Antoine J. Panossian¹ and Christopher J. Haggerty²

¹Panossian Oral and Maxillofacial Surgery, Massapequa, New York, USA

²Private Practice, Lakewood Oral and Maxillofacial Surgery Specialists, Lees Summit; and Department of Oral and Maxillofacial Surgery, University of Missouri–Kansas City, Kansas City, Missouri, USA

The injection of a neuromodulator for the temporary paralysis of specific muscles for the aesthetic management of facial rhytids resulting from repeated muscle animation.

Facial Aesthetic Indications

1. Glabellar rhytids
2. Horizontal forehead rhytids
3. Crow’s feet
4. Bunny lines
5. Nasal flaring
6. Perioral lip lines
7. Mouth frown
8. Platysmal banding
9. Peau d’orange chin
10. Blepharospasm

Contraindications

1. Hypersensitivity to ingredients (albumin, sodium chloride, and botulinum toxin type A [Botox]) (Allergan, Irvine, California, USA)
2. Infection at the proposed injection site
3. Pregnancy or lactation
4. Patients with neuromuscular disorders or diseases (Eaton–Lambert, myasthenia gravis, and motor neuron disease)
5. Medications that interfere with neuromuscular transmission (aminoglycosides, penicillamine, quinine, calcium channel blockers, neuromuscular blocking agents, anticholinesterases, magnesium sulfate, and quinidine)
6. Unrealistic expectations (patients who would be better treated with surgical intervention or patients with psychological disorders)

Anatomy

• Frontalis muscle: Originates from the galea aponeurotica and inserts within the dermis at the level of the eyebrow, procerus, corrugator, and orbicularis oculi muscles. Elevates the eyebrow and produces horizontal forehead rhytids.
• Corrugator supercilii muscle: Originates from the medial supraorbital ridge and inserts at the caudal aspect of the frontalis muscle, the medial aspect of the orbicularis oculi, and the skin in the region of the midbrow. Contraction produces vertical glabellar rhytids (#11) and/or a dimpled radix depression.
• Procerus muscle: Originates at the periosteum of the nasal bone and inserts into the mid-forehead dermis. Contraction produces transverse rhytids over the nasal bridge (bunny lines).
• Orbicularis oculi: Originates from the frontal process of the maxilla, the nasal portion of the frontal bone, and the medial palpebral ligament, and inserts laterally around the orbit and at the lateral palpebral raphe. The lateral orbicularis oculi are responsible for lateral canthal rhytids (crow’s feet).

Technique

1. The patient is placed in an upright position, and the injection sites are cleansed with alcohol pads. EMLA cream can be applied to the areas of injection. Local anesthesia is typically not utilized.
2. The patient is asked to contract their facial muscles in the areas to be treated. Facial animation will allow the practitioner to delineate the extent, size, and strength of the muscles to be treated. Figure 35.1 illustrates the muscles used in facial animation.

3. Injection sites can be marked (see Figures 35.5 and 35.5 in Case Report 35.1) with a sterile marking pen for less experienced practitioners. More experienced practitioners will modify injections to suit individual patient needs and anatomic variation for best results.

4. A total of 25–35 units of Botox for women and 35–45 units in men is injected to treat horizontal forehead rhytids and glabellar rhytids. These units are patient dependent and can vary greatly with gender and anatomic variation.
5. Injections are a minimum of 1–1.5 cm above the supraorbital rim to avoid unwanted eyelid ptosis, and even higher lateral to the midpupillary line in women to maintain a high lateral brow.
6. Lateral canthal rhytids are evaluated with the patient smiling and squinting. Six to ten units are injected on each side. Injections are placed a minimum of 1–1.5 cm lateral to the lateral orbital rim and above the zygomatic arch (Figure 35.4, Case Report 35.1).
7. Bunny lines are treated with 2–4 units on each side injected into the transverse nasalis muscle. Injecting four units into the alar part of the nasalis muscle on each side will decrease nasal flaring.
8. Perioral lip lines are treated with two units injected in each quadrant at the vermillion border.
9. Mouth frown is caused by lack of balance between the depressor anguli oris (DAO) and zygomaticus muscles. To allow the commissures to return to a more horizontal position, two units are injected i/>
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