Botulinum toxin allows the reduction of wrinkles by inhibiting  acetylcholine release at the level of motor plate, which generates a muscular paralysis.

To date, botulinum toxin is allowed to be placed on the market (French AMM) in esthetic indications, only for glabella, forehead and crow’s feet wrinkles. However, many professional use it in other face parts, especially in the inferior third. Areas « out of AMM » are specified in each of this chapter subsection.

In France, 3 main laboratories  provide botulinic toxin : Merz, Allergan and Galderma. Each of these laboratories has a functional use toxin and an esthetic use one. Warning : concentrations of products are not identical in every laboratory.

 

Laboratory	Functionnal	Esthetic	Ratio
Merz	Xeomin	Bocouture	1
Allergan	Botox	Vistabel	1
Galderma	Dysport	Azzalure	2.5

 

Products that are usually used are 50 UI bottles for Vistabel® and Bocouture® and 125 UI for Azzalure® (in this case, they are calles Speywood units).

Dilutions : clarification

Products are diluted with 0.9% injectable NaCI, not with sterilized water which would make the injection painful. Depending of the effect of the wished concentration, dilution can vary. However, we recommend to always use the same dilution during the first injection sessions, in order to avoid a waste of time or operating faults. It should be reminded that the effect of toxin is more extended and as a result, less precise, if we use a more important dilution for the same toxin quantity. On the contrary, if a very precised effect is wished, a more concentrated product would be used in order to limit the product diffusion in close risk areas.

Diluted with 1.25mL saline solution (AMM)®, from a 50 UI bottle can be obtained :

• 4 UI of Vistabel® or of Bocouture® by 0.1 mL

However, so as to be even more precise, you can use the following dilution :

Diluted with 1 mM saline solution, from a 50 UI bottle can be obtained :

• 5 UI of Vistabel® or of Bocouture® by 0.1 mL

Azzalure® is diluted with 0.63 mL saline solution (given by the laboratory). . In these 0.63mL you can find the 125 UI of Azzalure®, which is equal in terms of clinical efficacity to the 50 UI of Bocouture® or Vistabel®.

 

The examples taken here are Bocouture® and Vistabel®. It is all about multiplying by 2.5 dosages in order to have the Azzalure® equivalent (125/50 = 2.5).

 

Tools

For the injection, you better use 05 or 1mL volum insulin needles. In case of very sensitive patients, you can use Emla® ointment before injection, but it is not the rule for botulinic toxin injections, contrarily to hyaluronic acids.

Injection plans

Depending on the depth of the muscle where you wish to inject, the needle will have to go through more or less deep. A perfect knowledge of anatomy is then essential. We invite you to go visit our antomy section, which contains many dissections which will indicate the different plans to respect depending on the injected zone. Moreover, we reuse these informations in clinical applications section below.

Forehead

Forehead wrinkles can be diminished or removed thanks to botulinic toxin. The numer of injection points dépend essentially on the height of the forehead and dosages used are often more important for men than women.

Pre-injection clinical examination will determine if a median point must be utilized. Indeed, you must not forget that the forehead muscle has a median diastasis, which is not necessary to inject in most cases. Usually, two lignes are enough, the lowest at 3cm at least from the eyebrow. In case of too low injection, the « eyebrow lift » effect of the forehead muscle will be diminished and can result in the fall of the latter.About 4 to 5 units a point are necessary with 5 points each side.

The injection must be superficial subcutaneous. You must not go as far as touching the periosteum.

In particular cases, the presence of a wrinkle in the lateral up eyebrow can exist. It is then impossible to inject laterally the forehead muscle. As a result, a minor fall of the eyebrow tail can appear, which will be easily diminished by an injection point under the lateral eyebrow.

 

Glabella

Glabellar wrinkles are created by the contraction of four muscles : corrugators and procerus which are intertwined between left and ride (horizontal wrinkles). In theory, 5 injection points are necessary in the glabellar area, with 4 or 5 units by point.

We use 2 injection points by corrugator muscle. It is necessary to always respect the cm accuracy diffusion of the toxin, so 10  to 12mm above and inside the orbital edge. The simple respect of that rule avoids the diffusion of toxin at the superior eyelid raising muscle level and at the oculomotor muscles, consequence of which is admittedly reversible but very debilitating for the patient. Injection points are deeper corrugators on contact with periosteum for the most median point, superficial subcutaneous for the most lateral point. About the procerus injection, it is also deep. Risk of lateral diffusion is close to zero.

 

Orbit lateral part

The injection of the crow’s feet wrinkles constitutes the major indiction of the orbital orbicular muscle. 3 to 4 injection points are used by each side. It is also necessary to respect the safety margin in relation to the orbital edge. Points from 2 to 4 UI units are used. As the skin is thin and there is no fat subcutaneous tissue in this area, the injection must be very superficial, making an injection « papule » appear.It is possible to raise the eyebrow tail with botulinic toxin. In this area, the orbicular (eyebrow lowering muscle) does not present any antagonistic muscle. The use of a point each 2 units is enough.

 

Tempe (Out of AMM)

There are too little indications for botulinic toxin injection in the temple area.
Sometimes you can find an orbitary orbicular muscle particularly laterally developed, with crow’s feet wirnkles very lateralized, but injections in the temple area are governed by fillers.

 

Oval and neck (Out of AMM)

The improvement of the oval with botulinic toxin is out of AMM. Injections cannot be made by beginners as they would be too risky. By injecting low facial lowering muscles (DAO, patysma), it is possible to improve the face oval. The DAO can be injected laterally and inferiorly in relation with the mouth orbicular muscle (2 UI). The risk is the diffusion of botulinic toxin in muscles close to DAO, especially the upper zygoma, mouth orbicular and the DLI. This would lead to an asymmetrical smile, or even a labial incontinance.

The injection of platysmal lines superseded the realisation of pexies  with other median cervical liftings. Many points of 2 units are used, layered with 2 or 3 cm, to the paramedian part of the cervical platysma. Never inject in the median level in pre-laryngeal, and the injection is always very superficial.

The horizontal cervical wrinkles are creasing wrinkles, different from superficial wrinkles related to the muscular contracture (just as vertical frontal wrinkles, the said-pillow wrinkles. Injections of botulinic toxin are not efficient on these wrinkles. They cannot be treated specifically, but they can be efficiently treated with hyaluronic acid injections or mesotherapy.
Injection in masseter muscles allows the diminishment of the square face effect with hypertrophy of the masseter. 25 to 50 units by each side are necessary.

 

Cheekbones, cheeks (out of AMM)

Injection of the risorius muscle, superficial, allows the diminishment of cheek wrinkles situated laterally to the labial commissures, wrinkles called « in brackets ». 1 point of 2 units is recommended.

The risk is the diffusion of the product towards the upper zygoma and it will lead to a smile shortening. This injection is not recommended to beginners.

 

Nose (out of AMM)

Two injection points are mainly used in the nose area :

• In case of bunny lines, related to the nose transverse muscle, the injection of 2 units each side allows the reduction of these wrinkles.
• Injection in septi nasi depressor muscle allows to avoid the fall of the tip of the nose to the smile.

A more uncommon point of injection is that of the dilator muscle in the nostrils, which allows the diminishent of « dilated nostrils » effect.

 

Lips, chin (out of AMM)

Injections of botulinic toxin in the perioral area must be very cautious and measured. Communication, expression and supply functions are important and cannot be disturbed.

Injection in mentalis muscle allows the diminishment of orange skin effect by injection in 1 or 2 points by 2 units of toxin.

Injections in oris orbicular muscle are not recommended at first. The use of filling products is a better option, if you know facial artery anatomy.

Toxicity risks and drug interactions

There is no risk of toxicity or botulism inherent in the use of botulinic toxin. Toxic dosages of botulinic toxin of A type are 50 times higher than that used in therapeutic treatments.

However, please always make sure to note the absence of contraindication before usting botulinic toxin :

• Presence of hypersensitivity to one of the components,
• Pregnancy and breastfeeding
• Diseases of neuromuscular (Lambert-Eaton syndrom, myasthenia)
• Infection of injection point

Drug interactions must also be known. Some of them have potentializer effects on botulinic toxin : aminosides, cyclosporin, D-Penicillamine, tiopronin.

You must be careful with patients treated with anti agreggating or anticoagulants, because there is a higher risk of hematoma.

 

Complications related to injection

Erythema, oedema  and bruises are rare and can be controled by a slight local compression. Be careful not to make the product spread, especially in periorbitary area. The cessation of anti agreggating or anticoagulants treatments is a better option, if it is possible.

Pains remain rare and bearable. Be careful and use saline solution and not sterilized water.

Complications related to an unproper use of the product

Diffusion

With normal used dosages, the product diffusion is around 1 cm. It is then essential to respect this diffusion zone, especially in periorificial area.

In the face superior third, the diffusion of the eyelid raising muscle will lead to a ptosis and in oculomotor muscles a diplopia. If these complications are transitory, they are nevertheless very uncomfortable for patients. Mephisto effect is the result of a too important contraction of frontal muscle lateral part. It is caused by a reduction of adjacent muscles.

We can easily correct it with botulinic toxin injection in the frontal muscle lateral part. The eyebrow fall is the result of an injection too close to the orbital edge in the frontal muscle. It is necessary to respect the recommended 3cm above the eyebrow.

In the face inferior third, injections of toxin in perioral area must be very cautious because of the many functions assigned to this anatomical area : speaking, expression and feeding. A diffusion to the oris orbiculary muscle or to the DLI must be avoided.

 

Treatment Insufficiency

« Less is more ». It is always a better option to anticipate 2 injection sessions than injecting too much product all in once and resulting in an adverse effect. You must always warn the patient about the possibility of a second session, to complement the gesture or for a result harmonisation.

It is possible, and sometimes recommended, to combine botulinic toxin and hyaluronic acids. These two products have different effects that are complementary.

Usually, we use botulinum toxin before hyaluronic acid, so as to straighten and reduce muscular contractions. When toxin effects occurs, hyaluronic acid is injected and it lays on rested muscles.

It is the case for example with the chin : if you need to increase the chin projection, you will first relax the mentalis muscle, and then 3 weeks after, proceed to acid hyaluronic injection.

Other areas can be treated with this combination : forehead, nose, perioral wrinkles. If you are not at ease with botunilic toxin injections in perioral area, a well-conducted treatment based on hyaluronic acid is also efficient.