Patients must be selected carefully for cosmetic Botox treatment. They must be well educated about the benefits, risks, and limitations to the procedure. Patients with deep folds, severe age spots, spider veins and poor skin texture will not get great improvement with Botox treatment alone. They should realize that the treatments will need to be repeated every 3-6 months to sustain the effect. People with unrealistic expectations will not be satisfied.
Treatment of the upper face includes horizontal forehead wrinkles, Crow’s feet, and lines between the eyebrows.
General procedure
Before treatment, photographs should be taken as a part of before and after shots, with the muscles fully contracting and at rest. Various movements should be done including smiling and frowning. The skin lines are marked with a soft eyeliner pencil. Botox is drawn up into a syringe with a very fine silicon coated needle that minimizes the pain with injections. Anesthesia is not needed but can be used. Pressing ice onto the area to be injected may help. Failing that, an anesthetic cream can be applied about 30 minutes before injection. Injections should be into the muscle. Injecting into the skin will be less effective. Multiple injections are often necessary to make sure the drug is dispersed thoughout the muscle being targeted.
Glabellar Frown Lines (wrinkles between the eyebrows)
Males have more muscle in the brow compared to females. Therefore, they will need 60-80 units of Botox, while females may need 30-40 units total. If this is not effective then the doses can be increased to 50 and 100 units for women and men respectively. The subject should be seated chin down, and below the operator. The first injection is just above the eyebrow directly above the inner corner of the eye. 4-6 units are given, then the needle is advanced upward and 4-5 more units are given. The opposite side is done the same way. Then 5-10 units are injected right between the eyes to get the procerus muscle. Another injection can be done above the eyebrow about ½ inch directly above the middle of the eye. The patients should stay upright for 2-3 hours. They should frown a lot but not push on the treatment area. A follow up appointment should be in 2-3 weeks and touch up injections can be done. Botox treatments can be repeated every 3-4 months for a year. Sometimes the improvement may last 6-8 months however.
Treating the glabellar frown lines Injection sites for treating the glabella
Before and after injections for glabellar frown lines
Horizontal Forehead Lines
Injecting the forehead for wrinkles usually lasts 4-6 months. However, over treatment can cause lowering of the brow resulting in an angry expression. Keeping injection sites well above the brow and using conservative dosing will help avoid complications. In females 48 units are used, ½ the dose into the frontalis muscle and the other half into the brow depressor muscles.
Injection sites for forehead lines
Injecting the forehead for wrinkles usually lasts 4-6 months. However, over treatment can cause lowering of the brow resulting in an angry expression. Keeping injection sites well above the brow and using conservative dosing will help avoid complications. In females 48 units are used, ½ the dose into the frontalis muscle and the other half into the brow depressor muscles.
Injection sites for forehead lines
Before and after forehead injections Before and after forehead injections
Prominent Orbicularis Oculi Muscle
Contraction of parts of the orbicularis oculi muscle during a smile will decrease the eye lid opening. If the muscle is too bulky, the eye may appear swollen. A well placed injection just below the eye can help. The dose is limited to 2-4 units to avoid the dry eye side effect. This therapy works well for patients with a good snap test result. When the eyelid is pulled off the eye, it snaps back quickly when released. This is the normal response. If the lid movement is sluggish, then Botox may lead to drooping of the lower lid and inability to close the eye.
Injections site for treatment of the orbicularis oculi muscle
Combination Treatment
Botox can be used for the fine wrinkles and injectable fillers like collagen or Restylane can be used to fill in the deeper folds. Botox is usually given about a week before the filler to keep the area still and get a better result with the filler implant. Botox can be given with plastic surgery to prevent recurrence of wrinkling. It is also used before laser resurfacing procedures where laser burns can heal over without the skin folding over trying to create a new wrinkle.
Complications
Short term side effects include bruising and swelling at the injection site, headaches, and flu like symptoms. There is a less than a 1% chance of eye lid or eyebrow drooping. This could result in the eyebrows appearing asymmetric or give an angry expression. To avoid this several things can be done. Patients with baseline brow sagging should not be treated. Injections of the brow depressor muscles should be done first before injecting the frontalis to treat forehead lines. Injections should be above the lowest forehead line seen when the patient contracts the frontalis muscle to raise the eyebrows. Injections should be kept at least 3 cm above the brow. Higher concentrations of Botox allow for more exact placement of the drug with a longer lasting effect and fewer adverse effects. Injection of lower concentrations of Botox in larger volumes of fluid lead to more spread of the toxin, possibly into unintended areas. The area of paralysis is about a 1-1.5 cm diameter around the injection site. The patient should stay upright, exercise the muscle frequently for 4 hours, and avoid rubbing the area. Brow depression is more common if the forehead and glabella (area between the eyebrows) is treated at the same time.
The eyelid can droop as well if Botox leaks into this area. It is seen when the glabella is treated between 48 hours and 2 weeks after injection. It may last 2-12 weeks. To avoid this complication, large volumes of Botox solution is avoided, and injections kept 1 cm above the bony rim above the eye. Patients again should sit up and not rub the area. Other complications include double vision, inability to completely close the eye, too much white of the eye showing, or a disfigured smile (if the toxin spreads to the cheek muscles). For upper eyelid sagging, apraclonidine (Iopidine 0.5%) eyedrops 1-2 drops 3 times a day can be used until the drooping goes away.
Before and after treatment of eyelid drooping
Contraction of parts of the orbicularis oculi muscle during a smile will decrease the eye lid opening. If the muscle is too bulky, the eye may appear swollen. A well placed injection just below the eye can help. The dose is limited to 2-4 units to avoid the dry eye side effect. This therapy works well for patients with a good snap test result. When the eyelid is pulled off the eye, it snaps back quickly when released. This is the normal response. If the lid movement is sluggish, then Botox may lead to drooping of the lower lid and inability to close the eye.
Injections site for treatment of the orbicularis oculi muscle
Combination Treatment
Botox can be used for the fine wrinkles and injectable fillers like collagen or Restylane can be used to fill in the deeper folds. Botox is usually given about a week before the filler to keep the area still and get a better result with the filler implant. Botox can be given with plastic surgery to prevent recurrence of wrinkling. It is also used before laser resurfacing procedures where laser burns can heal over without the skin folding over trying to create a new wrinkle.
Complications
Short term side effects include bruising and swelling at the injection site, headaches, and flu like symptoms. There is a less than a 1% chance of eye lid or eyebrow drooping. This could result in the eyebrows appearing asymmetric or give an angry expression. To avoid this several things can be done. Patients with baseline brow sagging should not be treated. Injections of the brow depressor muscles should be done first before injecting the frontalis to treat forehead lines. Injections should be above the lowest forehead line seen when the patient contracts the frontalis muscle to raise the eyebrows. Injections should be kept at least 3 cm above the brow. Higher concentrations of Botox allow for more exact placement of the drug with a longer lasting effect and fewer adverse effects. Injection of lower concentrations of Botox in larger volumes of fluid lead to more spread of the toxin, possibly into unintended areas. The area of paralysis is about a 1-1.5 cm diameter around the injection site. The patient should stay upright, exercise the muscle frequently for 4 hours, and avoid rubbing the area. Brow depression is more common if the forehead and glabella (area between the eyebrows) is treated at the same time.
The eyelid can droop as well if Botox leaks into this area. It is seen when the glabella is treated between 48 hours and 2 weeks after injection. It may last 2-12 weeks. To avoid this complication, large volumes of Botox solution is avoided, and injections kept 1 cm above the bony rim above the eye. Patients again should sit up and not rub the area. Other complications include double vision, inability to completely close the eye, too much white of the eye showing, or a disfigured smile (if the toxin spreads to the cheek muscles). For upper eyelid sagging, apraclonidine (Iopidine 0.5%) eyedrops 1-2 drops 3 times a day can be used until the drooping goes away.
Before and after treatment of eyelid drooping
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