Các Kỹ Thuật Tiêm Thẩm Mỹ (Cosmetic Injection Techniques)

36
SECilON II • Neurotoxin InJection Techniques
Nasali.s m.
Levator labii-------
supedoris m.
Levator labii superroris
alaeq ue nasi m.
•
•
•
Alternative technique:
additional injections
w correct extensive lines
Fig. 11.1 A single injection is used for each muscle, or, for larger musdes, several injections may be
placed, with care being taken to stay medial to the levator labii superioris alaeque nasi.

CHAPTER 11 • Neurotoxin Injection for Bunny Lines
37
• 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
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

12
-------···-------
Neurotoxin Injection for Nasal Tip Lift
Difficulty: •
Patient Satisfaction: •
Risk: •
• Indications
Neurotoxin can be injected into the base
of the nasal columella to produce a sub-
tle elevation of the nasal tip (increase in
tip rotation). This is indicated in patients
with a mild drooping of the nasal tip.
It will not improve a severely ptotic
nose with thick, sebaceous skin. Consider
surgical treatment for severely ptotic
noses. This procedure is a mild ••finesse"
technique.
• Anatomic Considerations
inserts onto the medical crural foot-
plates. It pulls the nasal tip down with
smiling. Weakening of this muscle will
result in elevation of the tip or widening
of the nasolabial angle. The nasolabial
angle should be approximately 90 de-
grees in men, and more obtuse in women.
• Injection Technique
Topical anesthesia may be used; how-
ever, this single injection usually can
be tolerated without anesthesia. The de-
pressor septi nasi muscle is located at
the base of the columella and is the
muscle targeted with the injection. Use
approximately 2 BU or 5 to 9 DU.
• Precautions
The depressor septi nasi muscle is an This injection will not improve a se-
extension of the orbicularis muscle and verely ptotic tip. Use with caution in
38

OIAPJ'ER 12 • Neurotoxin InJection for Nasal11p Lift
39
I
Depressor
septi nasi m.
Fig. 12.1 A single injection at the
base of the columella can produce a
subtle nasal tip elevation.
women who already have an elevated aware that this is a subtle improvement.
tip. Use with caution in men, who gen-
Do not overtreat.
erally do not want an over-rotated tip.
• Post-Injection lnstrudions
None. Bruising is unlikely.
• Risks
Overtreatment of this area may cause a
drooping of the upper lip.
• Pearls of Injection
Proceed slowly; try half the suggested
dose first. Make sure that the patient is
• 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
Redaelli A Medical rhinoplasty with hyal-
uronic add and botulinum toxin A: a very
simple and quite effective technique.J Cos-
met Dermatol 2008;7:21 0-220 PubMed

13
-------···-------
Neurotoxin Injection for Nasal Flare
Difficulty: • • •
Patient Satisfaction: •
Risk: •
• Indications
Some individuals inadvertently flare
their nostrils while speaking.
• Anatomic Considerations
• Injection Technique
Topical anesthesia may be used; how-
ever, this single injection usually can
be tolerated without anesthesia. One
injection point is used per side. Approx-
imately 5 BU or 15 DU are used per side.
Inject into the immediate subdermal
tissue, with care being taken to avoid
the alar cartilage.
• Precautions
The dilator nasalis muscle is the lower None.
portion of the nasalis muscle and at-
taches to the alar cartilage. Contraction • Post-Injection Instructions
of the dilator nasalis muscle results in
alar flaring. This muscle lies superficial None. Bruising is unlikely.
to the lateral crura of the lower lateral
cartilage.
40

OIAPTER 1l • Neurotoxin InJection for Nasal Flare
41
\
Nasalis m.
•
Dilator
nasalis m.
'---------i---levaror labu
superioris
ala.eque nasi m.
Fig. 13.1 A single injection of BoNTA is placed in the superficial subcutaneous tissue (on each side)
to decrease nostril flare.
• Risks
None.
• Pearls of Injection
Proceed slowly; try half the suggested
dose first. Make sure that the patient is
aware that this is a subtle improvement.
Do not overtreat. Results may last 3 to
4 months; however, frequent injections
may not be necessary as the patient may
••unlearn" to contract the musde while
speaking.
• 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

14
----···----
Neurotoxin Injection for Elevating
the Oral Commissures
Difficulty: ••
Patient Satisfclction: •
Risk: ee
• Indications
Neurotoxin can be injected in the de-
pressor anguli oris (DAO) muscles to
elevate the oral commissures. This is
indicated in patients with downturned
corners of the mouth. Neurotoxin alone
can be used in this area, but most often
must be combined with filler injections
to the oral commissure (see Chapter 38).
• Anatomic Considerations
DAO muscle pulls down the comers of
the mouth. Weakening this muscle will
result in a compensatory upward pull of
the zygomaticus muscles, which results
in elevation of the oral commissures.
• Injection Technique
A single injection per muscle is suggested
and well tolerated. The DAO muscle
should be palpated while having the
patient actively frown. If the belly of the
muscle cannot be palpated, a rough es-
timate of its location can be made by
going 1 em lateral to the oral commis-
sure and then 1 em inferiorly. Inject ap-
proximately 2 to 5 BU or 6 to 15 DU
deeply into each muscle.
Alternate Technique
The DAO muscle originates along the
oblique line of the mandible and inserts To avoid other perioral muscles, injec-
into the modiolus. Contraction of the tions may be placed into the inferior as-
42

CHAPTER 14 • Neurotoxin Injection for Elevating the Oral Commlssures
43
pect of the musde. A single injection is
ment in the downturned oral commis-
placed just above the mandibular bor-
sure is seen, especially in patients with
der, diagonally and inferior to the oral heavy surrounding skin. The major risk
commissure.
is that BoNTA will affect the wrong peri-
• Precautions
oral musdes and affect the smile or
expression.
This injection will not improve severely • Pearls of Injection
depressed oral commissures and will not
elevate the marionette lines.
• Post-Injection Instructions
None. Bruising is unlikely.
• Risks
Overtreatment of this area is unlikely. It
is more likely that only a mild improve-
Neurotoxin alone may improve mild
down-turning of the oral commissures.
More resistant cases likely will require
hyaluronic acid filler injection to the
oral commissure in addition to BoNTA
injection of the DAO muscles. Be sure
to inform the patient that only a subtle
improvement is likely.

44
SECilON II • Neurotoxin InJection Techniques
Inject 1 em lateral
and 1 em inferior
to oral .commissure
........
; I em
; •
Depressor
anguli oris m.
•
Alternative technique:
inject inferiorly on
the mandibular ramus
Fig. 14.1 (Left) BoNTA can be injected into the depressor anguli oris muscle, which can be pal-
pated 1 em lateral and inferior to the oral commissure. (Right) Alternate injection site of the de-
pressor anguli oris muscle is 1 em above the mandibular border, on a line positioned diagonally
and inferior to the oral commissure.
• Additional Reading
Carruthers J, Carruthers A. Aesthetic botu-
linum A toxin in the mid and lower face
and neck. Dermatol Surg 2003;29:468-
476 PubMed
Dayan SH, Maas CS. Botulinum toxins for
facial wrinkles: beyond glabellar lines.
Facial Plast Surg Oin North Am 2007;15:
41-49, vi PubMed

15
-------···-------
Neurotoxin Injection for Lip Lift
Difficulty: ••
Patient Satisfaction: •
Risk: ••
• Indications
A small improvement in the visible pink
lip can be achieved by the use of BoNTA.
This can be used to enhance the upper
and/or lower lips.
• Anatomic Considerations
The orbicularis oris muscle is the sphinc-
lips. This pull will result in more visible
pink lip and a slight "lip lift."
• Injection Technique
Botulinum toxin is injected at the base
of the philtrum at the vermillion border.
The corresponding location of the lower
lip may also be injected. Approximately
1 to 2 BU is used for each injection. (Be-
cause of the increased zone of effect of
Dysport, the authors prefer to use Botox
in this area.)
• Precautions
ter that surrounds the mouth. The pull Injections around the mouth must be
of the muscle is toward the center; symmetric, to avoid asymmetry of the
therefore, weakening this pull will allow mouth when smiling or puckering the
the upper lip elevators and the lower lip lips. Awid these injections in persons
depressors to increase their pull on the who play the flute, whistle, or do similar
45

46
SECilON II • Neurotoxin InJection Techniques
..
..
Orbicu]ads
oris m.
Fig. 15.1
BoNTA is injected at the base of the philtra! columns on the upper lip and may also be
injected in similar locations on the lower lip to cause a subtle increase in pink lip, or a pseudo-
augmentation.
activities. Warn patients that they may
initially experience difficulty drinking
through straws.
• Post-Injection Instructions
None.
• Risks
Asymmetry can be reduced by en-
suring that the injections are placed
symmetrically.
• Pearls of Injection
This technique produces a very subtle
augmentation in the lips, possibly a 1 to
2 mm increase in pink lip visibility. The
relative size of the lip increases but there
is no increase in lip volume. The patient
should not expect this procedure will
produce the same results as fillers; how-
ever, this procedure can be used in ad-
dition to fillers and is encouraged in
patients who have very thin lips.
• Additional Reading
Fagien S. Botox for the treatment of dynamic
and hyperkinetic facial lines and furrows:
adjunctive use in facial aesthetic surgery.
Plast Reconstr Surg 1999;103:701-713
PubMed
Semchyshyn N, Sengelmann RD. Botulinum
toxin A treatment of perioral rhytides.
Dermatol Surg 2003;29:490-495, discus-
sion 495 PuhMed

16
-------···-------
Neurotoxin Injection for
Smoker's Lines
Difficulty: ••
Patient Satisfaction: •
Risk: •••
• Indications
Perioral wrinkles extend radially from
the lips due to the repeated puckering
motion from speaking or smoking. In
women, lipstick may "bleed" into these
lines. In nonsmokers, these lines can be
produced in patients who purse their lips
while talking.
• Anatomic Considerations
The orbicularis oris muscle is the sphinc-
ter that surrounds the mouth. Repeated
contraction of this muscle may result in
circumoral rhytids.
• Injection Technique
BoNTA is injected at the vermillion bor-
der, usually 1 to 2 units per quadrant.
Not more than four injections are done
on each lip, and not more than two
per side. (Because of the increased zone
of effect for Dysport, the authors prefer
Botox in this area.) The wrinkles them-
selves do not necessarily need to be in-
jected, as the mild paresis of the entire
muscle will improve the entire region
injected.
• Precautions
Injections around the mouth must be
symmetric, to avoid asymmetry of the
mouth when smiling or puckering the
lips. Avoid these injections in persons
who play the flute, whistle, or do similar
activities. Warn patients that they may
47

48
SECilON II • Neurotoxin InJection Techniques
•
•
•
•
•
•
Fig. 16.1
To treat smoker's lines, either 2 or 4 injections should be placed symmetrically on the
upper and/or lower lip. Do not attempt to inject every wrinkle.
initially have difficulty drinking through
straws.
• Post-Injection Instructions
None.
• Risks
Asymmetry can be reduced by en-
suring that the injections are placed
symmetrically.
• Pearls of Injection
This technique can be performed on one
or both lips, but care must be taken not
to inject near the oral commissure, and
not to over-inject the lips, which poten-
tially could cause oral incompetence. The
concomitant use of fillers in this area can
improve results. For those who charge
by the unit, the benefit-risk ratio for
this area is not favorable, and only tiny
amounts are used, resulting in low re-
imbursement yet the risk of asymmetry
and/or overtreatment is high because of
the small sensitive musdes being treated.
The novice injector should beware.

CHAPTER 16 • Neurotoxin Injection for Smoker's Unes
49
• 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
Cohen JL, Dayan SH, Cox SE, Yalamanchili R,
Tardie G. OnabotulinumtoxinA dose-
ranging study for hyperdynamic perioral
lines. Dermatol Surg 2012;38(9):1497-
lSOS PubMed
Romagnoli M, Belmontesi M. Hyaluronic
acid-based fillers: theory and practice. Clin
Dermatol2008;26:123-159 PubMed

17
-------···-------
Neurotoxin Injection for
Gummy Smile
Difficulty: • • •
Patient Satisfaction: • •
Risk: •••
• Indications
Some patients pull their upper lip up
dramatically while smiling, which re-
veals a large part of the gingival tissue,
often referred to as a "gummy smile."
• Anatomic Considerations
lip snarl, and this muscle has been re-
ferred to as the "Elvis" muscle.
• Injection Technique
Topical anesthesia may be used; how-
ever, this single injection (per side) usu-
ally can be tolerated without anesthesia.
The levator labii superioris alaeque
nasi muscle travels just lateral to the
nose; 1 to 2 BU is used in this area. Ti-
trate to determine the necessary dosing
for the patient.
The upper lip is elevated during smile by • Precautions
the levator labii superioris alaeque nasi --------------
muscles. These muscles originate on the This injection will elongate the upper
frontal process of the maxilla and insert lip. Use with caution in older patients
on the skin of the lateral aspect of the who may have long upper lips. Younger
nostril and upper lip. Unilateral contrac-
patients may benefit more from this
tion of this muscle results in an upper procedure than do elderly patients.
so

CHAPIER 17 • Neurotoxin InJection for Gummy Smile
51
Use with caution for patients who
cannot tolerate a weakening of the
upper lip (e.g., wind instrument musi-
cians, actors).
• Post-Injection lnstrudions
None. Bruising is unlikely.
Levator labii
superior is
alae;que nasi m.
• Risks
Overtreatment of this area may cause
severe drooping of the upper lip.
• Pearls of lnjedion
Proceed slowly; try half the suggested
dose first.
-
Fig. 17.1
Injection of BoNTA into the inferior aspect of the levator labii superioris alaeque nasi
muscle will decrease the upward pull on the lip when the patient smiles.

a
b
52
SECilON II • Neurotoxin InJection Techniques
Fig. 17.2a, b (a) Patient with gummy smile pre-injection. (b) Post-injection BoNTA with patient
producing maximum smile excursion. Also note improvement in the horizontal crease below the
columella.

CHAPTER 17 • Neurotoxin Injection for Gummy Smile
53
• Additional Reading
Polo M. Botulinum toxin type A {Botox) for
the neuromuscular correction of excessive
gingival display on smiling {gummy smile).
Am J Orthod Dentofacial Orthop 2008;
133:195-203 PubMed
Stephan S, Wang TD. Botulinum toxin: dini-
cal techniques, applications, and compli-
cations. Facial Plast Surg 2011 ;27:529-539
PubMed

18
-------···-------
Neurotoxin Injection
for Dimpled Chin
Difficulty: •
Patient Satlsf.:Jction: • • •
Risk: •
• Indications
Some patients inadvertently wrinkle
their chins either at rest or while talk-
ing. Usually it is not noticed by the
patient until it is pointed out by the cli-
nidan. Dimpled chins can also be seen
after chin implants, or in patients with
retrognathia. Atrophy of the subcutane-
54
ous fat and dermis overlying the mus-
cles can contribute to a dimpled appear-
ance. Because this dimpling somewhat
resembles the skin of an orange, this de-
formity is called "peau d'orange" chin.
• Anatomic Considerations
The paired mentalis muscles originate
on the incisor fossa of the mandible and
insert directly onto the dermis of the
chin skin. Contraction of the mentalis
muscles elevates the lower lip, produc-
ing a "pout." Contraction also contrib-
utes the mental crease.

CHAPTER 18 • Neurotoxin Injection for Dimpled Chin
55
• Injection Technique
Botulinum toxin is injected deeply into
each muscle in three or four injection
sites. A total of3 to 10 BU or 9-30 DU is
injected.
• Precautions
Place injections low in the chin, between
the mental crease and the lower edge of
the mandible.
• Post-Injection Instructions
None.
• Risks
Injection above the mental crease can
affect the orbicularis oris muscle and
may result in lower lip droop, or even
drooling.
• Pearls of Injection
• Inject symmetric amounts of neuro-
toxin into the muscle bodies.
• This is a relatively painless injection.
• Show patients how their muscle
looks contracted, so that they un-
derstand the rationale for this
treatment.

56
SECilON II • Neurotoxin InJection Techniques
-
Menral crease - 4------....
~~--..
...
Menralis m. --+-------,;,---
Fig. 18.1 Suggested techniques for injection of BoNTA into the paired mentalis musdes to improve
dimpled chin.
• 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
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
Wise JB, Greco T. Injectable treatments for
the aging face. Facial Plast Surg 2006;22:
140-146 PubMed

19
-------···-------
Neurotoxin Injection for
Platysma/ Banding
Difficulty: •••
Patient Satisfaction: •
Risk: •
• Indications
Platysma( bands are vertical bands in
the neck that are seen at rest and are
accentuated with neck tightening and
forced jaw opening. This procedure
may be used in younger patients who
are not yet ready for surgery, or in older
patients who do not desire surgery, and
to treat recurrent bands in postopera-
tive patients.
• Anatomic Considerations
ide and upper chest and inserts onto
the superficial musculoaponeurotic
system (SMAS), the skin of the lower
face, facial muscles, and the mandible.
Although in youth it is considered a con-
tinuous sheet, in the elderly this muscle
may splay centrally and produce promi-
nent vertical bands. Platysma( bands
can be prominent in patients with thin
necks, thin skin, and without abundant
overlying fat.
• Precautions
Over-injection in this region may affect
the muscles involved in swallowing.
Bruising is not uncommon.
• Injection Technique
The platysma muscle is a thin super-
Having the patient grimace to tighten the
ficial muscle that originates on the clav-
neck will often bring out the problem
57

58
SECTION II • Neurotoxin Injection Techniques
muscles and make the injection easier
to perform. Ask the patient to sit upright
and lean forward slightly, with the chin
elevated just above the horizontal plane.
With the platysma muscle in full con-
traction, the edge of the muscle band
is grasped with two fingers while the
muscle is injected. The needle is placed
deeply into the muscle, between the fin-
gers and perpendicular to the muscle
fibers. Approximately 3 to 5 BU is in-
jected into each injection site, for a total
of 15 BU per band or 20 to 40 DU per
band. A series of approximately three
injections is placed down the length of
the band approximately 1.5 to 2 em
apart. If lateral bands are prominent on
full contraction, then these can be in-
jected in the same fashion, though they
may need fewer units. Begin injections
at the cervicomental angle and work
inferiorly, staying approximately 2.0 to
2.5 em below the mandibular border, so
as not to affect the upper facial muscles
of expression.
• Post-Injection Instructions
Hold pressure to prevent bruising.
• Risks
Patients with heavy necks may not be
good candidates for this procedure, as
the results of injection may not be im-
pressive. Over-injection of BoNTA in
this region can result in dysphagia or
dysphonia.
• Pearls of Injection
Although very effective for some pa-
tients, the results can be short lived and
can require large doses. This technique
may need to be combined with subman-
dibular gland injection for optimal neck
contouring (see Chapter 24). Appropri-
ate surgical candidates should be given
the option for lower face and neck lift
surgery.

CHAPIER 19 • Neurotoxin Injection for Platysmal Banding
59
Plarysn;al. band
•
•
Fig. 19.1 A l-inch (2.5of each platysma! band. Grasp the muscle during injection to ensure intramuscular injection.
• 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
Matarasso A, Matarasso SI., Brandt FS, Bell-
man B. Botulinum A exotoxin for the
management of platysma bands. Plast Re-
constr Surg 1999;103:645-652, discussion
653-655 PubMed

20
-------···-------
Neurotoxin Injection for
Necklace Lines
Difficulty: ••
Patient Satisfaction: •
Risk: •
• Indications
Horizontal lines of the neck are noted at
rest and can deepen with aging.
• Anatomic Considerations
These lines occur due to the dermal at-
tachments of the superficial musculo-
aponeurotic system (SMAS). They are
seen in the neck from birth, but can
increase and deepen during the aging
process. Treatment of these areas will
soften the lines in this area, but not com-
pletely remove them.
60
• Injection Technique
This is an intradermal injection I One
or 2 BU is injected at 1.0- to 1 .5-cm in-
tervals along the horizontal crease. There
should be a wheal of product in the skin.
Do not use more than 15 to 20 units per
treatment session.
• Precautions
Deep injection may affect the muscles
involved in swallowing.
• Post-Injection Instructions
None. Bruising is unlikely.

CHAPIER 20 • Neurotoxin InJection for Nedclace Unes
61
•
•
•
• Imra.dermaJ
injections
Fig. 20.1 Superficial injections of BoNTA are placed at 1.~ to l.~cm intervals along the crease to
soften "necklace lines· of the neck.
• Risks
Because the swallowing musdes are cho-
linergic, overtreatment of this area can
result in a weak or diminished swallow.
• Pearls of Injection
• Stay intradermal; do not inject
deeply.
• Proceed slowly; try half the sug-
gested dose first.
• Inform the patient that this is only a
subtle improvement.
• Do not overtreat.
• Inform the patient of the risk of di-
minished swallowing.
• Additional Reading
Carruthers J, Carruthers A. Aesthetic botu-
linum A toxin in the mid and lower face
and neck. Dermatol Surg 2003;29:468-476
PubMed

21
-------···-------
Neurotoxin Injection for
Nefertiti Neck Lift
Difficulty: •••
Patient Satisfaction: •
Risk: ••
• Indications
The Andent Egyptian Queen Nefertiti
has been referred to as one of the most
beautiful women to have ever lived. Im-
ages ofNefertiti generally bring to mind a
graceful neck and sculpted jawline, based
on the famed 3,300-year-old bust found
in Egypt in 1912 and now displayed in
Berlin. The .. Nefertiti neck lift" procedure
uses BoNTA to increase the definition of
the mandible, in selected patients.
62
• Anatomic Considerations
The platysma musde is a neck depres-
sor. It originates at the davide and fas-
da of the upper chest and inserts onto
the mandible and skin of the chin and
cheek. Release of the downward pull of
the platysma will allow the fadal eleva-
tors to elevate the sagging skin over the
lower face and more dearly define the
mandibular border.
• Injection Technique
Patient selection is extremely important
when performing this procedure. Pa-
tients who desire a more defined man-
dibular contour should be assessed for

CHAPIER 21 • Neurotoxin Injection for Nefertiti Neck Uft
63
the extent of platysma! pull on their • Post-Injection Instructions
lower face. It is suggested that the pa-
tient be asked to contract the platysma None.
musdes; if the mandibular border be-
comes less visible, the patient is a good
candidate for this procedure.
• Risks
Injections of BoNTA are placed along --------------
the inferior aspect of the mandible and Over-injection of this area can result in
in the upper aspect of the strongest dysphagia, or an irregular smile. Exces-
lateral platysma band. Injections are sive pull upward on the lower face can
deep into the musde; approximately result in irregular bunching of the tissue
14 to 20 BU (or 42 to 60 DU) is used per over the mandible.
side in equal injections.
• Pearls of Injection
• Precautions
This technique is difficult to perform
Extending these injections too far medi-
well and should be performed only by
ally can affect the depressor labii inferi-
experienced injectors. Patient selection
oris and cause a lip droop or asymmet-
and meticulous technique is imperative.
ric smile. Do not inject medial to a line Stay low and lateral on the mandible to
drawn down from the nasolabial fold to avoid complications. Results may last up
the mandible.
to six months.

64
SECilON II • Neurotoxin InJection Techniques
Fig. 21.1
Photograph of the famed Queen Nefertiti bust, crafted ca. 1345 BC in Egypt and un-
earthed in 1912. (Courtesy of Album/Art Resource, NY)

OIAPJ'ER 21 • Neurotoxin InJection for Nefertltl Neck Uft
65
Mandible
Nasolabial fold
Pl:arys:rn:al band!
Do not inject
anterior to line
Fig. 21.2 Injections of BoNTA should be placed along the inferior aspect of the mandibular border
and into the strongest platysma! band noted during contraction. Stay lateral to avoid weakening the
depressor labii inferioris muscle.
• Additional Reading
Levy PM. The "Nefertiti lift": a new tech-
nique for specific re-contouring of the jaw-
line. j Cosmet Laser Ther 2007;9:249-252
PubMed

22
-------···-------
Neurotoxin Injection for
Masseter Hypertrophy
Difficulty: •••
Patient Satisfaction: • •
Risk: ••
• Indications
Square jaw lines and wide mandibular
• Anatomic Considerations
The masseter musde's origin is along
the inferior aspect of the anterior zygo-
matic arch and it inserts into the angle
of the mandible along both the horizon-
tal (body) and the vertical portions of
the mandible (ramus).
borders are often desirable masculine • Injection Technique
characteristics but can be unattractive
for women and become exaggerated
when anatomic hypertrophy exists.
Bruxism (teeth grinding), anxiety, and
denching can lead to masseter musde
enlargement and accentuate the hori-
zontal width of the mandibular border.
Occasionally Asian patients note hyper-
trophic masseter musdes and may re-
quest improvement in this area.
66
TWo different techniques for injecting
the musde can be attempted: intraoral
or transcutaneous. In the intraoral tech-
nique, the injector's thumb is placed in-
side the buccal mucosa until the angle
of the mandible is palpated and the pa-
tient is asked to bite down (but not
on the injector's finger I). The anterior
edge of the masseter musde is palpated

CHAPTER 22 • Neurotoxin Injection for Masseter Hypertrophy
67
between the thumb and fingers of the
same hand resting outside on the cheek.
A l-inch (2.5-cm), 30-gauge needle is
passed intraorally anterior to the man-
dibular ramus and into the muscle belly.
This will be somewhat uncomfortable
for the patient. BoNTA is injected in a
retrograde fashion as the needle is with-
drawn. Two to four passes are performed
in several tangential intramuscular injec-
tions for a total of20 BU (or 60 DU) to the
muscle.
In the transcutaneous technique, it is
useful to place one finger along the
lower border of the mandible, one along
the vertical border of the mandible, and
one as a reference at the inner aspect of
the mandibular angle with the patient
clenching as a way to mark out the pe-
rimeter of the muscle. With a half- or
*-inch (1.27-1.9 em) needle or longer,
injection can be performed inside that
perimeter down to just above the bone,
and depot injections of 4 to 5 units can
be placed per area. An average of 20
units should be used depending on the
mass of the muscle being treated.
• Precautions
Care must be taken to keep the injections
low and posterior, and centered in the
muscle itself. If placed too far anteriorly,
the smile may be affected by diffusion
into the zygomaticus major or risorius
muscles.
• Post-Injection Instructions
Holding pressure and gentle massage
helps to prevent bruising. It can take up
to a month for atrophy of the muscle to
occur.
• Risks
Improper injection into surrounding
muscles can result in swallowing and
speech disorders. Over-injection of the
masseter is unlikely to result in prob-
lems with bite or chewing because the
temporalis muscle, one of the strongest
primary muscles of mastication, is un-
affected. Undertreatment can be re-
treated with more product and can be
tested by asking the patient to clench
while you palpate the masseter.
• Pearls of Injection
Reduction of muscle hypertrophy and
mandibular width narrowing occurs
gradually and it may take 6 weeks to see
the full effect. If not adequately im-
proved, touch-up treatments may be
required approximately 6 weeks after
the initial treatment. Results can last 6
to 12 months.

68
SECllON II • Neurotoxin InJection Techniques
Mandible --7---------'/
b
Fig. 22.1 i1, b Possible injection patterns for transcutaneous BoNTA injection for the treatment of
masseter hypertrophy.
• Additional Reading
Choe SW, Cho WI, Lee CK, Seo Sj. Effects of
botulinum toxin type A on contouring of
the lower face. Dermatol Surg 2005;31:
502- 507, discussion 507- 508 PuhMed
Wu WI'. Botox facial slimming/facial .sculpt-
ing: the role of botulinum toxin-A in the
treatment of hypertrophic masseteric mus-
cle and parotid enlargement to narrow the
lower facial width. Facial Plast Surg Clin
North Am 2010;18:133-140 PubMed
Yu CC, Chen PK. Chen YR. Botulinum toxin a
for lower facial contouring: a prospective
study. Aesthetic Plast Surg 2007;31:445-
451, discussion 452-453 PubMed

23
-------···-------
Neurotoxin Injection for Parotid
Gland Hypertrophy
Difficulty: • • • •
Patient Satisfaction: • •
Risk: •••
• Indications
Hypertrophy of the parotid gland can be
caused by many different factors. Ruling
out neoplasms and other diseases should
be undertaken before beginning treat-
ment to shrink the gland with BoNTA.
Benign glandular enlargement from aging
and xerostomia conditions are some-
times appropriate indications for neuro-
toxin injection. HIV patients can develop
lymphoepithelial enlargement of the
parotid, and bulimic patients can also
develop benign parotid enlargement.
• Anatomic Considerations
The parotid gland rests anterior to the
ear, beneath the superficial musculoapo-
neurotic system {SMAS) and platysma
muscles, over the lateral mandible. The
external carotid artery and posterior fa-
cial vein pass just posterior to the gland.
The five branches of the facial nerve,
which provides motor innervation to fa-
cial mimetic musculature, pass through
the middle of the gland.
• Precautions
Injection above the gland and through
the mandibular notch can lead to neuro-
toxin spread into the lateral pterygoids,
which assist in jaw opening and contra-
lateral jaw thrust.
69

70
SECTION II • Neurotoxin Injection Techniques
• Injection Technique
A 30-gauge, l-inch (2.5-cm) needle is
inserted perpendicular to the gland and
20 to 30 BU (or 60 to 90 DU) of BoNTA is
injected as the needle is withdrawn via
several passes through the parenchyma
of the gland. It is definitely discernible
that the needle has entered the firmer
body of the gland after passing through
the SMAS/platysma muscle. Patients will
also be able to sense when the needle
is in the gland as they will feel an elec-
tric or tingling sensation that is dearly
different from what they felt before the
needle passed into the gland. It is neces-
sary to use a longer needle (1 inch/2.5
em) to reach the gland.
• Post-Injection Instructions
Holding pressure and gentle massage
helps to prevent bruising. It can take up
to a month for involution and shrinking
of the gland to occur. Shrinkage of 20 to
30% can be seen, often lasting 6 months
or longer. Repeat treatments can be ex-
pected. If cosmetic narrowing of the
lower third of the face is desired, then
injection of the masseter muscle should
be undertaken at the same time (see
Chapter 22).
• Risks
Improper injection into surrounding
muscles can result in swallowing and
speech disorders. Hematoma or major
bruising could result from injury to one
of the large vessels near the gland.
• Pearls of Injection
Turning the patient's head slightly up-
ward and away from the side of injec-
tion, and grasping either side of the
gland with the thumb and first finger
to stabilize it, will help ensure proper
placement of the neurotoxin.

OIAPJ'ER Zl • Neurotoxin lnjedlon for Parotid Gland Hypertraphy
71
Fig. 23.1 BoNTA is injected into the body of the parotid gland by using a fanning tedmique to re-
duce gland hypertrophy.
• Additional Reading
Wu wr. Botox facial slimming/facial sculpt-
ing: the role of botulinum toxin-A in the
treatment of hypertrophic masseteric
muscle and parotid enlargement to nar-
row the lower facial width. Facial Plast
Surg Clin North Am 2010;18:133-140
PubMed

24
-------···-------
Neurotoxin Injection for
Submandibular Gland Hypertrophy
Difficulty: • • • •
Patient Satisfaction: • •
Risk: •••
• Indications
Ptosis or hypertrophy of the subman-
dibular glands can be seen with aging.
Post-necklift/facelift and liposuction pa-
tients are often left with more elegant
jaw lines; however, ptotic submandibu-
lar glands can be unmasked, which can
produce an unsightly lump on an other-
wise smooth neck. Benign hypertrophy
of the submandibular glands can be
treated with BoNTA
• Anatomic Considerations
The submandibular glands are located
midline, on each side of the neck. The
facial artery passes just posterior to the
gland, the marginal mandibular branch
of the facial nerve passes over the cap-
sule of the gland, and the facial vein
passes around the gland's posterior as-
pect. Deep to the gland are pharyngeal
muscles and muscles of the floor of the
mouth and base of the tongue.
• Precautions
Injection into surrounding structures
may result in significant side effects in-
cluding bleeding, hematoma, intravas-
cular injection, swallowing dysfunction,
and tongue movement disorders. Care
must be taken to ensure that the BoNTA
is injected into the body of the gland.
• Injection Technique
under the mandible, beneath the pia-
Botulinum toxin (12 to 15 BU, or 36 to
tysma muscle, 2 to 3 em posterior from
45 DU, per gland) is injected in a retro-
72

CHAPIER 24 • Neurotoxin InJection for SUbmandibular Gland Hypertrophy
73
grade fashion via several passes through • Risks
the parenchyma of the gland. The injec- -------------
tor should "feel" that the needle has en-
Improper injection into surrounding
tered the firmer body of the gland after muscles can result in swallowing and
passing through the platysma. Patients speech disorders or even aspiration. He-
will be able to sense when the needle is matoma or major bruising could result
in the gland as they will feel an electric from injury to one of the facial vessels
or tingling sensation that is dearly dif-
near the gland.
ferent from what they felt before the
needle passed into the gland. It is neces-
sary to use a longer needle (1.0 to 1.5 • Pearls of Injection
inch/2.5 to 3.8 em) to enter the gland.
Proper placement of BoNTA can be en-
sured by turning the patient's head
• Post-Injection Instructions
slightly upward and away from the side
of injection. The gland should be grasped
Holding pressure over the injection site and stabilized during injection. Reflux
and gentle massage help to prevent bruis-
on the syringe prior to injection pre-
ing. It can take up to a month for involu-
vents intravascular injection.
tion and shrinking of the gland to occur.
Shrinkage of 30 to 60% can be seen.
Fig. 24.1 A long needle is used to inject BoNTA into the body of the submandibular gland to im-
prove submandibular gland hypertrophy.

25
-------···-------
Neurotoxin Injection for Gustatory
Sweating (Frey Syndrome)
Difficulty: • • • •
Patient Satisfaction: • •
Risk: ••
• Indications
Gustatory sweating can be seen after su-
perfidal parotidectomy. These patients
notice mild to profuse sweating of the
cheek during meals.
• Anatomic Considerations
Acetylcholine, the neurotransmitter
blocked by botulinum toxin, is released
when eating, and it stimulates secretion
of saliva by the salivary glands. When
the gland has been partially resected,
such as in superficial parotidectomy, the
acetylcholine is released and diffuses to
the skin, where it stimulates the sweat
74
glands. These patients notice sweating of
the cheek skin overlying the parotid bed.
The starch-iodine test is useful when
first treating these patients because the
pattern of sweating may not be predict-
able. On subsequent treatments, once
the injector has developed an idea of the
affected sites, further treatments may be
performed without repeating the starch-
iodine test.
The starch-iodine test can be per-
formed prior to injection. Povidone io-
dine {Beta dine) is painted over the cheek
on the side of the parotidectomy and
is left for a few minutes to air dry. The
Betadine application should extend over
the mandible into the neck, onto the
ear, and into the temporal hairline. Corn
starch (available from a food shop) is
sprinkled lightly onto the cheek; a large
makeup brush works well for this appli-
cation. The patient may need to suck on
a sour candy to stimulate the salivary
glands. The areas of sweating will cause

CHAPIER 25 • Neurotoxin InJection for Ciustatwy SWeating (R'ey Syndrome)
75
the cornstarch to tum black, and a grid uct is injected into the dermis in small
is drawn in the area of the sweating. The wheals separated by 1.0 to 1.5 em. Each
starch-iodine testing can also be uti-
injection is 0.05 to 0.1 cc, or approxi-
lized for touch-up treatments, and to mately 1 to 2 units per injection.
identify untreated areas that require
re-treatment.
• lnjedion Technique
This is a slightly uncomfortable proce-
dure, and generally well tolerated by pre-
• Precautions
Care must be taken to maintain the level
of injection into the dermis.
treating with topical anesthetics. usu-
• Post-lnjedion Instructions
ally 30 to 50 BU or 100 to 150 DU may be
necessary for this treatment. The prod-
None.
-
Fig. 25.1 A starch-iodine test is used to delin-
eate the areas of gustatory sweating, and BoNTA
is injected intraderrnally in a grid-like pattern at
the sites of maximum sweating.
• Pearls of lnjedion
Inject in a grid pattern and inject su-
perficially. Wait at least 2 weeks for
maximum response before considering
a touch-up. Weakening of the fadal
mimetic muscles is unlikely and can be
prevented by not injecting anterior to the
anterior border of the masseter muscle.
• Additional Reading
Arad-Cohen A. Blitzer A Botulinum toxin
treatment for symptomatic Frey's syn-
drome. Otolaryngol Head Neck Surg 2000;
122:237-240 PubMed
Guntinas-Lichius 0. Management of Frey's
syndrome and hypersialorrhea with botu-
linum toxin. Facial Plast Surg Oin North
Am 2003;11:503-513 PuhMed

26
-------···-------
Neurotoxin Injection for Profusely
Sweating Underarms
Difficulty: ••
Patient Satisfaction: • • •
Risk: •
• Indications
Profuse sweating of the armpits can be
treated with BoNTA Results of treatment
are impressive and can last up to a year.
• Anatomic Considerations
Neurotoxins act by preventing release of
acetylcholine from nerve endings at the
neuromuscular junction, the effect of
which is to inhibit musde contraction.
Acetylcholine is also the neurotransmit-
ter for the sweat glands. Injection of
botulinum toxin into sweat glands will
prevent sweating and is an excellent
treatment for patients who complain of
76
profuse underarm sweating. The starch-
iodine test can be performed prior to in-
jection. The axilla is painted with Beta-
dine and is left for a few minutes to air
dry. Com starch (available from a food
shop) is sprinkled lightly onto the axilla;
a large makeup brush works well for
this application. The areas of sweating
will cause the cornstarch to tum black.
This is a messy procedure, and often
unnecessary because most sweating usu-
ally occurs in the hair-bearing skin of
the axilla. Touch-up treatments are oc-
casionally required several weeks later
if not all areas were adequately treated.
A starch-iodine test can be helpful in
these cases.
• Injection Technique
This is a relatively painless procedure,
well tolerated without the use of topical
anesthetics. Usually 100 BU or 300 DU is

OIAPJ'ER Z& • Neurotoxin InJection for Profusely SWeating Underanns
77
used for this treatment, divided evenly
for each axilla. The product is injected
into the dermis in small wheals sepa-
rated by 1.0 to 1.5 em. Each injection is
0.05 to 0.1 cc, or approximately 1 to 2 BU
or 3 to 6 DUper injection.
• Precautions
Care must be taken to maintain the level
of injection into the dermis. Deep in-
jection may weaken the muscles of the
arm. Deep injection also will not ade-
quately treat the sweat glands, which lie
in the dermis.
• Post-Injection Instructions
None.
• Pearls of Injection
• Inject in a grid pattern. into the hair-
bearing areas of the axilla.
• The injector may make use of the
starch-iodine test for more accu-
rate injections or for touch-up
treatments.
• Wait at least 2 weeks for maxi-
mum response before considering a
touch-up.
.
. .
•
. . .. . .
. -. .
• ..
. .
•
Fig. 26.1
Injection of BoNTA in the axilla is intradennal and placed in a grid-like pattern with injec-
tions separated by 1.0 to 1.5 em. If a starch-iodine test is not perfonned. injections should be placed
in the hair-bearing area.

78
SECilON II • Neurotoxin InJection Techniques
Fig. 26.2 Corn starch is lightly brushed on the area that has been painted with Betadine.
Fig. 26.3 The injection grid is placed in the areas of maximum sweating, denoted by the dark areas.

CHAPTER 26 • Neurotoxin Injection for Profusely Sweating Uncleranns
79
• Additional Reading
Cohen JL, Solish N. Treatment of hyperhidro-
sis with botulinum toxin. Facial Plast Surg
Clin North Am 2003;11 :493-502 PubMed
Doft MA, Hardy KL, Ascherman JA. Treat-
ment of hyperhidrosis with botulinum
toxin. Aesthet Surg 1 2012;32:238-244
PubMed
Naver H, Swartling C, Aquilonius S-M. Pal-
mar and axillary hyperhidrosis treated
with botulinum toxin: one-year clinical
follow-up. Eur 1 Neurol 2000;7:55-62
PubMed

27
-------···-------
Neurotoxin Injection for Profusely
Sweating Hands
Difficulty: • • •
Patient Satisfaction: • •
Risk: ••
• Indications
Profuse sweating of the hands may be
treated by BoNTA injections.
• Anatomic Considerations
Neurotoxins act by preventing release
of acetylcholine from nerve endings at
the neuromuscular junction, the effect of
which is to inhibit muscle contraction.
Acetylcholine is also the neurotrans-
mitter for the sweat glands. Injection of
botulinum toxin into sweat glands will
prevent sweating and is an excellent
80
treatment for patients who complain of
profuse sweating of the hands.
• Injection Technique
This is a painful procedure and some
type of anesthesia is required. Because
of the thick skin of the hands, topical
anesthetics may not be well absorbed by
callused hands. Numbing the hands in
ice baths, using a regional block, or even
sedation may be necessary.
Usually 100 BU (or 300 DU) is used for
this treatment, divided evenly for each
hand. The product is injected into the
dermis in small wheals separated by 1.0
to 1.5 em. Each injection is 0.05 to 0.1 cc,
or approximately 1 to 2 BU or 3 to 6 DU
per injection. Because of the thickness
of the skin, a 30- or 26-gauge needle may
be necessary.

OIAPTER 27 • Neurotoxin InJection for Profusely SWeating Hands
81
•
•
•
•
•
•
•
•
•
• r n rradermal
injections
Fig. 27.1
BoNTA is injected in a grid-like pat-
tern on the palmar suriace of the hand to reduce
profuse sweating.
• Precautions
Care must be taken to maintain the level
of injection into the dermis. Deep injec-
tion may weaken the hand muscles.
• Post-Injection Instructions
None.
• Pearls of Injection
• Needles dull quickly when used on
hands and feet. so multiple needles
may be needed.
• Be careful to inject superfidally.
• Patients are likely to experience
some weakness of the hand muscles
during maximal grip, which can last
for several weeks post-injection.
• Results can last an average of 6
months .
• Additional Reading
Cohen JL, Salish N. Treatment of hyperhi-
drosis with botulinum toxin. Facial Plast
Surg Clin North Am 2003;11:493-502
PubMed
Doft MA. Hardy KL. Ascherman JA. Treat-
ment of hyperhidrosis with botulinum
toxin. Aesthet Surg j 2012;32:238-244
PubMed
Naver H, SWartling C, Aquilonius S-M. Pal-
mar and axillary hyperhidrosis treated
with botulinum toxin: one-year clinical
follow-up. Eur j Neural 2000;7:55-62
PubMed
Yamashita N, Shimizu H, Kawada M. et al.
Local injection of botulinum toxin A for
palmar hyperhidrosis: usefulness and ef-
ficacy in relation to severity. J Dermatol
2008;35:325-329 PubMed

28
-------···-------
Neurotoxin Injection for Profusely
Sweating Feet
Difficulty: • • •
Patient Satisfaction: • •
Risk: ••
• Indications
Profuse sweating of the feet. Results of
treatment can last up to a year.
• Anatomic Considerations
Neurotoxins act by preventing release
of acetylcholine from nerve endings at
the neuromuscular junction, the effect
of which is to inhibit muscle contrac-
tion. Acetylcholine is also the neuro-
transmitter for the sweat glands. In-
jection of botulinum toxin into sweat
glands will prevent sweating and is an
82
excellent treatment for patients who
complain of profuse sweating of the feet.
• Injection Technique
This is a painful procedure and some
type of anesthesia is required. Because
of the increased thickness of the skin,
topical anesthetics may not be well ab-
sorbed by callused feet. Using a regional
block (posterior tibial and sural nerve
block) or even sedation anesthesia may
be necessary.
Usually 100 BU or 300 DU is injected
for this treatment, divided evenly for
each foot (occasionally more is neces-
sary for larger feet). The product is in-
jected into the dermis in small wheals
separated by 1.0 to 1.5 em. Each injec-
tion is 0.05 to 0.1 cc, or approximately
1 to 2 BU or 3 to 6 DU per injection. Be-

CHAPTER 28 • Neurotoxin InJection for Profusely SM .. ng Feet
83
• Inrradermal
injections
Fig. 28.1
BoNTA is injected in a grid-like pat-
tern on the soles of the feet to reduce profuse
sweating.
cause of the thickness of the skin, a 30-
or 26-gauge needle may be necessary.
• Precautions
Care must be taken to maintain the level
of injection into the dermis. Deep injec-
tion may V~teaken the muscles of the foot.
• Post-Injection Instructions
None.
• Pearls of lnjertion
Needles dull quickly on the hands and
feet. so multiple needles may be needed.
Be careful to inject superficially.
• Additional Reading
CohenJL, Salish N. Treatment of hyperhidro-
sis with botulinum toxin. Facial Plast Surg
Clin North Am 2003;11 :493-502 PubMed
Doft MA. Hardy KL. AschennanjA Treatment
of hyperhidrosis with botulinwn toxin.
Aesthet Surgj2012;32:238-244 PubMed

29
-------···-------
Neurotoxin Injection for Migraines
Difficulty: • • •
Patient Satisfaction: •
Risk: ••
• Indications
Symptoms of classic migraines may
include auras, photophobia, unilateral
foci, nausea, and pounding headaches.
BoNTA has been used successfully in
some patients to reduce the frequency
or severity of their headaches. Similarly,
BoNTA may be used to treat patients
with recurrent tension headaches in the
frontal and occipital regions.
• Anatomic Considerations
Individual patients may be able to de-
termine "trigger points" for their head-
84
aches. If feasible, try to inject directly
into the site of the trigger area. Most
often, the glabella, forehead, and lateral
brow as well as the temporalis muscle
and upper portion of the trapezius mus-
cle as it enters into the occiput are the
most common areas in which injection
can relieve classic or common migraines
and tension headaches.
• Injection Technique
Topical anesthesia may be used and ice
may be applied, though neither is neces-
sary in most cases. Injection techniques
as described herein for the treatment of
the glabella, forehead, and lateral brow-
lift are used for migraine headache as
well. In addition, BoNTA injections of the
temporalis muscle may be performed
on the offending side.
For the posterior type headaches, trig-
ger points are identified by digital pres-