Botox technique

After familiarization with the Botox injection procedure, indications for its use, and possible complications, it is necessary to obtain informed consent from the patient. The patient must be informed that Botox injections were approved by the Food and Drug Administration (USA) in 1989 as an effective method for correcting blepharospasm, strabismus, and hemifacial spasm. In 1990, the Consensus Conference of National Health Organizations added such indications as spasmodic dysphonia, oromandibular dystonia, facial dystonia, writer's cramp, and torticollis. In 1998, spastic changes were made to the instructions. Indications not specified in the instructions are tremor, cerebral palsy, excessive sweating, sphincter dysfunction, and the presence of hyperfunctional facial folds.

After obtaining the patient's consent, assessing the functional lines on a scale and taking a photograph, areas where maximum muscle tension causes the formation of hyperfunctional folds are marked on the patient's face with a marker. Marks are applied to the site of each injection to affect these muscles. Circles with a diameter of 1-1.5 cm are drawn around the marks - the toxin diffusion zone. Their combination should completely cover the area of the excessively functioning muscle, but not affect the neighboring, adjacent muscles. A photograph or diagram of the injection points and the dose for each point should be part of the patient's outpatient card so that it would be possible to evaluate the effectiveness of the correction performed and create a kind of "geographical map" for future injections. The location of the drug injection points where the desired result was achieved is entered into the outpatient card with an indication of the dose.

After marking, ice or EMLA cream may be applied to the injection areas to reduce discomfort associated with the needle piercing the skin. The toxin is drawn into a tuberculin syringe with a 27-gauge monopolar Teflon-coated EMG needle. It is connected to the EMG machine, grounded, and electrodes are placed on the patient’s face. The needle is passed through the skin into the muscle to be injected. The patient is asked to make a specific facial expression, such as frowning, squinting, or raising an eyebrow. If the needle is in an active part of the muscle, a loud tone will be heard in the EMG speaker. If the tone is weak, the needle should be moved until the tone is at its loudest before the toxin is injected. This procedure is repeated at each injection site. The use of EMG technique increases the accuracy of the injection and thus reduces the dose required to achieve the desired effect. If a larger dose is required for a particular area, a larger volume of solution or the same volume at a higher concentration can be injected. Increasing the volume may cause the toxin to diffuse into adjacent muscles, causing unwanted hypotension. To prevent this, the concentration of toxin in the same volume of solution is increased, which results in greater relaxation of the desired muscle without increasing the area of toxin diffusion. Injections around the eye to relax the orbicularis oculi muscle can be performed with a tuberculin syringe with a 30 G needle that is 1.25 cm long. In patients with prominent muscles or those who have previously been injected and their muscles are clearly visible, the injection can be performed without the use of an EMG. We are now introducing a 30 G coated needle that is 2.5 cm long and can be used with a portable EMG, allowing for precise injection of the toxin without the discomfort that occurs with a needle larger than 27 G. After the injection, the injection site can be gently pressed to prevent ecchymosis. Carruthers introduced the technique of gently pressing the injected toxin away from the eye or from an important adjacent muscle in order to encourage its penetration into precisely those areas where relaxation is desired. The patient is asked not to touch the injection site for 6 hours to prevent excessive penetration of the toxin into adjacent muscles and thereby reduce the possibility of their excessive relaxation.

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Botox injections in the glabellar area

Injections into the glabellar area regulate overactivity of the procerus and corrugator muscles, which form the “angry” lines on the forehead. To eliminate them, we inject 7.5-25 U of Botox into this area. We usually start with 2.5-5 U in 0.1 ml of solution into each corrugator muscle, and 2.5 U in 0.1 ml of solution into the procerus muscle. The dose of Botox depends on the size of the muscle, which is assessed before the procedure. Men tend to have larger muscles, so they require a larger dose. Injections into the corrugator supercilii can be done with several separate needles, or the muscle can be “mounted” on an EMG needle and treated with toxin as it is excreted. The toxin should then spread far enough to cover the entire muscle within the vertical lines drawn through the middle of the pupils. Injection of the drug significantly more laterally or closer to the eyebrow may result in relaxation of the muscles that lift the upper eyelids and cause ptosis.

When ptosis occurs, apraclonidine is used in the form of 0.5% eye drops (Iopidine). They stimulate the Müller muscle (an adrenergic muscle) located under the muscle that lifts the upper eyelid. As a result of treatment, it is usually possible to achieve a 1-2 mm rise in the eyelid margin.

Botox injections into the frontalis muscle

The frontalis muscle contracts vertically, creating horizontal folds in the skin of the forehead. Botox should not be injected close to the eyebrows, as this may cause drooping of the eyebrows and even the elevator muscles. We prefer to gradually raise the injection sites above the eyebrow, moving from the center, in order to leave the lateral part of the frontalis muscle functioning, preserving its function of emotional expression and eliminating most of the frontal folds. Our patients usually prefer to keep the mobility of the eyebrows. If there are several rows of horizontal lines on the forehead, then several rows of injections may be needed to affect them. For this, again 1-1.5 cm diameter marks are drawn. After that, the forehead is treated with ice or EMLA cream. In order to ensure that the needle is in the overactive part of the frontalis muscle, the toxin is injected under EMG control. We usually inject 2.5 U of 0.1 ml of solution into each mark on the forehead. The general dose of Botox is 10-30 U. If there are particularly hyperactive areas above the eyebrows, to avoid excessive diffusion into the adjacent muscles, we use a more concentrated solution (5 U of toxin per 0.1 ml of solution).

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Eyebrow correction

Often, if the lateral part of the frontalis has not been treated, the relaxation of the frontalis and glabella muscles will cause an upward arching of the lateral brows. Relaxation of the lateral part of the frontalis will often cause the brow to droop. If the arching is large, a small amount of toxin (1 U of toxin in 0.1 ml of solution) is injected into the lateral part of the frontalis to lower the brow somewhat. Conversely, if sufficient brow elevation is not achieved, the same dose of Botox injected into the lateral orbital rim will weaken the orbicularis oculi at its insertion and allow the frontalis to elevate the brow more.

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Botox injections to eliminate crow's feet

Lateral orbital lines, or crow's feet, are the result of overactivity of the lateral orbicularis oculi muscle. This muscle is responsible for closing, blinking, and squinting the eye, but overactivity of the lateral orbicularis oculi muscle causes the skin of the face at the lateral orbital rim to wrinkle excessively, creating crow's feet. A small amount of Botox can weaken the lateral orbicularis oculi muscle, thereby reducing wrinkling without affecting blinking or closing the eye. To create the desired relaxation, a mark is placed 1 cm from the lateral canthus. The patient is asked to close their eyes, and if hyperfunctional folds form above the first mark, a second mark is placed in this upper portion. Folds that appear below the first mark are marked with a third mark. The marks are placed on both sides. Avoid injecting too close to the eyelids or orbit as this may cause delayed eyelid closure, epiphora, mild ectropion, diplopia or impaired blinking.

The skin is treated with ice or EMLA cream. Injections around the eyes are usually performed with a 1.25 cm, 30 G needle. If the desired result is difficult to achieve, an electromyograph is used to increase the accuracy of needle insertion. The usual initial dose is 2.5 U of toxin per 0.1 ml of solution in each of the pre-drawn marks. The usual dose is 7.5-15 U on each side.

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Nasolabial folds

Injections can smooth out the lines of hyperactivity at the junction between the orbicularis oris and the elevator muscles (zygomatic major, minor, and levator anguli oris). However, weakening these muscles changes the appearance of the smile and is unacceptable for most people. Fillers and other approaches often provide better results.

Nose flare

Some patients express concern about excessive flaring of the nasal alae. This is the result of excessive contraction of the nasal muscles. We use the technique described by Carruthers, in which Botox is injected bilaterally into the nasal muscles at a dose of 5 U in 0.1 ml of solution. This gives excellent results if a small volume of solution is injected, preventing diffusion into the muscles that raise the lip.

Injections in the chin area

Patients with excessively pursed lips tend to have excessive activity of the mentalis and orbicularis oris muscles. This effect is especially evident after the placement of chin implants or surgical correction of the bite. Muscle activity can cause abnormal positioning of the lips and lead to the skin in this area having an "orange peel" appearance. We have found that the introduction of small amounts of Botox (2.5-5 U) on each side can prevent excessive activity in this area and improve the appearance of the skin. The injection is made at a point located midway between the edge of the vermilion border of the lower lip and the edge of the chin, 0.5-1 cm medial to the oral commissure. The patient is asked to pucker his lips and the drug is injected using EMG. Botulinum toxin should not be injected too close to the lip to avoid excessive weakening of the orbicularis oris muscle with subsequent change in smile and drooling.

Botox injections into the platysma muscle of the neck

Botox injections to patients with distinctive protruding platysma muscle, both before and after a facelift, can provide a positive effect without making a submental incision and suturing the muscle. When performing these injections, we first mark the anterior and posterior edges of the muscle on both sides. We mark the area of pronounced platysma muscle strands, on which horizontal lines are drawn at 2 cm intervals. There are usually three of them. A monopolar EMG needle is inserted into the muscle towards the medial edge of the strand. It is advanced perpendicular to the muscle fibers. The patient is asked to tense the platysma muscle, lowering the lower lip. The drug is injected as the needle moves back along the muscle. The muscle is usually injected with 2.5-5 U of toxin in 0.1 ml of solution per injection, 2-3 injections on each side. The dose of Botox on one side is 7.5-20 U. To prevent diffusion of the toxin to the anterior surface of the neck, into the sublingual muscle, the relaxation of which can cause dysphonia or dysphagia, it is necessary to administer the drug in a small volume and with a minimal dose.

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Botox adjuvant injections

Relaxing the underlying facial muscles has been found to significantly improve the results of laser resurfacing or injectable fillers such as collagen. The best results are achieved in stages - the patient receives Botox injections first, and then returns a week later for a follow-up treatment. If the patient is undergoing laser resurfacing, relaxing the skin folds around the wrinkles helps the collagen fibers orientate correctly, resulting in better and longer lasting results. With long-term relaxation of the underlying muscles, the skin heals without wrinkling. Muscle strength is restored after 4-5 weeks, and Botox injections can be repeated.

Botox can relax skin lines and thereby minimize the amount of collagen or other injectable filler needed to improve the cosmetic result. If there is no constant compressive action of muscles when filling deep wrinkles, the injectable material is retained in the tissue much longer. Therefore, if the correction is performed in combination with additional Botox, less material is needed and it stays in its original location longer.

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