History of Dermal Fillers

The advent of dermal fillers traces back to the late 19th century, with Dr. Neuber’s groundbreaking fat auto-grafting procedure in 1893. A substantial leap forward occurred in the 1970s with the development of bovine collagen, and the subsequent FDA approval of the Zyderm implant in 1983. Nevertheless, skin testing was necessary as 2-3% of patients exhibited hypersensitivity reactions to bovine collagen. The landscape of dermal fillers underwent a transformational shift in 2003 with the introduction of hyaluronic acid (HA) into the U.S. market, specifically with the product Restylane®. Since then, various HA-based fillers have dominated the aesthetic industry, including prominent brands like Juvederm, RHA, Versa, and Belotero.

Hyaluronic Acid

As a principal polysaccharide in the extracellular matrix, hyaluronic acid (HA) is instrumental in maintaining skin elasticity and fullness. Age-associated HA loss results in skin laxity and volume deficit. Crosslinked HA forms the basis of most contemporary dermal fillers, which are predominantly produced by gram-positive bacteria. This innovative development has led to the creation of non-animal sourced hyaluronic acid (NASHA) gel.

Crosslinked HA is characterized by its remarkable versatility, facilitating the customization of its physical properties, such as hardness, lift, duration of survival, and resistance to heat and degrading enzymes. It is a stable, cost-effective, safe, and tissue-compatible biomaterial. Furthermore, HA’s tissue residency is significantly prolonged due to cross-linking.

G Prime is a measure of the viscosity and elasticity of a dermal filler. It is a dimensionless quantity that is calculated using the following formula:

G’ = shear stress / shear rate

Shear stress is the force that is applied to the filler to make it flow.

Shear rate is the rate at which the filler flows.

A higher G Prime value indicates a more viscous and elastic filler. This means that the filler will be more difficult to inject and will be more likely to hold its shape once it is injected.

G Prime is an important factor to consider when choosing a dermal filler. The G Prime value will affect the way the filler flows and how it holds its shape. For example, a filler with a high G Prime value would be more suitable for volumizing and lifting, while a filler with a low G Prime value would be more suitable for filling fine lines and wrinkles.

The G Prime values for dermal fillers vary depending on the type of filler and the brand. In general, hyaluronic acid based dermal fillers have a lower G Prime value than calcium hydroxyapatite based dermal fillers.

The G Prime value of a dermal filler can affect the results of injections in a number of ways. For example:

• A filler with a high G Prime value will be more difficult to inject and may cause more pain. Conversely, a filler with a low G Prime value will be easier to inject and may cause less pain.
• A filler with a high G Prime value will be more likely to hold its shape, which can lead to longer results. Conversely, a filler with a low G Prime value will be less likely to hold its shape, which can lead to more temporary results.

Differences in Hyaluronic Acid-Based Dermal Fillers: A Deep Dive into the Restylane Family

Restylane is a comprehensive line of hyaluronic acid (HA)-based dermal fillers developed by Galderma, each with its unique properties to address different cosmetic concerns. Understanding these differences allows providers to choose the most appropriate product for each patient’s unique needs. Below is a comparative exploration of Restylane products: Restylane, Restylane L, Silk, Lyft, Refyne, Defyne, Kysse, Contour, and Eyelight.

1. Restylane: Restylane is the flagship product with 20mg/ml of HA and a moderate G Prime. It’s versatile, suitable for moderate-to-severe wrinkles, facial contouring, and lip enhancement. The moderate particle size provides both lifting and smoothing properties.
2. Restylane L: This is similar to the original Restylane but includes 0.3% lidocaine, a local anesthetic, for improved patient comfort during the injection. The inclusion of lidocaine doesn’t alter the HA concentration or the G prime.
3. Restylane Silk: Restylane Silk contains smaller, smoother particles (around 500 microns) than its counterparts, making it perfect for subtle lip augmentation and smoothing fine lines, especially around the mouth. It also has 20mg/ml HA but a lower G prime due to its smoother consistency.
4. Restylane Lyft: Formerly Perlane, Lyft has larger gel particles and a higher G prime, offering more substantial volumizing and lifting capacity. It’s excellent for enhancing cheeks and correcting volume loss in the midface. The HA concentration is 20mg/ml.
5. Restylane Refyne: Using XpresHAn technology, Refyne has a flexible gel consistency, providing subtle correction of laugh lines while maintaining natural expression. It has 20mg/ml of HA, but the G prime varies due to the crosslinking process, enhancing flexibility.
6. Restylane Defyne: Also using XpresHAn technology, Defyne has more crosslinking than Refyne, offering more support for deeper laugh lines while still allowing natural facial movement. It also contains 20mg/ml of HA.
7. Restylane Kysse: Tailored for lip augmentation and the smoothing of upper perioral lines, Kysse also uses XpresHAn technology for flexibility and naturalness. It has 20mg/ml of HA, but its unique cross-linking gives it a different G prime, ensuring longevity and a softer feel.
8. Restylane Contour: Designed specifically for cheek and chin augmentation. It uses a novel crosslinking method (XpresHAn technology), creating a product with variable G prime, allowing for excellent lift and longevity. It also has 20mg/ml of HA.
9. Restylane Eyelight: This specific filler is designed for tear troughs, with a lower HA concentration (15mg/ml) and a lower G prime. Its softer gel consistency is ideal for delicate areas like under the eyes. It also contains lidocaine for added comfort during injection.

Each Restylane product is tailored to different needs, with variations in HA concentration, G prime, particle size, and the presence of lidocaine. Some newer products leverage XpresHAn technology for different crosslinking levels, affecting their consistency and allowing for a more natural look while maintaining volume and lift. Knowledge of these differences will enable providers to optimize treatment outcomes.

Differences in Hyaluronic Acid-Based Dermal Fillers: A Detailed Review of the Juvederm Family

The Juvederm range of dermal fillers, developed by Allergan, is well-regarded for its specialized products, each addressing different aesthetic needs. A deep understanding of their individual characteristics enables providers to select the best-suited filler for their patients. The discussion below explores Juvederm Ultra, Ultra XC, Ultra Plus XC, Voluma, Volbella, Vollure, Volux, and Skinvive.

1. Juvederm Ultra: With 24mg/ml of HA, Ultra provides versatility in treating moderate to severe wrinkles and folds, particularly nasolabial folds. Its moderate G Prime and Hylacross technology, which provides a high degree of cross-linking, offer a balance between volume and spreadability.
2. Juvederm Ultra XC: Like Ultra, Ultra XC offers 24mg/ml of HA and the same degree of cross-linking. The difference lies in the inclusion of 0.3% lidocaine, intended to increase patient comfort during and after injection.
3. Juvederm Ultra Plus XC: Ultra Plus XC has a higher G Prime than Ultra and Ultra XC due to a more robust cross-linking process, resulting in a more substantial lift and higher viscosity. It’s ideal for addressing more severe wrinkles and folds.
4. Juvederm Voluma: Voluma is tailored for deep injection in the cheeks to correct age-related volume loss. It has a high G Prime due to its proprietary Vycross technology (which involves cross-linking low and high molecular weight HA) and offers 20mg/ml of HA.
5. Juvederm Volbella: Volbella is designed for lip augmentation and correction of perioral lines. It uses Vycross technology, has a low HA concentration (15mg/ml), and a lower G Prime for a smooth consistency suitable for delicate areas. 
6. Juvederm Vollure: Vollure uses Vycross technology and offers an HA concentration of 17.5mg/ml. Its moderate G Prime makes it an excellent option for moderate to severe facial wrinkles and folds.
7. Juvederm Volux: Designed for the lower face, Volux is used to sculpt the chin and jawline. It uses Vycross technology, has a high G Prime and an HA concentration of 25mg/ml, ensuring longevity and a significant lift.
8. Juvederm Skinvive: Skinvive is designed for superficial dermal injection to improve skin quality, texture, and elasticity. Its HA concentration is lower, and it includes a unique blend of antioxidants, amino acids, and vitamins for overall skin health.

In summary, the differences among the Juvederm fillers range from variations in HA concentration, G Prime, the inclusion of lidocaine, to the use of proprietary technologies like Hylacross and Vycross. The specific characteristics of each product are designed to optimize outcomes for different cosmetic needs, and a detailed understanding of these is beneficial to treating your patient.

Differences in Hyaluronic Acid-Based Dermal Fillers: A Detailed Review of the RHA Family

Developed by Teoxane Laboratories, the Resilient Hyaluronic Acid (RHA) fillers are the first dermal fillers designed for dynamic areas of the face, adapting and stretching to work with facial movements. The family consists of RHA Redensity, RHA 2, RHA 3, and RHA 4. The specific details and key differences of these products are explored below.

1. RHA Redensity: This product, also known as Teosyal Redensity (15mg/ml). Its low G Prime makes it ideal for injection into the dermis and superficial dermis of the face, for the correction of moderate to severe dynamic perioral rhytids, in adults aged 22 years or older
2. RHA 2: With an HA concentration of 23mg/ml, RHA 2 is intended to fill moderate facial wrinkles such as perioral, periorbital, or glabellar lines. It has a moderate G Prime, allowing it to balance between firmness and flexibility. The HA in RHA 2 is crosslinked with 1,4-butanediol diglycidyl ether (BDDE), which increases its viscosity and longevity.
3. RHA 3: RHA 3 also has an HA concentration of 23mg/ml but has a higher G Prime than RHA 2, making it firmer and more suited for filling severe facial wrinkles and folds, such as nasolabial folds. Like RHA 2, RHA 3’s HA is crosslinked with BDDE.
4. RHA 4: This product, with 23mg/ml HA, has the highest G Prime in the RHA series and is tailored for the correction of severe wrinkles and facial contours. RHA 4 is typically used for volumizing areas such as the cheeks and contouring the jawline. Like the other RHA products, the HA in RHA 4 is crosslinked with BDDE.

One key feature of the RHA series is its “Preserved Network” technology. Unlike traditional fillers that can lose their structural integrity upon injection, the RHA series preserves the native HA structure, resulting in a more natural look and feel.

In summary, the RHA family differentiates itself by varying degrees of G Prime, while keeping the HA concentration consistent. This enables the provider to tailor the product selection based on the severity of the wrinkles and the desired level of firmness and lift. Furthermore, the unique “Preserved Network” technology enhances the fillers’ performance in dynamic facial areas.

Differences in Hyaluronic Acid-Based Dermal Fillers: A Detailed Review of Versa and Lips+

The Versa lines of hyaluronic acid-based dermal fillers are each known for their unique manufacturing processes and properties. 

1. Versa: Manufactured by Prollenium, Versa is a homogenous, monophasic dermal filler that contains 24mg/ml of HA. The product is created using a proprietary wet milling technology, which produces spherical and uniform particles. These particles result in high-quality HA, reduced inflammation, and longevity. Versa has a relatively high G prime, giving it a good lifting capacity.
2. Versa+: Also part of Prollenium’s portfolio, Versa+ is similar to the original Versa but includes Lidocaine for enhanced patient comfort during the procedure. Versa+ also contains 24mg/ml of HA and has the same manufacturing process, properties, and G prime as Versa.
3. Lips+: Specifically designed for lip augmentation, Lips+ is another Prollenium product with 24mg/ml of HA. 

Differences in Hyaluronic Acid-Based Dermal Fillers: A Detailed Review of Belotero Products

Here we’ll explore the specific details and key differences between Belotero Balance, and Belotero Balance Plus.

1. Belotero Balance: Manufactured by Merz Aesthetics, Belotero Balance is unique due to its Cohesive Polydensified Matrix (CPM) technology, which produces a smooth, flexible gel. Belotero Balance has 22.5mg/ml of HA and a moderate G prime that offers a balance between lift and spread. This filler is suitable for moderate lines and wrinkles.
2. Belotero Balance Plus: Belotero Balance Plus is similar to Belotero Balance but contains 0.3% lidocaine hydrochloride to reduce pain on injection. 

Combined List of Contraindications

• Dermal fillers are contraindicated for patients with severe allergies manifested by a history of anaphylaxis, or history or presence of multiple severe allergies.
• Dermal fillers, which contain trace amounts of gram-positive bacterial proteins, are contraindicated for patients with a history of allergies to such material.
• Dermal fillers should not be used in patients with previous hypersensitivity to local anesthetics of the amide type, such as lidocaine.
• Dermal fillers should not be used in patients with bleeding disorders.
• Dermal fillers are contraindicated for use by anyone with a skin infection or a susceptibility to keloid formation or hypertrophic scarring.
• Dermal fillers should not be used by pregnant women or nursing mothers.
• People under the age of 22 should not be treated with certain types of dermal fillers.
• Patients with evidence of scars at the intended treatment sites should not be treated with dermal fillers.
• Patients with acne and/or other inflammatory diseases of the skin should not be treated with dermal fillers.
• Patients with unattainable expectations should not be treated with dermal fillers.
• Dermal fillers should not be used in patients who have plans to undergo desensitization therapy.
• Dermal fillers should not be used in patients with acute or chronic skin disease in or near the injection sites, or with any infection or unhealed wound of the face.
• Patients under concomitant anticoagulant therapy, antiplatelet therapy, or with a history of coagulation defects or connective tissue disorders should not use dermal fillers.
• Dermal fillers are not intended for intravascular use and must not be injected into blood vessels, as implantation into dermal vessels may cause vascular occlusion, infarction, or embolic phenomena.
• Dermal fillers should not be used in conjunction with a laser, intense pulsed light, chemical peeling or dermabrasion treatments, or with over-the-counter (OTC) wrinkle products or prescription wrinkle treatments within 4 weeks (28 days) prior to treatment.

Please note that this list is a combination of all contraindications from each product, and each individual product may not have every listed contraindication. Always refer to the specific product’s package insert.

Warnings

This is a consolidated list of all the specific warnings.

• Avoid injecting dermal fillers directly into blood vessels, as this may cause vessel occlusion, embolization, or infarction.
• Rare but serious adverse events associated with the intravascular injection of soft tissue fillers in the face have been reported and include temporary or permanent vision impairment, blindness, cerebral ischemia or cerebral hemorrhage, leading to stroke, skin necrosis, and damage to underlying facial structures.
• Use of these products on patients who are pregnant, breastfeeding, or under 18 years old has not been studied, and therefore is not recommended.
• The safety and effectiveness of these products for treatment in areas other than those specified in their respective FDA-approved labeling have not been established.
• Do not overcorrect (overfill) a contour deficiency because the depression should gradually improve as treatment continues.
• Do not mix these products with any other products before implantation.
• As with all skin injection procedures, there is a risk of infection.
• Injections of greater than 1.5 mL per lip (upper or lower) per treatment session significantly increases the occurrence of the severity of lip swelling.
• Dermal fillers should not be used in areas that have high vascularity as there is a risk of vascular embolization.
• Injection site reactions (for example: redness, temporary swelling, tenderness, or pain) have been observed and are short term in duration (less than seven days). Any reactions in excess of this anticipated reaction should be reported to a healthcare professional.
• If immediate blanching occurs, the injection should be stopped, and the area massaged until it returns to a normal color. Blanching may represent a vessel occlusion. If normal skin coloring does not return, do not continue with the injection.
• Patients should receive prompt medical attention and possibly evaluation by an appropriate healthcare practitioner specialist should an intravascular injection occur.
• This product should only be used by healthcare practitioners who have appropriate training, experience, and who are knowledgeable about the anatomy at and around the site of injection.
• Patients with adverse inflammatory reactions that persist for more than one week should report this immediately to their doctor.
• Health care practitioners are encouraged to discuss all potential risks of soft tissue injection with their patients prior to treatment and ensure that patients are aware of signs and symptoms of potential complications.
• Serious adverse events have been reported related to the use of dermal fillers in the area of the eye.
• Localized superficial necrosis and scarring may occur after injection in or near vessels, such as in the lips, nose, or glabellar area. It is thought to result from the injury, obstruction, or compromise of blood vessels.
• Delayed onset inflammatory papules have been reported following the use of dermal fillers. Inflammatory papules that may occur rarely should be considered and treated as a soft tissue infection.

These warnings provide important information for safe and effective use of dermal fillers and should be carefully considered by healthcare providers and patients alike. It is essential to reach out to the respective product manufacturers or healthcare providers for additional information.

Precaution

• Dermal fillers are intended for single use only. They should not be resterilized or used if the package is opened, damaged, or past its expiration date.
• The product should be used with caution in patients undergoing immunosuppressive therapy or patients who are using substances that reduce coagulation.
• The injection of dermal fillers into patients with a history of herpetic eruptions may lead to reactivation of the herpes.
• The patient should be informed that they should minimize exposure of the treated area to excessive sun or heat, UV lamp exposure, saunas, and extreme cold weather until any initial swelling and redness have resolved, and puncture sites have healed.
• Any syringe that shows signs of content separation or appears cloudy should not be used.
• If nodules or persistent papules occur, consider appropriate treatment, such as hyaluronidase injection or surgical removal.
• Prior to treatment, the patient should avoid taking aspirin, nonsteroidal anti-inflammatory medications, St. John’s Wort, or high doses of Vitamin E supplements, as these agents may increase bruising and bleeding at the injection site.

Aging Skin

The process of skin aging encompasses numerous interconnected and complex changes that occur within the skin and underlying tissues. These changes are typically observed as loss of subcutaneous volume, thinning of the skin, and modifications in bony structures, all of which contribute to the deterioration of youthful facial contours. Additionally, aging skin is characterized by a reduction in collagen and elastin, proteins integral to maintaining the skin’s elasticity and firmness. This loss, coupled with the relentless tug of gravity, results in skin laxity and a downward shift of the skin and underlying tissues. 

Dermal landmarks of aging skin include the pronounced laugh lines and marionette lines, a clear depiction of the loss of subcutaneous support. The lips, once plush and rounded, become thin, flat, and deflate, losing their characteristic curvature and fullness. The emergence of vertical lines both above and below the lips, often termed as ‘smoker’s lines’, become increasingly visible. The oral commissures, or corners of the mouth, gradually turn downward, giving the face a perpetual frown. 

Consultation

The crux of a successful practice hinges upon comprehensive patient selection and education. Often, patients tend to confuse neurotoxins like Dysport® or Botox® Cosmetic with Dermal Fillers, erroneously assuming they serve the same purpose. It is incumbent upon the medical practitioner to elucidate the fundamental differences between these two treatment options, particularly when a patient requests inappropriate treatments, such as Dysport® injections in the lips to enhance fullness.

Start your consultation by acquiring a full medical history and conducting a physical examination to rule out potential contraindications. This includes probing for any underlying health conditions or allergies that could impede the successful administration of dermal fillers.

Next, ask the patients about the specific areas they wish to correct or enhance. Assess these areas: nasolabial folds, marionette lines, smile lines, lips, and perioral lines, or vertical lines around the mouth. It’s also crucial to guide the patient through the process. Instead of pointing out perceived flaws, demonstrate the beneficial effects of dermal filler treatment.

Evaluate the depth and severity of wrinkles by performing a stretch test, using your thumb and index finger to see if the wrinkle can be flattened. Not all folds can be completely corrected due to excess sagging tissue or scar tissue, so it’s crucial to set patient expectations appropriately.

Timing of the treatment is another vital consideration. It is generally not recommended to initiate a new treatment, such as lip augmentation with Restylane, close to a major event like a wedding, especially if the patient has never had the treatment before.

Discuss the potential need for touch-ups in the future, the cumulative costs, and their pain tolerance. Offer information about various pain control options available. 

Practitioners should strive to foster a rapport with their patients, taking the time to listen, educate, and set realistic expectations. Some patients may have unrealistic treatment expectations, desiring too many areas to be treated with one syringe, which would lead to suboptimal results. In such cases, it might be preferable to defer treatment rather than risk dissatisfaction. 

Pre-Injection Checklist

Prior to any dermal filler injection, following a systematic pre-injection checklist ensures a smooth and safe procedure.

1. Photography: Maintain a photographic record of the patient’s pre-injection features. This documentation aids in managing any misdirected blame regarding treatment results.
2. Asymmetry Evaluation: Assess for any pre-existing asymmetry. If the patient desires a symmetrical result, ensure sufficient product quantity to treat each side evenly.
3. Pain Management: Offer a topical anesthetic or ice to cool and numb the area before injection to improve the patient’s comfort.
4. Cleanliness: Thoroughly cleanse the area with alcohol wipes to minimize the risk of infection.
5. Proper Equipment: Always use the needle provided by the vendor and ensure it is fully seated to the hub. This reduces the chance of needle disengagement from the syringe and prevents product waste or accidental spills.
6. Needle Position: Orient the eye of the needle upwards towards the skin surface, ensuring accurate and safe product delivery.
7. Air Purge: Push the plunger until a droplet appears at the tip of the needle, removing any air that might be inside the needle hub.
8. Preventive Measures: For patients with a history of cold sores, consider pretreatment with antiviral medication, as any injection around the mouth can trigger a recurrence.

Injection

Dermal filler injections require a meticulous technique to achieve optimal results and minimize complications. Always insert the needle into the middle to deep dermis for appropriate product placement. You can gently stretch the skin to aid needle insertion, which also helps visualize the treatment area better. 

The contour of the needle should be barely visible or not at all, depending on the type of filler used and the severity of the wrinkle being treated. If utilizing a threading technique, apply even pressure on the syringe plunger while slowly retracting the needle. Ensure you stop the injection before completely removing the needle to prevent the product from oozing out or a superficial placement.

Superficial injections can cause a bluish hue on the skin due to the Tyndall effect. If this occurs, consider massaging the product deeper into the tissue, expressing it out, or dissolving with Hyaluronidase.

In fanning technique, keep the needle inside the skin while angling the syringe and reinserting the needle to the hub. Be aware of the potential for intravascular injection. If blanching occurs, immediately stop injecting and massage the area until normal skin color returns. 

Throughout the procedure, you should always feel the resistance of the dermis, indicating correct plane injection. If you encounter too much or too little resistance, you may be in the wrong plane. At the end of the treatment, the injected wrinkle should be visibly lifted and filled.

Post Injection

After administering the dermal filler, a careful evaluation is critical to ensure an optimal result. The treated area should feel smooth with no detectable empty spaces or lumps. Strive for a precise correction – neither under nor overcorrect. 

Gently massage the injection site to blend the product with surrounding tissue. If you feel any bumps or lumps, massage them until they flatten. In most cases, any protrusions will resolve naturally, but reassure the patient and schedule a follow-up appointment within a week. If a lump persists at this follow-up, consider using Hyaluronidase to dissolve the filler.

Symmetry assessment immediately post-injection can be challenging due to localized swelling and bruising. Invite the patient back after a week for re-evaluation once the swelling has subsided. 

Lastly, any post-injection swelling or internal bruising should resolve in a few days. To minimize these side effects, provide your patient with an ice pack, which can also help to reduce potential bleeding. 

This comprehensive approach to patient consultation, preparation, and treatment will facilitate optimal results when using dermal fillers like Restylane, Juvederm, RHA, Versa, and Belotero, and ensure your patients are satisfied with their treatments.

Injection Technique

The success of dermal fillers is not only dependent on the type of product used but also on the technique of injection. There are various injection techniques, each with its own set of advantages and potential pitfalls.

Serial Puncture

The serial puncture technique involves multiple, closely spaced injections along a wrinkle. The key to this technique is the precise placement of the filler. If the filler is not accurately placed, gaps may be found between the injection sites. This technique is less desirable due to the multiple puncture wounds it generates. However, it can be effective for treating fine lines and wrinkles, provided that the practitioner has a steady hand and a keen eye for detail.

Linear Threading

Linear threading is a technique where the needle is fully inserted into the wrinkle up to the hub and the product is injected along the track as the needle is gradually withdrawn. This technique requires continual pressure and even distribution of the product. It is crucial to stop the injection several millimeters before completely removing the needle from the skin to avoid superficial placement or leakage of the product above the skin.

Some practitioners prefer the push-ahead technique, where the product is injected as the needle is being advanced through the skin. This requires a certain level of skill and dexterity, as the practitioner must simultaneously push the plunger of the syringe while pulling back the syringe from the skin. With practice, this technique can be mastered and can provide a smooth, even distribution of the filler.

Cross Hatching

Cross hatching is a technique that involves injecting a series of parallel linear threads at 5 – 10 mm apart, followed by a perpendicular series of parallel linear threads at the same distance. This creates a grid-like pattern and is particularly useful for adding volume to a larger area or when multiple wrinkles are close in proximity. The cross-hatching technique allows for a more uniform distribution of the filler, resulting in a more natural-looking result.

Fanning

The fanning technique involves puncturing the epidermis once, as in the linear threading technique, and before the needle is completely removed from the skin, the needle is moved in a fan pattern to create a triangular shape. Additional evenly spaced fanning injections may be performed without removing the needle from the skin, depending on the size of the triangular area to be filled. Care must be taken to avoid over-injecting at the proximal end of each “fan” as this can result in an overlap of the product in one region.

Ferning

Ferning is a technique that involves short linear threading perpendicular to the fold, followed by advancing a few millimeters away from the fold in either direction. This technique is typically used on dynamic facial lines that require stiffness of the skin on either side of the wrinkle. The ferning technique can provide a more structured support to the skin, helping to smooth out dynamic lines and wrinkles.

Nasolabial Folds: Anatomical, Injection, and Post-Injection Considerations

The nasolabial fold is a noticeable line or crease that extends from the lateral border of the nostril to the corner of the mouth, a signifier of facial aging. 

The formation of the nasolabial folds occurs due to several anatomical changes with age, such as the gradual medial and inferior movement of the malar fat pad caused by collagen loss and diminished skin elasticity. A heavy mid-face, as seen with aging or obesity, might amplify the depth of these lines.

For the provider, it’s essential to understand the intricate anatomy of the nasolabial fold area. It consists of five layers: skin, subcutaneous fat, superficial musculoaponeurotic system (SMAS), facial muscles (like levator labii superioris, zygomaticus minor, and major), and the periosteum of the maxilla. The vascular structures around this area include the facial artery, angular artery, and infraorbital artery. As the facial artery runs near the nasolabial fold, always aspirate before injecting to avoid intravascular injection and subsequent complications.

When treating nasolabial folds, the choice of dermal filler is critical. Older patients with deeper folds might need a higher G Prime filler – G Prime refers to the elasticity or firmness of the filler. Higher G Prime fillers can create lift and sustain their form under pressure, which is beneficial in areas where a more substantial correction is required. 

The injection technique varies depending on the fold’s depth. For shallow to medium folds, linear threading with fanning is typically used. This involves a retrograde injection technique, wherein the needle is inserted at the lower part of the nasolabial fold and advanced superiorly towards the nose, depositing 0.05 to 0.1 mL of the filler per injection. Fanning, a technique where injections are administered in a starburst or radial pattern, is particularly useful at the upper Y-shaped area beneath the naris and lateral to the ala.

However, when progressing inferiorly towards the oral commissure, the correction duration tends to decrease due to increased muscular activity. Also, the correction here may be challenging due to the lack of underlying bone and the gravitational effect on cheek tissue. 

Following the injection, the provider should mold the filler to ensure optimal distribution and smoothness. This is accomplished by placing a gloved thumb on top of the treated fold and one or two fingers inside the mouth, then gently molding along the injection site to check for nodules or lumps. HA fillers are particularly amenable to molding due to their malleability.

However, while treating nasolabial folds, multiple superficial lines lateral to the fold might tempt an injector. These lines are often a result of dynamic facial expressions and should be addressed cautiously, as treating these might lead to visible filler implants during facial movements, which may appear as cord-like structures on the face. 

Post-procedural monitoring is crucial, and patients should be educated about potential complications such as swelling, redness, pain, bruising, lumps, skin necrosis, and even rarer complications like blindness due to accidental intra-arterial injection. Additionally, patients should avoid vigorous physical activities, exposure to intense heat or cold, and alcohol for the first 24 hours post-procedure to minimize risks and enhance recovery.

Remember, while hyaluronic acid fillers provide an effective, minimally invasive approach to correct nasolabial folds, patient safety and aesthetic results should always be the primary considerations. Therefore, a thorough understanding of facial anatomy, injection techniques, and product characteristics are prerequisites to performing these procedures safely and effectively.

Oral Commissures: Anatomical, Injection, and Post-Injection Considerations

The oral commissures, or the corners of the mouth, concern patients as they can begin to descend with aging, lending a melancholic or “sad” appearance. This phenomenon occurs due to a combination of factors such as fat atrophy, dermal thinning, and gravitational effects, along with the actions of the depressor anguli oris muscle, contributing to the downward turn.

The anatomy of the oral commissures includes important structures such as the orbicularis oris muscle, the depressor anguli oris muscle, the depressor labii inferioris, and the mentalis muscle. Surrounding vascular structures include the superior and inferior labial arteries, which arise from the facial artery. A detailed knowledge of these structures is crucial to avoid inadvertent intravascular injection, which can lead to serious complications.

Treatment aims at restoring volume to the marionette lines and lifting the corners of the mouth, thereby restoring a more youthful and refreshed appearance. The choice of dermal filler is critical. Fillers with high G Prime are often preferred for their robust lifting capacity and longevity.

The choice of injection technique depends on the extent and depth of the oral commissure depression. Deep depressions may necessitate a serial puncture technique, a method that involves injecting small aliquots of the filler at different levels within the depression. This technique is preferred for its ability to provide volume and support at different tissue levels. On the other hand, shallow, longer grooves might benefit more from linear threading, a technique that involves a continuous injection of the filler while the needle is slowly withdrawn.

The injection often extends down into the melomental fold, also known as the marionette lines, particularly in older patients. This is due to the shared etiology of aging changes between the oral commissures and the melomental folds. 

A useful tip for injectors is to request the patient to open their mouth slightly, which can help relax the surrounding muscles and facilitate easier filler placement. Be mindful of injecting too superficially to avoid the Tyndall effect, a bluish discoloration that occurs when filler is placed too close to the skin surface. 

Typically, the injection volume ranges from 0.05mL to 0.1mL per injection. Be aware that augmentation in the mouth corners may not persist as long as in other facial areas due to the high muscular activity in this region.

Post-injection, the injector should gently mold the filler to ensure optimal distribution and smoothness. The HA fillers are malleable and can be molded to achieve a more natural-looking result. The patients should be advised to minimize excessive facial movements, such as extreme smiling or frowning, in the first 24-48 hours to prevent displacement of the filler.

Possible complications that patients should be educated about include bruising, swelling, redness, pain at the injection site, asymmetry, and lumps or nodules. More serious but rarer complications include vascular occlusion, infection, and granuloma formation. In case of vascular occlusion, the area should be immediately massaged, warmth applied, and hyaluronidase injected to dissolve the filler.

In summary, rejuvenating the oral commissures with HA fillers requires a comprehensive understanding of the anatomical structures, injection techniques, filler characteristics, and possible complications to achieve safe and satisfactory results.

Melomental Fold: Anatomical and Procedural Nuances

The melomental fold (MMF), also known as the marionette line, extends inferiorly from the oral commissure towards the mandible, reflecting one’s age or emotional expressions, such as sourness or anger. The MMF’s prominence arises due to collagen and elastin loss, gravitational descent of facial tissues, and bony resorption, all of which are hallmarks of facial aging.

MMFs can present as a single line when viewed frontally. However, a three-dimensional perspective, achievable by looking superiorly from a lower point, may reveal a deepened groove or a delta. This is an essential observation for determining the most suitable injection technique.

For more advanced MMFs, linear threading or serial puncture might fall short in providing a satisfactory result. Instead, constructing a scaffold-like support using a fanning or cross-hatching technique might be more beneficial. These techniques offer structural support and create a lifting effect, contributing to a more youthful facial contour.

The injector should aim for the deep dermis when treating MMFs. The injections should progress from the inferior to the superior direction vertically, and medially to laterally in a horizontal fashion. This approach reduces the risk of inadvertently injecting into the facial vein, which lies laterally to the MMF. 

Layering can be beneficial for deep MMFs, with the initial layer providing a scaffolding effect, and subsequent layers achieving the desired volume. A high G Prime filler may be particularly beneficial in this region due to its structural integrity and volumizing effect. Research suggests injections should deliver 0.05mL to 0.1mL per pass, avoiding excess filler placement, which can lead to complications such as lumping or over-correction.

One must exercise care to prevent inadvertent injections into the lower lip, which may result in unwanted lip augmentation or palpable lumps. It’s recommended to palpate the area post-injection and smooth any palpable nodules. 

In terms of patient comfort, injectors should note that MMF injections are often more painful than injections into other facial regions, like the nasolabial folds. Providers can consider offering topical anesthetics or using fillers containing lidocaine to improve patient comfort.

Potential complications of MMF injections include swelling, bruising, infection, asymmetry, nodules, and granulomas. More severe, though rarer, complications include vascular occlusion, skin necrosis, and hypersensitivity reactions. A rapid response to vascular occlusion with hyaluronidase is essential to prevent skin necrosis.

In conclusion, HA filler injections into the MMF present a powerful tool for facial rejuvenation. However, a deep understanding of the anatomical and procedural intricacies, coupled with a thorough knowledge of potential complications, can enhance treatment outcomes and patient satisfaction.

Lip Augmentation: The Art of Balance and Precision

The lips, reaching their peak volume by the mid-30s, represent a hallmark of beauty and youthfulness. However, with age, features such as the vermilion border, philtral ridge, and cupid’s bow undergo changes including thinning, drooping, and flattening, respectively. The upper lip often becomes thin and elongated, whereas the lower lip thins and rolls inwards. Simultaneously, the orbicularis oris muscle’s activity contributes to radiating perioral lines, commonly referred to as “lipstick lines.” 

Achieving a natural, balanced augmentation of the lips is a complex task requiring a thorough understanding of facial proportions, anatomy, and the unique characteristics of dermal fillers. When discussing proportions, it’s generally accepted that the lower lip should be fuller than the upper, with an ideal ratio of 1:1.6 according to the Fibonacci sequence.

The clinician’s approach must be nuanced according to the patient’s age. Younger individuals typically seek enhancement of size and shape. While even small volumes of filler (0.1 – 0.3mL) can significantly enhance the lips’ appearance, caution should be exercised to prevent the undesirable “duck lip” appearance. 

Older patients, in contrast, generally wish to restore their lips to their previous state rather than increasing size. Such patients may not desire lip eversion or an unnatural appearance and might require adjunctive treatments like laser resurfacing or chemical peels for perioral wrinkling or deep lipstick bleeding. 

Pain during the procedure can be managed using HA products containing lidocaine, nerve blocks, or topical anesthetics. However, if nerve blocks are used, it’s crucial to work promptly as the numbness can distort the lip position. 

In terms of injection techniques, threading is recommended for minimizing puncture sites. The vermilion border and the wet-dry junction are common targets for lip volume enhancement. To increase lip size and provide lift and contour, the needle should be inserted 1-2mm from the vermillion border towards the mucosa border, creating a “ski jump” appearance. However, overfilling near the vermilion border should be avoided to prevent the “duck-like” appearance.

When focusing on volume enhancement, the needle should be inserted 3-5mm from the vermillion border near the wet-dry border, which will plump up the lips without everting the edges. 

For enhancing the philtral column, the needle should be inserted at the junction of the Cupid’s bow and philtral column, advancing superiorly.

Vertical lip lines can be managed by direct injection into the lines or along the vermilion border. Care should be taken to use minimal amounts to prevent overcorrection and unnatural bulging. 

As the lips are a focal point of the face, precision is paramount. Overcorrection or asymmetry can be glaringly apparent. In addition, the lips’ rich vascularity makes them prone to complications such as bruising and swelling. It’s recommended to apply ice post-procedure to mitigate these immediate side effects and to ensure equal amounts of filler are administered. 

Additionally, due to their high G-prime, fillers such as Juvederm Voluma or Restylane Lyft are generally avoided in lips, favoring softer fillers such as Juvederm Volbella or Restylane Silk, to avoid lumpiness and provide a softer, more natural feel. 

Potential complications include not only immediate post-treatment swelling and bruising but also longer-term problems such as lumps, bumps, asymmetry, or, more seriously, vascular occlusion. In the case of vascular occlusion, immediate management with hyaluronidase is critical. 

In conclusion, HA dermal filler injection in the lips requires a deep understanding of lip anatomy, precise injection techniques, and careful patient selection and counseling. A conservative approach with a focus on balance and proportion can yield the most satisfying and natural results.

Peri-Oral (Smoker’s Lip Lines) Dermal Filler Injection

Peri-oral lines, often referred to as “smoker’s lines” or “lipstick lines,” are common concerns for many older patients and smokers. These vertical, radial lines extending from the vermillion border are typically the result of collagen loss, habitual muscle contraction of the orbicularis oris muscle, and environmental factors such as sun exposure and smoking. Dermal filler injections, predominantly with hyaluronic acid (HA) fillers, offer an effective treatment to improve these lines. 

Anatomy

The peri-oral region consists of several anatomical layers: skin, subcutaneous tissue, orbicularis oris muscle, and the underlying skeletal structure. Understanding the dynamic interplay between these structures is key to achieving a natural-looking result while minimizing potential complications. It’s also important to be aware of the location of the superior and inferior labial arteries, which provide blood supply to the lips, to avoid inadvertent vascular occlusion.

Warnings

In the peri-oral region, care must be taken to avoid overcorrection, which can lead to an unnatural fullness and alter the natural curvature of the lips. Overcorrection can also cause the formation of bumps or lumps, which can be aesthetically displeasing. The treatment should aim to restore natural lip definition rather than enhancement.

Consider additional treatments like laser resurfacing, chemical peels, or botulinum toxin injections in patients with significant photodamage, dynamic lines, or poor skin texture. 

Injection Technique

1. For Fine Wrinkles: Inject along the course of the wrinkles vertically, using 0.025ml – 0.05ml per injection. Insert the needle at the wrinkle/lip junction in the vermillion border and orient it along the wrinkle. This reduces the risk of inadvertently injecting the product into the lip but may increase the risk of bruising.
2. For Deep Wrinkles: Implement a cross-hatching technique, using vertical and horizontal placement of the product (0.05ml per injection). It’s essential to avoid overcorrection to prevent the formation of bumps or an unnatural fullness. 
3. Post-Injection Molding: Use your thumb and index finger to guide and mold the product after injection, applying firm pressure to smooth out the filler and ensure that the wrinkle is not overcorrected.

Complications

The most common complications include bruising, swelling, and lumpiness. In rare cases, intravascular injection can occur leading to vascular occlusion. Therefore, a good understanding of the vascular anatomy is crucial. Overcorrection can lead to an unnatural appearance, dubbed “Homer Simpson” lips.  

In conclusion, HA-based dermal filler injections can be an effective treatment for peri-oral or smoker’s lip lines, but require a deep understanding of the underlying anatomy, skilled technique, and an aesthetic eye to achieve a natural and pleasing outcome. Providing patients with realistic expectations and discussing potential adjunctive treatments can also contribute to increased patient satisfaction.

Cheek Augmentation 

The injection of hyaluronic acid-based dermal fillers in the cheeks is a non-surgical procedure used to rejuvenate or augment the facial aesthetic. It’s imperative to understand the facial anatomy, injection technique, and potential complications to provide safe and effective treatment. 

Anatomy:

The cheek area is complex and involves multiple anatomical layers, including the skin, subcutaneous fat, the superficial musculoaponeurotic system (SMAS), and deep fat compartments. There are three fat compartments in the cheek: medial, middle, and lateral, each presenting different aging signs. The zygomatic and buccal branches of the facial nerve are also located in this area and are crucial to avoid during injection. The infraorbital artery, a branch of the internal carotid artery, supplies this region. The artery’s course should be kept in mind during injections to avoid intravascular complications. 

Warnings:

While dermal fillers have an impressive safety profile, complications can occur, especially if proper injection techniques are not used. Intravascular injection and compression of vessels can lead to vascular occlusion, necrosis, or even blindness. Therefore, thorough knowledge of the vascular anatomy is vital. 

Injection technique:

The injection technique depends on the desired aesthetic outcome. However, a common approach is injecting the filler deep, either sub-muscular or at the periosteal level, to provide lift and projection. Using a cannula instead of a needle may minimize the risk of vascular compromise. 

Firstly, the midface is divided into three aesthetic units: zygomatico-malar, submalar, and anterior cheek. The filler is typically injected in the zygomatico-malar area for volumizing and in the anterior cheek for contouring. The injection should start from the zygomatic arch, moving medially towards the nasolabial fold, and then downwards towards the mandible. The sub-malar area requires expert technique as this area lack the boney support and the transverse facial artery courses underneath the zygomatic arch.

A typical bolus technique is used, injecting the filler as the cannula or needle is withdrawn to reduce the risk of intravascular injection. In addition, the supraperiosteal space is the preferred plane of injection as it provides an even distribution of filler, reduces the risk of contour irregularities, and limits filler migration.

The amount injected:

The amount of dermal filler injected varies according to the individual patient’s needs and the desired result. Generally, 0.5 to 1 mL of filler per side is a reasonable starting point. However, it’s crucial to reassess the patient’s face after each injection to avoid overcorrection. 

G Prime:

The G prime of a filler represents its firmness or ability to resist deformation and is crucial in choosing the appropriate filler for each facial area. For cheek augmentation, a filler with a high G prime such as Juvederm Voluma or Restylane Lyft is preferred as they provide substantial lift and projection.

Complications:

As mentioned earlier, potential complications include vascular occlusion, necrosis, and blindness if filler is inadvertently injected into blood vessels. Additionally, improper injection technique can lead to contour irregularities, nodules, or granulomas. Overcorrection is another common problem, leading to an unnatural aesthetic outcome. 

Pearls:

1. A thorough understanding of facial anatomy and the desired aesthetic outcome is key to successful treatment.
2. Choose a filler with a high G prime for cheek augmentation for optimal results.
3. Always inject slowly and in small aliquots, reassessing the face after each injection to avoid overcorrection.
4. Use a cannula instead of a needle whenever possible to minimize the risk of vascular compromise.
5. Always have hyaluronidase readily available in your clinic to manage vascular complications promptly.

In conclusion, HA-based dermal filler injections in the cheeks provide a minimally invasive option for facial rejuvenation and contouring. However, successful treatment requires careful patient selection, meticulous injection technique, knowledge of facial anatomy, and the ability to manage potential complications.

Enhancing Complication Management in Hyaluronic Acid Based Dermal Filler Injections 

Complications can be broadly divided into early and delayed based on the time of occurrence, and minor and major based on the severity.

Early Minor Complications 

Early minor complications, such as bruising, pain, edema, and erythema, can occur immediately or within a few hours post-injection. They generally resolve within a week. The majority of patients might experience at least one of these localized injection site reactions, and it’s essential to inform patients about these potential side effects before the procedure. 

To minimize pain, especially in highly innervated sites like the lips, pre-treatment with topical anesthetic or ice is recommended. Avoiding anticoagulants and nonessential supplements pre-procedure can also reduce the risk of post-injection ecchymosis. Arnica, a homeopathic ointment, is often used to reduce ecchymosis. Its active ingredient, helenalin, has demonstrated anti-inflammatory effects, but clinical studies remain inconclusive. 

Further minor complications like asymmetry, lumpiness, or bluish discoloration, often result from suboptimal injection techniques. Incorrect filler placement can lead to nodules or papules, and superficially implanted filler might cause a visible bluish hue, known as the Tyndall effect. To manage these reactions, manual massage, aspiration, incision and drainage, or hyaluronidase are viable treatment options.

Early Major Complications 

Although rare, severe complications like anaphylaxis due to an immediate hypersensitivity reaction can occur. These hypersensitivity reactions are estimated to occur in 1 in 10,000 individuals. Cases have been documented where a patient developed an angioedema-type reaction about an hour after Restylane injection into the lips, which resolved with corticosteroid injection. Consequently, it’s crucial to have an emergency management protocol in your practice for such occurrences.

Post-procedure cellulitis, a common complication seen with any injection procedure, is usually caused by bacterial infection, predominantly from Staphylococcus and Streptococcus. Culturing lesions and treating with appropriate antibiotics is standard management. Pre-procedure cleansing with chlorhexidine can minimize the risk of infection. 

The trauma from the injection can also trigger a recurrent herpetic lesion. Prophylactic antiviral treatment is recommended when injecting the lips and the procedure should be avoided during an active herpes outbreak. Inflammatory nodules may occur if bacteria is injected with the filler and gets encapsulated by the HA within the skin. These painful, red nodules can be treated with incision, drainage, culture, and a course of antibiotics, such as clarithromycin, for 2 to 6 weeks. Steroids are contraindicated in such cases. Extra care is necessary in patients with diabetes, immunocompromised conditions, chronic sinusitis, or chronic dental problems.

Delayed Major Complications 

Granuloma formation is a delayed major complication that can occur six months after the injection. Though HA fillers are rarely linked to granuloma formation, it has been reported in 0.1% of patients, typically those injected with permanent or semi-permanent fillers. The body mounts a foreign body reaction, resulting in fibrosis at the injection site. Management includes steroid injections, surgical excision, or hyaluronidase.

Delayed hypersensitivity reactions can also occur, as was seen in a 2009 case report where a patient developed acute facial angioedema with urticaria three weeks post Restylane injection in her nasolabial folds.

The most severe delayed complication is tissue necrosis due to a direct blockage of a vessel, compression near the vessel, or injury to the vessel. The risk is 0.09% in patients who received collagen injections. The patient might experience delayed capillary refill, pain, followed by a mottled pattern of purple discoloration, and eventually ulceration due to necrosis. The glabellar area (due to blockage of the supratrochlear or supraorbital artery), the alar or nasal area (due to the blockage of nasal arteries), and regions along the facial and angular artery are common sites for this complication. Thorough knowledge of facial anatomy can help prevent this complication. Other preventive measures include aspiration prior to injection, slow anterograde injection, constant needle movement, usage of small particle size fillers, superficial injection technique, avoiding injections near vessels, and using blunt tip cannulas to reduce the risk of intravascular injection. Management involves immediate cessation of the injection, massage, heat application, nitroglycerin paste (1/2 inch of 2% nitroglycerin) to vasodilate the area, and hyaluronidase to dissolve the filler. When nitroglycerin is used topically, patients should be warned of potential side effects, such as headache, bradycardia, and hypotension.

Re-emphasizing the Early Signs of Vascular Occlusion Complications

Early recognition of complications is key to effective management. The two primary diagnostic symptoms of vascular occlusion are pain and changes in skin color. Immediate, severe, and disproportionate pain and acute onset of color changes—blanching (or white spots/blotches)—are an indication of arterial occlusion. Venous occlusion may be associated with less severe, dull, or delayed pain; in some cases, there may be no pain (this is rare in the case of arterial occlusion). Skin color changes may be immediate or up to 3-4 hours later, and red/bluish coloration is indicative of venous occlusion.

Hyaluronidase

Hyaluronidase is an enzyme that hydrolyzes and breaks down hyaluronic acid, facilitating the successful elimination of unwanted HA implantation. It’s been utilized effectively to correct asymmetry, overcorrection, Tyndall effect, and vascular occlusion. Hyaluronidase dissolves the filler and reduces edema, thereby helping to minimize occluded vessel pressure. 

For use, hyaluronidase is diluted with saline in a 1:1 ratio. Mandatory skin testing involves injecting 3-5 units intradermally. A wheal formation within 5 minutes, persisting for 20-30 minutes with localized itching, indicates a positive skin test. A total of 10-30 units should be injected per 2×2 cm area of impending necrosis. It’s crucial to check the package insert for any hyaluronidase product for complete instructions and information regarding warnings and contraindications.

Attempts should be made to dissolve or eliminate the injected product. In the case of hyaluronic acid-based fillers, hyaluronidase should be injected all over the affected area, “flooding the area with hyaluronidase”, as soon as possible in a dose applicable to the product to be reversed, for example, 10-20 units per injection point.

Hyaluronidase injections should be repeated on a daily basis where appropriate and continued for at least 4 days or as long as there are signs of ischemia. An anticoagulant, such as low-molecular weight heparin, aspirin, clopidogrel, or pentoxifylline, could also be prescribed to increase blood flow to the wound. Other authors have suggested the use of sildenafil to dilate compromised vasculature.

Timing of Other Cosmetic Procedures

Botulinum toxin treatment should be planned 2 weeks prior to filler. Microdermabrasion, chemical peels, and intense pulsed light (IPL) should ideally be carried out 1-2 weeks pre-or post-treatment and fractional resurfacing 3-4 weeks distant to allow erythema to diminish and the skin barrier to reestablish.

In conclusion, although HA-based dermal filler injections have an impressive safety record, it’s important for providers to familiarize themselves with the potential complications and their management. Meticulous injection technique, careful patient selection, pre and post-procedure care, and prompt complication management can significantly enhance patient safety and satisfaction.

For more information about Comprehensive Guide to Dermal Filler Injection Training, contact us at email@CosmeticMedicalTraining.com or call us at (212) 470-8059.

Statement of Responsibility

Cosmetic Medical Training recognizes that many of the techniques and recommendations are for procedures that are considered off-label use.  Our recommendations are based on many textbooks, published articles, seminars, and practical knowledge and experience.  The authors have attempted to maintain up to date knowledge and information in this training manual with the current standard of care.  However, due to the continuing flow of new research and information relating to the drugs being used in this course, we recommend that you check with the manufacturer for any changes in the package inserts, warnings, and precautions.  All information and tools presented within this site are intended for educational purposes. We do not guarantee that the information will be completely accurate and up to date; therefore the authors will not be held responsible for any errors, omissions, or inaccuracies published.  Application of the knowledge is ultimately the responsibility of the practitioner.

Originally published at Dermal Filler Training Los Angeles

 

The History of Botulinum Toxin

The history of Botulinum Toxin, often referred to as “botox”, is a fascinating journey that spans over several decades. This potent neurotoxin, produced by the bacterium Clostridium botulinum, has found its place in the world of cosmetic dermatology, offering a non-surgical solution to a variety of aesthetic concerns.

The discovery of Botulinum Toxin dates back to the 19th century when a German physician, Justinus Kerner, first identified it while investigating a series of food poisoning cases. Kerner coined the term “botulism” from the Latin word for sausage, “botulus,” as the affected individuals had consumed improperly prepared sausages. He was the first to recognize the paralytic symptoms of botulism and postulated the existence of a “fatty poison” that interfered with the transmission of nerve impulses.

In the early 20th century, Emile Pierre van Ermengem, a Belgian bacteriologist, isolated the bacterium we now know as Clostridium botulinum. He discovered that the bacterium produced a toxin that caused the symptoms of botulism. This marked the first step in understanding the nature of this potent neurotoxin.

The therapeutic potential of Botulinum Toxin was not realized until the mid-20th century. During the 1940s and 1950s, scientists at the United States Army’s biological warfare laboratories at Fort Detrick, Maryland, conducted extensive research on Botulinum Toxin as a potential biological weapon. Although the military applications of the toxin were never fully realized, this research paved the way for understanding the toxin’s therapeutic potential.

In the 1960s, Dr. Alan B. Scott, an ophthalmologist, began investigating the potential use of Botulinum Toxin to treat strabismus (crossed eyes), a condition that was difficult to treat surgically. His research led to the development of a purified and diluted form of the toxin that could be injected into muscles to cause temporary paralysis. In 1989, the U.S. Food and Drug Administration (FDA) approved the use of Botulinum Toxin type A (marketed as Botox) for the treatment of strabismus and blepharospasm (uncontrolled blinking).

The cosmetic applications of Botulinum Toxin were discovered somewhat serendipitously. Jean Carruthers, a Canadian ophthalmologist, noticed that her patients who received Botox treatments for eye disorders also experienced improvement in facial wrinkles. This observation led to a series of studies conducted by Jean and her husband, Alastair Carruthers, a dermatologist, which eventually led to the FDA approval of Botox for cosmetic use in 2002.

Since then, the use of Botulinum Toxin in cosmetic dermatology has skyrocketed. It is now used to treat a variety of conditions, including forehead wrinkles, crow’s feet, and frown lines. The toxin works by blocking the nerve signals to the muscles, causing them to relax and reducing the appearance of wrinkles.

The journey of Botulinum Toxin from a deadly poison to a beloved wrinkle reducer is a testament to the power of scientific research and innovation. As our understanding of this potent neurotoxin continues to grow, so too will its applications in cosmetic dermatology and beyond.

Different Botulinum Toxins

BOTOX Cosmetic (onabotulinumtoxinA): 

Indication

This drug is used in adults for temporary improvement in the appearance of moderate to severe glabellar lines (lines between the eyebrows) associated with corrugator and/or procerus muscle activity. It is also indicated for the treatment of moderate to severe lateral canthal lines (crow’s feet) associated with orbicularis oculi activity, and moderate to severe forehead lines associated with frontalis muscle activity. 

Dilution

This drug is supplied in single-dose 50 Units and 100 Units per vial. It should be reconstituted with sterile, preservative-free 0.9% Sodium Chloride Injection USP to obtain a solution at a concentration of 4 Units/0.1 mL. The reconstituted BOTOX Cosmetic should be clear, colorless, and free of particulate matter. It should be administered within 24 hours after reconstitution and stored in a refrigerator during this time period. The vials are for single-dose only.

Administration

The drug is administered intramuscularly into five sites, two each corrugator muscle and one in the procerus muscle for a total dose of 20 Units. The dosage for simultaneous treatment with lateral canthal lines is 64 Units, comprised of 20 Units for forehead lines, 20 Units for glabellar lines, and 24 Units for lateral canthal lines. The drug should be administered no closer than 1 cm above the central eyebrow to reduce the risk of ptosis.

Storage

The product is supplied as a vacuum-dried powder in single-dose vials of 50 or 100 Units. Unopened vials should be stored in a refrigerator (2° to 8°C). Reconstituted BOTOX Cosmetic should also be stored in a refrigerator and used within 24 hours.

DYSPORT (abobotulinumtoxinA): 

Indication

This drug is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines associated with procerus and corrugator muscle activity in adults less than 65 years of age.

Dilution

This drug is supplied as a dry powder in single-dose 300 Unit and 500 Unit vials. It should be reconstituted with preservative-free 0.9% Sodium Chloride Injection, USP using aseptic technique. The reconstituted DYSPORT should be a clear, colorless solution, free of particulate matter. It should be used for only one injection session and for only one patient. Once reconstituted, it can be stored in a refrigerator, protected from light for up to 24 hours until time of use.

Administration

The dose for the treatment of glabellar lines in adults is a total of 50 Units given intramuscularly in five equal aliquots of 10 Units each to achieve clinical effect. The drug should be administered no more frequently than every three months. To reduce the risk of ptosis, the drug should be injected at least 1 centimeter above the bony supraorbital ridge and no closer than 1 centimeter above the central eyebrow.

Storage

This is supplied as a sterile, lyophilized powder in a single-dose, glass vial. Unopened vials must be stored refrigerated (2°C to 8°C) and protected from light.

XEOMIN (incobotulinumtoxinA): 

Indication

It is indicated for temporary improvement in the appearance of moderate to severe glabellar lines with corrugator and/or procerus muscle activity.

Dilution

It should be reconstituted with only 2.5mL sterile, preservative-free 0.9% Sodium Chloride Injection, USP to obtain a solution at a concentration of 4 Units/0.1 mL. The frequency of XEOMIN treatments should be no sooner than every 12 weeks.

Administration

The drug is administered intramuscularly into five sites, two injections into medial corrugator and lateral corrugator muscles respectively, and one injection in the procerus muscle for a total dose of 20 Units. To reduce the risk of ptosis, the drug should be injected no less than 1 centimeter above the superior orbital rim.

Storage

Supplied in single-dose vials of 50, 100, or 200 Units. Unopened vials can be stored at room temperature (20°C to 25°C), in a refrigerator (2°C to 8°C), or a freezer (-20°C to -10°C). Reconstituted XEOMIN should not be used if the solution appears cloudy or contains particulate matter, and any unused solution should be discarded after 24 hours.

JEUVEAU (prabotulinumtoxinA-xvfs):

Indication

This drug is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity in adult patients.

Dilution

This drug is supplied in a single-dose 100 Unit vial. It should be reconstituted with only 2.5mL sterile, preservative-free 0.9% Sodium Chloride Injection, USP to obtain a solution at a concentration of 4 Units/0.1 mL. The reconstituted JEUVEAU should be clear, colorless, and free of particulate matter. It should be administered within 24 hours after reconstitution and stored in a refrigerator during this time period. The vials are for single-dose only.

Administration

The drug is administered intramuscularly into five sites, two injections into medial corrugator and lateral corrugator muscles respectively, and one injection in the procerus muscle for a total dose of 20 Units. To reduce the risk of ptosis, the drug should be injected no less than 1 centimeter above the superior orbital rim.

Storage

Supplied as a vacuum-dried powder in a single-dose vial of 100 Units. Unopened vials should be stored in a refrigerator (2° to 8°C) and protected from light.

DAXXIFY (daxibotulinumtoxinA-lanm)

Indication

This drug is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity in adult patients.

Dilution

This drug is supplied in single-dose 50 Unit and 100 Unit vials. It should be reconstituted with the required amount of sterile, preservative-free 0.9% Sodium Chloride Injection, USP to obtain a solution at a concentration of 8 Units/0.1 mL. The reconstituted DAXXIFY solution should be clear to slightly opalescent and colorless and free of particulate matter. It should be administered within 72 hours after reconstitution and stored in a refrigerator during this time period.

Administration

The drug is administered intramuscularly into five sites, two injections into medial corrugator and lateral corrugator muscles respectively, and one injection in the procerus muscle for a total dose of 40 Units. To reduce the risk of ptosis, the drug should be injected no less than 1 centimeter above the superior orbital rim.

Storage

Supplied as a sterile lyophilized powder in single-dose vials of 50 or 100 Units. Unopened vials should be stored at room temperature (20°C to 25°C) or refrigerated (2°C to 8°C) and protected from light.

General Contraindications

Botulinum toxin drugs are contraindicated in patients with:

Known hypersensitivity to any botulinum toxin products or to any of the components in the formulation. This includes specific hypersensitivity to cow’s milk protein, which may be present in trace amounts in some formulations.

Presence of infection at the proposed injection site(s).

These contraindications apply to all the mentioned botulinum toxin drugs: BOTOX Cosmetic, DYSPORT, XEOMIN, JEUVEAU, and DAXXIFY.

Warnings and Precautions

Lack of Interchangeability between Botulinum Toxin Products

The potency units of botulinum toxin products, including BOTOX Cosmetic (onabotulinumtoxinA), DYSPORT, XEOMIN, JEUVEAU, and DAXXIFY (daxibotulinumtoxinA-lanm), are specific to the preparation and assay method utilized. They are not interchangeable with other preparations of botulinum toxin products. Therefore, units of biological activity of these products cannot be compared to nor converted into units of any other botulinum toxin products assessed with any other specific assay method.

Spread of Toxin Effect: 

Postmarketing safety data from botulinum toxin products, including BOTOX Cosmetic, DYSPORT, XEOMIN, JEUVEAU, and DAXXIFY, suggest that botulinum toxin effects may, in some cases, be observed beyond the site of local injection. The symptoms are consistent with the mechanism of action of botulinum toxin and 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 related to the spread of toxin effects. Patients should be advised to seek immediate medical care if swallowing, speech, or respiratory difficulties occur. Although no serious adverse reactions of distant spread of toxin effect associated with these products have been reported in clinical studies for their specific approved indications, these reactions are possible.

Serious adverse reactions with unapproved use:

Serious adverse reactions, including excessive weakness, dysphagia, and aspiration pneumonia, with some adverse reactions associated with fatal outcomes, have been reported in patients who received botulinum toxin injections for unapproved uses. These adverse reactions were not necessarily related to distant spread of toxin, but may have resulted from the administration of botulinum toxin products to the site of injection and/or adjacent structures. In several cases, patients had pre-existing dysphagia or other significant disabilities. There is insufficient information to identify factors associated with an increased risk for adverse reactions associated with the unapproved uses of botulinum toxin products. The safety and effectiveness of botulinum toxin for unapproved uses have not been established.

Hypersensitivity Reactions:

Serious and/or immediate hypersensitivity reactions have been reported for botulinum toxin products. These reactions include anaphylaxis, serum sickness, urticaria, soft tissue edema, and dyspnea. If such a reaction occurs, further injection of the botulinum toxin product should be discontinued and appropriate medical therapy immediately instituted. The use of botulinum toxin products in patients with a known hypersensitivity to any botulinum neurotoxin or to any of the components in the formulation could lead to a life-threatening allergic reaction.

Cardiovascular System:

There have been reports following administration of botulinum toxins of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. Some of these patients had risk factors including pre-existing cardiovascular disease. Use caution when administering to patients with pre-existing cardiovascular disease.

Increased Risk with Pre-Existing Neuromuscular Disorders:

Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis, or neuromuscular junction disorders (e.g., myasthenia gravis or Lambert-Eaton syndrome) should be monitored particularly closely when given botulinum toxin. Patients with neuromuscular disorders may be at increased risk of clinically significant effects including generalized muscle weakness, diplopia, ptosis, dysphonia, dysarthria, severe dysphagia, and respiratory compromise.

Dysphagia and Breathing Difficulties:

Treatment with botulinum toxin products can result in swallowing or breathing difficulties. Patients with pre-existing swallowing or breathing difficulties may be more susceptible to these complications. In most cases, this is a consequence of weakening of muscles in the area of injection that are involved in breathing or swallowing. Deaths as a complication of severe dysphagia have been reported after treatment with botulinum toxin. Dysphagia may persist for several months, and require use of a feeding tube to maintain adequate nutrition and hydration. Aspiration may result from severe dysphagia and is a particular risk when treating patients in whom swallowing or respiratory function is already compromised. Treatment with botulinum toxins may weaken neck muscles that serve as accessory muscles of ventilation. This may result in a critical loss of breathing capacity in patients with respiratory disorders who may have become dependent upon these accessory muscles. There have been postmarketing reports of serious breathing difficulties, including respiratory failure. Patients treated with botulinum toxin may require immediate medical attention should they develop problems with swallowing, speech or respiratory disorders. These reactions can occur within hours to weeks after injection with botulinum toxin.

Pre-existing Conditions at the Injection Site: 

Caution should be used when botulinum toxin treatment is used in the presence of inflammation at the proposed injection site(s), ptosis, or when excessive weakness or atrophy is present in the targeted muscle(s). This also applies to patients who have marked facial asymmetry, excessive dermatochalasis, deep dermal scarring, thick sebaceous skin, or when subjects do not respond to 20 Units of botulinum toxin (e.g., the inability to substantially lessen glabellar lines even by physically spreading them apart). Use caution when administering to patients with surgical alterations to the facial anatomy. Do not exceed the recommended dosage and frequency of administration.

Corneal Exposure and Ulceration: 

This may require protective drops, ointment, or closure of the eye by patching or other means. Because of its anticholinergic effects, botulinum toxin should be used with caution in patients at risk of developing narrow angle glaucoma. To prevent ectropion, botulinum toxin products should not be injected into the medial lower eyelid area. Ecchymosis easily occurs in the soft tissues of the eyelid. Immediate gentle pressure at the injection site can limit that risk.

Ophthalmic Adverse Reactions: 

Dry Eye: 

Dry eye has been reported with the use of botulinum toxin products in the treatment of glabellar lines. Reduced tear production, reduced blinking, and corneal disorders may occur with use of botulinum toxins. If symptoms of dry eye (e.g., eye irritation, photophobia, or visual changes) persist, consider referring the patient to an ophthalmologist.

Spatial Disorientation and Double Vision Treated for Strabismus: 

Inducing paralysis in one or more extraocular muscles may produce spatial disorientation, or double vision.. Covering the affected eye may alleviate these symptoms.

Human Albumin and Transmission of Viral Diseases: 

The product contains albumin, a derivative of human blood. Based on effective donor screening and product manufacturing processes, it carries an extremely remote risk for transmission of viral diseases and variant Creutzfeldt-Jakob disease (vCJD). There is a theoretical risk for transmission of Creutzfeldt-Jakob disease (CJD), but if that risk actually exists, the risk of transmission would also be considered extremely remote. No cases of transmission of viral diseases, CJD or vCJD have ever been identified for licensed albumin or albumin contained in other licensed products.

Facial Anatomy in the Treatment of Glabellar Lines: 

Caution should be exercised when administering botulinum toxin to patients with surgical alterations to the facial anatomy, excessive weakness or atrophy in the target muscle(s), marked facial asymmetry, inflammation at the injection site(s), ptosis, excessive dermatochalasis, deep dermal scarring, thick sebaceous skin, or the inability to substantially lessen glabellar lines by physically spreading them apart. Do not exceed the recommended dosage and frequency of administration. In clinical trials, subjects who received a higher dose had an increased incidence of eyelid ptosis.

Intradermal Immune Reaction: 

The possibility of an immune reaction when injected intradermally is unknown. The safety of botulinum toxin for the treatment of hyperhidrosis has not been established. It is approved only for intramuscular injection.

Side Effects/ Adverse Reactions

Here is the list of major side effects taken from the Xeomin, botulinum toxin. Most botulinum toxin share similar side effect / adverse event profile. Please check your package insert for a detailed list.

Immunogenicity

As with all therapeutic proteins, there is a potential for immunogenicity. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to botulinum toxin in different studies or to other products may be misleading.

Treatment with botulinum toxins may result in the formation of neutralizing antibodies that may reduce the effectiveness of subsequent treatments by inactivating the biological activity of the toxin. The critical factors for neutralizing antibody formation have not been well characterized. The results from some studies suggest that botulinum toxin injections at more frequent intervals or at higher doses may lead to a greater incidence of antibody formation. The potential for antibody formation may be minimized by injecting with the lowest effective dose given at the longest feasible intervals between injections.

Post Marketing Experience

Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. The following adverse reactions have been identified during post-approval use of botulinum toxin products:

Death, sometimes associated with dysphagia, pneumonia, and/or other significant debility or anaphylaxis.

Adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. Some of these patients had risk factors including cardiovascular disease.

New onset or recurrent seizures, typically in patients who are predisposed to experiencing these events.

Ear and labyrinth disorders: Hypoacusis; tinnitus; vertigo.

Eye disorders: Diplopia; dry eye; lagophthalmos; strabismus; visual disturbances; vision blurred.

Gastrointestinal disorder: Abdominal pain; diarrhea; dry mouth; nausea; vomiting.

General disorders and administration site conditions: Denervation; malaise; pyrexia.

Metabolism and nutrition disorders: Anorexia.

Musculoskeletal and connective tissue disorders: Localized muscle twitching/involuntary muscle contractions; muscle atrophy; myalgia.

Nervous system disorders: Brachial plexopathy; dysarthria; facial palsy; hypoaesthesia; localized numbness; myasthenia gravis; paresthesia; peripheral neuropathy; radiculopathy; syncope.

Respiratory, thoracic and mediastinal disorders: Aspiration pneumonia; dyspnea; respiratory depression and/or respiratory failure.

Skin and subcutaneous tissue disorders: Alopecia, including madarosis; hyperhidrosis; pruritus; skin rash (including erythema multiforme, dermatitis psoriasiform, and psoriasiform eruption).

Vertigo, photophobia, influenza-like illness, amyotrophy, burning sensation, facial paresis, hypoesthesia, erythema, dry eye, and excessive granulation tissue.

Hypersensitivity reactions including anaphylaxis.

Eye swelling, eyelid edema, dysphagia, nausea, flu-like symptoms, injection site pain, injection site reaction, allergic dermatitis, localized allergic reactions like swelling, edema, erythema, pruritus or rash, herpes zoster, muscular weakness, muscle spasm, dysarthria, myalgia and hypersensitivity.

Drug Interactions

Aminoglycosides and Other Agents Interfering with Neuromuscular Transmission: Co-administration of botulinum toxin and aminoglycosides or other agents interfering with neuromuscular transmission (e.g., curare-like compounds or tubocurarine-type muscle relaxants) should only be performed with caution as the effect of the toxin may be potentiated. If co-administered, the patient should be observed closely.

Anticholinergic Drugs: Use of anticholinergic drugs after administration of botulinum toxin may potentiate systemic anticholinergic effects such as blurred vision.

Other Botulinum Neurotoxin Products: The effect of administering different botulinum neurotoxin products at the same time or within several months of each other is unknown. Excessive neuromuscular weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered botulinum toxin.

Muscle Relaxants: Excessive weakness may also be exaggerated by administration of a muscle relaxant before or after administration of botulinum toxin.

Specific Populations

Pregnancy: There are no adequate data from postmarketing surveillance on the developmental risk associated with the use of botulinum toxin in pregnant women. In animal studies, administrations of botulinum toxin during pregnancy resulted in adverse effects on fetal growth (decreased fetal body weight and skeletal ossification) at clinically relevant doses, which were associated with maternal toxicity. 

Lactation: There are no data on the presence of botulinum toxin in human or animal milk, the effects on the breastfed child, or the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for botulinum toxin and any potential adverse effects on the breastfed infant from botulinum toxin or from the underlying maternal conditions.

Pediatric Use: Safety and effectiveness in patients below the age of 18 years have not been established for botulinum toxin.

Geriatric Use: In clinical studies of botulinum toxin, the responder rates appeared to be higher for subjects younger than age 65 than for subjects 65 years or older. However, no overall differences in safety or effectiveness were observed between older and younger patients. Other clinical studies have not identified differences in responses between older and younger patients, but increased sensitivity in older patients cannot be ruled out.

Females and Males of Reproductive Potential: In rats, botulinum toxin produced adverse effects on mating behavior and fertility.

Ethnic Groups: Exploratory analyses in trials for glabellar lines in African-American subjects with Fitzpatrick skin types IV, V, or VI and in Hispanic subjects suggested that response rates at Day 30 were comparable to and no worse than the overall population.

Overdose

Excessive doses of botulinum toxin, whether it’s BOTOX Cosmetic (onabotulinumtoxinA), DYSPORT, XEOMIN, JEUVEAU (prabotulinumtoxinAxvfs), or DAXXIFY, may be expected to produce neuromuscular weakness with a variety of symptoms. Symptoms of overdose are likely not to be present immediately following injection.

Should accidental injection or oral ingestion occur, or overdose be suspected, these patients should be considered for further medical evaluation and appropriate medical therapy immediately instituted, which may include hospitalization. The person should be medically supervised for several weeks for signs and symptoms of systemic muscular weakness which could be local, or distant from the site of injection.

In the event of overdose, antitoxin raised against botulinum toxin is available from the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. However, the antitoxin will not reverse any botulinum toxin-induced effects already apparent by the time of antitoxin administration.

In the event of suspected or actual cases of botulinum toxin poisoning, please contact your local or state Health Department to process a request for antitoxin through the CDC. 

Clinical Pharmacology

Mechanism of Action 

The mechanism of action of botulinum toxin involves several steps:

1. Binding: The botulinum toxin binds to specific surface receptors on nerve endings. This binding is facilitated by the heavy chain of the toxin molecule.
2. Internalization: Once bound, the toxin is internalized into the nerve terminal through a process known as receptor-mediated endocytosis.
3. Inhibition of Acetylcholine Release: Inside the nerve terminal, the toxin cleaves a pre-synaptic protein called SNAP-25. This protein is integral to the successful docking and release of acetylcholine, a neurotransmitter responsible for muscle contraction, from vesicles situated within nerve endings. The cleavage of SNAP-25 inhibits the release of acetylcholine, leading to a localized reduction in muscle activity.
4. Muscle Response: The affected muscle undergoes partial chemical denervation, which may lead to muscle atrophy. These changes contribute to the muscle’s reduced activity and the wrinkle smoothing.

The effects of botulinum toxin are not permanent. Over time, the muscle begins to regain its strength through a process known as reinnervation. This occurs as the neuromuscular junction recovers from SNAP-25 cleavage and new nerve endings are formed. The parent nerve terminal regains function, and the collateral terminals, which had sprouted during the period of denervation, retract. This gradual recovery of muscle function ensures the safety of botulinum toxin use in cosmetic medicine, as the effects can be reversed over time.

Pharmacodynamics: 

No formal pharmacodynamic studies have been conducted with these toxins. The primary pharmacodynamic effect is due to chemical denervation of the treated muscle resulting in a measurable decrease of the compound muscle action potential, causing a localized reduction in muscle activity. The return of increased muscle tone following injection typically occurs within 3 to 4 months.

Pharmacokinetics: 

Using currently available analytical technology, it is not possible to detect these toxins in the peripheral blood following intramuscular injection at the recommended doses.

Carcinogenesis, Mutagenesis, Impairment of Fertility: 

Long term studies in animals have not been performed to evaluate carcinogenic potential of these toxins. They were negative in a battery of in vitro and in vivo genetic toxicologic assays. In fertility studies, reduced fertility was observed in males and females at high doses. 

Patient Consultation

The patient consultation is a critical component of a successful botulinum toxin treatment. It provides an opportunity to understand the patient’s concerns, set realistic expectations, and plan the treatment accordingly. 

Initial Consultation

1. Patient History: Begin with a comprehensive history, including medical conditions, previous cosmetic procedures, allergies, and medications. This information is crucial to assess the suitability of botulinum toxin treatment and to anticipate potential complications.
2. Informed Consent: Explain the procedure, potential risks, benefits, and alternatives to the patient. Ensure they understand the information and have the opportunity to ask questions. Obtain written consent before proceeding with the treatment.
3. Photographic Documentation: Take standardized ‘before’ photographs from multiple angles. These photos serve as a reference for treatment planning and to evaluate the treatment outcome.

Patient Examination

1. Patient Concerns: Provide a mirror and ask the patient to point out the areas of concern. Ask them to animate their face to illustrate their concerns better. This step helps to understand the patient’s perception of their appearance and their aesthetic goals.
2. Facial Analysis: Conduct a thorough examination of the face, noting asymmetries, skin quality, muscle strength, and the depth and location of wrinkles. Point out any asymmetries to the patient and document them in the medical record.
3. Glogau Wrinkle Scale: Use the Glogau Wrinkle Scale to assess the severity of wrinkles. This scale categorizes wrinkles into four types, each associated with a specific age group and recommended treatment:

    – Type 1: ‘Early Wrinkles’ (20s to 30s) – botulinum toxin is typically sufficient.

    – Type 2: ‘Wrinkles in Motion’ (30s to 40s) – botulinum toxin and possibly dermal fillers may be needed.

    – Type 3: ‘Wrinkles at Rest’ (50s & older) – botulinum toxin and dermal fillers will likely be required.

    – Type 4: ‘Only Wrinkles’ (60s or 70s) – botulinum toxin and dermal fillers may not be enough; consider facelift or laser resurfacing.

4. Glabellar Spread Test: This test helps determine if botulinum toxin alone will soften a patient’s frown lines. Spread the glabellar wrinkles apart with your thumb and index fingers. Patients with thick skin and deep dermal folds who do not improve with manual spreading may need dermal filler injections alongside botulinum toxin.

Setting Expectations

1. Realistic Expectations: Discuss the expected outcomes and limitations of botulinum toxin treatment. Emphasize that the typical goal is to enhance their natural beauty and not to completely change their appearance.
2. Patient Education: Educate the patient about the procedure, post-treatment care, and the need for follow-up sessions. Explain that the effects of botulinum toxin are temporary and regular treatments are necessary to maintain the results.
3. Treatment Plan: Based on the patient’s concerns, facial analysis, and wrinkle assessment, develop a personalized treatment plan. Discuss the plan with the patient, including the areas to be treated, the type of botulinum toxin to be used, and the estimated cost.

The patient consultation is not just about gathering information but also about building a therapeutic relationship with the patient. A well-conducted consultation can lead to high patient satisfaction and a successful treatment outcome.

Counseling

Patients should be informed that injections of botulinum toxins, such as BOTOX Cosmetic, DYSPORT, XEOMIN, JEUVEAU, and DAXXIFY, may lead to potential swallowing, speaking, or breathing difficulties, or other unusual symptoms. If such symptoms develop or existing symptoms worsen, patients or caregivers should seek immediate medical care.

Patients should also be aware that these injections may cause eye dryness, and they should report any symptoms of eye dryness, such as eye pain, eye irritation, photosensitivity, or changes in vision, to their doctor.

In addition, patients should be advised to avoid driving a car or engaging in other potentially hazardous activities if they experience loss of strength, muscle weakness, blurred vision, or drooping eyelids.

It’s important to note that these are general guidelines and the specific details may vary between the different toxins. Always refer to the specific patient counseling information for each toxin for the most accurate information.

Injecting the Glabella/Procerus and Corrugator Muscle

The glabellar region, often referred to as the ‘frown lines,’ is a common area for botulinum toxin injections. The primary muscles involved in this region are the procerus and corrugator muscles.

Muscles Involved and Action

1. Procerus: This muscle originates from the nasal bone and inserts into the medial forehead and skin of the brow. Its action is to draw the medial brow inferiorly, contributing to the horizontal lines seen on the forehead.
2. Corrugator: The corrugator muscle originates from the medial superciliary arch and inserts into the skin of the medial forehead. It draws the brow medially and inferiorly, leading to the formation of vertical lines between the eyebrows.

Landmarks

Identifying the correct landmarks is crucial for successful injections. Here are the key landmarks for glabellar injections:

1. Medial Corrugator: The injection should be 1 cm above the bony orbital rim and vertical to the medial canthus.
2. Lateral Corrugator: The injection should be 1 cm above the bony orbital rim and medial to the vertical mid-pupillary line.
3. Procerus: The injection should be just above the crossing point of the ‘X’ formed by drawing a line from the medial eyebrow contralateral to the medial canthus.

Injection Technique

All injections for the glabella are intramuscular and perpendicular to the skin. The needle should be above the periosteum. It’s important to note that the frontalis muscle overlaps the corrugator superficially, so a superficial injection may cause paralysis of the inferior edges of the frontalis muscle. Therefore, corrugator injections should be deep intramuscular injections.

Previously, the recommendation was to inject until hitting the periosteum, then pull back several millimeters before injecting the botulinum toxin. However, this technique has been modified as it was found to increase the incidence of headaches in patients and dull the needle for subsequent injections.

The standard FDA-approved dose for glabellar lines, as per the BOTOX® Cosmetic package insert, is 20 units. However, men may require an additional 1-2 units per injection site due to typically larger muscle mass.

Complications and Solutions

The complication rate for glabellar injections is 1-3%. Potential complications include:

1. Lid Ptosis: This can occur if the injection is too close to the orbital rim, as diffusion of the botulinum toxin may affect the levator palpebrae superioris muscle.
2. Brow Ptosis: This can occur if the injection is placed too superficially (affecting the frontalis muscle) or too lateral to the mid-pupillary line. 

Complications can appear as soon as 48 hours or as late as 7 days post-injection and may persist for 4-8 weeks. Solutions include:

1. Lid Ptosis: Apraclonidine 0.5% drop can be used, one drop to the affected eye three times a day. This stimulates Mueller’s muscles to minimize the ptosis. Oxymetazoline 0.1%, which has the FDA approval for lid ptosis, can also be used. 
2. Brow Ptosis: A brow lift injection technique can be attempted. However, typically, time is required for frontalis movement to reappear to lift the brow up once again.

Injecting the Brow for a Brow Lift

Injections above near the brows that paralyzes the depressor muscles and create a “brow lift” like effect. 

Muscles Involved and Action

The primary muscles involved in a brow lift procedure using botulinum toxin are the Procerus and the Orbicularis Oculi.

Procerus

The Procerus muscle originates from the nasal bone and inserts into the medial forehead and skin of the brow. Its primary action is to draw the medial brow inferiorly, contributing to the formation of horizontal wrinkles on the bridge of the nose.

Orbicularis Oculi

The Orbicularis Oculi is a circumferential muscle group that functions like a sphincter or a purse string. It originates from the medial palpebral ligament and inserts into the lateral palpebral raphe, corrugator, frontalis, and depressor supercilii. Its action pulls the skin of the forehead, temple, and cheek toward the medial angle of the orbit, and it is also responsible for closing the eyelids.

Landmarks

The key landmarks for a brow lift procedure are the crossing point of the X formed by drawing a line from the medial eyebrow contralateral to the medial canthus for the Procerus, and the superolateral portion of the Orbicularis Oculi as it curves infralaterally lateral to the temporal fusion line for the Orbicularis Oculi.

Injection Technique

Procerus

The Procerus should receive a deep intramuscular injection, just above the periosteum. Inject 4 units of botulinum toxin to the Procerus just above the crossing point of the X formed by drawing a line from the medial eyebrow contralateral to the medial canthus.

Orbicularis Oculi

For the Orbicularis Oculi, inject 3 units subcutaneously to the superolateral portion of the muscle as it curves infralaterally lateral to the temporal fusion line. Ensure that the movement of the lateral portions of the frontalis muscles is not felt in this superolateral injection site to avoid injecting the frontalis and creating brow ptosis. The injection should be placed 1 cm outside of the bony orbital rim.

Complications and Solutions

The primary complication of a brow lift procedure is brow ptosis, or drooping of the brow. This can be minimized by injecting superior and lateral to the orbital rim. If brow ptosis does occur, it will naturally resolve as the action of the botulinum toxin diminishes over time.

Additional Pearls

– Precise injection location and depth are crucial for achieving aesthetically pleasing brow outcomes and greater duration of efficacy. 

– Avoiding the frontalis muscle during injection is key to prevent brow ptosis.

– Always consider individual patient anatomy when planning and executing the procedure.

Injecting the Horizontal Forehead Lines or Frontalis Muscle

The primary indication for injecting the frontalis muscle is to reduce the appearance of horizontal forehead lines. These lines are a result of the repetitive contraction of the frontalis muscle, which lifts the eyebrows and furrows the forehead.

Muscles Involved and Action

The frontalis muscle is a broad muscle that varies in size and shape among individuals. Some may have a narrow or broad frontalis, while others may have a tall or short frontalis. The shape can also vary, being either V-shaped or rectangle-shaped. It is important to palpate the muscle before injecting to understand its size and shape.

The frontalis muscle originates from the galea aponeurosis and inserts into the muscles of the glabellar complex. The action of the frontalis muscle is to lift the eyebrows superiorly and depress the scalp inferiorly. The fibers of the frontalis muscles are oriented vertically, while the visible wrinkles formed by the contraction of the frontalis muscle are horizontal.

Landmark

The frontalis muscle is located on the forehead and is easily palpable. The lower 2-3 cm of the frontalis muscle is used to elevate the eyebrow and injection here should be avoided. The medial portions of the frontalis muscle fibers may be more fibrous or absent and may need less injection. A key point about the frontalis is to avoid injecting near the lowest horizontal wrinkle or at least 2-3 cm above the brow.

Injection Technique

The injections are subcutaneous and are typically placed roughly 2 cm apart. Typically, 2 units of botulinum toxin are injected per site. Men may require 1-2 additional units per injection site due to typically having a larger muscle mass.

Complications and Solutions

The most common complications associated with frontalis muscle injections include brow ptosis and Spock brow.

Brow ptosis: This can occur when the frontalis is treated without paralyzing the active brow depressor muscles (procerus and corrugator). Ideally, glabella muscles should be injected simultaneously. Another cause of brow ptosis is when the frontalis muscle, which is hyperfunctional, supports a normally ptotic upper eyelid. To avoid complete paralysis of the frontalis muscle, it is recommended to avoid injecting near the first horizontal line or at least 2-3 cm above the brow.

Spock brow: This can occur when the lateral fibers of the frontalis muscles have not been paralyzed. The solution is to inject 1-2 units where you feel the untreated lateral fibers of the frontalis muscle when you ask your patients to lift their eyebrows. It should be noted that some patients may actually prefer the “Spock brow” look.

Additional Pearls

1. Always palpate the frontalis muscle before injecting to understand its size and shape. This will help in determining the amount of botulinum toxin needed and the best injection sites.
2. Always avoid injecting near the lowest horizontal wrinkle line or at least 2-3 cm above the brow to prevent brow ptosis.
3. When treating the frontalis muscle, consider also treating the glabella muscles to prevent brow ptosis.
4. Be aware of the possibility of a Spock brow and know how to correct it if it occurs.

Injecting the Crow’s Feet or Orbicularis Oculi

Muscles Involved and Action

The orbicularis oculi is a single, circumferential muscle group that functions like a sphincter or purse string. The muscle originates from the medial palpebral ligament and inserts into the lateral palpebral raphe, corrugator, frontalis, and depressor supercilii. Its primary action involves pulling the skin of the forehead, temple, and cheek toward the medial angle of the orbit, resulting in the closure of the eyelids.

Landmark

The landmark for the injection is 1 cm outside of the bony orbital rim or 2 cm outside of the lateral cantus. Placing the non-injecting index finger into the bony rim can help identify this landmark. The injection site should not be below the zygomatic arch to avoid diffusion into the zygomatic muscles, which can affect the smile.

Injection Technique

The injection technique for the orbicularis oculi involves subcutaneous injections, typically 1 cm apart in a slightly curving arch. Each injection typically contains 3 units of botulinum toxin. Men may require an additional 1 unit per injection site due to their typically thicker skin and stronger muscle mass.

Complications and Solutions

The most common complications include asymmetrical smile or diplopia due to migration of the toxin. To avoid this, it is crucial to inject 1 cm outside of the bony orbital rim. Excessive wrinkles underneath the lower lid may become accentuated if medial portions of the Orbicularis Oculi are left unopposed. This may require injection into the lower/medial parts of the Orbicularis Oculi or the Nasalis muscle. 

Injecting the Lower Eyelid

Botulinum toxin injections in the lower eyelid are primarily indicated for the treatment of wrinkles below the lower eyelid and narrow palpebral aperture.

Muscles Involved

The primary muscle involved in this procedure is the Orbicularis Oculi. This muscle is a circumferential muscle group that functions like a sphincter or purse string. It originates from the medial palpebral ligament and inserts into the lateral palpebral raphe, corrugator, frontalis, and depressor supercili. Its action pulls the skin of the forehead, temple, and cheek toward the medial angle of the orbit, and it is responsible for closing the eyelids.

Injection Technique

The injection technique for the lower eyelid involves a subcutaneous injection of botulinum toxin. The standard dose is 1 unit, injected 0.5 cm below the lower lid margin in line with the midpupillary line. Some individuals may require an additional unit for optimal results. It is important to avoid injections medial to the pupil to minimize the risk of complications.

Complications

The most common complication of lower eyelid injections is bruising, as this is a vascular area. Other potential complications include ectropion, where the lower lid turns outwards, and epiphora, which is excessive tear production. These complications are extremely rare but can occur.

To minimize the risk of ectropion, it is crucial to select patients appropriately. Patients with a history of lower lid ablative resurfacing or blepharoplasty may be contraindicated. Even in the absence of these contraindications, it is recommended to perform a snap test before proceeding with the injection. This test involves pulling the lower eyelid downward; a return to its normal position in less than 1 second is considered normal. Any patient with a time greater than 1 second should not be treated.

Injecting the Nasalis/Bunny Nose Lines

Muscles Involved and Action

The primary muscles involved in the formation of bunny nose lines are the Nasalis and Procerus muscles. Treatment of both the Procerus and Nasalis is necessary to diminish the horizontal and vertical lines on the bridge of the nose.

The Nasalis muscle, originating in the maxilla, is a complex structure that inserts into the aponeurosis of the Procerus and continues over the bridge of the nose onto the other side. Its primary function is to draw the skin of the nose superiorly and medially. Procerus muscle, which originates from the nasal bone, inserts into the medial forehead and skin of the brow. Its primary function is to draw the medial brow inferiorly.

Landmarks

When it comes to injecting these muscles, accurate identification of the landmarks is crucial. For the Nasalis, the injection site is anterior and medial to the nasofacial groove on the lateral nose. For the Procerus, the injection is performed just above the crossing point of the X formed by drawing a line from the medial eyebrow contralateral to the medial canthus.

Injection technique 

The Procerus requires a deep intramuscular injection, above the periosteum, with an injection of 4 units at the identified landmark. The Nasalis, on the other hand, requires a subcutaneous injection, with 2 units injected at the landmark.

Complications

One potential complication is upper lip ptosis due to diffusion into muscles lateral to the Nasalis muscle. To avoid this, ensure the injection is performed medial and anterior to the nasofacial groove, thus avoiding the levator muscles of the lip.

Injecting the Lip for a Lip Flip

Muscles Involved and Action

The primary muscle involved in the lip flip procedure is the orbicularis oris muscle. This muscle encircles the mouth and is responsible for various lip movements, including closing the lips, puckering, and other complex movements necessary for speech and facial expression. 

When botulinum toxin is injected into the orbicularis oris muscle, it causes a temporary paralysis of the muscle. This results in a slight eversion or ‘flip’ of the lip, giving the appearance of a fuller and more pronounced upper lip.

Landmark

The landmark for the lip flip procedure is the vermilion border of the upper lip. The vermilion border is the line where the pink-red lip tissue meets the surrounding skin. The injections are typically placed along this border at several points across the upper lip.

Injection Technique

The injection technique for a lip flip involves the careful placement of 1-2 units into the orbicularis oris muscle. The injections are typically administered using a fine needle, and the procedure is usually performed without anesthesia as it causes minimal discomfort. 

The injections are placed along the vermilion border of the upper lip, typically at 2-3 points on each side of the midline. The exact number and placement of injections can vary depending on the individual patient’s anatomy and desired results.

Complications and Solutions

Complications from a lip flip procedure are generally rare and mild, but can include:

– Asymmetry: This can occur if the botulinum toxin is not evenly distributed on both sides of the lip. It can be corrected in a follow-up appointment with additional injections to balance the effect.

– Difficulty with lip movements: Over-paralysis of the orbicularis oris muscle can lead to difficulty with certain lip movements, such as puckering or drinking from a straw. This is usually temporary and resolves as the effect wears off.

– Bruising or swelling at the injection site: This is a common side effect of any injection and usually resolves on its own within a few days.

Additional Pearls

– The effect of the lip flip procedure is temporary, with muscle function typically beginning to return approximately 1 to 2 months after injection due to the low dosage.

– The lip flip procedure can be a good alternative for patients who want a more pronounced upper lip but do not want or are not ready for more invasive procedures such as fillers or surgery.

– It’s important to have a thorough understanding of the patient’s anatomy and desired outcome to achieve the best results with a lip flip procedure. 

– Patient education is key. Make sure patients understand that the results are subtle and that this procedure is different from a dermal filler injection.

Injecting the Orbicularis Oris / Smoker’s Lip Lines

Muscles Involved and Action

The primary muscle involved in this procedure is the Orbicularis Oris. This muscle originates from the buccinator and fibers at the angle of the mouth, and inserts symmetrically at the vermillion border. The primary action of the Orbicularis Oris is to close the lips, which is crucial for functions such as speaking, eating, and expressing emotions.

Landmark

The Orbicularis Oris is a complex muscle that encircles the mouth. It is located directly beneath the skin and is easily palpable. The vermillion border of the lips serves as a key landmark for this muscle. The muscle extends from the corners of the mouth and wraps around the lips, meeting at the midline.

Injection Technique

The injection technique for the Orbicularis Oris involves subcutaneous symmetrical injections less than 3 mm above and below the vermillion border. Each injection should contain 1-2 units of botulinum toxin. It is important to avoid injecting more than 2 units in each lip quadrant to prevent overcorrection and potential complications. 

The mid upper lip and the corners of the mouth should be avoided during the injection process. The mid upper lip is a sensitive area, and injecting it could lead to flattening of the lip. The corners of the mouth are also crucial for facial expressions, and injecting them could lead to an asymmetrical smile or other complications.

Complications and Solutions

Potential complications of botulinum toxin injections in the Orbicularis Oris include an asymmetrical smile, difficulty with speech, and drooling. These complications can be mitigated by using a low dose of botulinum toxin and ensuring symmetrical injections. 

It is also recommended to avoid injecting individuals who rely heavily on their facial expressions for their profession, such as singers, orators, and musicians. These individuals may experience a significant impact on their ability to perform their work if any complications arise.

If a patient has a history of cold sores, it is recommended to include pretreatment with Valtrex®. The patient should take 2 grams at the time of treatment and 2 grams 12 hours later to prevent a herpes outbreak.

Additional Pearls

Patient Selection: It is crucial to select patients carefully for this procedure. Patients deep peri-oral grooves may benefit from laser resurfacing, microneedling or dermal filler injection.

Dysport: Introduction and Differences from Botox

Dysport requires an explanation, because the units are different from other botulinum toxins. All package inserts state that units are not interchangeable with other preparations of botulinum toxin products. However, most commercially available botulinum toxins use 20 units for the glabellar line. Except for Dysport. Units are a measure of the biological activity of a botulinum toxin which cannot be compared to nor converted into units of any other botulinum toxin products assessed with any other specific assay method. 

Reconstitution

Dysport is supplied as a single-use vial with 300 Units per vial. Each 300 Unit vial of Dysport is to be reconstituted with 2.5 mL of 0.9% sterile, preservative-free saline prior to injection. The concentration of the resulting solution will be 10 Units per 0.08 mL. Each 300 Unit vial of Dysport may also be reconstituted with 1.5 mL 0.9% sterile, preservative-free saline for a solution of 10 Units per 0.05 mL to be delivered. Just as a provider can dilute Botox Cosmetic with Preserved (Bacteriostatic) 0.9% Sodium Chloride, Dysport may also be diluted with the same to increase its half-life.

Unit Conversion from Botox Cosmetic to Dysport

The striking difference between Dysport and Botox Cosmetic is the amount of units injected. Botox Cosmetic requires 20 units at 4 units per injection site in treating the glabellar area, whereas Dysport requires 50 units at 10 units per injection site in treating the glabellar area. This constitutes a 1:2.5 concentration ratio. Many other users have contended that the actual ratio should be 1:3 or 1:4. These concentrations ultimately increase the amount of Dysport being injected. We recommend that you start with a 1:2.5 ratio conversion from the Botox Cosmetic unit injection recommendations offered at this course until you feel comfortable with the use of Dysport.

Comparative Studies

Studies have shown that Dysport will start working faster than Botox Cosmetic, last longer than Botox Cosmetic, and have a lower diffusion rate than Botox Cosmetic due to its high concentration. However, it’s important to note that individual patient results may vary, and it’s crucial to tailor the treatment plan to the patient’s unique needs and desired outcomes.

In conclusion, Dysport provides an effective alternative to Botox Cosmetic, with its own unique properties and considerations. As with any treatment, understanding the product and its appropriate use is key to achieving optimal results. 

Treatment Failure in Botulinum Toxin Cosmetic Injection

One of the most significant challenges is treatment failure, which can be classified into primary and secondary nonresponse.

Primary Nonresponders:

Primary nonresponders are individuals who do not respond to their first BTX Cosmetic treatment. This lack of response can be attributed to several factors:

1. Static Wrinkles: The most common reason for primary nonresponse is the presence of static wrinkles, which are not dynamic in origin. These wrinkles are usually due to photodamage or age-related changes and require the injection of a filler material. A positive spread test often indicates this.
2. Inadequate Injection Amount: Another common cause of primary nonresponse is an inadequate amount of BTX injected. This could be due to the patient having strong muscles or the injection missing the targeted muscle.
3. Denatured Toxin: If the BTX has denatured, it will not produce the desired effect. In such cases, contact your representative for a new vial.

Secondary Nonresponders:

Secondary nonresponders are patients who initially respond to BTX Cosmetic but lose the response on subsequent injections. The reasons for this can be:

1. Neutralizing Antibodies: Some patients may develop neutralizing antibodies to BTX. This is a rare side effect, but it has been observed in some patients. In such cases, using a different Botulinum Toxin may yield better results.
2. Inadequate Injection Amount: Similar to primary nonresponse, secondary nonresponse can also be due to an inadequate amount of BTX injected. This could be due to the patient having strong muscles or the injection missing the targeted muscle.

Botulinum Toxin Complications and Treatments for Complications

Localized Complications

Localized complications are those that occur in the immediate area of the injection. These can include:

– Bruising and Bleeding: This is a common complication that can occur due to the puncture of blood vessels during the injection process. It is usually minor and resolves on its own. Applying a cold compress to the area immediately after the injection can help reduce bruising and swelling. Over-the-counter pain relievers can also be used to manage any discomfort.

– Pain and Swelling: Some patients may experience pain and swelling at the injection site. This is typically transient and can be managed with over-the-counter pain relievers and cold compresses. 

– Infection: Although rare, infections can occur if the injection site is not properly cleaned before the procedure. If an infection is suspected, it should be treated promptly with antibiotics. 

Systemic Complications

Systemic complications are those that affect the entire body or multiple body systems. These can include:

– Botulism: This is a rare but serious complication that can occur if the toxin spreads beyond the injection site. Symptoms can include muscle weakness, difficulty swallowing, and respiratory problems. If suspected, immediate medical attention is required. If botulism is suspected, the patient should be hospitalized immediately. Antitoxin therapy should be initiated as soon as possible to neutralize the toxin.

– Allergic Reactions: Some patients may have an allergic reaction to the BTX. Symptoms can include hives, difficulty breathing, and swelling of the face, lips, tongue, or throat. If an allergic reaction occurs, the patient should be treated with epinephrine and antihistamines. In severe cases, hospitalization may be necessary.

Managing Lid Ptosis Complication and Treatment

Lid ptosis, or drooping of the upper eyelid, is a potential complication of botulinum toxin injections. It can occur when the toxin diffuses into the levator palpebrae superioris muscle, which is responsible for lifting the eyelid. This can lead to an undesirable aesthetic outcome and, in severe cases, can interfere with vision. 

The management of lid ptosis following botulinum toxin injection involves both preventive and corrective measures.

Preventive Measures

1. Accurate Injection Technique: The most effective way to prevent lid ptosis is to ensure accurate injection technique. This includes proper identification of the injection site, avoiding the levator palpebrae superioris muscle, and injecting the toxin at a safe distance from the eyelid.
2. Patient Positioning: The patient should be in an upright position during the injection and for 3-4 hours post-injection. This helps to minimize the diffusion of the toxin.
3. Patient Instructions: Patients should be instructed to avoid rubbing or massaging the injection area for at least 24 hours post-injection to prevent the spread of the toxin.

Corrective Measures

1. Alpha-adrenergic eye drops: In the event of lid ptosis, alpha-adrenergic eye drops such as apraclonidine 0.5% can be used. Oxymetazoline, Upneeq, 0.1% has been FDA approved for the treatment of eyelid ptosis. These drops stimulate the Müller muscle, a smooth muscle that assists in elevating the eyelid, thereby providing a temporary lift to the drooping eyelid. These drops can be used until the ptosis resolves.

Naphcon-A, Naphazoline/Pheniramine, is another over the counter option. This class of drug is known as sympathomimetic amines. There are no comparative clinical trials examining the benefits of any of the medications with each other. 

2. Wait for Toxin to Wear Off: Botulinum toxin effects are temporary, and the ptosis will resolve naturally as the effects of the toxin wear off, typically within 4-6 weeks.

Pearls in Botulinum Toxin Cosmetic Injection

As health care providers, we are always seeking to refine our skills and improve patient outcomes. This chapter will provide you with valuable insights and pearls of wisdom for administering botulinum toxin injections for cosmetic purposes. 

The Power of Touch

The human hand is an incredible tool. Use your hands to feel the face and identify the muscles causing visible wrinkles. This tactile approach will guide you to the precise injection site. Always inject a relaxed face, not a face where the muscle is contracted. Contracted muscles can distort your landmarks and lead to less than optimal results.

Marking the Territory

Until you become proficient, use a marking pen or a white eyeliner pencil to mark your injection sites. However, be sure to place the marks below where you will inject. Injecting into a mark on the face is akin to tattooing someone. 

Landmarks: More Than Skin Deep

Many landmarks are bony, not just on the skin’s surface. Do not rely solely on surface skin landmarks as your reference. Understanding the underlying anatomy is crucial for successful injections.

Complications: Be Prepared

Complications can occur as soon as 48 hours or as late as 7 days post-injection and may persist for up to 4 – 8 weeks. Most complications are almost always temporary. In your practice, you are likely to experience a complication. Be prepared for it. Good hand holding and patient reassurance that the complication is temporary will appease most patients. In some cases, offering a money-back refund can eliminate tension and potential headaches.

Documentation: Before and After Photos

Always obtain before and after photos. This is essential documentation to resolve any complaints. It also provides a visual record of the treatment’s effectiveness.

Reinjection: Patience is Key

Reinjection should be done no earlier than one week after the first injection if the patient perceives no desired effect. Sometimes, it takes a week until a patient sees the effects. Patience is key.

Comfort Measures: EMLA and Ice Packs

Application of topical EMLA anesthetic or cold ice pack will help alleviate patient discomfort and injection fears. These simple measures can significantly improve the patient experience.

Pre and Post Injection Instructions

Please become familiar with our standard Pre and Post injection instructions. Your patients will ask you about them. Compliance with these instructions will reduce complications and improve outcomes.

Botulinum Toxin Pricing

Botulinum toxin injections are a significant investment for both the provider and the patient. Understanding the pricing structure is crucial to ensure a profitable practice and to provide clear and transparent information to patients.

Pricing Structure: Per Area, Per Syringe, or Per Unit?

There are different approaches to pricing botulinum toxin injections, and the choice often depends on the provider’s preference and the standard practice in their region. Some practices charge per area or per syringe, often using about 20 units per “area” or “syringe”. However, all manufacturers of botulinum toxin prefer the “per unit” pricing model. This approach provides patients with knowledge of the units they are receiving, promoting transparency and consistency in treatment. 

Setting Your Prices

When setting your prices, it’s recommended to research your local market. Call local competitors and inquire about their pricing. If they charge per area, ask how many units they use per area. 

As a general guide, here are some typical pricing ranges across the U.S.:

– Dermatologist/Plastic Surgeons: 150-200% higher than manufacturer purchase price

– Average pricing: 100-150% higher than manufacturer purchase price

– Competitive pricing: 75-100% higher than manufacturer purchase price

Remember, these are just guidelines. Your pricing should reflect your expertise, the quality of your service, and your local market conditions.

Legal Considerations

It’s worth noting that purchasing any botulinum toxin products from outside the U.S., such as Canada, is illegal. The FDA has strict regulations on the import of medications, and non-compliance can lead to serious legal consequences.

Additional Pearls

– Transparency is key: Always be upfront with your patients about the cost of their treatment. This includes the number of units they will receive and the total cost.

– Document everything: Keep a record of the number of units used for each patient and each treatment area. This can help you track your usage and costs, and can also be useful in case of any disputes.

– Adjust as needed: Don’t be afraid to adjust your prices as needed based on changes in your costs, market conditions, or the value you provide.

Botulinum Toxin Marketing

Marketing is a crucial aspect of any successful medical practice, and this is especially true for practices offering botulinum toxin injections. The following strategies can help you effectively market your services and attract new patients.

Understanding Your Target Market

Before you begin marketing your services, it’s important to understand who your target market is. Botulinum toxin injections are popular among women aged 35 to 50 years old, but this can vary depending on your location and the specific services you offer. Understanding your target market will allow you to tailor your marketing efforts to the needs and interests of these potential patients.

Branding and Collaboration

Improving the branding of your botulinum toxin services can significantly increase your bookings. This includes creating a professional and appealing logo, using consistent colors and fonts across all marketing materials, and developing a unique selling proposition that sets you apart from competitors.

Collaborating with influencers and local businesses can also be an effective way to drive interest in your services. This could involve partnering with a local fitness center or spa, or working with a popular local blogger or social media influencer to promote your services.

Online Marketing

Having a strong online presence is essential in today’s digital age. This includes having a professional and user-friendly website, as well as active profiles on relevant social media platforms. Search engine optimization (SEO) and pay-per-click (PPC) advertising can also be effective ways to increase your online visibility and attract new patients.

Collecting email addresses from existing patients and using email marketing campaigns can also be a powerful way to keep your services top of mind and encourage repeat bookings.

Traditional Media Advertising

While online marketing is crucial, don’t overlook the potential of traditional media advertising. This could include print ads in local newspapers or magazines, radio ads, or even television commercials. The best platforms for your practice will depend on your target market and local media landscape.

Customer Service and Experience

Providing excellent customer service is crucial for retaining patients and attracting new ones. This includes everything from the initial phone call or email inquiry, to the consultation and treatment process, to follow-up care.

Offering a unique patient experience can also set your practice apart. This could involve offering additional services, such as skincare consultations or massage, or creating a relaxing and luxurious treatment environment.

Education and Promotions

Educating potential patients about the benefits of botulinum toxin injections, and addressing common concerns or misconceptions, can help to build trust and interest in your services.

Offering promotions or discounts can also be an effective way to attract new patients. This could involve offering a discount for first-time patients, or a special promotion for existing patients who refer a friend.

Remember, marketing is not a one-time effort but an ongoing process. Regularly evaluating and adjusting your marketing strategies based on their effectiveness and changes in the market can help to ensure your practice’s success.

For more detailed strategies and tailored advice, consider consulting with our internal marketing specialist or taking advantage of resources offered by botulinum toxin manufacturers.

For more information about Comprehensive Guide to Botulinum Toxin Injection Training, contact us at email@CosmeticMedicalTraining.com or call us at (212) 470-8059.

Statement of Responsibility

Cosmetic Medical Training recognizes that many of the techniques and recommendations are for procedures that are considered off-label use.  Our recommendations are based on many textbooks, published articles, seminars, and practical knowledge and experience.  The authors have attempted to maintain up to date knowledge and information in this training manual with the current standard of care.  However, due to the continuing flow of new research and information relating to the drugs being used in this course, we recommend that you check with the manufacturer for any changes in the package inserts, warnings, and precautions.  All information and tools presented within this site are intended for educational purposes. We do not guarantee that the information will be completely accurate and up to date; therefore the authors will not be held responsible for any errors, omissions, or inaccuracies published.  Application of the knowledge is ultimately the responsibility of the practitioner.

The owners, authors, and any participants disclaim all liability or loss in conjunction with any content provided here. We disclaim any liability for products or services recommended including defective products or direct, indirect, special, incidental, or consequential damages, arising out of the use or the inability to use the materials/information published.

Originally published at  Botox Training Los Angeles