Detailed Information on Botox
Favorable safety profile for cosmetic use in the face for patients age 18-65.
FDA Approval
2002 Frown Lines Between Eyebrows
2013 Crow’s Feet Lines
2017 Forehead Lines
Botox Effects
Blocks presynaptic acetylcholine release from motor neuron resulting in neuromuscular block.
Transient and reversible effect within 3-4 days.
Maximum result in 10-14 days.
Recall for potential dose adjustment at 2 week check up.
Repeat injections 4 times in first year, every 3 months.
Repeat injections 3 times in second year and beyond since muscles may be less active.
Re-inject before the initial Botox wears off to keep muscles weak and avoid muscle memory.
Botox Shelf Life
Botox has a shelf life of 24 months unreconstituted in refrigerator.
Manufacturer recommends use within 4 hours of reconstitution.
Studies show efficacy after 5 weeks reconstituted if refrigerated.
Reconstitution of Botox
Reconstitute with sterile saline with or without preservative.
Remove the metal ring and rubber stopper from the glass vial of Botox.
Use a 21 gauge needle and 1.0 ml syringe to draw up sterile saline.
Gently push sterile saline into bottle of Botox with no air bubbles.
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ml dilution into 100 unit vial of Botox
0.5 ml dilution into 50 unit vial of Botox
0.01 ml = 1 unit of Botox
Syringes
Use BD (Becton Dickson) ultra-fine insulin syringe 3/10 cc 31 gauge 5/16 short needle.
Each dash equals 0.01 ml or 1.0 unit of Botox.
For Patient
Medical history
Informed consent form is re-signed and dated yearly.
Medication guide for Botox cosmetic.
Hand mirror for consultation and discussion of reason for patient visit.
Ask patient what they wish to improve.
Have patient smile, frown, raise eyebrows, pucker lips.
Pretreatment standardized baseline photograph
Gummy Smile
Ask the patient to smile and simultaneously palpate the muscles on contraction.
Inject the right and left levator labii superioris alaeque nasi, levator labii superioris and zygomaticus minor and levator labii superioris muscle sites.
Inject lateral to the nares with the needle depth 1/2-2/3
2-4 units Botox per side.
Upper Lip Lines
Have patient pucker their lips.
Inject orbicularis oris muscle just below the skin.
Use equal spacing of injections between Cupid’s Bow and lateral lip.
Inject right at the vermillion border.
2-4 units Botox per side of upper lip.
See eversion of upper lip and increased fullness of upper lip.
Decreases intensity of upper lip rhytids (wrinkles).
It may feel strange to patient for the first 1-2 weeks since we are used to strong lip muscles.
It may be difficult for patient to drink from a cup once you soften lip muscle function.
You can consider filler at 2 week check up if necessary.
Smile Lift
Inject the right and left depressor anguli oris which pulls down the corners of the mouth and forms jowls.
Inject low and laterally to avoid the mentalis muscle and avoid lower lip rolling inward or drooping.
Inject at least 1.0 cm lateral and inferior to oral commissure.
May also inject 1.0 cm above inferior border of mandible within DAO muscle.
Avoid injection superiorly too close to the lips into orbicularis oris muscle.
Needle insertion 1/2-2/3 depth.
3-6 units of Botox per side.
Dimpled Chin
Inject the right and left mentalis muscle.
Needle insertion 1/2-2/3 depth.
Inject the lower third of the mentalis muscle with 2-6 units of Botox per side.
Avoid depressors laterally and avoid orbicularis superiorly toward upper lip.
Crow’s Feet
Inject subcutaneously not deep into muscle
Do not enter skin straight. Angle the injection away from the eye.
Stay 1.0-2.0 cm away from orbital rim.
Inject 3 sites per side with 4 units of Botox each.
Use 12 units of Botox per side for a total of 24 units..
Frown Lines Between Eyebrows
Have the patient actively frown.
Plan Botox injections directly into contracted muscles at or above each forehead wrinkle.
Stay 1.0-2.0 cm above the orbital rim.
Five injection sites total.
Four units of Botox per injection site for a total of 20 units.
One injection superficially into Procerus muscle in midline with needle at 1/2 depth.
Two injections deeply into each Corrugator muscle underneath Frontalis muscles bilaterally with needle at full depth.
Eyebrow Lift
Have patient squint tightly to see where the eyebrow pulls down.
Also palpate the bony frontotemporal fusion point to determine injection points.
Inject Procerus superficially and Corrugator muscles deep to Frontalis muscles as above with 4 units of Botox in 5 injection sites 20 units total.
Lateral to where the frontalis muscle ends, inject the lateral brow depressor, the orbicularis oculi muscle in the superiolateral portion.
Do not inject the frontalis muscle.
Stay 1.5 cm away from the orbital rim and septum to avoid dropping levator palpebrae superioris muscle.
Inject 2 units of Botox in 2 injection sites (4 units total) below the lateral third of the brow on each side.
28 units of Botox total for the eyebrow lift.
Bunny Lines on Nose
Have patient smile or scrunch their nose like they smell something bad.
Injections are placed into the transverse nasalis high up on the nose, to the sides of the bridge of the nose and into the area of maximum wrinkling.
Do not to inject too laterally or inferiorly, to avoid affecting the Levator Labii Superioris Alaeque Nasi muscle that runs down the side of the nose to the upper lip.
Inject subcutaneously not deep into muscle.
Inject 2-3 units of Botox per side.
Horizontal Forehead Lines
Have patient raise their eyebrows in a surprised look.
Inject Botox subcutaneously into Frontalis muscle.
Inject 2 units of Botox into 8-12 injection sites.
Inject at least 1.0 cm above eyebrow.
Space injections at least 1.0 cm apart.
Neck Bands
Ask patient to grimace or pronounce the letter “E”.
Lateral neck injections are intramuscular.
Strongest muscle bands receive 3-5 unit per injection point.
Injections are spaced 1.5 cm apart.
Consider injecting DAO with 3-6 units of Botox per side.
Pout Boost or Lip Flip
Flip out the lip line or gently roll the lip outward.
The lip appears more full.
Botox relaxes the orbicularis muscle and rolls the lip outward
Inject Botox into superficial upper lip at the sides of the orbicularis oris muscle.
Inject 2-4 units of Botox near the lateral vermillion border.
May require dermal filler if require volume.
Marionette Lines
Have patient exaggerate a sad or dissatisfied scornful look.
Inject at least 1.0 cm lateral and inferior to oral commissure into depressor anguli oris muscle.
May also inject 1.0 cm above inferior border of mandible within DAO muscle.
Avoid injection superiorly too close to the lips into orbicularis oris muscle.
Avoid injection medially into depressor labii inferioris muscle.
Needle insertion 1/2-2/3 depth.
3-6 units of Botox per side
Needle insertion 1/2-2/3 depth.
3-6 units of Botox per side.
May require dermal filler to restore volume.