valve Stenting ......................................................................................... 146
r. 48 Filler Injection for Medial Midfiilce Hollowing............................................................................ 149
r • 49 Filler Injection for Cheekbone Augmentation............................................................................. 152
r. 50 Filler Injection for Sunken Cheeks................................................................................................... 156
51 Filler Injection for Chin Augmentation.......................................................................................... 160
r•
1 52 Filler Injection for the Mental Crease ............................................................................................. 164
r. 53 Filler Injection for jawline Rejuvenation....................................................................................... 166
r• 54 Filler Injection for Earlobe Rejuvenation...................................................................................... 168
55 Filler Injection for Acne Sc:ars ............................................................................................................ 170
56 Filler Injection for Aging Hands ........................................................................................................ 173
r• 57 Filler Injection with Poly-L Lactic Add for Fadal Volumizing (Sculptra)......................... 176
58 The "Liquid Facelift" ............................................................................................................................... 180
59 Management of Filler Injection Complications .......................................................................... 182
Appendices
A
Neurotoxin/filler Injection Techniques Arranged by Order of Difficulty
and Level of Experience Required..................................................................................................... 190
B
Sample Informed Consent Form for Neurotoxin Injections.................................................. 192
C
Sample Informed Consent Form for Filler Injections............................................................... 193
Index. ...................................................................................................................................................................... 195

Foreword
Drs. Theda C. Kontis and Victor G. La-
combe, two highly respected facial plas-
tic surgeons, share their combined ex-
periences in this practical handbook on
Cosmetic Injection Techniques. If "Seeing
Is Believing," the authors have done a
superb job in making the facial tissue
"transparent" for everyone interested in
this increasingly important subject area.
Universal appreciation of the predict-
able effectiveness and safety of cosmetic
injections has opened up the possibili-
ties of other medical treatments to the
benefit and health of millions.
Cosmetic surgeons have the privilege
of using transcutaneous treatments to
restore patients' faces to their natural
best. Drs Kontis and Lacombe written
a text to assist with this process. The
anatomy drawings are precise, dearly
labeled, and well correlated with the
clinical issues under discussion. Details
X
of injection technique are carefully
explained and demonstrated. But none
of this efferent response is possible
without a secure afferent knowledge of
anatomy-both classical and as found
with the subject themselves.
This book is a labor of love written
by authors who represent variations in
techniques from the East and West coasts
of the United States. I recommend it to
all readers who choose to review their
treatment plans from start to finish and
who value learning from experts who
teach with passion as well as knowledge.
jean D. Carruthers MD, FRCSC, FRC{Ophth)
Fellow American Society of Ophthalmic
Plastic and Reconstructive Surgery,
Clinical Professor, Department of
Ophthalmology
University of British Columbia
Vancouver, British Columbia

Preface
I hear and I forget
I see and I remember.
I do and I understand.
Con.fudus
Chinese philosopher (551 BC-479 BC)
The number of nonsurgical facial en-
hancements has skyrocketed in the past
10 years. As a consequence of patient
demand, many physicians, nurses, and
physician assistants have begun to treat
such patients. This book is a guide and
quick reference for the many profession-
als and paraprofessionals who have be-
come facial injectors. It is not, however,
a training manual for the naive injector.
We highly discourage the novice injec-
tor from using this book as a primer on
injections. In our opinion, nothing can
replace training that is offered by courses
and by one-on-one preceptorships.
This book was designed to augment
the knowledge of a beginner injector
and to train the experienced injector in
how to perform "finesse" injections. The
face can be shaped and minor irregu-
larities and asymmetries improved by
performing the techniques we describe.
In addition, we hope to help the injector
"look through" the skin to the under-
lying anatomy. This will help to identify
both the targets of injection and the
important structures to avoid.
The authors are aware that there is
certainly more than one way to treat a
certain anatomic region. It was our aim,
by having authors from two very differ-
ent locales (East Coast and West Coast),
and different practices, that the "best"
injection technique would be described
by comparing our techniques of injec-
tion. In cases where our techniques
markedly differed, alternate techniques
are presented.
The products described in the book
are all U.S. Food and Drug Administra-
tion (FDA)-approved fillers and neuro-
toxins; however, most of the techniques
described are considered "off-label" uses
of the products. The doses of products
described serve as a general guide for
injection. Although the utmost care was
taken in ensuring the accuracy of the
dosing listed, we urge the injector to use
his or her best judgment or experience
in the unlikely event that a misprint sug-
gests an inappropriate dose. The com-
ments we make about specific products
are often our opinion derived from
clinical observation. Others may have
xi

xii
Preface
different observations clinically, and we
respect these variations in clinical prac-
tices and results.
We realize that this book will be uti-
lized by injectors with different skill
levels. In an attempt to promote safe uti-
lization of these products, we have de-
vised a rating scale for each technique.
Each injection technique is evaluated in
terms of difficulty for the trainer, risks
involved in performing the injection,
and patient satisfaction with the results.
Appendix A lists the chapters by degree
of difficulty, as a cross-reference for in-
jectors who would like to safely advance
to more challenging injection techniques.
The rating system is as follows:
Degree of difficulty for the injector:
•Easy
• • Intermediate
•••Advanced
• • • • Expert injectors only should at-
tempt these injections
Patient satisfaction with procedure:
• Variable results; results may be subtle
•• Good results; patients usually
pleased
• • • High patient satisfaction; predict-
able results
Risks of complications:
•Low
••Medium
eeeHigh
The products described in this book
include Botox, Dysport, Xeomin, Re-
stylane, Perlane, juvederm Ultra and
Ultra Plus, Belotero, Radiesse, Sculptra,
and Artefill. These products are the
most commonly used fillers and neuro-
toxins at the time this manual was writ-
ten. New products are being developed
and may be available at the time of
publication. However, because we have
no experience with these new products,
they will not be described in this edi-
tion. The experienced injectors, however,
will be able to extrapolate the tech-
niques and dosing strategies described
in this book to newer products, if they
desire.
• Disclosure
T.C.K. is a speaker/trainer for Allergan,
Medicis, and Valeant. V.G.L is a speaker/
trainer for Allergan, Medicis, and Vale-
ant, and serves as a principal investiga-
tor for juvederm Voluma.
Disclaimer
The material presented is a compilation
of the clinical experiences of the authors.
Off-label uses of FDA approved products
are described. A qualified health care
professional should be consulted before
using any therapeutic procedure dis-
cussed. Readers should verify all infor-
mation and data before treating patients
or employing any therapies described in
this publication.

Acknowledgment
The authors would like to thank the skill have made this volume one that is
people at Thieme Publishers for believ-
not only thorough, but easy to read and
ing that a well-illustrated manual for understand. We would also like to thank
facial injectables was needed in the Kristi Fritz for scheduling patients for
medical literature. Specifically, we ap-
injection technique demonstrations and
preciate the editorial assistance of for acting as videographer for such ses-
Timothy Hiscock and J. Owen Zurhellen sions. Finally, and most importantly, we
at Thieme. This quality of this book was thank our patients who have graciously
enhanced by the fabulous artwork of agreed to have their procedures filmed
our medical illustrator, Sarah E. Faris. so that medical professionals can learn
Her attention to detail and her artistic safe injection techniques.
xiii

(Trang không có chữ)

•SECTION I•
Introduction to Neurotoxins

1
-------···-------
Neurotoxins Overview
• Action
Peripheral neuromuscular blocking
agents.
• Mechanism of Action
Botulinum toxins irreversibly bind to
the presynaptic terminal of the neuro-
muscular junction and prevent release
of acetylcholine, thereby preventing
musde contraction.
• Botulinum Toxin A (BoNTA)
Formulations
Botox: OnabotulinumtoxinA
(BaNTA-ONA)
2
• 1 00 BU (Botox units) per vial (also
contains 0.5 mg human serum albu-
min, 0.9 mg sodium chloride)
• Vacuum dried
• Store in freezer until reconstituted;
refrigerate after reconstitution
Dyspart: AbabatulinumtaxinA
(BaNTA-ABO)
• 300 DU (Dysport units) per vial (also
contains 0.125 mg human serumal-
bumin, 2.5 mg lactose)
• Lyophylized
• Store in freezer until reconstituted;
refrigerate after reconstitution
Xeomin: lncabotulinumtoxinA
(BaNTA-INC)
• 1 00 XU (Xeomin units) per vial (also
contains 1.0 mg human albumin,
4. 7 mg sucrose)
• Lyophylized
• Stored at room temperature; refrig-
erate after reconstitution

Neuronox
• Approved in 2004 by South Korean
Food and Drug Administration (FDA),
manufactured by Medy-Tox Inc.
(Seoul, Korea)
• Not U.S. FDA-approved in the United
States
• 50, 1 00, and 200 U vials available
(100 u contains 0.5 mg human
serum albumin and 0.9mg sodium
chloride)
• Lyophilized
• Conversion ratio appears to be 1:1
withBotox
CHAPTER 1 • Neurotoxins Overview
3
• The only botulinum toxin A regis-
tered with the Chinese government
• Lyophilized
• Contains 5 mg bovine serum albu-
min, 25 mg dextran, 25 mg sucrose
per 100 units
• Conversion ratio to Botox unknown
• Store in freezer, refrigerate after
reconstituted
• Botulinum Toxin B (BoNTB)
Formulation
Myobloc: BoNTB
• Stored in freezer until reconstituted;
(rimabotulinumtoxinB)
refrigerate after reconstitution
Purtox
• Pending FDA approval
• Similar to Xeomin without complex-
ing proteins
BTXA
• Not FDA-approved in the United
States
• Solstice Neurosciences Inc., Mal-
vern,PA
• Minimal use cosmetically due to
painful
injection
and
limited
duration
• FDA-approved only for cervical
dystonia

4
SECTION I • Introduction to Neurotoxins
Table 1.1
Comparison of Botulinum Toxin A Formulations
Doslllfl
Slmlltlr
Ratio
Year of
Product
Comp11red
FDA
Trade
with
Product
Approval
Generic Ntlme
Composition
Manu(ucturer Names
Boto1C
Botox
2002
Onabotu-
900kd
Allergan, Inc.,
Botox
NA
linumtoxinA
Irvine, CA
cosmetic,
Vista bel,
Vistabex
Dysport
2009
Abobotu-
500-900 kd
Medicis
Relaxin,
2.5-3:1
linumtoxinA
Aesthetics,
Azzalure
Inc., Scotts-
dale,AZ
Xeomin
2011
lncobotu-
150 kd
Merz Aesthet-
Xeomeen,
1-1.5:1
linumtoxinA
No complex-
ics, Inc.,
Bocouture
ing proteins
Franksville,
WI
Neuron ox
N/A
N/A
900kd
Medy-Tox
Meditoxin,
1:1
Inc., Seoul,
Cunox,
Korea
Siax, and
Botulift
Purtox
Pending
N/A
150 kd
Mentor Corp.,
1-1.5:1
No complex-
Santa
ing proteins
Barbara, CA
BTXA
N/A
N/A
900kd
Lanzhou
Prosigne
7
Biologics,
Lanzhou,
China
Abbreviation: N/A, not applicable.
• Additional Reading
Flynn TC. Advances in the use of botulinum
neurotoxins in facial esthetics. 1 Cosmet
Dermatol2012;11 :42-50 PubMed
Nettar K, Maas C. Neuromodulators: avail-
able agents, physiology, and anatomy. Fa-
cial Plast Surg 2011 ;27:517-522 PubMed
Moers-Carpi M, Dirschka T, Feller-Heppt G,
et al. A randomised, double-blind compar-
ison of 20 units of onabotulinumtoxinA
with 30 units of incobotulinumtoxinA for
glabellar lines. 1 Cosmet Laser Ther 2012
PubMed

2
-------···-------
Neurotoxin Preparation
Package inserts for the neurotransmit-
ters state that they should be reconsti-
tuted with nonpreserved saline (0.9%
sodium chloride). However, clinical prac-
tice has determined that using preserved
saline results in much less patient dis-
comfort.
Botox, Botox Cosmetic-1 00 BU {Botox
units) may be reconstituted with:
• 1 mL preserved saline, which pro-
duces a solution of 10 BU per 0.1 mL
• 2 mL preserved saline, which pro-
duces a solution of 5 BU per 0.1 mL
• 2.5 mL preserved saline, which pro-
duces a solution of 4 BU per 0.1 mL
• 4 mL preserved saline, which pro-
duces a solution of2.5 BU per 0.1 mL
Xeomin-100 XU (Xeomin units) may
be reconstituted and used similar to
Botox, above.
Dysport-300 DU (Dysport units) may
be reconstituted with:
• 2.5 mL preserved saline, which
produces a solution of 12 DU per
0.1 mL
• 1.5 mL preserved saline, which
produces a solution of 20 DU per
0.1 mL
• 1.0 mL preserved saline, which
produces a solution of 30 DU per
0.1 mL
General conversion ratios:
• 1 BU = 1.0 to 1.5 XU
• 1 BU = 2.5 to 3.0 DU
• Additional Reading
Moers-Carpi M, Tan K. Fulford-Smith A.
A multicentre, randomized, double-blind
study to evaluate the efficacy of Onabotu-
linumtoxinA (20 units) in the treatment of
glabellar lines when compared to Incobot-
ulinumtoxinA ( 30 units). European Mas-
ters in Aesthetic and Anti-aging Medicine,
September 30-0ctober 1, 2011, Paris
5

3
-------···-------
Instrumentation for
Neurotoxin Injections
After reconstitution, botulinum toxin A
{BoNTA) can be injected using a 1-mL
syringe with a 30-gauge needle. Product
can be withdrawn from the vial with
a 20-gauge needle, and a 30-gauge or
smaller needle can then be used for in-
jection. A "No Waste" syringe with or
without a Luer lock {Acuderm Inc., Fort
Lauderdale, FL, or Exelint International,
Los Angeles, CA) is also available that
pushes the last drop of product through
the needle hub. Alternatively, non-drip
insulin syringes {BD Ultra-Fine Needle,
Becton Dickinson, Franklin Lakes, NJ)
may be used. These syringes are avail-
able in 0.3 and 0.5 mL and have an at-
tached 31-gauge, 8-mm needle.
6
When using these non-drip insulin
syringes, the needle is pre-attached.
The BoNTA must be reconstituted and
the vial stopper removed. Neurotoxin is
drawn up into each syringe and the sy-
ringes labeled with the product name,
lot number, and expiration date. The sy-
ringes are stored in the refrigerator. Be-
cause the needles are so fine and fragile,
care must be taken not to hit the vial
with the needle tip while aspirating the
product. In addition, the utmost care is
required during re-capping of the needle
(prior to patient use) to prevent damage
or blunting of the fine needle tip.

.
~ 11
•
I . .
!-2
OIAP'TfR l • lnstJumentatton for Neurotoxin InJections
7
Flg. 3.1
Dripless 0.5 ml (left) and 0.3 ml (right)
Ag. 3.2 •No Waste• syringe pushes plunger
BD insulin syringes may be used fur BoNTA in-
into needle hub. (Left) Acuderm, (right) Exelint.
jections. These syringes have a pre-attached 31-
gauge needle.

4
-------···-------
The Physicians Coalition for
Injectable Safety
The increased popularity of injectable
procedures has been accompanied by an
unfortunate increase in the performance
of these procedures by unqualified per-
sonnel. It is the authors' concern that
the use of this book by untrained indi-
viduals could produce disastrous results.
The Physicians Coalition for Injectable
Safety (PCIS) was created to provide the
public with information on qualified in-
jectors, Food and Drug Administration
(FDA)-approved materials, and informa-
tion on injectable training that can be
obtained by qualified professionals. We
direct patients and injectors to the PCIS
Web site,
.org, for appropriate information about
the safe use of injectable materials.
The PCIS is represented by over 5,000
board-certified members of the Ameri-
8
can Society for Aesthetic Plastic Surgery
(ASAPS), the American Society of Plastic
Surgeons (ASPS), the American Society
for Dermatologic Surgery (ASDS), the
American Academy of Facial Plastic and
Reconstructive Surgery (AAFPRS), the
American Society of Ophthalmic Plastic
and Reconstructive Surgery (ASOPRS),
the International Society of Aesthetic
Plastic Surgery (ISAPS), the International
Federation of Facial Plastic Surgery Soci-
eties (IFFPSS), and the Canadian Society
for Aesthetic Plastic Surgery. We en-
courage professionals to utilize the PCIS
Web site for up-to-date information
about injectables and injectable safety,
laws and ethical guidelines pertaining
to the purchase of injectables, research
and statistics, and courses available for
training in the use of injectables.

•SECTION II•
Neurotoxin Injection Techniques

5
-------···-------
Neurotoxin Injection for Glabellar
Frown Lines
Difficulty: •
Patient Satisfaction: • • •
Risk: ••
• Indications
Neurotoxins are commonly used to treat
the vertical lines between the brows.
This is the only area currently Food and
Drug Administration (FDA) approved
for treatment with botulinum toxin A
(BoNTA).
• Anatomic Considerations
The vertical lines of the glabella are pro-
duced by contraction of the paired cor-
rugator supercilii musdes, and the hori-
10
zontal lines are caused by contraction
of the centrally located procerus musde.
The corrugators originate on the supra-
orbital ridge of the frontal bone and in-
sert on the skin above the middle third
of the eyebrow. The procerus musde
originates on the nasal bone and inserts
onto the skin of the glabella or mid-
forehead.
Although this anatomy seems straight-
forward, there are subtle anatomic
variations that can be visualized during
facial animation. We have noted two
distinct patterns of corrugator position-
ing: either straight along the brow, or
more vertically oriented in a V shape.
For this reason, the injector should not
rely on only one technique in this area.
The injector should .. look through" the
skin to imagine the location of the mus-
des and their contribution to the wrin-
kles produced during movement.

CHAPIER 5 • Neurotoxin Injection for Glabellar Frown Unes
11
• Injection Technique
Topical anesthesia may be used; how-
ever, this injection usually can be toler-
ated without anesthesia.
Prior to injecting the patient, have the
patient frown the brow. Attempt to look
through the skin to determine the size,
strength, and location of the procerus
and corrugator musdes.
Usual doses in this region are 20 to
30 BU (Botox units) or 50 to 80 DU (Dys-
port units), but injector experience with
these treatments has shown that some
patients can do well with as little as 10
units, and others (often men) may need
substantially more.
Injections must be placed 1 em above
the superior orbital rim to reduce the
risk of upper eyelid ptosis. Injections are
placed in the musde belly. Try not to
"bump" the periosteum, as this occasion-
ally can be associated with post-injection
headache.
• Precautions
Injection in this area can result in an
upper lid ptosis, which can be seen up to
2 weeks after injection, and may last 2
to 4 weeks post-injection.
• Post-Injection Instructions
There is no dinical data to suggest that
giving patients post-treatment instruc-
tions decreases ptosis or improves re-
sults. However, some physicians ask their
patients not to bend over, push on the
injection sites, or lie down for 4 hours.
They also recommend the patient not
exercise that day and to actively move
the injected musdes for 90 minutes.
Alternate Post-Injection Instructions
No exercise immediately after injection,
as it may accentuate bruising.
• Risks
Diffusion of product into the eyelid
may affect the levator palpebrae supe-
rioris musde and result in a transient
ptosis.
• Pearls of Injection
Ask the patient to frown as you assess
the size and shape of the musde. Tailor
the treatment to the anatomy. Filler
injections may be necessary for deep
rhytids in this region. Consistent re-
treatment of the glabella may result in
the patient "unlearning" to move the
brow, and thus not only improve the
rhytids but also extend the time re-
quired between injections. Placing the
thumb along the orbital rim during in-
jection may reduce the likelihood of
diffusion toward the levator palpebrae
superioris musde.

a
b
12
SECilON II • Neurotoxin InJection Techniques
Fig. 5.1 a, b Clinical photographs of the differing anatomy of corrugators muscles. (a) More hori-
zontal muscles. (b) More vertical V-like muscles. The injector should learn to "look through• the skin
to determine the anatomy.

Optional
injection site
CHAPIER 5 • Neurotoxin InJection for Cilabellar Frown Unes
13
Frontalis m.
\
•
•
0
•
•
Procerus m.
Corrugator
supercilii m.
•
•
•
0
Levaror
palpebrae
superioris m.
a
•
0
Injection$ to medial
orbicularis oculi m.
b
Fig. 5.2a, b Suggested patterns of injection for more horizontal corrugator supercilii muscles. De-
pending on the length of the muscle, the injections may need to be placed farther our laterally. (Open
drcles denote optional injection sites.)

14
SECilON II • Neurotoxin InJection Techrjques
Fronta.lis m.
\
•
•
a
•
•
b
Procerus m.
Corrugator
supercilii m.
•
Levator
palpebtae
superioris m.
Injections: to medial
orbicularis oculi m.
Fig. 5.3a, b Suggested patterns of injection for the V-lilce corrugator supercilii muscles.

CHAPIER 5 • Neurotoxin InJection for Cilabellar Frown Unes
15
Frontalis m.
Procerus m.
\
•
•
Corrugaror
supercilii m.
Levator
palpebrae
superioris m.
a
Injections to medial
orbicularis oculi m.
b
Fig. 5.4a, b Suggested injection sites for predominandy horizontal glabellar rflytids with more con-
tribution from the procerus musde and less contribution from the corrugator supercilii muscles.
• Additional Reading
Bassi chis BA, Thomas JR. The use of Botox to
treat glabellar rhytids. Facial Plast Surg
Oin North Am 2003;11 :453-456 PubMed
Carruthers J, Fagien S, Matarasso SL; Botox
Consensus Group. Consensus recommen-
dations on the use of botulinum toxin type
a in facial aesthetics. Plast Reconstr Surg
2004;114(6, Suppl)tS-225 PubMed
Moy R, Maas C, Monheit G, Huber MB: Re-
laxin Investigational Group. Long-term
safety and efficacy of a new botulinum
toxin type A in treating glabellar lines.
Arch Facial Plast Surg 2009;11 :77-83
PubMed

6
-------···-------
Neurotoxin Injection for
Forehead Wrinkles
Difficulty: ••
Patient Satisfaction: • • •
Risk: ••
• Indications
Transverse wrinkles of the forehead.
• Anatomic Considerations
central position of the forehead is not
devoid of wrinkles. Therefore, treatment
of the forehead should include injections
in the central aspect of the forehead.
The upper face must be assessed both
in animation and at rest prior to injec-
tion. In women, the brow should lie at
or just above the superior orbital rim. In
men. it should lie at the bony rim.
• Injection Technique
Have the patient raise and lower the
Contraction of the paired frontalis mus-
brow and assess the extent of muscle
des raises the eyebrows and upper eye-
movement. The frontalis muscles are
lids, which produces transverse creases located superficially, so the injections
in the forehead. These muscles originate should be placed in the superficial sub-
on the galea aponeurotica of the era-
cutaneous tissue. Treat the entire fore-
nium and insert into the skin of the eye-
head from medial to lateral. As with all
brows. The frontalis muscles are often BoNTA injections, male patients may re-
described as paired muscles that do not quire a higher dose. The typical dose
meet centrally. However, clinically, the ranges from 10 to 20 BU or 30 to 60 DU.
16

CHAPTER 6 • Neurotoxin Injection for Forehead Wrinkles
17
• Precautions
The forehead is often described as the
most difficult area to inject well. Al-
though treatment of the forehead seems
intuitively simple, common errors in-
dude overtreatment or poor injection
planning. The most important rule of
injection is to assess the position of the
brows at rest, prior to injection of neu-
rotoxin. Two important conditions of
this region must be predetermined: the
presence of brow ptosis; and increased
resting tone of the muscles, which can
mask brow ptosis.
In some patients, horizontal forehead
creases are the result of compensation
for brow ptosis. These patients often re-
quest neurotoxins to improve their deep
forehead rhytids. It is important to re-
member that the frontalis muscles are
the only muscles that elevate the brows.
If the brow is ptotic, do not inject the
frontalis muscles, as this will worsen the
brow ptosis. If injection must be per-
formed on a patient with brow ptosis,
plan the injections high in the forehead
so that the patient retains some brow
elevation movement, or consider under-
treating this entire area.
In addition, the frontalis muscles can
sometimes show a resting tonic contrac-
tion that must be relaxed to determine
the resting position of the brow. This
may even require the injector to "smooth
out" the forehead manually to encour-
sition to determine if the frontalis con-
traction was masking brow ptosis.
Poor technique in this area can pro-
duce an odd-shaped brow. Do not limit
the injections to the central brow. Do not
assume that the injections cannot extend
laterally. If only the center of the brow
is treated, the brow will drop medially
and elevate laterally, which produces an
odd-appearing slanted look, sometimes
referred to as the "Mr. Spock," or "Me-
phisto (devilish) sign." A lateral browlift
can be obtained by using this technique,
but proceed with caution in this area to
avoid an overly slanted medial brow.
• Post-Injection Instructions
Instruct the patient not to exercise im-
mediately after treatment. Bruising may
decrease the effect of the BoNTA by pre-
venting diffusion to the neuromuscular
junction.
• Risks
Ptosis of the upper eyelid and unmask-
ing brow ptosis are the major risks of
this procedure. Minor risks include in-
appropriate injection planning, which
may result in unnatural-appearing brows
or persistent rhytids.
age relaxation of the muscles. Having the • Pearls of Injection
patient close his/her eyes can help relax
the frontalis muscles. Once the frontalis
More than with any other area, it is im-
muscles are at rest, assess the brow po-
perative to observe the patient contract-

18
SECilON II • Neurotoxin InJection Techniques
ing and relaxing the frontalis musdes
while the injector plans the injection
sites. If the rhytids extend up to the hair-
line, make sure the injections extend to
this area, or it will result in a smooth
forehead with a ridge of wrinkles supe-
riorly. Also be sure to assess the lateral
brows; occasionally these rhytids are
undertreated, and deep crescent-shaped
Do not inject
within 1 em of
a
supraorbital rim
Frontalis m.
..
1 em!
;
Supraorbital
rim
creases will be seen just above the lat-
eral brow. A unilateral forehead resting
contraction may be compensation for
upper eyelid ptosis. Assess these areas
carefully prior to injecting the patient.
One dose of BoNTA (20-25 BU or
50-70 DU) can occasionally be used to
treat both the glabella and the forehead
in selected patients.
Optional
injecrion sires
Fig. 6.1 a, b Frontalis musde injection sites may extend up to the hairline in some individuals. Main-
tain a distance of 1 on or more above the superior orbital rim. Alternate injection patterns are shown.
Tailor the injection pattern to the shape and action of the muscle.

Frontalis m.
Do not inject
within I em of
supraorbital rim
Fig. 6.1 a, b (Continued)
0
+
1 em! ..
CHAPIER 6 • Neurotoxin Injection for Forehead Wrinkles
19
Supraorbital
rim
0
Optional
injection sires
b

20
SECilON II • Neurotoxin InJection Techniques
Fig. 6.2 •Mr. Spack• brow produced by central injection of the forehead.
Fig. 6.3 In some patients, care must be taken to treat the crescent-shaped rhytids superolateral to
the brow.

CHAPTER 6 • Neurotoxin Injection for Forehead Wrinkles
21
• Additional Reading
Carruthers J, Fagien S, Matarasso SL; Botox
Consensus Group. Consensus recommen-
dations on the use of botulinum toxin type
a in facial aesthetics. Plast Reconstr Surg
2004;114{6, Suppl)1S-22S PubMed
Michaels BM, Csank GA, Ryb GE, Eko FN,
Rubin A. Prospective randomized compar-
ison of onabotulinumtoxinA {Botox) and
abobotulinumtoxinA {Dysport) in the
treatment of forehead, glabellar, and peri-
orbital wrinkles. Aesthet Surg J 2012;32:
96-102 PubMed

7
-------···-------
Neurotoxin Injection for Smile Lines
and Crow's Feet
Difficulty: •
Patient satisfaction: ••
Risk: •
• Indications
Smile lines and crow's feet are two of
the most commonly sought after areas
for treatment with BoNTA. To soften or
eliminate wrinkles around the lateral
and inferior orbit, injection of the or-
bicularis oculi muscles can prevent
movement-related creasing of the over-
lying skin assodated with expression and
baseline muscle tension. Neurotoxin in-
jection will not improve static wrinkles
or deep creases due to photoaging.
22
• Anatomic Considerations
The orbicularis oculi muscle surrounds
the eye and is separated into three divi-
sions: pretarsal, preseptal, and orbital.
The orbital portion extends laterally and
is intimately adherent to the overlying
skin. Contraction of this muscle results in
lines extending radially from the lateral
canthus. As the overlying skin thins and
ages, crows feet become visible in the
skin from repeated muscle contractions.
• Precautions
The periocular area often has many su-
petfidal and deep venous structures that
may or may not be visible through the
surface of the skin. Trying to avoid them

CHAPTER 7 • Neurotoxin Injection for Smile Lines and Craw's Feet
23
will keep the toxin from being washed firm pressure for a minute or two to
away and also prevent bruising.
minimize bruising.
• Injection Technique
Topical anesthesia may be used and ice
may be applied, though neither is neces-
sary in most cases. Three to four injec-
tions of BoNTA are placed radially in the
area of the craw's feet. A total of 8 to
20 BU or 20 to 60 DU may be placed in
each side. Care should be taken to inject
1 em lateral to the bony orbital rim, es-
pecially above the canthal angle, as upper
lid lag can occur. It is helpful to place a
finger of the noninjecting hand at the
lateral orbital rim as a guide.
The muscle is superficial, so the nee-
dle does not need to be placed deep into
the subcutaneous tissue. Because of the
wide zone of effect for BoNTA, a super-
ficial dermal injection will minimize
bruising without compromising clinical
results.
• Post-Injection Instructions
This is a highly vascular area, so bruising
is possible. If a vessel is injured, hold
• Risks
Extending the injections too far inferi-
orly and too deep under the orbicularis
can affect the zygomaticus major mus-
de and result in an upper lip droop or
asymmetric smile. Patients should be
made aware that injections cannot be ex-
tended too inferiorly in this area. Some
patients will note an accentuation of
lines in this region once the lateral lines
have been treated.
• Pearls of Injection
It is acceptable to have some movement
with full expressive action of the mus-
de. Because of the wider zone of effect,
some practitioners prefer BoNIA-ABO
(Dysport) in this area.

24
SECilON II • Neurotoxin InJection Techniques
Orbicularis
oculi m .
Superficial
veins
•
Zygomaticus
a
major m.
b
Orbicularis
oculi m.
Do not inject------, •
<1 em from
~
lateral orbital
• I em
rim
.........
-
Craw's
feet
Fig. 7.1 a, b Injections to treat the craw's feet are traditionally placed subcutaneously into the orbi-
cularis muscle in a radial fashion 1 em outside the lateral orbital rim. Avoid injection into the super-
ficial veins seen in that region.

CHAPIER 7 • Neurotmdn InJection for Smle Lines and Craw's Feet
25
Orbicularis
oculi m.
Fromalis:m. \
•
Orbiral rim----
-
-
- --
0
0
Zygomaticus~
major m.
Oprional
injecrions
•
0
Fig. 7.2 For patients with wrinkles under the eyes, optional sites are shown, but care must be taken
to avoid diffusion of BoNTA into the zygomaticus musdes.
• Additional Reading
Carruthers J, Fagien S, Matarasso SL; Botox
Consensus Group. Consensus recommen-
dations on the use ofbotulinum toxin type
a in facial aesthetics. Plast Reconstr Surg
2004;114(6, Suppl)1S-22S PubMed
Kim DW, Cundiff J, Toriumi DM. Botulinum
toxin A for the treatment of lateral perior-
bital rhytids. Facial Plast Surg Oin North
Am 2003;11 :445-451 PubMed

8
-------···-------
Neurotoxin Injection for
Lateral Brow Lift
Difficulty: ••
Patient Satisfaction: •
Risk: •
• Indications
Hyperactivity of the lateral aspect of the
orbicularis oculi muscle can result in
ptosis of the lateral aspect of the brow.
Vertically and obliquely oriented fibers
of muscle, when activated or with base-
line resting muscle tension, pull down
on the position of the tail of the brow
and oppose the lifting action of the fron-
talis muscle.
• Anatomic Considerations
superolateral orbicularis oculi is posi-
tioned at or just inferior to the level of
the lateral eyebrow hairs.
• Injection Technique
The best effect occurs when the non-
injecting hand is used to elevate the
brow and injections are kept approxi-
mately 1 em above the orbital rim. Topi-
cal anesthesia may be used and ice may
be applied, though neither is necessary
in most cases.
BoNTA is injected into the muscle in
two to three spots along the lateral
brow, each with 2 to 3 BU for a total of
4 to 6 BU per side.
• Precautions
The orbicularis oculi muscle is a strong Bruising is a risk in this area. The peri-
brow depressor. In most patients, the ocular area has many superficial venous
26

CHAPIER 8 • Neurotoxin Injection for Lateral Brow Uft
27
structures that may or may not be visible
through the surface of the skin. Bruising
can be minimized by injecting into the
superficial subcutaneous tissue.
• Post-Injection Instructions
Hold firm pressure. Bruising is possible
and more likely in this area than in many
others.
• Risks
There are few risks as long as the BoNTA
does not affect the levator palpebrae su-
perioris muscle.
• Pearls of Injection
• Not all patients will be able to
achieve significant brow elevation.
• Because brow elevation results from
the upward pull of the brow by the
frontalis muscle, simultaneous in-
jection of the lateral aspect of the
frontalis and the lateral orbicularis
muscles will negate the upward lift
of the brow in this region.

28
SECilON II • Neurotoxin InJection Techniques
Frontalis m. --~------'-----
Levator -----7---------
a
b
palpebrae
supenonsm.
Orbicularis
oculi m.
Fig. 8.1a, b Suggested patterns of BoNTA injection of the lateral aspect of the orbicularis muscle
can result in a laterc~l brow lift.
• Additional Reading
Ahn MS, Catten M, Maas CS. Temporal brow
lift using botulinum toxin A. Plast Recon-
str Surg 2000;105:1129-1135, discussion
1136-1139 PubMed
Chen AH, Frankel AS. Altering brow contour
with botulinum toxin. Facial Plast Surg
Oin North Am 2003;11 :457-464 PubMed
Maas CS, Kim Ej. Temporal brow lift using
botulinum toxin A: an update. Plast Re-
constr Surg 2003;112{5, Suppl)1 095-1125,
discussion 1135-1145 PubMed

9
-------···-------
Neurotoxin Injection for Chemical
Brow Lift
Difficulty: ••
Patient Satisfaction: •
Risk: ••
• Indications
Volume loss in the forehead, combined
with hyperactive corrugator, procerus,
and orbicularis oculi muscles, is often
responsible for brow ptosis. Vertically
and obliquely oriented muscle fibers,
when activated or with baseline resting
muscle tension, pull down on the posi-
tion of the brow relative to the upward
pull of the frontalis muscle.
• Anatomic Considerations
The corrugators, procerus, and lateral
orbicularis oculi muscles are brow de-
pressors. Inactivation of the depressor
muscles permits the elevation of the
brow by allowing the frontalis muscle to
overcome their downward pull. Medial
elevation is obtained by pladng BoNTA
in the corrugator and procerus muscles.
Lateral brow lift is achieved by treating
the lateral orbicularis oculi muscles. It
is imperative to preserve muscle func-
tion in the forehead by not overly treat-
ing (relaxing) the frontalis muscle with
BoNTA as the forehead will not be able
to elevate the brow, and brow ptosis may
occur.
• Injection Technique
Topical anesthesia may be used; ice may
be applied though neither is necessary
in most cases. Essentially, this lift is
created by combining the techniques of
treating the glabella and lateral brow
(see Olapters 5 and 8). A total of 20 to
29

30
SECTION II • Neurotoxin Injection Techniques
30 BU or 60 to 90 DU may be necessary
for this treatment.
• Precautions
Place injections at least 1 em away from
the bony orbital rim to reduce the risk of
spread to the levator palpebrae superi-
oris muscle.
• Post-Injection Instructions
Hold firm pressure. Bruising is possible
and more likely in the temporal area than
in many others. Patient instructions may
include the following: avoid exercise for
the day, do not bend over, lie flat, or push
on the injection sites for 4 hours. It also
may be advisable to have the patients
move their brows for 90 minutes after
injection to potentiate uptake of the
BoNTA. However, there are no clinical
studies to show that these instructions
improve the results or minimize ptosis.
Alternatively, patients are instructed
not to exercise immediately post-
injection.
• Risks
There are few risks as long as the neuro-
toxin does not affect the levator palpe-
brae superioris muscle.
• Pearls of Injection
• Not all patients obtain the same de-
gree of brow elevation using this
technique.
• Over treatment of the frontalis
muscle will negate any possible
brow elevation achieved with these
techniques.
• Patients with severe brow ptosis are
less likely to obtain a significant lift
from a neurotoxin.

CHAPIER 9 • Neurotoxin InJection for Chemical Brow Uft
31
a
b
Corrug.ator
supercilii m.
Frontalis m.
\
•
•
Medial fibers of
orbicularis oculi m.
Procerus m.
•
•
Orbicularis
oculi m .
Levator
palpebrae
superioris m.
Fig. 9.1a, b A chemical brow lift can be produced by treating the procerus and corrugator muscles
centrally and the orbicularis oculi musde laterally. The frontalis musde must not be treated so that it
can take over the upward pull of the brow. Alternative techniques are demonstrated.
• Additional Reading
Carruthers J. Carruthers A. Botulinum toxin
(Botox) chemodenervation for facial reju-
venation. Facial Plast Surg Clin North Am
2001 ;9:197-204, vii PubMed
Chen AH, Frankel AS. Altering brow contour
with botulinum toxin. Facial Plast Surg
Clio NorthAm 2003;11 ):457-464 PubMed
Frankel AS, Markarian A Cosmetic treatments
and strategies for the upper face. Facial Plast
Surg Oin North Am 2007;15:31-39, vi
PubMed

10
-------···-------
Neurotoxin Injection for
Lower Eyelid Roll
Difficulty: ••
Patient Satisfaction: •
Risk: ••
• Indications
Hypertrophy of the orbicularis oculi
musde can cause a fullness of the lower
eyelid when smiling or squinting. but is
not noticeable at rest.
• Anatomic Considerations
The orbicularis oculi musde surrounds
the eye and is divided into three parts:
orbital, preseptal, and pretarsal. Hyper-
trophy of the pretarsal portion of the
muscle can result in a fullness of the
lower eyelid when the patient smiles.
32
• Injection Technique
Botulinum toxin (1 to 2 BU) is injected
at the midpupillary line approximately
3 mm below the lash line. A single injec-
tion is placed per eyelid. The injection is
immediately subcutaneous.
• Precautions
Injection of the pretarsal orbicularis
muscle will result in a widening of the
palpebral aperture. Do not inject pa-
tients who have a preexisting lower lid
laxity or excessive scleral show.
• Post-Injection Instructions
None.

CHAPIER 10 • Neurotoxin Injection for Lower Eyelid Roll
33
O~:bi<.:ula.ris
oculi m.
Fig. 10.1 BoNTA is injected at the midpupillary line into the superficial subcutaneous tissue tore-
duce the bulging of a hypertrophic orbicularis oculi muscle.
• Risks
Widening of the palpebral aperture may
result in dry eyes. Inject with caution in
patients with lax lower eyelids, or with
dry eye syndrome. Bruising may occur
after injection.
• Pearls of Injection
Check the tone of the lower eyelid prior
to injection (snap test). Accurate diag-
nosis is key in these patients, who com-
plain of lower lid "bags." Patients must
be counseled on the differences between
lower lid fat herniation and orbicularis
musde hypertrophy and treated appro-
priately. Because of the increased zone
of effect for Dysport, Botox is preferred
for these injections.
• Additional Reading
Carruthers J, Carruthers A Aesthetic botuli-
num A toxin in the mid and lower face and
neck. Dermatol Surg 2003;29:468-476
PubMed
Flynn TC, Carruthers JA, Carruthers JA.
Botulinum-A toxin treatment of the lower
eyelid improves infraorbital rhytides and
widens the eye. Dermatol Surg 2001;27:
703-708 PubMed

11
-------···-------
Neurotoxin Injection for Bunny Lines
Difficulty: •
Patient Satisfaction: • •
Risk: •
• Indications
"Bunny lines" are wrinkles that radiate
from the medial canthal region and run
inferomedially on each side of the nose.
Bunny lines are not found on every
patient and are not universally disliked,
but can be unacceptable for some pa-
tients. Occasionally these rhytids con-
tribute to deep horizontal glabellar
rhytids. In those cases, BoNTA injections
can be used to soften this region.
• Anatomic Considerations
The superior portion of the nasalis mus-
cle (pars transversa) originates over each
34
indsor foramen and inserts into an apo-
neurosis on the nasal dorsum. At this
aponeurosis, the fibers meet those of
the opposite nasalis muscle and the mid-
line procerus muscle. When contracted,
these muscles create wrinkles or lines
on the nose as well as pull the center
of the forehead down and contribute to
horizontal glabellar creases.
• Injection Technique
Topical anesthesia may be used and ice
may be applied, though neither is neces-
sary in most cases. The patient is usually
asked to wrinkle his/her nose up ''like
a bunny." This will indicate where the
muscle is located and the strength of the
nasalis fibers. A single injection of 2 to
3 BU is placed per side. The muscle is
not deep, so the injection need only be
placed in the subdermal subcutaneous
tissue.