Tiêm Botulinum Toxin Trong Thực Hành Thẩm Mỹ (Tập 2): Giải Phẫu Chức Năng Và Kỹ Thuật Tiêm

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The use of botulinum toxin for the breast
Francisco Pérez Atamoros and Olga Macías Martínez
INTRODUCTION
The female breast is an important feature of the development of
secondary sexual characteristics, serving the dual function of an
end-organ, influenced by the endocrine system, and functioning as
a secondary sex organ in humans. For this reason, it is frequently
modified surgically in order to enhance volume, shape, and position.
In this chapter, we will focus on breast aesthetics, and on nonsurgical
techniques for improving the appearance of the female breast and/or
some breast-associated conditions.1
ANATOMY
The adult female breast lies between the second and sixth/seventh
ribs, and is located on the anterior chest wall between the subcutane­
ous fat of the skin and the superficial fascia of the pectoralis muscle
(Figure 16.1). The shape and contour of the breasts is produced by
dense connective tissue bands called Cooper’s ligaments. These bands
traverse the breast tissue and anchor themselves to the underlying
skin and fascia.1–3
The upper central and medial portions of the breast lie over the
pectoralis major muscle (Figure 16.2), with the lower portions of the
breast covering the anterolateral serratus anterior muscle and the
upper external oblique muscle, and fascia over the upper origins of
the rectus abdominis muscle inferomedially.2
The pectoralis major is a thick, triangular-shaped muscle that cov­
ers most of the upper thoracic area, with two muscular heads, the
clavicular and sternal heads that are separated by a cleft.3
The pectoralis minor muscle is covered by the pectoralis major
muscle. This muscle is enveloped by the clavipectoral fascia that proj­
ects into the axilla to combine with the axillary fascia.2,3
The breast varies in shape and size depending on age, parity, body
mass index, genetics, and race. They can be hemispherical, conical,
teardrop-shaped, pendulous, or flattened. On profile, the aesthetically
ideal female breast appears as a teardrop-shaped protuberance project­
ing at variable angles from the chest wall. Its ventral surface forms a
line that is almost straight from the second rib to the nipple, while the
lower part from the nipple to the inframammary crease is rounded. In
the non-pendulous breast, the nipple is located over the fourth inter­
costal space. The inframammary crease represents the inferior border
of the base of the breast and is an important aesthetic landmark.4
BREAST PTOSIS
In the normal growing phase, the breast can be considered to have a
hemispheric shape, with the nipple in the middle, at the most promi­
nent point. The breast mound and central pedicle will change posi­
tion, according to gravity.
The breast mound develops a natural glide on the chest wall with
age (Figure 16.3) and breast central and inferior pedicles follow the
breast mound in its descending movement.4
Breast ptosis is one of the most common conditions treated by plas­
tic surgeons. Despite practitioners’ familiarity with the evaluation and
treatment of breast ptosis, its underlying causes have not yet been clearly
defined and preventative measures have not yet been discovered.4–6
In a 1976 review, Regnault cited glandular hormonal regression
(postpartum or menopausal), weight loss, dermatochalasis, and post­
operative changes as the causes of breast ptosis.5
In a book chapter published in 1990, Hinderer added two addi­
tional factors: weight of the breast totaling more than 400 g and
ligamentous laxity. Such a list of causes, is the result of extensive
experience and undoubtedly appeals to common sense, but has not
been supported by scientific evidence.5,6
In 2010, Rinker found age, history of significant weight loss (50 lb),
higher body mass index, larger brassiere cup size, number of preg­
nancies, and smoking history to be significant risk factors for breast
ptosis. History of breast-feeding, weight gain during pregnancy, and
lack of participation in regular upper body exercise were not found to
be significant risk factors for ptosis.6,7
CLASSIFICATION OF FEMALE BREAST PTOSIS
Multiple classifications are in use, and it is important for the physician
to distinguish which classification is being used. The classification of
ptosis helps determine the type of treatment the patient needs.5,6
The standard classification for female breast ptosis has been that of
Regnault from 1976 (Figure 16.4).6,7
•• First degree (minor ptosis): The nipple lies at the level of the sub­
mammary fold, above the lower contour of the gland and skin
brassiere.
•• Second degree (moderate ptosis): The nipple lies below the level of
the fold but remains above the lower contour of the breast and
skin brassiere.
16
Inframammary crease
Inframammary crease
ligament
Transverse horizontal
septum
Intercostal arteries
Pectoralis major
Deep pectoral fascia
Retromammary space
Breast tissue
Superficial pectoral fascia
envelope
Subcutaneous fat
Skin
Figure 16.1  Anatomy of the breast. (With kind permission from Springer
Science+Business Media: Cosmetic Surgery: Art and Techniques, 2013, 47–55,
Prendergast P.)

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•• Third degree (major ptosis): The nipple lies below the fold level
and at the lower contour of the breast and skin brassiere.
•• Pseudoptosis: The nipple lies above the submammary fold level.
The breast is not ptotic.
BOTULINUM TOXIN AND MECHANISM OF ACTION
The botulinum toxin (BoNT) molecule induces chemodenervation
through its action on presynaptic neurons and inhibits acetylcho­
line release at the neuromuscular junction, leading to functional
­denervation of striated muscle for 2–6 months after injection. (See
Chapter 7.)8
BOTULINUM TOXIN AND POSITION OF THE BREAST
Botulinum toxin could, in selected patients, produce a change in
breast presentation such that the patient would obtain a breast lift
nonsurgically.
In 2003, the author (FPA) conducted a study in which nearly 100
female patients between 30 and 55 years of age and with varying
degrees of breast ptosis successfully achieved a noticeable elevation
of the breasts (Personal communications, BOTOX®, Fillers & More,
Vancouver, BC, August 2003; American Academy of Dermatology,
Washington DC, February 2004, and April 2004 and Botulinum
Toxin in Clinical Dermatology, 2006, 219–236).
The elevation of ptotic female breasts has been achieved averaging
1.1 cm with the maximum elevation being 1.8 cm. In this study, the
author has noticed that the invariable distance measured between the
sternal notch and the nipple does not change with the body position,
thus ensuring a correct measurement of the elevation of the breast
(Figure 16.5).
Muguea proposed to better define the position of the nipple-
areola complex on the chest wall (Figure 16.6), that two inverted
triangles be used, which are specific for the trunk as landmarks,
Teenager
Young female
Adult female
Figure 16.3  Changes in the breast mound position with age. The blue lines represent the breast mound limits and the red one the initial nipple level. (With kind permission
from Springer Science+Business Media: Aesthetic Surgery of the Breast, 2015, 605–632, Mugea T.)
Deltoid muscle
Biceps muscle
Latissimus
dorsi muscle
Serratus anterior muscle
Rectus abdominis muscle
Pectoralis major
(sternocostal origin)
Pectoralis major
(clavicular origin)
Figure 16.2  Anatomy of the breast, axilla, and chest wall. (With kind permission from Springer Science+Business Media: Breast Disease: Conprehensive Management,
2015, 1–22, Kalimuthu R et al.)

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295
the acromio-pubian triangle (Ac-Pb-Ac) and the spino-manubrial
triangle (Sp-Mn-Sp), which are defined by the lines between the
manubrium (sternal notch) and the anterosuperior iliac spine
points.4
Considering the natural evolution with aging, the normal nip­
ple position is in a downward glide, on the external margins of the
“inverted triangles,” corresponding to a high position in young teen­
agers and to a low position in older female patients. The aesthetically
perfect position is in the upper part of the triangles, close to the junc­
tion point of the external margins.4
The author (FPA) applied three injection points of 15 units of onabotu­
linumtoxinA/ incobotulinumtoxinA or 30 U of abobotulinumtoxinA
(a)
(c)
(d)
(b)
Figure 16.4  Regnault’s classification: (a) first degree (minor ptosis); (b) second degree (moderate ptosis); (c) third degree (major ptosis); (d) pseudoptosis. (With kind per­
mission from Springer Science+Business Media: Aesthetic Surgery of the Breast, 2015, 605–632, Mugea T.)
Figure 16.5  Correct measurement: distance between the sternal notch and nipple.
Figure 16.6  Nipple position related to the inverted triangles, acromio-pubian trian­
gle (Ac-Pb-Ac) and the spino- manubrial triangle (Sp-Mn-Sp), in young female (a)
and in mature female with breast ptosis (b). (With kind permission from Springer
Science+Business Media: Aesthetic Surgery of the Breast, 2015, 605–632, Mugea T.)

Botulinum Toxins in Clinical Aesthetic Practice
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into the inferior part of the pectoralis major which lies to the inferior
part of the sternum and diaphragm (Figures 16.7 through 16.9). The
total dose recommended per breast is 45–90 U of onabotulinumtox­
inA (OnaBTX-A) and 90–180 U of AboBTX-A.
Each patient was injected with OnaBTX-A on only one side in this
pilot study, with the contralateral side as control. Of 100 patients, 65
rated the results good to very good and 73 of the 100 patients would
repeat the procedure. Five patients had pain which lasted longer than
a week.
The ideal candidates for this treatment seem to be non-obese
women with slightly rounded shoulders or who are slightly stooped
forward, with breasts of cup size A or B. Older women, and those with
larger breasts, tend to respond more slowly and to a lesser extent.
Recent refinements in the injection technique have led the author to
suggest a different type of application (Figures 16.10 and 16.11) which
consists of applying/injecting 10–15 U OnaBTX-A/IncoBTX-A or
20–30 U of AboBTX-A per injection at 5 points, with a total dose per
breast of 50–75 ona/inco or 100–150 of AboBTX-A.
This new injection method allows the toxin to spread more read­
ily/efficiently into the pectoralis major at the diaphragmatic and
sternal union, which denervates the inferior part of the pectora­
lis. Without the opposing action of the inferior pectoralis muscle,
the force of the upper part of the pectoralis major is increased and
moves all muscles in the direction of the shoulders, consequently
lifting the breasts.
The proposed mechanism of action consists of relaxation of the
inferior medial portion of the pectoralis major, which allows the
superior portion to lift the ptotic breast.
We have seen in patients where this new technique is used, an
increase in the average of the breast lifting, 2.5 cm with a maximum
observed of 3.6 cm.
The benefits of botulinumtoxinA (BoNT-A) treatment usually
develop over a period of 1–2 weeks, and persist for 3–4 months. The
duration of the effect lasts somewhat longer than might be expected
considering the relatively low doses of BoNT-A in proportion to the
size of the muscles.
Some women have noted that there is a pleasing outward pro­
jection of their nipples which develops about a week after the
OnaBTX-A treatment. The reason for this observation is not clear.
However, OnaBTX-A has been shown to block the release of sub­
stance P (SP) and calcitonin gene-related peptide (CGRP) from the
nerve terminal. Perhaps some of the injected BoNT-A makes its
way from injection sites to the nipple-areolar complex and affects
smooth muscle in the nipples by way of its effect on the release of
SP and CGRP.9
Figure 16.7  Right breast medium size “B” lift. Three injection points technique.
Before treatment.
Figure 16.8  Same patient as in Figure 16.7, two weeks after treatment; right
breast lifted 1.8 mm. Left breast medium size; three injection points of 15 units of
OnaBTX-A/IncoBTX-A or 30 U of AboBTX-A.
Figure 16.9  Same patient as in Figure 16.7, two weeks after left breast application
and one month after right breast application of three injection points of 15 units of
OnaBTX-A/IncoBTX-A or 30 U of AboBTX-A. Lift 1.8 mm.
Figure 16.10  New technique proposed. 10–15 U per injection of OnaBTX-A/
IncoBTX-A or 20–30 U of AboBTX-A per injection at 5 points. Before treatment.

16.  the use of botulinum toxin for the breast
297
OTHER RECENT USES OF BOTULINUM TOXIN IN BREAST
Implant Stabilization and Capsular Formation
The most demanding complications involving aesthetic and recon­
structive breast surgery are the malpositioning of the implant and
capsular contracture. The etiology, prevention, and management
remain to be fully explained. Botulinumtoxin administration has
anti-inflammatory effects that can possibly decrease incidence of
malrotation.10 Sena et al. identified in vitro and in vivo negative effects
of BoNT-A on capsule formation, by expression of TGF- β1 and dif­
ferentiation of fibroblasts into myofibroblasts.11
Pectoral Muscle Spasm After Mastectomy and Post Mastectomy
Pain Syndrome
In the past 10 years, reports on the use of BoNT-A for pain relief in a
wide array of clinical conditions have increased tremendously. One
of the most rapidly expanding indications for BoNT-A is in the treat­
ment of various painful muscle spasms (e.g., para-vertebral muscle
spasm, fibromyalgia-myofascial pain, temporomandibular joint pain,
etc.). The explosion of interest in the biology and clinical applications
of BoNT-A is reflected by the number of publications in the last few
years on the subject.12
Concerning the use of botulinum toxin and its use in breast
pain conditions such as post-mastectomy pain syndrome (PMPS)
is a chronic pain condition, persisting for more than three months
after breast surgery.11 Pain can result from any surgical procedure,
but this syndrome is more commonly associated with radical mas­
tectomy with axillary lymphadenectomy. Although rare, in some
patients, persistent spasms of the chest wall musculature develop
after surgery.12,13
A possible etiology of the aforementioned patients’ symptoms is
suspected traction or manipulation of the medial pectoral nerve
during reconstructive surgery, but no clear etiology has been ascer­
tained. Neither patient had pectoral muscle spasms prior to the
surgeries.11–14
Several studies and a systematic review11 have been published to
evaluate the effect of botulinum toxin on breast pain syndromes and
pain syndromes after mammoplasty:
•• A study revealed that patients who had OnaBTX-A injected into
the pectoralis major before the placement of a silicone implant
had less pain during recovery than those who did not receive
the injection,13
•• Three other cases reported the use of OnaBTX-A injections to
treat pectoral muscle spasms after breast reconstruction or after
breast implant surgery.14,15
•• Two different cases of PMPS refractory to pain killers and inter­
costal nerve blocks were treated with percutaneous ­infiltration
of OnaBTX-A under the anterior intercostal nerves. The result
was the complete resolution of the syndrome.16,17
Pseudogynecomastia
Pseudogynecomastia is attributable to hypertrophy of the pectora­
lis major. This form is particularly evident in body builders, with
the pectoralis major progressively enlarging due to hypertrophy
of muscle fibers. In most cases, this is a desired and appreciated
aspect, but it may be unpleasant for some individuals reporting a
breast with a female appearance. When rapid reduction of muscular
hypertrophy is desired to correct this form of pseudogynecomastia,
OnaBTX-A injection represents a nonsurgical procedure for achieving
it (Figures 16.12, 16.13, and 16.14).18
Figure 16.12  Pseudogynecomastia. Before treatment. (From Dessi L. et al. Aesth
Plast Surg 2007; 31: 104–6, with permission.)
Figure 16.13  Same patient as in Figure 16.12 after treatment. (From Dessi L. et al.
Aesth Plast Surg 2007; 31: 104–6, with permission.)
Figure 16.11  Same patient as in Figure 16.10 after treatment.

Botulinum Toxins in Clinical Aesthetic Practice
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CONCLUSION
The use of botulinum toxin in both aesthetic and reconstructive pro­
cedures involving the pectoralis major can be further expanded in
other areas of the body. Consequently, this treatment is beneficial to
female or male patients concerned with breast aesthetics (breast pto­
sis, pseudogynecomastia) as well as several medical conditions when
other treatments have failed or are contraindicated. The effective­
ness of BoNT treatments depends on the sum of mechanical forces
exerted by the muscles and on the recently described analgesic, anti-
inflammatory, and anti-proliferative effects of the botulinum toxin
molecule.
Many patients could benefit from a temporary aesthetic improve­
ment of the appearance of the breasts, which can be achieved with
effective, safe, and non-surgical treatment with BoNT-A.
REFERENCES
1. Kalimuthu R, Yegiyants S, Brenzek C. Anatomy of the breast, axilla,
and chest wall. In: Breast Disease: Conprehensive Management, A I
Riker (ed.). Springer Science + Business Media, New York. 2015,
1–22.
2. Prendergast P. Anatomy of the breast. In: Cosmetic Surgery: Art
and Techniques, M A Shiffman and A Di Giuseppe (eds.). Springer,
Berlin. 2013, 47–55.
3. Hamdi M, Würinger E, Schlenz I, Kuzbari R. Anatomy of the
breast: A clinical application. In: Vertical Scar Mammoplasty.
Springer. 2005, 1–8.
4. Mugea T. New breast volume and ptosis classification. In: Aesthetic
Surgery of the Breast, T Mugea and M A Shiffman (eds.). Springer
Science + Business Media, New York. 2015, 605–32.
5. Regnault P. Breast ptosis, definition and treatment. Clin Plast Surg
1976; 3(2): 193–203.
6. Rinker B, Veneracion M, Walsh C. Breast ptosis causes and cure.
Ann Plast Surg 2010; 64(5): 579–84.
7. Shiffman M. Classification of breast ptosis. In: Breast Augmen­
tation. Principles and Practice, M A Shiffman (ed.). Springer
Science + Business Media, New York. 2009, 251–255.
8. Wheeler A, Smith H. Botulinum toxins: Mechanisms of action,
antinociception and clinical applications. Toxicology. 2013; 124–46.
9. Smith K, Pérez-Atamoros F. Other dermatologic uses of botu­
linum toxin. In: Botulinum Toxin in Clinical Dermatology, A V
Benedetto (ed.). Taylor & Francis, UK. 2006, 219–36.
10. Irkoren S, Ozkan H, Ceylan E, Sivrioglu N, Tataroglu C, Durum
Y. The effect of botox on the implant stabilization and capsular
formation. Ann Plast Surg 2015; 75: 91–7.
11. Kim S, Moosang A, Piao Y, Choi D, Yi M, Shin N. Effect of
botulinum toxin type A on TGF-beta/Smad pathway signal­
ing: Implications for Silicone-induced capsule formation. Plast
Reconstr Surg 2016; 138(5): 821e–829e.
12. Winocour S, Murad M, Bigdoli-Moghaddam M, Jacobson S, Bite
U, Saint-Cyr M, Tran N, Lemaine V. A systematic review of the use
of botulinum toxin type A with subpectoral breast implants. J of
Plastic, Recons Aesth Surg 2014; 67: 34–41.
13. Gabriel A, Champaneria M, Maxwell P. The efficacy of Botulinum
Toxin A in post-mastectomy breast reconstruction. A Pilot Study.
Aesth Surg J 2015; 35(4): 402–9.
14. Cattin T. Botulinum toxin for Tethering of breast implants. Plast
Recons Surg. Letters ahd view of points. 2005; 116(2): 687–8.
15. ÖDonnell C. Pectoral muscle spasms after mastectomy succes­
fully treated with botulinum toxin injections. Phys Med and Rehab
2011; 2011(3): 781–2.
16. Dessy L, Mazzocchi M, Scuderi N. Treatment of post Mastectomy
pain syndrome after Mastopexy with botulinum toxin. J Plast
Reconstr Aesthet Surg 2014; 67(6): 873–4.
17. de Carlos E, Cabezón A, Mosquera M, Rodríguez G, Ruiz-
Soldevilla JM, Sancho B. Botulinum Toxin application for the pain
control in breast cancer. Rehabilitación (Madr) 2012; 46(2): 112–9.
18. Dessi L, Curinga G, Mazzocchi M, Scuderi N. Treatment of mus­
cular Pseudogynecomastia with Botulinum Toxin. Letter to the
Editor. Aesth Plast Srg 2007; 31: 104–6.
Figure 16.14  Schematic design of the OnaBTX-A injection sites in the pectoral
areas (20 microinjections of 0.1 mL/2.5 U for each side). Total dose 100 U diluted
with 4 mL of saline solution (From Dessi L. et al. Aesth Plast Surg 2007; 31: 104–6,
with permission.)

299
Aesthetic use of botulinum toxin in Asians
Kyle K. Seo
INTRODUCTION
Individualized assessment and treatment are necessary before per­
forming botulinum toxin injection for cosmetic use because there
is significant variability among individuals in terms of facial shape
and aesthetic needs. Dosages and injection points should be differ­
entiated on the individual’s muscle activity, pattern of muscle shape,
and judgment of what is aesthetically appropriate in the context of
the individual’s overall facial shape and aesthetic needs. In such con­
text, physicians should take a different approach when performing
BoNT-A injection for Asians because there are marked ethnic differ­
ences between Asians and Caucasians. However, most publications
have focused exclusively on Caucasian subjects. This chapter covers
the ethnic differences between Asians and Caucasians for the aes­
thetic use of BoNT-A in terms of anatomy, appropriate dose, injection
points, indications of BoNT-A, and aesthetic needs, thereby providing
some practical guidelines for the aesthetic use of BoNT-A in Asians.
However, Asia is a huge continent and Asians are not a uniform popu­
lation. Therefore, this chapter does not cover ethnicities from Indian
and Arab nations although these groups are often considered to be
Asian in terms of their geographic location. Instead, this chapter
mainly focuses on characteristics of East Asians and Southeast Asians.
Differences between Asians and Caucasians
Different Facial Shapes and Different Aesthetic Standards between
Asians and Caucasians
Asians have a relatively wide, round, and flat face compared to
Caucasians. Their faces tend to be wider and shorter with less anterior
projection than Caucasian faces.1 For this reason, Asians consider a
smaller, narrower, and more three-dimensional face to be more attrac­
tive and so may wish to achieve this ideal using botulinum toxin. One
of the most typical examples of this is treatment for masseter hypertro­
phy using botulinum toxin, which is not popular in western countries
even though it was first developed in western countries more than 20
years ago.2 This novel treatment helps Asians with a square-looking face
to achieve a decreased facial width and “V” shape to their face in their
front view. In a similar context, botulinum toxin treatment for tempo­
ralis hypertrophy and for the parotid gland enlargement, is also gaining
more popularity among Asians as a method of decreasing facial width.
BoNT-A injection for widening the palpebral aperture (the eye-
opening) is another typical example of the ethnic difference when
considering treatment approaches between Asians and Caucasians.
BoNT-A injection can remove the pretarsal bulge and slightly lower
the inferior ciliary margin to widen the palpebral aperture.3 From
the viewpoint of Caucasians, this treatment may help Asians’ smaller
eyes to become bigger. Actually, this treatment is appealing to some
Southeast Asians who regard almond shaped eyes as a beautiful
hallmark because eliminating the pretarsal bulge creates more of an
almond-shaped eye. However, it is important not to apply this treat­
ment to East Asians, who consider pretarsal bulge one of the impor­
tant hallmarks of female beauty.4 The pretarsal muscular bulge is
usually exaggerated when people smile by the action of the orbicularis
oculi muscle. Therefore, it is called a “charming roll” in East Asians
because the people with pretarsal muscular bulge when at rest look
soft and friendly. Another reason for explaining the popularity of the
“charming roll” in East Asians is that the “charming roll” brings the
optical illusion of a “big eye” like double eyelid surgery in Asians with
inherently smaller eyes. The purpose of the double eyelid surgery is
to create an upper eyelid with a crease (i.e., “double eyelid”) from an
eyelid that is naturally without a crease. Therefore, physicians even
enhance the “charming roll” by the injection of filler in Asians. In
such a context, BoNT-A injection for widening the palpebral aperture
should be avoided in Asians.
Eyebrow “shaping” with BoNT-A, popular in Caucasians,5,6 is also
not recommended for East Asians, especially Koreans who consider
flat eyebrows a beautiful shape for women.7 High arched eyebrows
are generally considered as tough looking in this region of Asia and
are even called “Samurai eyebrows.” Aesthetically high arched eye­
brows may look unnatural in an Asian with wide facial shape. The
“Korean look” sets a beauty standard in Asians due to the “Korean
wave” influenced by Korean pop and Korean drama. Consequently,
eyebrow “shaping” with BoNT-A resulting in high arched eyebrows is
not recommended for Asians.
Three Asian Facial Types
Ethnic groups in East Asia and Southeast Asia can be classified into
three Asian facial types as northern, intermediate, and southern type
(Figure 17.1).8 Northern facial types have a narrow palpebral fissure
with no supratarsal crease, high and long nose with narrow nasal ala,
prominent zygoma, well-developed mandibular angle which gives a
square face or square jaw, and relatively white skin. Ethnic groups of
northern type are individuals from Mongolia, Korea, and Northern
China (Figure 17.1). Southern facial types have the wide palpebral fis­
sure with a supratarsal crease, flat and short nose with wide nasal
ala, less prominent zygoma, less developed bony mandibular angle
which gives a narrow and oval facial shape, and relatively dark skin
with a Fitzpatrick phototype of III to IV. Ethnic groups in Southern
facial type are individuals from Southeast Asian countries such as the
Philippines, Thailand, Indonesia, and so on. Intermediate types show
intermediate characteristics between the northern type and southern
type and may be seen in Southern China, Hong Kong, and Taiwan.
Of course, this classification does not cover all ethnicities in this
region and mixed characteristics and variation exists even within the
same ethnic group. For example, some Koreans show typical char­
acteristics of the northern type, while others show characteristics
of the southern type. In addition, it is possible for an Asian subject
in one area to possess mixed characteristics of different facial types
(Figure 17.2). Therefore, BoNT-A injection strategy in Asians should
be guided individually and not just by facial type in their geographic
region even though the Asian facial type is a good reference when
planning BoNT-A injection.
Anatomic Differences between Asians and Caucasians
Asians generally tend to have a smaller muscle mass and less hyper­
dynamic activity compared to Caucasians. Specifically, Asians are
reported to have shorter corrugator muscles than Caucasians. The
smaller muscle mass of Asians seems to come not only from genetic
differences9 but also from cultural differences related to facial expres­
sion.10 According to one paper analyzing facial expressions by video­
taping, Asians tend to use their upper facial expression muscles less
than Caucasians by up to 30%.10 Moreover, Asians have fewer wrin­
kles, compared with Caucasians because Asians have a thicker der­
mis,11 increased fat, and denser fat in comparison with Caucasians.12
All these mean that lower doses of BoNT-A should be administered
in Asians than in Caucasians.
17

Botulinum Toxins in Clinical Aesthetic Practice
300
Site Specific Differences
BOTOX is the only BoNT-A product used in this chapter.
Forehead Horizontal Lines

1. Asians require lower doses of BoNT-A since Asians have a
smaller muscle mass and less hyperdynamic activity than
Caucasians. Low initial doses from 3 U to 6 U are recommended
and no more than 12 U in total because of the risk of eyebrow
ptosis.

2. Assessment for those at risk of eyebrow ptosis, for example, for
patients with ptosis, or people who congenitally open their eyes
with their frontalis, is a prerequisite because eyebrow ptosis is a
more embarrassing side effect from the aesthetic viewpoint in
Asians with inherently wider distance between the eyebrow and
the palpebral fissure compared with Caucasians. Typical at-risk
patients for eyebrow ptosis are older people, that is, in their fifties
and above; these patients require a low initial dose from 2 U to 3 U.

3. Injection points and techniques: Generally, two rows of 6–7
injection points (IPs) are recommended (Figure 17.3a).
Alternatives include three rows of injections for people with a
high forehead (Figure 17.3b). Low initial doses from 3 U to 6 U
are recommended and no more than 12 U in total because of
the risk of eyebrow ptosis.
Glabellar Frown Lines

1. Asians require lower doses of BoNT-A since Asians have rela­
tively shorter and narrower corrugator muscles compared to
Caucasians9 and also have less hyperdynamic activity than
Caucasians.10 Therefore, a 4-point injection pattern with injec­
tion of the medial corrugators and the procerus is generally
recommended for Asian females instead of a standard 5-point
pattern for Caucasians covering lateral parts of the corruga­
tor.13 Approximately 10–12 units (U) are usually recommended
as an initial dose for glabellar frown lines. Of course, a 5-point
injection pattern with 16–20 U could be appropriate for Asian
subjects with greater muscle mass.

2. Injection points and techniques: Intramuscular injection into 4
IPs should be used (2 U of 2 IPs in the procerus and 3 U of 2 IPs
in the medial part of corrugator) (Figure 17.4a). The standard
Caucasian pattern for glabellar frown lines requires an addi­
tional 1–2 U at the mid-pupillary line for the lateral part of the
corrugator (Figure 17.4b).
Lateral Canthal Rhytides (Crow’s Feet)

1. Lower doses for lateral canthal rhytides are required in order to
avoid an unnatural look since Asians with inherently smaller eye
apertures look scary if they don’t show any wrinkles around the
eyes or their eye aperture doesn’t become smaller when they smile

2. After injections of BoNT-A for the treatment of crow’s feet,
Asians with prominent zygomas and abundant premalar fat
Figure 17.2  Mixed characteristics of different facial types in an Asian subject.
A Korean woman shows prominent zygoma of northern facial type with round
facial contour of intermediate facial type, while she has the southern characteristics
such as wide palpebral fissure with a supratarsal crease and relatively short nose.
Figure 17.1  Three Asian facial types. Ethnic groups in East Asia and Southeast Asia can be simply classified into three Asian facial types as northern, intermediate, and
southern types (from the left to the right). (From Sundaram H, Huang PH, Hsu NJ et al. Aesthetic applications of incobotulinumtoxinA in Asians: An international, mul­
tidisciplinary, pan-Asian consensus. Plast Reconstr Surg Glob Open 2016; 4(12); e872. With permission.)

17.  aesthetic use of botulinum toxin in asians
301
above the nasojugal groove tend to show more prominence
of the lateral malar area when they smile because a weakened
orbicularis oculi cannot elevate the lateral malar area further
upward.14 However, Asians generally hate more prominence
of the lateral malar area. For those patients with a prominent
zygoma and abundant premalar fat, injections at a lower part of
the orbicularis oculi is unnecessary and injections in line with
the lateral canthal line should be performed with a lower dose,
that is, with only 0.5–1 U of BoNT-A.

3. Injection points and techniques: At least 3 IPs with 2 U per IP
should be used, with an optional additional 1–2 IPs more and/or
less than this, depending on the wrinkle pattern (Figure 17.5).
Infraorbital Wrinkles

1. It is important not to inject the pretarsal part of the orbicu­
laris oris close to the lower ciliary margin because injections of
BoNT-A into this area diminishes the pretarsal muscular bulge
in Asians who consider it a hallmark of female beauty.

2. Injection points and techniques: IPs are usually recommended
between the preseptal part and orbital part of the orbicularis
oris. One row of 5–6 IP per eye, with a total of less than 2 U
dose is recommended (Figure 17.5).
0.4 U
Total 5.6 U
(a)
(b)
0.4 U
Total 8.4 U
Figure 17.3  Injection points and dose of BoNT-A for forehead horizontal lines in Asians. (a) Injection points and dose of BoNT-A for two rows with 6–7 IPs per row.
(b) Alternatives include three rows of injections for people with high foreheads. (Reproduced with permission from Seo K, Botulinum Toxin for Asians; Seoul Medical
Publishing Ltd. 2014.)
(a)
(b)
0.5 U
1 U
2 U
3 U
4 U
Figure 17.4  Injection points and dose of BoNT-A for glabellar frown lines. (a) Asian standard pattern with 4 IPs (2 U of 2 IP in the procerus and 3 U of 2 IP in the medial
part of corrugator). (b) Standard Caucasian pattern with 5 IPs. (Reproduced with permission from Seo K, Botulinum Toxin for Asians; Seoul Medical Publishing Ltd. 2014.)
1.5~2 cm
Figure 17.5  Injection points and dose of BoNT-A for lateral canthal rhytides and
infraorbital wrinkles. At least 3 IPs with 2 U per IP should be used for lateral
canthal rhytides, with an optional additional 1–2 IPs more and/or less than this,
depending on the wrinkle pattern. One row of 5–6 IP per eye, with a total of less
than 2 U dose is recommended for infraorbital wrinkle. (Reproduced with permis­
sion from Seo K, Botulinum Toxin for Asians; Seoul Medical Publishing Ltd. 2014.)

Botulinum Toxins in Clinical Aesthetic Practice
302
Cobblestone Chin

1. Asians usually tend to show stronger mentalis muscle activ­
ity than Caucasians. It is aesthetically important to reduce the
mentalis activity by injections of BoNT-A since hyperactivity
of the mentalis may aggravate the severity of a recessed and
smaller chin in Asians (Figure 17.6).15

2. Injection points and techniques: Intramuscular injection
with 4 U into 2 IPs 1 cm apart from the central line at the
lower border of the chin is recommended. Two more injec­
tions with 2 U per IP above these are required subdermally
(Figure 17.7).
Square jaw (Masseter Hypertrophy)

1. Botulinum toxin for masseteric hypertrophy was first reported
in the Western literature in 1994.2 However it didn’t attract
much attention in western countries due to the general lack of
need for its cosmetic application. In Asia, however, this novel
technique has spread rapidly, owing to its advantages in terms
of ensuring a quick and convenient procedure and an absence
of social downtime compared to the conventional angular
reduction bone surgery (Figure 17.8).

  The main benefit from this novel indication for BoNT-A
injections is to reduce the facial width and enhance the shape
of the lower face from the frontal view. Anyone can achieve a
reduced facial width to some extent by reducing the thickness
of the masseter muscle since the thickness of the masseter mus­
cle is known to be 0.8 cm in normal people and 1.3 cm in people
with masseteric hypertrophy, respectively.16

2. The mechanism of action of BoNT-A in the treatment of mas­
seteric hypertrophy is a type of disuse muscular atrophy.
Therefore, this treatment results in a time lag both in onset
and peak of action that differs from conventional treatment for
wrinkles, where the onset of action begins after just 2–3 days
and the peak effect is reached 1–2 weeks after injection. In clini­
cal practice, the effect of BoNT-A for masseteric hypertrophy
has an onset time of 2 weeks after injection, and the peak effect
develops at 2–3 months after injection.17,18

3. Six months later, the muscle volume will usually have returned
to some extent, and by 9–12 months postinjection, the muscle
volume may approach its previous state. Therefore, repetition
of BoNT-A treatment for the masseteric hypertrophy is rec­
ommended every 6 months for maintaining the best result,
while 9–12 months’ interval can be also possible considering
the initial muscle volume as a guideline. However, the dura­
tion of the effect is variable and depends on the individual’s
personal habits, such as bruxism, unconscious jaw clenching,
and excessive chewing of hard food.19 There have also been
many reports that the effects of BoNT-A in the treatment of
masseteric hypertrophy can last for more than 1–2 years, even
after only one session of injections.20 This extended duration
of the effect of BoNT-A is particularly noted in those sub­
jects who have the acquired form of masseteric hypertrophy,
as long as they avoid eating tough foods and do not have the
habit of jaw clenching.
1 U
3 U
1 cm1 cm
Figure 17.7  Injection points and dose of BoNT-A for cobblestone chin.
Intramuscular injection with 4 U into 2 IPs 1 cm apart from the central line at the
lower border of the chin is recommended. Two more injections with 2 U per IP
above these are required subdermally. (Reproduced with permission from Seo K,
Botulinum Toxin for Asians; Seoul Medical Publishing Ltd. 2014.)
(a)
(b)
Figure 17.6  Before (a) and 2 weeks (b) after BoNT-A injection in a cobblestone chin (mentalis hyperactivity).

17.  aesthetic use of botulinum toxin in asians
303

4. Proper assessment is also a prerequisite to screening at risk
patients who may show unpleasing and undesirable results
after BoNT-A injections for hypertrophic masseter reduction.
A pre-existing sunken cheek may look more aggravated with
the disappearance of the masseter muscle volume, which brings
not only a fatigued and older look but also prominence of the
zygoma. A pre-existing sagging jowl also tends to become more
intense following this procedure because of a visual illusion.
Patients at risk for such untoward results should be informed in
advance of these possibilities and countermeasures with volu­
mizing fillers for sunken cheeks and thread lifting for sagging
jowls should be offered.

5. Mild temporary muscle weakness, resulting in difficulty with
chewing, will occur after BoNT-A injections in a small pro­
portion of subjects. However, this is temporary and chewing
strength returns to normal within 3 months.21

6. For the cosmetic purpose of reshaping a lower facial contour,
the lower part of the masseter under an imaginary line con­
necting the tragus to the corner of the mouth is the main tar­
get area for injections with BoNT-A since the lower part of the
masseter is more important in lower facial contouring.

7. Injection points and techniques: Deep injections sufficient
enough to touch the mandibular bone, rather than injections at
a medium depth, are very important. Superficial injections can
weaken the rizorius attached superficially to the anterior part
of the masseter, causing embarrassing changes of facial expres­
sion, for example, an asymmetric unnatural smile. To reduce
the risk of adverse changes of facial expression when treating
masseteric hypertrophy, physicians should start by injecting at
least 1 cm inside the anterior margin of the masseter muscle in
addition to deep injection.
A safe and effective zone for injecting a square jaw and reducing
the size of the masseter can be delineated by the upper margin being
an imaginary line connecting the tragus to the corner of the mouth,
the lower margin as the mandibular bony border, and the anterior
and posterior margins as the anterior and posterior borders of each
masseter muscle. IPs are at least 1 cm within these borders to avoid
unwanted diffusion of BoNT-A into other facial muscles.
Four to six IPs of 5 U each are recommended depending on the
muscle volume (Figure 17.9).
Temporalis Hypertrophy

1. While masseteric hypertrophy is an important factor for lower
facial width, temporalis hypertrophy may contribute to the
width of the upper face. Temporalis hypertrophy also can be
improved by injections of BoNT-A producing the same disuse
muscular atrophy as in masseteric hypertrophy. For Asians
with wide faces, BoNT-A for temporalis hypertrophy can cam­
ouflage their congenital characteristics in terms of reducing the
facial width (Figure 17.10).22

2. Injection points and techniques: Deep injections sufficient to
touch the bone, rather than injections that are at medium depth,
are recommended. An effective injection zone for temporalis
hypertrophy can be delineated by the lower margin being an
imaginary line connecting the upper margin of helix to the tail
of the eyebrow and the posterior margins as an imaginary verti­
cal line parallel to the tragus. Five to eight IPs of 5 U are recom­
mended depending on the thickness of the muscle (Figure 17.11).

Injection of BoNT-A should be focused into the muscle bulge
at the superior temporal fusion line since the upper part of the
temporalis is more important in upper facial contour.

3. A pre-existing temporal hollow may become aggravated
with the disappearance of the temporalis fullness. However,
this would be treated by filler revolumization or fat graft­
ing. Mild, temporary muscle weakness, such as difficulty
with chewing, will occur after BoNT-A injections in a
(a)
(b)
Figure 17.8  Before (a) and 3 months (b) after BoNT-A injection for a square jaw (masseter hypertrophy). (Reproduced with permission from Seo K, Botulinum Toxin for
Asians; Seoul Medical Publishing Ltd. 2014.)

Botulinum Toxins in Clinical Aesthetic Practice
304
small proportion of patients, especially when combined with
BoNT-A injections for masseteric hypertrophy. However, this
is also temporary.
Parotid Gland Enlargement

1. Enlarged parotid glands can contribute to a square-shaped lower
face appearance. Because acetylcholine, the neurotransmitter
in the salivary glands, can be blocked by BoNT-A, injections
of BoNT-A into the parotid gland can result in atrophy of the
parotid gland in humans.23 Indeed, injection of BoNT-A into
an enlarged or protruding parotid gland can reduce the width
of the lower face (Figure 17.12).

2. Injecting BoNT-A into the parotid gland seldom results in dry
mouth as 71% of salivary production comes from the subman­
dibular gland.24
(a)
(b)
Figure 17.10  Before (a) and 3 months (b) after BoNT-A injection for temporalis hypertrophy. (Reproduced with permission from Seo K, Botulinum Toxin for Asians; Seoul
Medical Publishing Ltd. 2014.)
5 U,
Total 20 U
5 U,
Total 30 U
(a)
(b)
Figure 17.9  Injection points and dose of BoNT-A for a square jaw (masseter hypertrophy). Four (a) to six (b) IPs with 5 U are recommended, depending on the muscle
volume. (Reproduced with permission from Seo K, Botulinum Toxin for Asians; Seoul Medical Publishing Ltd. 2014.)

17.  aesthetic use of botulinum toxin in asians
305

3. Injection points and techniques: The most protruding part of the
parotid gland around the mandibular angle is the most effective
injection site. Deep intraglandular injections are required. Six to
eight IPs with 5 U per injection site are recommended depending
on the thickness of the parotid gland (Figure 17.13).
Intradermal Botulinum Toxin (“Mesobotox,” “Dermotoxin,” etc.)

1. Multiple intradermal injections of BoNT-A (intradermal
BoNT-A) have been widely performed in Asia, under various
names such as “mesobotox”, “dermotoxin”, or “microtoxin”. The
purpose of this treatment is not only for the reduction of dynamic
facial wrinkles but also for the reduction of static wrinkles and
pore sizes, as well as creating the so-called perceived “lifted look”
or “pseudolift”. Therefore, intradermal BoNT-A can be consid­
ered as a full package of antiaging effects that BTA can deliver.
5 U,
Total 40 U
Figure 17.11  Injection points and dose of BoNT-A for temporalis hypertrophy.
Five to eight IPs with 5 U are recommended depending on the muscle volume.
(Reproduced with permission from Seo K, Botulinum Toxin for Asians; Seoul
Medical Publishing Ltd. 2014.)
(a)
(b)
Figure 17.12  Before (a) and 3 months (b) after BoNT-A injection for parotid gland enlargement. (Reproduced with permission from Seo K, Botulinum Toxin for Asians;
Seoul Medical Publishing Ltd. 2014.)
5 U
Figure 17.13  Injection points and dose of BoNT-A for parotid gland enlargement.
Six to eight IPs with 5 U per injection site are recommended depending on the
parotid gland volume. (Reproduced with permission from Seo K, Botulinum Toxin
for Asians; Seoul Medical Publishing Ltd. 2014.)

Botulinum Toxins in Clinical Aesthetic Practice
306

2. The same dynamic wrinkle reduction as in wrinkle treatment
with BoTX can also be achieved by diffusion of intradermal
BoNT-A into underlying muscles of facial expression, because
BoNT-A spreads in a three-dimensional manner from the der­
mis and because several muscles of facial expression also have
intracutaneous insertions.

3. The improvement of static wrinkles and tightening of pores,
which imparts a shine and a tighter look to the skin, has been
already reported in conventional BoNT-A injections for the
treatment of glabellar and forehead wrinkles.25 My hypothesis
for this improvement seems to be due to dermal edema result­
ing from a transient and mild lymphatic insufficiency induced
by underlying muscular paralysis. The same effect may happen
after intradermal BoNT-A.26

4. Another effect of intradermal BoNT-A is the reduction of sebum
production and pore size, thus improving the skin texture by
giving it a smooth appearance.27,28 This might be due to a pos­
sible humoral effect of BoNT-A reducing the activity of the seba­
ceous gland and the pore size since acetylcholine receptors have
been reported to be present in sebaceous glands.29 The reduction
(a)
(b)
Figure 17.15  Before (a) and 2 months (b) after BoNT-A injection for calves (gastrocnemius hypertrophy). (Reproduced with permission from Seo K, Botulinum Toxin for
Asians; Seoul Medical Publishing Ltd. 2014.)
(a)
(b)
0.25 U
0.4 U
0.5 U
2 U
1 U
3 U
4 U
Figure 17.14  Injection points and dose of BoNT-A for intradermal BoNT-A. (Reproduced with permission from Seo K, Botulinum Toxin for Asians; Seoul Medical
Publishing Ltd. 2014.)

17.  aesthetic use of botulinum toxin in asians
307
of sebum production and pore size by intradermal BoNT-A in
patients with oily skin was also objectively elucidated.30

5. The pseudo-lift effect is in fact not true lifting but a kind of visual
illusion caused by reducing the lower part of the facial contour,
and thus elevating the center of gravity upward. This effect
can be achieved by narrowing the width of the lower face with
reducing the volume of the masseter and giving a sharper defini­
tion to the chin line by weakening the mentalis and platysma.

6. Injection points and techniques: Combining multiple intrader­
mal injections with the conventional intramuscular injection is
usually recommended. Conventional intramuscular injections
can be used for supplementation in areas with deep muscles
such as corrugator, mentalis, and masseter. Areas for intra­
dermal injection are forehead, periorbital, cheek, perioral, and
anterior malar area (Figure 17.14).
Body Shaping (Bodytoxin)

1. The popularity of body shaping with botulinum toxin type
A is rapidly increasing in Asian subjects leveraging the same
mechanism of disuse atrophy as in treatment of BoNT for mas­
seteric hypertrophy. Even though any muscles with hypertro­
phy can be targeted for body shaping using BoNT, the most
popular site is the calves (Figure 17.15).4,31 Asian women tend
to have short legs relative to their torsos.32 Thick calves with
hypertrophied calf muscles further accentuate this dispropor­
tion in Asian women. Injection of BoNT into the calves brings
about reducing muscular bulge and a slimmer lower leg line.
Gastrocnemius and the lower part of the soleus muscle are tar­
get muscles for bodytoxin of the calf.

  Regarding the dose of BoNTs for bodytoxin, 50–100 U
BoNTs is recommend for the head of each gastrocnemius at
up to 25 IPs depending on the muscle volume4 (Figure 17.16).
Approximately 40–60 U BoNT per leg is required for the lower
part of the soleus. For the cosmetic purpose of reshaping the
lower leg contour, the lower two-thirds of the medial head of
the gastrocnemius is the main target area for injections with
BoNT-A while the upper two-thirds is the main target for the
lateral head of the gastrocnemius.

2. Injection into upper body muscles, such as the deltoids and tra­
pezius, has also been described to shape the upper arms and
shoulders.4,31 Slimming the upper arms by reducing the deltoid
muscle is another novel indication of bodytoxin (Figure 17.17).
Injection of BoNT-A into the upper part of the trapezius can
create an elongated neck line which is useful for camouflag­
ing women’s short neck (Figure 17.18). Therefore, BoNT-A for
trapezius is often called “bride toxin” and “wedding toxin” in
Korea since this is helpful for brides who must wear wedding
dresses revealing the shoulder and neck line. Approximately
40–50 U BoNT per side is required for the deltoid and the
upper part of the trapezius, respectively (Figure 17.19).

3. Mild temporary muscle weakness would occur in some pro­
portion of subjects. Even though this is temporary and muscle
strength returns to normal within 3 months, the physician
Gastrocnemius
lateral head
Soleus
Peroneus
longus
2/3
2/3
Figure 17.16  Injection points and dose of BoNT-A for calves. Approximately
50–100 U BoNTs is recommend for the head of each gastrocnemius at up to 25
injection points depending on the muscle volume. (Reproduced with permission
from Seo K, Botulinum Toxin for Asians; Seoul Medical Publishing Ltd. 2014.)
(a)
(b)
Figure 17.17  Before (a) and 2 months (b) after BoNT-A injection for arm contour­
ing (deltoid muscle). (Reproduced with permission from Seo K, Botulinum Toxin
for Asians; Seoul Medical Publishing Ltd. 2014.)

Botulinum Toxins in Clinical Aesthetic Practice
308
injector should pay attention to adjusting the dose of BoNT-A
depending on the individual muscle volume. A two-step
approach where a half dose of BoNT-A is administered at an
interval of 2–3 months would be recommended in cases that
require higher doses of BoNT-A.4

4. As is the case with treatment of masseteric hypertrophy with
BoNT-A, the bodytoxin has an onset time of 2 weeks after
injection, the peak effect at 2–3 months after injection, and
the longevity of 6–12 months postinjection. However, the
duration of the effect is variable depending on the individual’s
habit to use the target muscle. Therefore, repetition of body­
toxin is recommended every 6–12 months depending on the
individual’s need.
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Neck line
2 cm
Figure 17.19  Injection points and dose of BoNT-A for trapezius. Approximately
40–50 U BoNT per side is required for the upper part of the trapezius. (Reproduced
with permission from Seo K, Botulinum Toxin for Asians; Seoul Medical Publishing
Ltd. 2014.)
(a)
(b)
Figure 17.18  Before (a) and 2 months (b) after BoNT-A injection for shoulder contouring (trapezius muscle). (Reproduced with permission from Seo K, Botulinum Toxin
for Asians; Seoul Medical Publishing Ltd. 2014.)

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310
Muscles of facial expression
appendix 2
Muscle
Origin
Insertion
Action
Function
I. Forehead
Frontalis (s)
Galea aponeurotica
Skin of forehead and brow
Raises eyebrow; retracts
scalp
Wrinkles forehead; used in frowning
and to express surprise and
astonishment
II. Glabella
a. Corrugator supercilii (d)
Medial superciliary arch
(nasal process of frontal
bone)
Skin in the mid portion of
brow
Adducts and draws brow
down
Used to squint and protect eyes
b. Orbicularis oculi, (s)

i. orbital portion
Upper orbital margin,
medial palpebral
ligament and inferior
medial orbital margin
Surrounds orbital opening
as a sphincter: into
eyebrow, temple and
cheek skin
Shuts eyelid intentionally
Wrinkles brow to produce a frown;
used to wink, squint and protect
eyes

ii. Palpebral portion (s)
Medial palpebral ligament
Lateral palpebral raphe
Shuts eye involuntarily
Produces sphincteric action of the
eyelids

iii. Lacrimal portion (d)
Lacrimal crest
Upper and lower tarsal
plates
Draws eyelids posteriorly
Facilitates the lacrimal pump
c. Depressor supercilii (s)
Nasal process of frontal
bone
Skin of medial brow
Pulls down medial brow
Pulls eyebrows down, shuts eyelids,
facilitates the lacrimal pump
d. Procerus (d)
Nasal bone and transverse
nasalis
Skin of forehead between
eyebrows
Pulls down medial brow
Wrinkles central brow to produce
frown; used to squint and shield
eyes (conveys disdain or dislike)
III. Nose
a. Compressor naris
(transverse nasalis) (s)
Canine eminence of
maxilla
Nasal bridge aponeurosis
Compresses nasal
aperture
Slows exhaled air
b. Posterior dilator naris
(alar nasalis) (s)
c. Anterior dilator naris
Maxilla above lateral
incisor and alar cartilage
Lower lateral cartilage
and lateral crus
Nasal tip and alar skin,
lateral crus cartilage and
alar facial groove
Rim of the lateral alar
skin and nasal spine
Draws ala and posterior
aspect of columella
downward, widening
nasal aperture
Stabilizes most flaccid
portion of lateral nasal
wall and assists in
dilating nostrils
Prevents alar collapse in forceful
breathing; flares nostrils during
anger or exertion
Prevents ala nasi from collapsing,
especially during inspiration;
maintains competency of external
nasal valve
d. Depressor septi nasi (d)
Incisive fossa of maxilla
Lower nasal septum and
under surface of lower
lateral alar cartilage
Draws nasal tip and alae
downward
Narrows the nostrils; depresses nasal
tip
IV. Mouth
a. Orbicularis oris (s & d)
Modiolus and angle of
mouth; medial maxilla,
mandible and many
muscles that converge
around mouth; deep
surface of perioral skin
Mucous membrane of
lips; incisive fossa of
maxilla, caudal septum
and anterior nasal spine
Closes lips
Forms a sphincter around mouth;
closes oral aperture; protrudes,
puckers and shapes lips (kissing);
resists distension when blowing;
inverts upper and lower lip
b. Levator labii superioris
alaeque nasi (d & s)
Frontal process of maxilla
Alar cartilage and lateral
upper lip and modiolus
Dilates nares and everts
and elevates lateral upper
lip and elevates alae nasi
Deepens the upper nasolabial fold,
dilates nasal aperture and used in
scowling
c. Levator labii superioris
(d & s)
Lower margin of orbit,
above infraorbital
foramen on maxilla
Angle of mouth and
upper lip
Elevates and everts upper
lip
Used in expressing seriousness and
sadness and deepens medial
nasolabial fold
d. Zygomaticus minor
(d & s)
Malar surface of
zygomatic bone (near
maxillary suture line)
Upper lip at angle of
mouth into orbicularis
oris and levator labii
superioris (via modiolus)
Draws mouth upward and
laterally
Elevates and everts upper lip used in
expressing sadness (see next above)
e. Zygomaticus major
(d & s)
Lateral surface of
zygomatic bone, anterior
to zygomaticotemporal
suture
Modiolus and angle of
mouth
Draws mouth upward and
laterally
Elevates oral commissures used in
laughing or smiling (bilateral);
sneering and to show disdain
(unilateral)
f. Levator anguli oris (d)
Canine fossa below
infraorbital foramen of
maxilla
Modiolus and angle of
mouth and upper lip
musculature
Raises angle of mouth and
lateral upper lip
Widens oral aperture to grin or
grimace and used in smiling and
laughing; it deepens nasolabial
furrow as in contempt or disdain
(Continued)

appendix 2
311
Muscle
Origin
Insertion
Action
Function
g. Risorius (d & s)
superficial muscular
aponeurotic system
(SMAS), buccal skin and
parotideomasseteric fascia
Modiolus and angle of
mouth
Retracts angle of mouth
laterally
Used in smiling and laughing when
present
h. Depressor anguli oris (s)
Oblique line of mandible
Modiolus and angle of
mouth, upper and lower
lip
Depresses angle of mouth
downward and laterally
Used in grimacing and snarling; used
in expressing sadness
i. Depressor labii inferioris
(d)
Between symphysis menti
and mental foramen;
platysma
Skin of lower lip and
orbicularis oris and
modiolus
Draws lower lip
downward and laterally
Everts the lower lip, used in drinking,
pouting and expressing irony;
sorrow and doubt
j. Mentalis (d)
Incisive fossa of mandible
Skin of chin (mentolabial
sulcus)
Raises and protrudes
lower lip and wrinkles
skin of chin
Used in pouting and to elevate skin
of chin when expressing doubt or
disdain
k. Buccinator (d)
Outer surface of
mandible; alveolar
process of maxilla and
mandible;
pterygomandibular
raphe; buccinator crest
Modiolus and angle of
mouth; upper and lower
lips; interdigitates with
orbicularis oris
Flattens cheek against
gums; used when
distending cheeks with
air and compresses them
to force air out of mouth
Presses cheek against molar teeth;
works with tongue to keep food
between occlusal surfaces and out of
oral vestibule when chewing; used
in sucking and to puff up cheeks
and blow air out of mouth as when
blowing up a balloon or playing a
wind instrument
l. Platysma (s)
Pectoralis fascia of 2nd to
4th rib, deltoid fascia and
subcutaneous tissue of
infraclavicular and
supraclavicular regions
Modiolus, angle of mouth,
lower jaw, parotid fascia,
skin of cheek and lower
lip; orbicularis oris
Widens mouth aperture at
commissures; pulls skin
of lower face and neck
taught
Used in expressing horror, tension
and stress; assists in shaving or in
relieving pressure of a tight collar;
and depresses lower lip and
mandible against resistance
s = superficial
d = deep
Muscles of Facial Expression in Action
Frontalis
Corrugator supercilii
Procerus and transverse
part of nasalis
Orbicularis oculi and
depressor supercilii
Alar part of levator labii
superioris alaeque nasi and
alar part of nasalis
Buccinator and
orbicularis oris
Levator labii superioris
alaeque nasi
Risorius

appendix 2
312
Risorius and depressor labii
inferioris
Zygomaticus major, risorius,
levator anguli oris and lower
lip depressors: mentalis,
depressor anguli oris, and
asymmetry of right
depressor labii inferioris
Orbicularis oris
Depressor anguli oris
and mentalis
Mentalis
Platysma and depressor
anguli oris
Right—platysma, pars
labialis, depressor anguli
oris; Left—levator labii
superioris, zygomaticus
major and mentalis
Depressor anguli oris,
mentalis, and platysma
Left—levator labii
superioris, levator labii
superioris alaeque nasi,
zygomaticus major and
risorius
Right—depressor anguli oris,
depressor labii inferioris,
mentalis, and platysma
labialis
Left—zygomaticus major
and minor, levator labii
superioris, levator anguli
oris, risorius, and
mentalis
Right—zygomaticus
major and minor,
depressor labii
inferioris, levator labii
superioris, and mentalis
Zygomaticus major and
minor, levator labii
superioris, levator labii
superioris alaeque nasi,
levator anguli oris, risorius,
depressor labii inferioris,
and mentalis
Levator labii superioris,
zygomaticus minor, risorius,
depressor labii inferioris,
and platysma
Depressor anguli oris,
mentalis, and Right—
depressor labii
inferioris, and platysma
Left—levator labii
superioris, levator labii
superioris alaeque nasi

appendix 2
313
19
28
27
23
29
26
4
1
2a
3
2b
25
24
18
22
5
6
7
8
9
10
11
20
12
13
21
17
14
15 16
13
19
18
26
Figure A2.1  The bony origins of the muscles of facial expressions; their insertions are in soft tissue: 1, corrugator supercilli; 2, orbicularis oculi: 2a, upper orbital part; 2b,
palpebral part; 3, medial palpebral ligament; 4, procerus; 5, levator labii superioris alaeque nasi; 6, levator labii superioris; 7, zygomaticus minor; 8, zygomaticus major; 9,
levator anguli oris; 10, nasalis, transverse; 11, nasalis, alar; 12, depressor septi; 13, buccinator; 14, depressor labii inferioris; 15, depressor anguli oris; 16, platysma; 17, men­
talis; 18, masseter; 19, temporalis; 20, incisivus labii superioris; 21, incisivus labii inferioris; 22, sternocleidomastoid; 23, levator palpebrae superioris; 24, inferior oblique;
25, inferior rectus; 26, lateral rectus; 27, superior oblique; 28, medial rectus; 29, superior oblique. (Image from Berkowitz, Moxham, Head and Neck Anatomy: A Clinical
Reference, CRC Press, Boca Raton, FL, 2002, with permission.)

appendix 2
314
18
22
21
17
18
12
24
12
16
15
14
23 13
10
9
8
11
7
19
20
3
4
2
6
5
1
2
Figure A2.2  The bony origins of the muscles of facial expressions; their insertions are in soft tissue: 1, corrugator supercilli; 2, orbicularis oculi (orbital and palpebral parts),
3, orbicularis oculi (lacrimal parts); 4, medial palpebral ligament; 5, procerus; 6, levator labii superioris alaeque nasi; 7, levator labii superioris; 8, nasalis, transverse; 9,
nasalis, alar; 10, depressor septi; 11, levator anguli oris; 12, buccinator; 13, mentalis; 14, depressor labii inferioris; 15, depressor anguli oris; 16, platysma; 17, masseter; 18,
temporalis; 19, zygomaticus major; 20, zygomaticus minor; 21, sternocleidomastoid; 22, occipital belly of occipitofrontalis; 23, incisivus labii inferioris; 24, incisivus labii
superioris. (Image from Berkowitz, Moxham, Head and Neck Anatomy: A Clinical Reference, CRC Press, Boca Raton, FL, 2002, with permission.)

315
The preparation, handling, storage, and mode of injection of
OnaBTX-A
STORAGE OF OnaBTX-A
BOTOX•/BOTOX• Cosmetic (OnaBTX-A) is a purified neurotoxin
complex distributed in vials of 100 U or 50 U of sterile, vacuum-dried
crystalline powder without preservative. The vials of onabotulinum­
toxinA (OnaBTX-A) have a holographic film on the vial label with the
name “Allergan” within the horizontal lines of rainbow color. They
are shipped frozen, in insulated, styrofoam containers containing dry
ice. When they reach their destination the vials of OnaBTX-A can be
stored in their dry, powdered form in the refrigerator at a constant
temperature of 2°C–8°C for up to 36 months for the 100 U vial and
for up to 24 months for the 50 U vial.1 Once reconstituted, the solu­
tion of OnaBTX-A can be stored again in the refrigerator at a constant
temperature of 2°C–8°C. Do not refreeze reconstituted OnaBTX-A.
Although the package insert for OnaBTX-A recommends the recon­
stituted product be used within 4 hours, studies have shown that
after reconstitution, the potency of OnaBTX-A should remain con­
sistent and unchanged for up to 6 weeks, and can be used without any
noticeable change in clinical efficacy.2–6 Similar results were found by
Parsa et al. when they compared reconstituted OnaBTX-A frozen for
up to 6 months with OnaBTX-A not frozen and used within 4 hours
after reconstitution in 118 sites in the upper one third of the face in
80 patients.7 They concluded that reconstituted OnaBTX-A may be
reconstituted and refrozen, thawed, and injected without losing its
potency for up to 6 months. Initially, OnaBTX-A was thought to be
a fragile molecule. However, subsequent studies following anecdotal
observations confirm the persistence of activity of BoNT-A in differ­
ent clinical situations, confirming that BoNT-As may be sturdier and
more resistant to degradation than previously understood.8
PREPARATION OF OnaBTX-A
The package insert for OnaBTX-A suggests that the 100 U vial be
reconstituted with 2.5 mL of 0.9% non-preserved saline for a final con­
centration of 4 U/0.1 mL and the 50 U vial with 2.25 ml of the same.1
The report of a consensus conference of key multispecialty physician
injectors held in 2004 recommended that a 100 U vial of OnaBTX-A
be reconstituted at a “dilution that minimizes the likelihood of dif­
fusion to neighboring muscle groups,” and can be anywhere from 1
to 10 mL of normal saline for each 100 U vial of product.10 Anecdotal
and published reports suggest that volume may influence duration
of effect, in that the greater the volume, the shorter the duration of
effect.5 In addition, because higher dilutions can be associated with
a greater risk of diffusion into untargeted sites, this also can lead to
unsatisfactory results and even unexpected adverse events, along with
a shorter duration of effect.9 In a prospective, randomized, controlled
study with 10 volunteers, Hsu et al. injected the forehead with 5 U
of OnaBTX-A. On one side of the forehead 5 U of OnaBTX-A was
injected with 0.25 mL (2 U/0.1 mL). On the other side of the forehead
OnaBTX-A was injected with 5 U in 0.05 mL (2 U/0.02 mL). There was
a 5-fold difference in volume injected.9 They found that low concentra­
tion and higher-volume injections resulted in greater diffusion, affect­
ing a larger anatomic area. They concluded that the size of the muscle
and its pattern of contraction influences the pattern of toxin spread.
Consequently, an ideal strategy may be to inject concentrated BoNT
at a low volume to target smaller muscle groups, while using a larger
volume for larger, broad muscle groups, such as the frontalis muscle.
Their results show that the dilution of OnaBTX-A can have pharma­
cokinetic implications on the desired effect of OnaBTX-A.9 There is
no standardized dilution for BoNT treatment of focal hyperhidrosis.
Dilutions reported vary from 1 to 10 mL of saline for OnaBTX-A, with
most clinicians using between 2 and 5 mL.8
The 2004 consensus conference report also confirmed that the
majority of dermatologic and aesthetic physician injectors reconsti­
tute OnaBTX-A with preserved normal saline instead of nonpreserved
diluent and store and reuse the vials of reconstituted OnaBTX-A after
more than 4 hours.10 Preserved saline includes benzyl alcohol, which
has anesthetic properties. The result of a bilateral, comparative pro­
spective study has shown that there is less pain with injection (up to
50% reduction detected on numerical pain scales) when preserved
isotonic saline is used instead of nonpreserved isotonic saline.8,10–12
There was neither loss of efficacy nor duration of potency whether
OnaBTX-A was reconstituted with preserved or unpreserved normal
saline. Once reconstituted, the vial of OnaBTX-A should be clear, col­
orless, and free of particulate matter, regardless of diluent used.1 There
is a single report of contact dermatitis in fragrance-sensitive patients
associated with reconstitution of botulinum toxin with preserved
saline, but no indication of an increased risk associated with the stor­
age or reuse of toxin.12
Several studies have assessed the potential risk for contamination
of reconstituted botulinum toxin. In one study, 11 consecutive vials
of reconstituted toxin were exposed to room air for 4 hours, then
refrigerated for 3–5 days, and then cultured for possible microbial
contamination; none was detected.5,13 In another study, the routine
refrigerator storage of 100 unit vials of reconstituted OnaBTX-A
did not result in any microbial contamination even after serial re-
extractions of the reconstituted solution from the vials by differ­
ent personnel. Storage of reconstituted OnaBTX-A and subsequent
multiple extractions from the same vial of botulinum toxin appears
safe for clinical use for at least 7 weeks after reconstitution.5,11,14 Up
until the present, there is no evidence that any serious or nonserious
adverse events have been associated with the use and reuse of vials
of OnaBTX-A that have been reconstituted for more than 4 hours
and reused in the treatment of multiple patients.5 Of the 322 board-
certified dermatologists who responded to a survey, 68.6% reported
routinely storing toxin for more than 1 week after reconstitution and
routinely using each vial for more than 1 patient. Also, 67.0% of the
respondents believed that BoNT-A could be safely stored and reused
for 1–4 weeks. None of the respondents, who had been in clinical
practice for a median duration of 15 years, reported any local infec­
tions associated with cosmetic BoNT-A injections.5,7,15 The consensus
statement approved by the ASDS Task Force on Guidelines for the
Use and Storage of Neuromodulators on March 15, 2014, and adopted
as amended by the ASDS Board of Directors on May 12, 2014, reads
as follows: “(1) although it is likely that reconstituted toxin can be
refrigerated or refrozen for longer than 4 weeks before use, there is
insufficient evidence for a strong recommendation in this regard,
(2) apart from practical considerations regarding the limited volume
of material available for use, there is no specific limit on the number
of patients who can be treated with a single vial of reconstituted botu­
linum toxin.”5
HANDLING OF OnaBTX-A
Concerns over a potential loss of potency resulting from rough
handling, agitation, and foaming during reconstitution were also
addressed at the 2004 consensus conference.10 Trindade de Almeida
appendix 3

appendix 3
316
et al. treated one side of six patients in the glabella and periocular
area with OnaBTX-A that was reconstituted by agitation to the point
of bubbling and foaming, and the opposite side with OnaBTX-A
that was not agitated.17 There was no difference in muscle relaxation
between the two sides treated, and the duration of effect remained
constant on both sides for approximately 16 weeks. In another pro­
spective, double-blinded, randomized study by Kazim and Black,
seven patients were injected with gently reconstituted OnaBTX-A
at 4 sites on one side of the forehead. On the opposite side of the
forehead the same seven patients were injected with vigorously
reconstituted OnaBTX-A at another 4 sites that were symmetrically
parallel to the contralateral side.17 To vigorously reconstitute the
vial of OnaBTX-A, it was placed on the Vortex Touch Mixer Model
232 at the maximum speed of 10 for a duration of 30 seconds. Foam
was observed on the top of this vial for 1 1/2 minutes after vigor­
ous reconstitution. Eyebrow excursion was measured in millimeters
before the injections, 1 week after the injections, and every month
thereafter for up to a total of 6 months. There was no statistically sig­
nificant difference in eyebrow excursion between the two sides of the
forehead, and the effect of OnaBTX-A was maintained and had the
same duration when brow excursion was measured at every interval.
This study quantitatively demonstrated that there is no change in
effectiveness or duration of OnaBTX-A that is related to the speed
or manner of reconstitution. Physicians administering OnaBTX-A
can do so without worrying about compromising the effectiveness of
the product during the reconstitution process.17 Similar results were
anecdotally confirmed by the majority of those present at the 2004
consensus conference.10
INJECTION TECHNIQUE OF OnaBTX-A
OnaBTX-A should be injected with sterile, plastic, single-use syringes.
To minimize the pain and bruising of injection, the use of tuber­
culin syringes with a 30- to 32-gauge needle is recommended. For
those injectors who want to reconstitute OnaBTX-A with a mini­
mum amount of diluent (1 mL or less) and be able to control the
minutest amount of solution injected, an U-100 insulin syringe with
an attached 29- or 31-gauge needle can be used (Becton-Dickinson,
Franklin Lakes, NJ).18 The preattached needle is silicone-coated, which
easily penetrates the skin. The needle stays sharp for approximately
4–6 punctures.18 Insulin syringes (0.5 mL or 0.3 mL) have no potential
dead space at the hub where the needle is preattached, thereby mini­
mizing any wastage of solution.18 Full depression of the plunger leaves
less than 0.01 mL in the needle itself, a contrast with the 0.07 mL that
is retained in the dead space in a commonly available 30-gauge needle
attached to a Luer Lok syringe. At 100 U/mL, this means that 7 U of
botulinum exotoxin A cannot be used.18 In addition, the barrel of the
syringe is scored with markings representing 0.01 mL that can be eas­
ily seen and which will correspond to 1 U of OnaBTX-A when a 100 U
vial is reconstituted with 1 mL of diluent.18 To further reduce some of
the discomfort associated with any type of intramuscular injection,
the pretreatment application of either a topical anaesthetic, ice, or both
on the skin surface at the injection site can help provide a more com­
fortable, positive experience for some patients.
Although there are no controlled studies to support certain com­
monly prescribed post-treatment recommendations made to prevent
local spread of the OnaBTX-A beyond the injection site, many expert
physician injectors still recommend the following for their patients:

1. DO NOT massage the OnaBTX-A treated areas for 2–4 hours.

2. DO contract treated muscles for 2–3 hours immediately after an
OnaBTX-A treatment. This promotes the uptake of OnaBTX-A
by the receptor sites at the neuromus­cular junctions.

The following recommendations have been refuted because
lack of evidence:

3. DO NOT bend over (e.g., to tie shoes or pick up something from the
floor) for 2–3 hours after an OnaBTX-A treatment of the upper
face.

4. LIMIT heavy physical activity, and lying down or sleeping for 2–3
hours after an OnaBTX-A treatment of the upper face.10
Postmarketing reports indicate that the effects of OnaBTX-A and
all botulinum toxin products may spread from the area of injection
to produce symptoms consistent with botulinum toxin effects.1 These
symptoms have been reported hours to weeks after injection. The risk
of symptoms is probably greatest in children treated for spasticity but
symptoms also can occur in adults treated for spasticity and other con­
ditions, particularly in those patients who have underlying conditions
that would predispose them to these symptoms. In unapproved uses
and approved indications, cases of the spread of effect have occurred at
doses comparable to those used to treat cervical dystonia but not at the
lower doses generally used for cosmetic purposes. Furthermore, using
currently available analytical technology, it is not possible to detect
OnaBTX-A in the peripheral blood following intramuscular injection
at the recommended doses.1 A thorough review and understanding
of the current package insert for the brand of BoNT-A being used is
recommended before treating patients.
Table A3.1 sets out specifies the recommendations and methods for
preparation, handling, and storage of OnaBTX-A.
REFERENCES
1. Allergan, Inc. Botox Cosmetic (botulinum toxin type A) purified
neurotoxin complex (Package Insert). Irvin, California: Allergan,
Inc., revised January; 2016.
2. Garcia A, Fulton JE Jr. Cosmetic denervation of the muscles of
facial expression with botulinum toxin: A dose-response study.
Dermatol Surg 1996; 22: 39–43.
Table A3.1  Current Popular Mode of Preparing, Handling, and Storing OnaBTX-A
Popular methods
Manufacturer’s recommendations1
Storage
Before reconstitution
≤36 months at 2°C–8°C (100 U vial)
≤36 months at 2°C–8°C (100 U vial)
  24 months at 2°C–8°C (50 U vial)
  24 months at 2°C–8°C (50 U vial)
After reconstitution
  16 weeks at 2°C–8°C3,4,10
  4 hours at 2°C–8°C
Preparation
Diluent
Preserved normal saline (0.9% saline with 0.9% benzyl alcohol)10,12
Non-preserved normal saline (0.9% saline)
Concentration
Concentrations 1–10 mL/100 U vial as needed for appropriate uptake and diffusion2,10
2.5 mL/100 U vial
Handling
No special precautions 10,16–18
DO NOT agitate or cause foaming
Injection technique
Insulin syringe with 30-gauge needle18 or tuberculin syringe with 30–32-gauge needle9
None recommended

appendix 3
317
3. Hexsel DM, de Almeida AT, Rutowitsch M et al. Multicenter, dou­
ble-blind study of the efficacy of injections with botulinum toxin
type A reconstituted up to six consecutive weeks before applica­
tion. 2003; 29: 523–9.
4. Hui JI, Lee WW. Efficacy of fresh versus refrigerated botulinum
toxin in the treatment of lateral periorbital rhytids. Ophthal Plast
Reconstr Surg 2007; 23(6): 433–8.
5. Alam M, Bolotin D, Carruthers J Consensus statement regarding
storage and reuse of previously reconstituted euromodulators.
Dermatol Surg 2015; 41: 321–6.
6. Yang GC, Chiu RJ, Gillman GS. Questioning the need to use Botox
within 4 hours of reconstitution: A study of fresh vs. 2-week-old
Botox. Arch Facial Plast Surg 2008; 10: 273–9.
7. Trindade de almeida AR, Cardoso Secco L, Carruthers A.
Handling Botulinum toxins: An updated literature review.
Dermatol Surg 2011; 37: 1553–65.
8. Hsu J, Dover J, Arndt K. Effect of volume and concentration on the
diffusion of botulinum exotoxin A. Arch Dermatol 2004; 140: 1351–4.
9. Carruthers J, Fagien S, Matarasso SL. Consensus recommenda­
tions on the use of botulinum toxin type A in facial aesthetics.
Plast Reconstr Surg 2004; 114(6 Suppl): 1S–22S.
10. Klein AW. Complications and adverse reactions with the use of
botulinum toxin. Dis Mon 2002; 48: 336–56.
11. Alam M, Dover JS, Arndt KA. Pain associated with injection of
botulinum A exotoxin reconstituted using isotonic sodium chlo­
ride with and without preservative: A double-blind, randomized
controlled trial. Arch Dermatol 2002; 138: 510–4.
12. Amado A, Jacob SE. Letter: Benzyl alcohol preserved saline used
to dilute injectables poses a risk of contact dermatitis in fragrance-
sensitive patients. Dermatol Surg 2007; 33: 1396–7.
13. Menon J, Murray A. Microbial growth in vials of Botulinum toxin
following use in clinic. Eye (Lond) 2007; 21: 995–7.
14. Alam M, Yoo SS, Wrone DA, et al. Sterility assessment of multiple
use botulinum A exotoxin vials: A prospective simulation. J Am
Acad Dermatol 2006; 55: 272–5.
15. Liu A, Carruthers A, Cohen JL et al. Recommendations and cur­
rent practices for the reconstitution and storage of botulinum
toxin type A. J Am Acad Dermatol 2012; 67: 373–8.
16. Trindade de Almeida AR, Kadunc BV, Di Chiacchio N, Neto DR.
Foam during reconstitution does not affect the potency of botuli­
num toxin type A. Dermatol Surg 2003; 29: 530–1.
17. Kazim NA, Black EH. Botox: Shaken, not stirred. Ophthalmic
Plastic and Reconstructive Surgery 2008; 24: 10–12.
18. Flynn TC, Carruthers A, Carruthers J. Surgical pearl: The use of
the Ultra-Fine II short needle 0.3 cc insulin syringe for botulinum
toxin injections. J Am Acad Dermatol 2002; 46: 931–3.
19. Parsa AA, Lye KD, Don Parsa F. Reconstituted botulinum type A
neurotoxin: Clinical efficacy after long-term freezing before use.
Aesth Plast Surg 2007; 31: 188–91.
20. Carruthers A, Carruthers J, Cohen J. Dilution volume of botuli­
num toxin type A for the treatment of glabellar rhytides: Does it
matter? Dermatol Surg 2007; 33: S97–104.

318
Patient treatment record
appendix 4

319
Informed consent for the treatment of facial and body wrinkles
with botulinum toxin
RATIONALE
I am aware that when a small amount of purified botulinum toxin A
(BoNT-A) is injected into a muscle it causes weakness of that muscle.
This occurs in 3–5 days or even later, and usually lasts 3–5 months but
can last for shorter or longer amounts of time, depending on which
BoNT-A product is used.
Frown lines between the eyebrows are due to contraction of mus­
cles around and between the eyebrows. Injecting BoNT-A into this
area will temporarily weaken these muscles causing a reduction or
disappearance of the frown lines. Similarly, crow’s feet and horizon­
tal forehead lines can be improved by injecting BoNT-A into these
areas, weakening the muscles that cause the wrinkles on the forehead
and around the eyes. Many other areas of the central and lower face,
neck, and chest also can be treated successfully with BoNT-A, but
treatment of any area other than the forehead, between the eyebrows
and the crow’s feet is currently not FDA approved and is performed
off-label.
RESULTS AND AFTER TREATMENT CARE

1. I understand that I will not be able to “frown,” produce crow’s
feet, or see certain wrinkles while the injections of BoNT-A
into these areas and other areas are effective. After a period
of months wrinkles will return, at which time retreatment is
appropriate and needed to maintain the previously treated
areas without wrinkles.

2. I understand that I must remain upright and not bend or lower
my head (i.e., to tie my shoes, or pick up something from the
ground), and I must not manipulate or rub the treated areas for
2–3 hours after my treatment session.

3. I understand that I might experience quicker results if I repeat­
edly contract and use (e.g., frown or squint) the injected mus­
cles for the 2–3 hours after my treatment session.
RISKS AND COMPLICATIONS
The most common side effects associated with BoNT-A injections
for wrinkle correction are bruising and swelling. These local reac­
tions are temporary. Less commonly, headache, numbness, tempo­
rary drooping of one or both eyebrows or eyelids, the enlargement of
skin folds under the eyelids or asymmetry can occur in 2% of those
injected. Any of these side effects can last for a few hours up to 2–4
weeks and possibly longer.
In a very small number of individuals the injections may not work
as completely as they do in others nor may they last as long as they
do in others. Everyone responds to injections of BoNT-A in their own
way. Results also may vary depending on which BoNT-A product is
used. At times, a touch-up injection 2–3 weeks later can improve the
initial results.
You should inform the doctor if you develop any unusual symp­
toms (including difficulty with swallowing, speaking, or breathing),
or if any similar existing symptom worsens.
If loss of strength, muscle weakness, or impaired vision occurs, you
should avoid driving a car or engaging in other potentially hazardous
activities.
Adverse event information may be reported directly to Allergan
Inc. by phone to 800-433-8871. In addition, adverse events may also
be reported to the FDA MedWatch Reporting System by the follow­
ing methods:
• Online at
• Phone at 1-800-FDA-1088
PREGNANCY, NEUROLOGIC DISEASE, AND MEDICATIONS
I am aware that BoNT-A is absolutely contraindicated in all preg­
nant women and must not be injected if I am not sure whether I
am pregnant. If I am trying to conceive, BoNT-A should not be
injected for three months prior to conception. BoNT-A should not
be injected if I am breastfeeding or if I have any neurologic dis­
ease such as multiple sclerosis or myasthenia gravis. The effect of
BoNT-A may be potentiated by aminoglycoside antibiotics such as
spectinomycin, tobramycin, neomycin, gentamycin, kanamycin, or
amikacin. Please notify the doctor or nurse if you are currently on
such medications.
I am not nursing. Neither am I aware that I am pregnant nor do I
have any significant neurologic disease. (________) (initial).
Today’s treatment will be performed with: (circle one used)
BOTOX Cosmetic (onabotulinumtoxinA) or DYSPORT (abob­
otulinumtoxinA) or XEOMIN (incobotulinumtoxinA) or Name
other:________________.
PHOTOGRAPHS
I authorize the taking of photographs and their use for scientific and
medical purposes both in publications and presentations. I under­
stand that my identity will be protected.
PAYMENT
I understand this is a cosmetic procedure and payment is my respon­
sibility and due at the completion of treatment.
I have read and completely understand all of the above. All of my
questions have been answered satisfactorily by the doctor and nurse.
I accept the risks, benefits, and potential complications of this proce­
dure and hereby give my informed consent to be treated with: (circle
one) BOTOX Cosmetic (onabotulinumtoxinA) or DYSPORT  (abo­
botulinumtoxinA) or XEOMIN (incobotulinumtoxinA) or
Name other:______________
Signed:________________Date:_______________________
Name:_________________________
Witness’s name and signature:____________________
Treating physician:________________________
appendix 5

320
Side effects and contraindications to injections with
botulinum toxins
Physicians are instructed to have their patients read the Medication
Guide that is included in every carton of onabotulinumtoxinA
(OnaBTX-A) before they inject it and each time it is given to the
patient. This information does not take the place of the patient talking
with their physician about their medical condition(s) or their treat­
ment. Patients are encouraged to share this information with their
family members and caregivers.
OnaBTX-A (BOTOX® Cosmetic) is approved by the FDA only to
treat and temporarily improve moderate to severe horizontal fore­
head lines, glabellar frown lines and lateral canthal lines in adults
younger than 65 years of age. It is not known whether OnaBTX-A is
safe or effective in patients younger than 18 years of age for the treat­
ment of axillary hyperhidrosis, the only area on the body the FDA
approved for the treatment of hyperhidrosis. OnaBTX-A is not rec­
ommended for use in patients younger than 18 years of age.
POTENTIAL SIDE EFFECTS OF OnaBTX-A INJECTIONS

1. Adverse effects of limited duration that are common, localized,
and not of a serious nature:2,3

Common with any percutaneous injection
a. Mild stinging, burning, or pain with injection
b. Edema around injection site
c. Erythema around injection site
d. Mild headache, localized and transient

Technique dependent
a. Ecchymosis lasting 3–10 days
b. Asymmetry
c. Oral incompetence and asymmetric smile
d. Lack of neck strength
e. Lack of intended cosmetic effect

Rare and idiosyncratic
a. Numbness and paresthesias, localized and transient
b. Focal tonic movements (twitching)
c. Mild nausea and occasional vomiting
d. Dizziness or syncope
e. Mild malaise and myalgias (localized and generalized)
f. Dry mouth
g. Periorbital edema

2. Adverse effects of longer duration that can be serious and are
technique dependent:
a. Blepharoptosis
b. Brow ptosis
c. Diplopia
d. Blurred vision or diminished visual acuity
e. Diminished tearing and xerophthalmia with or without
keratitis
f. Ectropion (can lead to xerophthalmia)
g. Lagopthalmus (can lead to exposure keratitis)
h. Dysphagia
i. Dysarthria
j. Dysphonia

3. Adverse effects of longer duration that can be serious and are
not technique dependent: Immediate hypersensitivity reactions
a. Urticaria, pruritus, rash, or generalized erythema
b. Dyspnea, wheezing, or exacerbation of asthma
c. Soft tissue edema
d. Anaphylaxis
Contraindications to OnaBTX-A Injections
Patients should not be treated or otherwise treated with extreme cau­
tion who are

1. Psychologically unstable or who have questionable motives and
unrealistic expectations

2. Dependent on intact facial movements and expressions for
their livelihood (e.g., actors, singers, musicians, and other
media personalities)

3. Afflicted with peripheral motor neuropathic disease, amyo­
trophic lateral sclerosis, or neuromuscular junctional disor­
ders (e.g., myasthenia gravis or Lambert-Eaton syndrome)
or allergic to any of the component ingredients of BTX-A or
BTX-B (i.e., BoNT, human albumin, saline, lactose, and sodium
succinate)

4. Taking certain medications that can interfere with neuromuscu­
lar impulse transmission and potentiate the effects of BoNT (e.g.,
aminoglycosides, penicillamine, quinine, and calcium blockers)

5. Pregnant or lactating (BoNTs are classified as pregnancy cat­
egory C drugs)

6. Experiencing an active skin infection at the planned
injection site
POTENTIAL BENEFICIAL EFFECTS OF BOTOX® COSMETIC
INJECTIONS

1. Relief of frontal or occipital “tension headaches”

2. Relief of migraine headaches

3. Compensatory muscle strengthening of the same muscles when
segmentally treated (e.g., strengthening of the lower fronta­
lis and elevation of the eyebrows when the upper frontalis is
treated or improvement of posture and projection of breasts
when the lower pectoralis major or minor are treated)
appendix 6
Distant Spread of Toxin Effect1
Postmarketing reports indicate that the effect of OnaBTX-A
and all botulinum toxin products may spread from the area of
injection to produce symptoms consistent with botulinum toxin
effects. These may include asthenia, generalized muscle weakness,
diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria,
urinary incontinence, and breathing difficulties. These symptoms
have been reported hours to weeks after injection. Swallowing and
breathing difficulties can be life-threatening and there have been
reports of death. This risk of symptoms is probably greatest in chil­
dren treated for spasticity but symptoms can also occur in adults
treated for spasticity and other conditions particularly in those
patients who have underlying conditions that would predispose
them to these symptoms. In unapproved uses, including spastic­
ity in children and adults, and in approved indications, cases of
spread of effect have occurred at doses comparable to those used
to treat cervical dystonia and at lower doses.

appendix 6
321

4. Compensatory muscle strengthening of synergistic muscles
(e.g., strengthening of the lip levators and depressors when the
orbicularis oris is treated)

5. Compensatory muscle strengthening of antagonistic muscles
(e.g., strengthening of the lower frontalis and medial brow lift
when the medial brow depressors are treated or lateral brow lift
when lateral brow depressors are treated)
RISK EVALUATION AND MITIGATION STRATEGY
In 2009 when another BoNT-A was approved by the FDA for use in the
United States, Allergan, Inc. instituted a surveillance program called
“Risk Evaluation and Mitigation Strategy” (REMS) to update its physi­
cian injectors on safety issues regarding the use of BOTOX®/BOTOX®
Cosmetic (OnaBTX-A). The goals of the REMS program are to minimize
the risks of medication errors related to the lack of interchangeability of
OnaBTX-A units with those of licensed botulinum toxins of other man­
ufacturers and to inform prescribers and patients about the potential
occurrence of the spread of toxin effect beyond the injection site.
Physician injectors are advised to discuss the risks associated with
OnaBTX-A therapy outlined above and in the Medication Guide
for OnaBTX-A with patients and with all the health care personnel
who are involved in the preparation, prescribing, and/or injection of
OnaBTX-A. According to FDA regulations, a copy of the Medication
Guide must be distributed directly to each patient every time he
or she receives an OnaBTX-A injection. Copies of the OnaBTX-A
Medication Guide can be obtained by calling 1-800-433-8871 or
printing copies directly from the websites (
or ). A copy of the Medication Guide also is
included in every carton of OnaBTX-A.
Because there are currently multiple marketed botulinum toxin
products with different dose to potency ratios, there is a concern
about medication errors such as overdosing based on incorrect unit
administration from interchanging different BoNTA products.1
It is important to understand that BOTOX®/BOTOX® Cosmetic
(OnaBTX-A, Allergan, Inc.), MYOBLOC® (rimabotulinumtoxinB,
Solstice), DYSPORT® (abobotulinumtoxinA, Galderma Laboratories,
L.P., 14501 North Freeway, Fort Worth, TX), and XEOMIN® (inco­
botulinumtoxinA, Merz Pharmaceuticals, 6501 Six Forks Road,
Raleigh, NC) are unique biological products that are not interchange­
able with each other. The potency units of OnaBTX-A are specific
to the preparation and assay method utilized by the manufacturer.
Therefore, units of biological activity of OnaBTX-A cannot be com­
pared to or converted into units of any other BoNT product assessed
with any other specific assay method. Additionally, OnaBTX-A has
multiple indications which all require specific dosing. Caution should
be taken to ensure that the dosing, dilution, injection volume, and
injection patterns are appropriate for the product and the patient.
No definitive reports of serious adverse events of distant spread
of toxin effect associated with the cosmetic and dermatologic use of
OnaBTX-A have been reported when the recommended labelled dose
of 20 units for glabellar lines, 24 units for lateral canthal lines, or 100
units for severe primary axillary hyperhidrosis have been used.2,3
REFERENCES
1. Allergan, Inc. Botox Cosmetic (botulinum toxin type A) Purified
Neurotoxin Complex (Package Insert). Irvin, California: Allergan,
Inc., revised October 2017.
2. Coté TR, Mohan AK, Polder JA, Walton MK, Bruan MM.
Botulinum toxin type A injections: Adverse events reported to the
US Food and Drug Administration in therapeutic and cosmetic
cases. JAAD 2005; 53: 07–415.
3. Gershon SK, Wise RP, Braun MM. Adverse events reported with
cosmetic use of Botulinum toxin A. Pharmacoepidemiology Drug
Safety 2001; 10(Suppl): S135–6.

Taylor & Francis Taylor & Francis Group

323
Index
AbobotulinumtoxinA (AboBTX-A),
113, 231
AboBTX-A, see AbobotulinumtoxinA
Acquired asymmetry, 131
Aging, 105, 112, 152
chronological, 152, 211
Alar musculature, 199
Alar nasalis, 200
Anomalus nasi, 191, 192
Anterior dilator naris, 200
Apraclonidine, 128, 129
Asians, 299; see also Botulinum toxin use
in Asians
and Caucasians anatomic differences, 299
facial shapes and aesthetic standards, 299
facial types, 299, 300
injection points and dose of BoNT-A, 301
Asymmetric smile, 160, 195, 196, 229, 233;
see also Lower lip asymmetric smile
crooked, 131
iatrogenically created, 249
idiosyncratic, 256, 257
upper lip, 217
Asymmetry, 131, 132
acquired, 131
iatrogenic, 131, 133
Axillary hyperhidrosis, 320–321
Azzalure®, see DYSPORT®
Bands, vertical, 279
Becton-Dickinson insulin U-100
syringe, 120
Blepharoptosis, 120, 122, 128, 129,
130, 132
Blinking, 174
Bocouture®, see XEOMIN®
BOTOX®, 113
cosmetic injections, see
OnabotulinumtoxinA injections
Sign, 189, 190
Botulinum neurotoxin (BoNT), 188, 294
applications, 105
formulations of, 113
serotype A, 113
serotype B, 113
Botulinum neurotoxin serotype A
(BoNT-A), 113
arm contouring, 307
calves, 306, 307
in cobblestone chin, 302
formulations of, 113
intradermal, 306
parotid gland enlargement, 305
shoulder contouring, 308
square jaw, 303, 304
temporalis hypertrophy, 304, 305
trapezius, 308
Botulinum neurotoxin type B
(BoNT-B), 113
Botulinum toxin use in Asians, 299; see also
Asians; Caucasians
for arm contouring, 307
body shaping, 307–308
for calves, 306, 307
for cobblestone chin, 302
forehead horizontal lines, 300
glabellar frown lines, 300
infraorbital wrinkles, 301
injection points and dose, 301
intradermal botulinum toxin, 305–307
lateral canthal rhytides, 300–301
parotid gland enlargement, 304–305
for shoulder contouring, 308
site specific differences, 300
for square jaw, 302–303, 304
temporalis hypertrophy, 303–304, 305
for trapezius, 308
Breast, 293, 294
botulinum toxin and action
mechanism, 294
botulinum toxin and breast position,
294–296
changes in mound position with
age, 294
Cooper’s ligaments, 293
distance between sternal notch and
nipple, 295
implant stabilization and capsular
formation, 296–297
injecting 10–15 U U OnaBTXTX-A/
IncoBTXTX-A, 296–297
nipple-areola complex position, 295
post mastectomy pain syndrome, 297
ptosis, 293–294, 295
three injection points technique, 295–296
uses of botulinum toxin in breast, 296
Brow depressor, 114, 117
Brow elevation, 148
Brow ptosis, 169
Bruising, 181
Buccal sphincter incompetence, 233
Buccinator, 242, 243
Buccinator muscle, 111, 242, 243
Bunny lines, see Nasoglabellar lines
Calcitonin gene-related peptide
(CGRP), 296
Canine smile, 225, 228, 229; see also
Excessive maxillary gingival display
Care, post/operative, 319
Caucasians, 299; see also Botulinum toxin
use in Asians
facial shapes and aesthetic
standards, 299
injection points and dose of BoNT-A for
glabellar frown lines, 301
Central brow frown lines, 114
approximation and depression of medial
brow, 124
arching of eyebrows, 127
asymmetry, 131, 132
Becton-Dickinson insulin U-100
syringe, 120
brow depressors, 114
central brow anatomy, 116–118
compensatory brow lifting, 132
converging arrows pattern, 126, 127
corrugator dimple, 116, 117
corrugator supercilii, 116, 117
depressor supercilii, 117, 118
dilution for injecting central brow,
118–119
dosing, 119–126
elevating eyebrows, 121–122
erythema and edema in pattern of
injections, 134
eyelid ptosis, 128, 129
flat eyebrow arches, 115
glabella, 114
glabellar wrinkle patterns, 116
iatrogenic asymmetry, 131, 133
ideal eyebrows for man, 115
injecting technique, 122, 123
injection points for treating, 120, 121
insertion of corrugators, 116
inverted omega pattern of glabellar
frowning, 125
lagophthalmos, 129
low set eyebrows and upper eyelid and
lateral canthal hooding, 115
margin to reflex distance, 130
medial brow dip, 131
omega pattern of glabellar
frowning, 125
orbicularis oculi, 117, 118
patients treated with OnaBTX-A,
136–138
patterns of glabellar frowning, 123
pretreatment evaluation, 119
problem assessment and patient selection,
114, 116
pseudoblepharoptosis, 133
single brow elevator, 114
superior tarsal muscle of Müller, 118
treatment complications, 128–134
treatment implications, 135
treatment outcomes, 126–127
treatment with OnaBTX-A
injections, 115
unintentional frowning during intense
concentration, 115

Index
324
Central brow frown lines (Continued)
upper eyelid anatomy and muscle
attachments, 119
U type of glabellar contraction, 124
vigorous glabellar contraction and V
pattern of frown lines, 124
widening of glabellar interbrow space
and shortening of transverse length
of brow, 135
Central lip levators, 230
CGRP, see Calcitonin gene-related peptide
Chest
area of central upper chest with
extensive vertical and horizontal
wrinkling, 288
central upper chest area treated with
OnaBTX-A injection, 289, 290
upper chest and decollete wrinkling, 286
Chinese moustache, 258
Chin puckering and deep mental
crease, 264
depressor anguli oris, 269
dilution, 268
dosing, 269
functional anatomy, 266–268
mentalis, 269
mentolabial crease, 269
mentum, 269
patients treated with OnaBTX-A, 266,
267, 268, 269, 270–271, 272–273
problem assessment and patient selection,
264, 266
soft tissue fillers, 269
treatment complications, 271
treatment implications, 271, 273
treatment outcomes, 269
two-point injection technique, 268, 269
Commissural smile, see Mona Lisa smile
Complete smile, see Full denture smile
Complications
central brow frown lines, 128–134
chin puckering and deep mental
crease, 271
excessive maxillary gingival display, 232
eyebrow lift, 171–172
horizontal forehead lines, 144–149
horizontal lines and vertical bands of
neck, 285
jawline blunting, 278
lateral canthal lines, 160–162
lower eyelid lines, 180
lower lip asymmetric smile, 255
melomental folds, 262, 264
nasal flare, 203
nasal tip ptosis, 210–211
nasoglabellar lines, 195
nasolabial folds, 219–221
perioral lip lines and rhytides, 249–250
upper chest and decollete wrinkling, 289
upper platysma wrinkling, 278
Compressor naris, 189
Consent, 319
Converging arrows, 126, 127
Cooper’s ligaments, 293; see also Breast
Corrugator supercilii muscle, 109, 116, 117
technique of injecting medial, 122
Cranial nerve
seventh, 105, 131
Crooked smile, 254
Crow’s feet, 109, 152, 155, 158, 159, 160; see
also Lateral canthal lines
Cuspid smile, see Canine smile
Delicate massage, 180
Depressor anguli oris muscle, 112, 243,
258–260, 269
point of injection for, 261
Depressor labii inferioris muscle, 112, 243,
254, 255
Depressor septi nasi muscle, 110, 203,
205, 206
injection in center of columella, 208
Depressor supercilii muscle, 109, 117, 118
injecting in medial aspect of, 122
Dilator naris, 189, 200
Dilution
central brow frown lines, 118–119
chin puckering and deep mental
crease, 268
excessive maxillary gingival display, 227
eyebrow lift, 169
horizontal forehead lines, 140
horizontal lines and vertical bands of
neck, 283
jawline blunting, 276
lateral canthal lines, 155
lower eyelid lines, 176
lower lip asymmetric smile, 255
melomental folds, 260
nasal flare, 202
nasal tip ptosis, 206
nasoglabellar lines, 192
nasolabial folds, 217
perioral lip lines and rhytides, 244–245
upper chest and decollete wrinkling, 288
upper platysma wrinkling, 276
Diplopia, 195
Dosing
central brow frown lines, 119–126
chin puckering and deep mental
crease, 269
excessive maxillary gingival display,
228–231
eyebrow lift, 169–170
horizontal forehead lines, 140–143
horizontal lines and vertical bands of
neck, 283
jawline blunting, 276–277
lateral canthal lines, 155–158
lower eyelid lines, 178–180
lower lip asymmetric smile, 255
melomental folds, 260, 262
nasal flare, 202
nasal tip ptosis, 206–207
nasoglabellar lines, 192–193
nasolabial folds, 217–219
perioral lip lines and rhytides, 245–248
upper chest and decollete wrinkling, 288
upper platysma wrinkling, 276–277
Drool grooves, 258
Dry eye, see Xerophthalmia
Dynamic wrinkles, 152
DYSPORT®, 113
Ecchymosis, 182
Ectropion, 160, 161
Electromyograph (EMG), 233
EMG, see Electromyograph
Epimysium, 105
Exaggerated upper gummy smile, see
Gummy smile
Excessive maxillary gingival display, 223
canine or cuspid smile, 225, 228, 229
central lip levators, 230
dilution, 227
dosing, 228–231
exaggerated gummy canine smile, 228
full denture or complete smile, 225, 229
functional anatomy, 223, 227
high gingival smile, 224
ideal smile, 223
intraoral injection, 230
long face syndrome, 225
maxillary central incisor display, 225
Mona Lisa or commissural smile, 225,
227, 229
OnaBTX-A injection, 230
passive eruption, 225, 226
problem assessment and patient
selection, 223
rhinogingivolabial syndrome, 223
smile line, 224
transverse rhytide, 224, 232
treatment complications, 232
treatment implications, 232–233
treatment outcomes, 231–232
upper lip levators, 233
Yonsei point, 231
External carotid artery, 106
Eyebrow lift, 165
brow position, 168
brow ptosis, 169
complications, 171–172
dilution for, 169
dosing, 169–170
functional anatomy of, 169
ideal female brow, 167
injection point, 170, 171, 172
OnaBTX-A treatment, 169, 173, 174, 175,
176, 177
outcomes, 170–171
problem assessment and patient selection,
165–169
shapes of eyebrows, 166
treatment implications, 172
Eyebrows
arching of, 127
elevating eyebrows, 121–122
ideal eyebrows for man, 115

Index
325
low set eyebrows and upper eyelid and
lateral canthal hooding, 115
shapes of, 166
Eyelid, ptosis, 128
Eyelid skin, 152
Facial expression muscles, 310–311
in action, 311–312
bony origins of, 313, 314
Facial muscles, 106–112, see Muscles of
facial expression
lower face, 111–112
midface region, 109–111
platysma, 112
upper face region, 106–109
Facial nerve, 105, 107
Food and Drug Administration
(FDA), 113, 118
Forehead
horizontal lines, 135, 140–143,
144–149, 300
mild forehead wrinkling, 148
OnaBTX-A treatment of, 145, 146, 149,
150–151
Forehead lines, see Horizontal forehead
lines
Frontalis muscle, 106–107, 140
Full denture smile, 225, 229; see also
Excessive maxillary gingival display
Functional anatomy
chin puckering and deep mental crease,
266–268
excessive maxillary gingival display,
223, 227
eyebrow lift, 169
horizontal lines and vertical bands of
neck, 281–283
lateral canthal lines, 152–155
lower eyelid lines, 172–176
lower lip asymmetric smile, 254–255
melomental folds, 258–260
nasal flare, 199–202
nasal tip ptosis, 205–206
nasoglabellar lines, 189, 192
nasolabial folds, 212–217
perioral lip lines and rhytides, 238–244
platysma, 274–276
upper chest and decollete wrinkling,
287–288
upper platysma wrinkling, 274–276
Gingival smile, 224
Glabella, 114, 116
Glabellar frown lines, see Central brow
frown lines
Glabellar spread test, 119
Gummy smile, 205; see also Excessive
maxillary gingival display
anatomy of, 226
exaggerated gummy canine smile, 228
Habitual scowling, 134
Handling, BOTOX®, 315–316
Heavy/handed massage, 123, 143
HIFU, see Highintensity focused ultrasound
High gingival smile, 224; see also Excessive
maxillary gingival display
Highintensity focused ultrasound
(HIFU), 280
Horizontal forehead lines, 135
abrupt contraction of frontalis, 139
anatomy of, 139–140
compensatory brow elevation, 148
dilution, 140
dosing, 140–143
frontalis, 140
injection sites, 141, 144, 145, 146
location and extent of temporal fusion
line, 147
Mephisto or Mr. Spock look, 143
mild forehead wrinkling, 148
OnaBTX-A treatment of forehead, 145,
146, 149, 150–151
OnaBTX-A treatment of glabellar frown
lines, 150–151
problem assessment and patient selection,
135, 139
random pattern injections, 142
treatment complications, 144–149
treatment implications when injecting
frontalis, 149–152
treatment outcomes, 143–144
Horizontal lines and vertical bands of
neck, 279
anatomical landmarks of anterior neck, 282
deep horizontal wrinkles of anterior
neck, 280
dilution, 283
dosing, 283
functional anatomy of, 281–283
patients treated with OnaBTX-A
injection, 285, 286, 287
platysma, 281
problem assessment and patient selection,
279–281
raising wheal while injecting OnaBTX-A
in neck, 284
treatment complications, 285
treatment implications, 285–286
treatment outcomes, 283–285
turkey neck deformity, 281
types of decussating platysma, 282
Hyperkinetic mentalis, 264, 266, 267
Hyperkinetic upper lip levators, 224
Iatrogenic asymmetry, 131, 133
Ideal eyebrow, 115
Ideal smile, 223; see also Excessive
maxillary gingival display
Idiosyncratic asymmetric smile, 254, 256,
257, 258
Idiosyncratic asymmetry, 131, 133
Idiosyncratic facial morphology, 212
IncobotulinumtoxinA (IncoBTX-A), 113
IncoBTX-A, see IncobotulinumtoxinA
Increase in palpebral aperture (IPA), 180
Informed consent, 319
Injection points (IPs), 300
Insulin syringe, 118, 169, 181
Iopidine®, 128
IPA, see Increase in palpebral aperture
IPs, see Injection points
Jawline blunting, 273; see also Upper
platysma wrinkling
dilution, 276
dosing, 276–277
problem assessment and patient selection,
273–274
treatment complications, 278
treatment implications, 279
treatment outcomes, 277–278
Jelly rolls, 174, 177
Lagophthalmos, 129
Lash ptosis (LP), 129
Lateral brow elevation, 170, 172
Lateral canthal lines, 152
Crow’s feet, 152, 155, 159, 160
depressor supercilii, 154
dilution for treating, 155
dosing, 155–158
functional anatomy of, 152–155
lateral orbital wrinkles, 153
lower crow’s feet, 161
OnaBTX-A treatment, 163, 164, 165
orbicularis oculi, 153
patterns of crow’s feet, 158
problem assessment and patient
selection, 152
technique of injecting crow’s feet or
lateral orbital orbicularis oculi, 156
treatment complications, 160–162
treatment implications, 162–165
treatment outcome, 158–160
treatment with OnaBTX-A, 157, 159
wheals of injected OnaBTX-A, 156
zygomaticus major, 154
zygomaticus minor, 154
Leptorrhine shaped nose, 199
Levator alae nasi, 201
Levator anguli oris muscle, 111
Levator labii superioris (LLS), 192
Levator labii superioris alaeque nasi muscle
(LLSAN muscle), 110, 189, 217
Lip pars peripheralis, 239
Lipstick bleeding, 237, 238
LLS, see Levator labii superioris
Long face syndrome, 225; see also Excessive
maxillary gingival display
Lower crow’s feet, 161
Lower eyelid lines, 172
blinking, 174
dilution, 176
dosing, 178–180
festoons of lower eyelids, 174, 178
functional anatomy, 172–176
jelly rolls, 174, 177
nasolacrimal canalicular system, 176, 179

Index
326
Lower eyelid lines (Continued)
OnaBTX-A treatment for lower eyelid
folds, 174, 178
patients treated with OnaBTX-A,
182–184
problem assessment and patient
selection, 172
technique of injecting, 179
treatment complications, 180
treatment implications, 184–185
treatment outcomes, 180
Lower face, 111–112; see also Facial muscles
anatomic delineation of, 236
depressor anguli oris muscle, 112
depressor labii inferioris muscle, 112
mentalis muscle, 112
orbicularis oris muscle, 111–112
Lower lip asymmetric smile, 250
dilution, 255
dosing, 255
functional anatomy of, 254–255
by hyperkinetic central levators, 253
by hyperkinetic depressor labii inferioris,
254, 255
by hyperkinetic lateral levators, 253
patients treated with OnaBTX-A,
256–258
problem assessment and patient selection,
250, 254
treatment, 255
LP, see Lash ptosis
Margin to reflex distance (MRD), 128, 130
Marionette lines, 258
Masseter, 106, 111
Masseteric hypertrophy, 299, 302, 303
Masseter muscle, 111
Mastication, 188, 236, 243
Medial brow depressors, 117
Melomental folds, 258
depressor anguli oris, 258, 259
dilution, 260
dosing, 260, 262
functional anatomy of, 258–260
marionette lines, 258
patients treated with OnaBTX-A,
263–264, 265
point of injection for depressor anguli
oris, 261
treatment, 262, 264
Mentalis, 269
Mentalis muscle, 112, 269
Mental sling, 260
Mentolabial crease, 269
Mentolabial sulcus, 240
Mentum, 269
mesoBOTOX injections, 219
Mestizo nose, 199
microBOTOX injections, 219
Mid face, 188
Midface region, 109–111; see also Facial
muscles
buccinator muscle, 111
depressor septi nasi muscle, 110
levator anguli oris muscle, 111
levator labii superioris alaeque nasi
muscle, 110
masseter muscle, 111
mimetic muscles, 188
nasalis muscle, 109–110
risorius muscle, 111
zygomaticus muscle, 110
Mimetic muscles, 188
Modiolus, 213
Mona Lisa smile, 225, 227, 229; see also
Excessive maxillary gingival display
MRD, see Margin to reflex distance
Müller’s muscle, 128, 129
Muscles of facial expression, 105,
310–311
in action, 311–312
action mechanisms of Botulinum
toxin, 105
arteries of face, 106, 108
bony origins of, 313, 314
classification, 105
development, 105
facial muscles, 106–112
general facial anatomy, 106
general function, 105
motor branches of facial nerve, 106
nerves of face, 107
sarcomere, 105
veins of face, 106, 108
Muscle spasms, 297
Myobloc®, 113
Naphazoline, 129
Nasal flare, 197; see also Nose
alar musculature, 199
alar nasalis, 200
anterior dilator naris, 200
different nostril shapes, 198
dilution, 202
dosing, 202–203
external surface and skeletal anatomy of
nose, 201
functional anatomy, 199–202
leptorrhine shaped nose, 199
Mestizo nose, 199
nasal profile variations, 197
patients treated with OnaBTX-A,
202, 203
problem assessment and patient selection,
197–199
treatment, 203
Nasal flaring, 199
Nasalis muscle, 109–110
Nasal profile, 197
Nasal scrunch, see Bunny lines
Nasal tip ptosis, 203; see also Nose
concave curvature, 207
depressor septi nasi, 205, 206
dilution, 206
dosing, 206–207
downwardly rotated nasal tip, 204
dynamic nasal tip ptosis, 204
functional anatomy, 205–206
gummy smile, 205
injection of depressor septi nasi in center
of columella, 208
nasal tip, 205
nasolabial angle, 204
patients treated with OnaBTX-A, 208,
209, 210, 211
problem assessment and patient selection,
203–205
rhinogingivolabial syndrome, 204
treatment complications, 210–211
treatment implications, 211
treatment outcomes, 207, 210
upper lip transverse crease and
downward rotation of nasal tip, 205
Nasion, 116
Nasociliary rhytides, 189, 193, 194
Nasoglabellar lines, 188
anomalus nasi, 191, 192
BOTOX® Sign, 189, 190
compressor naris, 189
dilution, 192
dosing, 192–193
functional anatomy of, 189, 192
glabellar and nasoglabellar bunny
lines, 193
injecting injection, 193, 194
injecting transverse nasalis anterior and
superior to nasofacial angle, 192
myorelaxation of, 192
patients treated with OnaBTX-A, 195,
196, 197
posterior dilator naris, 189
problem assessment and patient selection,
188–189
transverse nasalis, 191
treatment complications, 195
treatment implications, 195–197
treatment outcomes, 193–195
Nasolabial folds, 211; see also Nose
accordion-like wrinkles down the
cheeks, 214
clinical examples of types of, 213
deep nasolabial folds, 220
different lengths of, 213
different morphological types of, 213
dilution, 217
dosing, 217–219
elevation of upper lip, 219
functional anatomy, 212–217
LLSAN, 217
location of injection, 218, 219, 220
microBOTOX injections, 219
OnaBTX-A injection, 220, 221, 222
problem assessment and patient selection,
211–212
quadratus labii superioris, 218
sections of, 214
treatment complications, 219–221
treatment implications, 221, 223
treatment outcomes, 219

Index
327
zygomaticus major, 213
zygomaticus minor, 215–216
Nasolacrimal canalicular system, 176, 179
Naso/orbicular rhytides, 193, 194
Neck, see Horizontal lines and vertical
bands of neck
Nefertiti, 278
lift, 276, 277
Nerves of face, 107
Neurobloc®, see Myobloc®
Non-steroidal anti-inflammatory drugs
(NSAIDs), 162
Nose, 198, 200; see also Nasal flare; Nasal
tip ptosis; Nasolabial folds
external surface and skeletal anatomy
of, 201
leptorrhine shaped, 199
Mestizo, 199
Nostril shapes, 198
NSAIDs, see Non-steroidal anti-
inflammatory drugs
OculinumTM, 113; see also Botulinum toxin
OnabotulinumtoxinA (OnaBTX-A),
236, 315
handling, 315–316
injection technique, 316
preparation, 315
storage, 315
OnabotulinumtoxinA injections, 320
beneficial effects of, 320–321
for central brow frown lines, 115
central upper chest area treated with,
289, 290
contraindications to, 320
distant spread of toxin effect, 320
for excessive maxillary gingival
display, 230
for horizontal lines and vertical bands of
neck, 285, 286, 287
for nasolabial folds, 220, 221, 222
for perioral lip lines and rhytides, 244,
245, 249
potential side effects of, 320
risk evaluation and mitigation strategy, 321
for upper platysma wrinkling, 277,
278, 279
OnaBTX-A, see OnabotulinumtoxinA
Orbicularis oculi muscle, 108–109, 117,
118, 152
frontal view of orbital portion of, 153
technique of injecting medial aspect
of, 122
Orbicularis oris muscle, 111–112, 236
four quadrants and eight segments
of, 241
Palpebral orbicularis oculi, 117
Parallel lines, 120, 123, 126
Parotid gland, 106
Parotid plexus, 106
Pars labialis, 240, 242, 254
Pars mandibularis, 241, 242, 259, 274
Pars modiolaris, 275
Patient selection
central brow frown lines, 114, 116
chin puckering and deep mental crease,
264, 266
excessive maxillary gingival
display, 223
eyebrow lift, 165–169
horizontal forehead lines, 135, 139
horizontal lines and vertical bands of
neck, 279–281
jawline blunting, 273–274
lateral canthal lines, 152
lower eyelid lines, 172
lower lip asymmetric smile, 250, 254
nasal flare, 197–199
nasal tip ptosis, 203–205
nasoglabellar lines, 188–189
nasolabial folds, 211–212
perioral lip lines and rhytides, 236–238
upper chest and decollete wrinkling,
286–287
upper platysma wrinkling, 273–274
Patient treatment record, 318
Perioral lip lines and rhytides, 236
aspects of mandible, 244
buccinator, 242, 243
deep perioral rhytides and solar elastosis,
238, 239, 240
depressor anguli oris, 243
depressor labii inferioris, 243
dilution, 244–245
dosing, 245–248
functional anatomy of, 238–244
injection technique, 246
lip pars peripheralis, 239
lipstick bleeding, 237, 238
mentolabial sulcus, 240
modiolus, 241
OnaBTX-A injections, 244, 245, 249
orbicularis oris, 241
patients treated with OnaBTX-A, 247,
248, 249, 250, 251–253
perioral wrinkles, 237
philtral columns, 240
philtrum, 240
platysma, 243
problem assessment and patient selection,
236–238
treatment, 249–250
vermilion border, 239
Perioral rhytides, 245
Periorbital area, see Eyebrow lift; Lateral
canthal lines; Lower eyelid lines
Philtrum, 240
Platysma, 112, 236, 243, 273, 281, 285, 287,
312, 313; see also Facial muscles;
Upper platysma wrinkling
absence of, 281
anterolateral view of extent of, 275
decussation, 282, 284
depressors, 219
excessive contractions of, 287
and facial expressions, 155
fibers into the mimetic muscles, 286
functional anatomy of, 274–276
horizontal wrinkles, 114, 123, 140, 142,
147, 152, 171, 214, 276, 280, 285, 286
hyperkinetic platysma, 273
hypertrophic platysma, 283, 284
mandibular, 274
in neck, 281
palpation of, 283
pars labialis, 242, 243, 254, 259, 260
pars mandibularis, 241, 242, 243, 259, 260
pars modiolaris, 243
perioral lip lines and rhytides, 243
vertical bands, 276, 280, 281, 283, 285
PMPS, see Post-mastectomy pain syndrome
Posterior dilator naris, 189
Postinjection ecchymoses, 181, 283
Post-mastectomy pain syndrome (PMPS), 297
Preparation, BOTOX®, 315
Procerus muscle, 109
Pseudoaugmentation, 249
Pseudoblepharoptosis, 133
Pseudogynecomastia, 297, 298
Pseudoherniation, 182
Quadratus labii superioris, 218
Radiofrequency (RF), 280
Reloxin®, see DYSPORT®
REMS, see Risk Evaluation and Mitigation
Strategy
Results
central brow frown lines, 126–127
chin puckering and deep mental
crease, 269
excessive maxillary gingival display,
231–232
eyebrow lift, 170–171
horizontal forehead lines, 143–144
horizontal lines and vertical bands of
neck, 283–285
jawline blunting, 277–278
lower eyelid lines, 180
nasal tip ptosis, 207, 210
nasoglabellar lines, 193–195
nasolabial folds, 219
upper chest and decollete wrinkling, 289
upper platysma wrinkling, 277–278
RF, see Radiofrequency
Rhinogingivolabial syndrome, 204, 223
RimabotulinumtoxinB (RimaBTX-B), 113
RimaBTX-B, see RimabotulinumtoxinB
Risk Evaluation and Mitigation Strategy
(REMS), 321
Risorius (laughter muscle), 111, 154
Sarcomere, 105
Serotypes, 105, 114
SMAS, see Superficial musculo-aponeurotic
system
Smile line, 224; see also Excessive maxillary
gingival display

Index
328
SNARE (soluble N-ethylmaleimide-
sensitive factor attachment protein
receptor), 105
Soft tissue fillers, 269
SOOF, see Suborbicularis oculi fat
SP, see Substance P
Square jaws, 299, 302
Squinting, 153
Static wrinkles, 152
Storage, BOTOX®, 315
Submandibular gland, 282
Suborbicularis oculi fat (SOOF), 106, 182
Substance P (SP), 296
Superficial musculo-aponeurotic system
(SMAS), 106, 152, 188, 241
Superior tarsal muscle of Müller, 118
Transverse nasalis, injection point
for, 194
Transverse rhytide, 224, 232
Triangularis, see Depressor anguli oris
Turkey neck deformity, 281, 282, 286
United States (US), 113
United States of America (USA), 113
Upper chest and decollete wrinkling,
286
dilution, 288
dosing, 288
extensive vertical and horizontal
wrinkling, 288
functional anatomy of, 287–288
injection site, 288, 289
problem assessment and patient selection,
286–287
treated with OnaBTX-A injection,
289, 290
treatment, 289–290
Upper face region, 106–109; see also Facial
muscles
corrugator supercilii muscle, 109
depressor supercilii muscle, 109
frontalis muscle, 106–107
orbicularis oculi muscle, 108–109
procerus muscle, 109
Upper gum mucosa, 224
Upper lip levators, 233
Upper platysma wrinkling, 273; see also
Platysma
dilution, 276
dosing, 276–277
functional anatomy of upper platysma,
274–276
injection points, 276, 277
lower face platysmal lines, 275
Nefertiti lift, 276, 277
problem assessment and patient selection,
273–274
treated with OnaBTX-A injection, 277,
278, 279
treatment complications, 278
treatment implications, 279
treatment outcomes, 277–278
Vasoconstrictor, 128
Vermilion border, 239
Vesicle (V-SNARE), 105
Wicked witch’s chin, 266
Wrinkling
mild forehead wrinkling, 148
upper chest and decollete wrinkling, 286,
287–288, 289
upper platysma wrinkling, 274–276,
276–277, 278
XEOMEEN®, see XEOMIN®
XEOMIN®, 113
Xerophthalmia, 172
Yonsei point, 231; see also Excessive
maxillary gingival display
Zygomatic arch, 106, 155, 156, 160, 181, 218
Zygomaticus major, 110, 154, 213
Zygomaticus minor (ZMi), 110, 154,
215–216