Cosmetic Botox and Fillers

History of Present Illness/Chief Complaint (HPI/CC)

• Patient concerns and goals

  • Personal preferences

  • Gender, social, cultural, ethnic considerations

  • Work and/or family considerations

  • Downtime

  • Cost

History

• General health

• Aesthetic treatment history

• Past medical history

• Systemic disease

  • Autoimmune/collagen vascular disease

  • Bleeding tendencies/hematologic conditions

  • Reaction to anesthesia

• Localized disease/condition

  • Ocular conditions

  • Herpes simplex virus (HSV)/cold sores

  • Facial nerve weakness/disorders

• History of allergic reactions

  • Severe allergies/anaphylaxis

  • Food allergies: milk and egg products

• Current medications

  • Steroids and other immunosuppressive agents, muscle relaxants, pain medications, anticoagulants (Coumadin or Plavix), psychiatric medications

• Over-the-counter medications and supplements

  • NSAIDs, other blood thinning products

• Females: Pregnancy and breast feeding

• Social history: Smoking and alcohol use

• Psychiatric history and conditions

  • Bipolar disorder

  • Body dysmorphic disorder (BDD)

• Family history: Cardiovascular, psychiatric, hematologic disorder

• Occupation/work history

Physical Examination

• Skin quality and texture

• Facial sagging and laxity

• Loss of volume/contour deficiencies

• Dynamic and static rhytids

• Examination of face/neck at rest and with dynamic expression

• Scars and/or acne scars

• Pre-existing facial asymmetries/irregularities

• Eyebrow/upper eyelid complex ptosis

• Lower eyelid and cheek complex

• Facial nerve evaluation/facial weakness

• Cranial nerve examination

• Muscles of facial expression: Assess strength and size.

• Weight and height

• Fitzpatrick skin type

• Affect and psychologic presentation

Other

• Photo documentation

• Informed consent process

• Answer patient concerns/questions

• Follow-up

The Ideal Patient for Nonsurgical Injectable Treatments

• Seeks nonsurgical options for rejuvenation

• Has aging changes mostly related to volume loss and/or dynamic rhytids

• Prefers minimal and/or no downtime

• Understands value of periodic ongoing treatments to maintain and achieve best results

Indications

• Dynamic rhytids

• Static rhytids: Mild to moderate rhytids/younger patients

• Brow shaping and sculpting

• Facial sculpting

• Wrinkle prevention

Contraindications

Pretreatment Planning

• Selection of neuromodulator (patient and physician preference, clinical situation)

• Determine dose and volume to be injected

• Reconstitution and preparation

• Account for and/or limit other procedures performed at or around the time of injection (other nonsurgical injectable treatments, skin resurfacing procedures, surgical procedures).

Precautions Prior to Injection

• Notification of any rash or infection near or at the planned injection site

• Avoid blood thinning agents such as aspirin/NSAIDs, fish oils, vitamin E, herbal supplements, and/or alcohol a few days prior to treatment.

• Continue prescribed medications, including medically necessary blood thinners.

Recommended Materials

• Materials for mixing

  • 21- to 25-gauge needles

  • Preservative-free normal saline

• Digital camera

• Wipes

• Mirror

• Topical anesthetic (benzocaine/lidocaine/tetracaine [BLT] or lidocaine mixture)

• Gloves

• 30-gauge needle or tuberculin syringes

• 1-mL syringe

• Alcohol pads (or other disinfectant skin preparations)

• Bottle opener (to remove rubber stopper of vial)

• Marking pen/pencil

• Gauze pads (4 × 4 or 2 × 2)

• Ice pack

• Medical waste container

Preparation/Dilution/Storage

• Vacuum-dried powder form in single-use 50-Unit or 100-Unit vials

• 2.5 mL of preservative-free 0.9% sodium chloride diluent to reconstitute each 100-Unit vial, yielding a concentration of 4 Units per 0.1 mL

• Common off-label preparation

  • Preservative containing saline

  • Adjusting diluent quantity (1.0 to 4.0 mL) to yield the desired dose per 0.1 mL

• Stored in refrigerator (2°C to 8°C) and administered less than 24 hours after reconstitution

• Off-label storage: Multiple studies showing preservation of drug potency up to 2 weeks

Botox Injection Technique

Upper Face Indications for Botox Cosmetic

• Injections of glabella/frown lines/11’s (corrugator/procerus muscles)

  • On-label FDA-approved glabellar indication: 4 Units injected intramuscularly into each of five sites, 2 in each corrugator muscle and 1 in the procerus muscle for a total dose of 20 Units ( Fig. 160.1 )

    

  • 10- to 40-Unit range for desired clinical effect/relaxation of the glabella

  • Higher doses needed for active muscles and male patients

• Injections of lateral canthal/CF lines (orbicularis oculi muscle):

  • On-label FDA-approved CF indication: 4 Units are injected intramuscularly into each of six sites, 3 on each side, into the orbicularis oculi muscle for a total dose of 24 Units ( Fig. 160.2 ).

    

  • Two variant patterns of injecting lateral canthal lines are provided in the trial (see Fig. 160.2 ).

  • 10- to 30-Unit range for desired clinical effect/relaxation of the CF

  • Concurrent treatment of glabellar lines and lateral canthal lines can be performed with an on-label suggested dose of 44 Units.

• Injections of horizontal forehead rhytids/lines (frontalis muscle):

  • 5 to 20 Units injected intramuscularly into the frontalis muscle

  • Variable pattern and number of injection sites—individualize treatment

  • Counsel patients before injection regarding the possibility of brow position changes and brow ptosis.

  • Use in conjunction with treatment of orbicularis oculi to alter brow shape and position.

• Injections for chemical browlift (orbicularis oculi/corrugators/procerus muscle):

  • 5 to 20 Units total injected into the superolateral portion of the orbicularis oculi in the lateral third of the brow

  • Keep injections superior and lateral to the orbital rim to minimize ptosis.

  • May need to treat brow elevator to achieve desired brow height and shape

  • Can achieve a modest nonsurgical browlift of up to a few millimeters

• Treatment of bunny lines (overactive procerus muscle):

  • Indicated for patients with excessive horizontal nasal lines

  • Can be unmasked by Botox treatment and relaxation of glabellar rhytids

  • In addition to treating the procerus, use small doses (1 to 2 Units Botox or 3 to 5 Units Dysport per side) injected directly over the bunny lines.

  • Injecting too low and lateral can affect the levator labii superioris.

• Injections for “jelly rolls” in the lower eyelid (hypertrophied orbicularis oculi)

  • 1 to 2 Units injected into the lower eyelid pretarsal orbicularis muscle

  • Decreases hypertrophied orbicularis muscle and increases the palpebral aperture

  • Reduced blinking can lead to corneal exposure and related symptoms.

  • Other potential complications include epiphora and edema of the lower eyelid.

Lower Face Indications for Botox Cosmetic

• Treatment of perioral lip lines (orbicularis oris), oral commissures (depressor anguli oris), and medial chin rhytids (mentalis muscles)

  • Can be used in conjunction with dermal fillers

  • Results are usually less dramatic and duration of effect shorter than those in the upper face.

  • Discuss the possibility of oral incompetence with your patient.

  • Contraindicated for patients who depend on use of muscles in perioral region (i.e., singers, musicians who play wind instruments)

• Injections of perioral (vertical) lip lines (orbicularis oris):

  • Inject the orbicularis oris muscle in small amounts, maximum 1 to 1.5 Units Botox or 3 Units Dysport per site, two to six sites in the upper lip and two to four sites in the lower lips.

  • Stay close (within 5 mm) to the vermilion border.

• Injections of oral commissures (depressor anguli oris muscles):

  • One to two injections (2 to 3 Units Botox or 6 to 9 Units Dysport) each side directly into the depressor anguli oris muscle overlying the mandibular body

  • Avoid injecting medial to the perpendicular line to the oral commissure.

  • Avoid injecting close to the mouth to minimize complications related to oral incompetence and/or lower lip ptosis.

  • Improves marionette lines and lifts mouth corners ( Fig. 160.3 )

    

• Treatment of dimpled chin (mentalis muscle):

  • Two injection sites in a paramedian position near the inferior mandibular border: total of 2 to 8 Units Botox or 6 to 20 Units Dysport

  • Avoid injecting too far lateral or superiorly.

Other Lower Face and Neck Indications for Botox

• Treatment of gummy smile (depressor septi muscle):

  • Indicated for patients with with “gummy smiles” gingival show upon smile

  • Use small doses (total 1 to 3 Units Botox or 3 to 9 Units Dysport) injected just below the nose into the lip elevator complex (one to two injections).

  • As a nonsurgical treatment option for dynamic ptotic noses

• Treatment of nasolabial folds (NLFs; levator labii superioris alaeque nasi muscle)

  • Patients with short upper lips and/or strong elevation of upper lip upon smile are potential candidates.

  • Use small doses (maximum 1 Unit Botox or 3 Units Dysport per side) injected just below the nose into the lip elevator complex and the levator labii superioris alaeque nasi muscle.

  • Advise patients that their smile pattern may be altered.

  • The area is best treated with dermal fillers.

• Treatment of neck bands (platysma muscle):

  • Consider in older patients who are not candidates for surgery

  • Younger patients who are not candidates yet for facelift surgery

  • Patients with good skin elasticity and minimal submental fullness

  • Botox has no effect on skin laxity or redundancy, laxity, or adipose tissue deposits

  • Requires higher dosages than the lower face

  • Use 10 Units Botox or 30 Units Dysport per platysmal band.

  • Can inject multiple sites per band from the mandible to the lower neck, or inject the band only at the cervicomental angle to recreate it

• Treatment of square jaw (masseter muscle):

  • Injected into the masseter muscle to alter shape of the jawline

  • Popular application in East Asian countries

  • 10 to 25 Units Botox or 30 to 75 Units Dysport used per side (two to four injections)

  • Treatment effect may require multiple sessions, and treatment onset is slower but effects tend to last longer.

  • Adverse effects include mastication difficulty, muscle pain, dysarthria, and awkwardness with smiling.

  • Patients with Temporomandibular Joint Disorders (TMJ) and/or grinding tendency may benefit.

Facial Sculpting Techniques Using Botox Cosmetic