Botulinum Toxin Injection

Aka: Botulinum Toxin Injection, Onabotulinum Toxin A, Onabotulinumtoxin A, Abobotulinum Toxin A, Botulinum Toxin Type A, Botox

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II. Indications: Cosmetic

  1. Dynamic facial lines and Wrinkles in the upper one third of the face
  2. Frown lines (FDA approved as of 2002)
    1. Vertical Wrinkles between the eyebrows
    2. Dynamic Wrinkles are most amenable to treatment (although static Wrinkles will also improve with treatment)
    3. Treatment of the Glabellar complex (Corrugator supercillii, procerus and depressor supercillii Muscles)
  3. Crow's Feet (FDA approved as of 2013)
    1. Wrinkles eminating laterally from lateral canthus region
    2. Treatment of the lateral obicularis oculi Muscle
  4. Horizontal forehead lines (off label use)
    1. Treatment of the frontalis Muscle

III. Indications: Neurologic

  1. Blepharospasm (first-line treatment, Botox or Xeomin)
  2. Cervical Dystonia (Dysport or Mybloc)
  3. Spasticity in Adults
  4. Chronic Migraine Headache (>15 days/month for at least 3 months)

IV. Mechanism

  1. Neurotoxin derived from Clostridium botulinum (cause of Botulism)
  2. Botulinum Toxin act Neuromuscular Junction and inhibits release of Acetylcholine
  3. Injection into overactive facial Muscles results in localized Muscle relaxation

V. Preparations

  1. Precautions
    1. Botulinum Toxin preparations are not interchangeable due to differences in concentration, formulation and effects
  2. Botulinum Toxin serotype A (most common serotype used for cosmetic procedures)
    1. Onabotulinum Toxin A (Botox)
    2. Abobotulinum Toxin A (Dysport), which also contains bovine Protein
    3. Incobotulinum Toxin A (Xeomin)
  3. Botulinum Toxin serotype B
    1. Rimabotulinum Toxin B (Mybloc)

VI. Dosing

  1. One treatment every 3-4 months

VII. Advantages

  1. Brief procedure and highly effective

VIII. Disadvantages

  1. Small margin of error for injection site

IX. Approach

  1. Precautions
    1. Botulinum Toxin Injection should only be performed by providers trained in this technique
    2. The technique described here is for review only, and not intended to replace proper training
  2. Consultation
    1. Review alternative options (see Skin Cosmetic Procedures)
    2. Obtain "before" photographs (static and dynamic)
    3. Prioritize cosmetic interventions
    4. Set realistic expectations
    5. Review potential adverse effects and complications
  3. Preparation
    1. Reconstitute Botulinum Toxin powder in sterile Normal Saline
    2. Draw solution into a tuberculin syringe or similar (1 ml) and apply a 30 gauge needle (1/2 or 1 inch)
    3. Anesthetic (e.g. Lidocaine) is NOT typically used
      1. Patient should be prepared to expect localized singing and burning in the region of injection
  4. Technique: Frown Lines (Glabellar Complex Muscle injection)
    1. Patient actively frowns
    2. Inject each of five sites
      1. Procerus Muscle (1 injection)
      2. Bilateral corrugator supercillii Muscles (4 injections total, 2 for each Muscle body)
  5. Aftercare
    1. Patient should stay upright (not supine) for at least 4 hours after procedure
    2. Patient should avoid massaging or applying heat to the area on the day of the procedure
    3. Patient should avoid Exercise, Alcohol or other activities that cause Flushing on the day of the procedure
  6. Follow-up (at 2 weeks)
    1. Effects will evident by day 3 following the procedure, maximal by 2 weeks and start to diminish at 3-4 months
    2. Obtain "after" photographs (static and dynamic)
    3. Evaluate effects and adverse effects

X. Adverse Effects

  1. Injection reaction
    1. Injection site erythema, edema or tenderness (resolve within 24 hours)
    2. Bruising (may persist for up to 2 weeks after injection)
  2. Headaches
    1. Treat with NSAIDs
  3. Collateral effects of adjacent Muscles (transient)
    1. Blepharoptosis (upper Eyelid droop)
    2. Eyebrow Ptosis
    3. Facial asymmetry

XI. Contraindications: Botulinum Toxin Injection

  1. Body Dysmorphic Disorder
  2. Career dependent of facial Muscle use (e.g. performers, vocal artists)
  3. Infection or dermatitis affecting the treatment area
  4. Pre-existing motor deficit in the treatment area (Bell's Palsy)
  5. Immunocompromised state
  6. Keloidal scarring
  7. Neuromuscular condition (e.g. ALS, Myasthenia Gravis)
  8. Pregancy or Lactation
  9. Allergy to components of Botulinum Toxin
    1. Dysport is contraindicated in Cow's Milk Allergy

XII. References

  1. Carruthers (2004) Plast Reconstr Surg 114(6 suppl): 1s-22s [PubMed]
  2. Neurology (2016) 86(19): 1818-26 [PubMed]
  3. Small (2014) Am Fam Physician 90(3): 168-75 [PubMed]
  4. Small (2009) Am Fam Physician 80(11): 1231-8 [PubMed]
  5. Wise (2006) Facial Plast Surg 22(2):140-6 [PubMed]

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