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Basic Botox Technique

  1. Horizontal lines- The frontalis muscle elevates the brow and is   associated with the development of horizontal forehead rhytides. 4-6 injection sites are recommended. Regardless of the no. of injection sites it is important to remain 1-2 cm above orbital rim to reduce potential for brow ptosis. Maximum dose recommended for horizontal lines is 10-12 units. Reason for brow ptosis is overtreatment with Botox of the frontalis muscle. It results from overtreating the entire frontalis muscle within one finger breadth or 1-2 cm of the eyebrow. Avoid injecting 1cm above the brow to reduce brow ptosis. Do not treat the forehead (only glabellar and crow’s feet) in patients over 60 who use frontalis to elevate the brow for better vision.
  2. Crow’s feet- Lateral orbital wrinkles called as crows feet result from muscle activity along with photoageing. The treatment goal is to soften the wrinkles & provides relaxed look and not to cause immobility. The lateral fibres of orbicularis oculi are injected. On an average, 3-5 sites are injected on each side. The injection site is kept 1-1.5 cm lateral to the orbital rim. The second and third injection sites are approx 1-1.5 cm above and below the first injection site respectively. Regardless of distribution of crow’s feet, the most anterior injection should be placed lateral to a line drawn vertically from the lateral canthus. The injections should be performed when the patient is not smiling. As the toxin may affect the ipsilateral zygomaticus complex, causing ptosis of the upper lip. Maximum dose per side is 12-16 units. Should be done for patients who perform well to a preinjection snap test (lower eyelid briefly pulled off the globe by downward pressure on the lower eyelid skin, then quickly released, and the speed with which the eyelid snaps back to the globe assessed).
  3. Glabellar Complex- The musculature of glabellar complex are corrugator supercilii, the procerus & depressor supercilii. Medial fibres of orbicularis oculi & frontalis can contribute as they interdigitate with the fibres of corrugator. Three to five injection sites are recommended. Additional bilateral points above supra orbital rim at the midpupillary line maybe considered. Injection sites depend on gender as male muscle mass is larger. Men tend to have a horizontal arch as against females who have gentle curved arch. Maximum dose for glabellar complex is 20 units.        

Advanced Botox Techniques

Mid & lower face botox should be included in the therapeutic armamentarium of a doctor who is already experienced in the indications for upper face.


  1. Perioral lines/ Smoker’s lines- Repeated purse string action of orbicularis oris exaggerates leading to perioral lines. 1-2 units of Botox per lip quadrant is sufficient to give cosmetic benefit without creating paresis of orbicularis oris that might interfere with elocution & suction.
  2. Nefertiti lift (Horizontal lines)- These are the muscular subaponeurotic system attachments in the neck. Simplest approach is to dance along the lines injecting 1-2 units of Botox at each site in the deep intradermal plane. The dose should not exceed 10-20 units per treatment session.
  3. Platysmal Bands- Anterior platysmal bands become more invisible while speaking, exercising or playing a musical instrument. Patient is asked to contract anterior neck by clenching teeth. It will exaggerate bands. Holding between thumb and index finger, insert into band & feel resistance. Inject 1-2 units into band perpendicularly at 1.0-1.5cm intervals from the jawline to the lower neck. Thinner bands respond to 5-10 units, while thicker bands respond to 10-15 units. Total dose of 20 units is delivered. Good patient selection is very important with good cervical skin elasticity & minimal fat descent.
    S/E- Dysphagia, Dystonia, Weakness of muscles.
  4. Mental crease / Popply chin- Deep semilunar groove interposed between perioral area and prominence of chin is called mental crease. 2-5 units is injected into depressor anguli oris lower down close to its junction with inferior border of mandible.
  5. Bunny Lines- Contraction of muscular fibres of upper nasalis across the bony dorsum of nose cause bunny lines. Injection point should be anterior to the nasofacial groove on the lateral wall of the nose & well above angular vein to avoid affecting levator labii superioris alaque nasi.
  6. Repeated nasal flare-It is repeated dilatation of nostrils under social situates. Injection of Botox in lateral nasalis fibres draped over lateral nasal ala will weaken its involuntary action.
  7. Gummy smile- It is an abnormally high retraction of the upper lip when a patient smiles. One unit of Botox on each levator labii complex in each nasofacial groove will relax the upper lips.
  8. Hypertrophic masseter- One of the causes of square face is a hypertrophic masseters & the other is bony prominence of mandible.
  9. Masseter hypertrophy could be due to habitual chewing movements or   teeth grinding (Bruxism). Only superficial and medial head is injected . Draw an imaginary between tragus of ear and corner of the mouth & inject only below this line. Ask the patient to clench teeth & mark the anterior and posterior border of masseter. Inject 1cm inside anterior & posterior border of masseter. Inject 1cm above the angle of the mandible/ jawline. Mark 3-6 pts. Maximum dose of 15 units per side.
    S/E- Temporary pain / tenderness.
    - Inability to chew hard/ open the jaw.
  1. Hyperhydrosis-  Done to reduce sweating in the axilla.The recommended dose is 50 units per axilla.The hyper hydrotic area to be injected should be defined using standard staining techniques, eg- Minor’s Iodine – Starch Test. Using 30 gauge needle, 50 units of Botox is injected intradermally in 1-2 units per side approx 2mm, at a angle of 45 degree to the skin surface with bevel side up to minimize leakage .


  • Muscle disorders
  • Epilepsy
  • Pregnancy
  • Breast feeding
  • Neuromuscular diseases

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