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Chemodenervation From Physiology of the Skin, Third Edition

By: Zoe Draelos, MD, and Peter T. Pugliese, MD
Posted: January 5, 2011, from the January 2011 issue of Skin Inc. magazine.
female spa client's face

page 3 of 6

The vials arrive on dry ice and must be placed in a freezer for storage. They are removed immediately before use and diluted with sterile water. The dilution depends on the wishes of the user. Some physicians add 1 cc of water per vial while others prefer a more dilute botulinum toxin, adding 2 cc of sterile water. The effect produced by the botulinum toxin is dependent on the number of units injected and not the volume. Once the botulinum toxin is diluted, it is drawn up into tiny insulin syringes. In the package insert for botulinum toxin, it states that it must be used within four hours of reconstitution; however, it can be used without loss of potency for three weeks.

Facial uses of botulinum toxin

Botulinum toxin can be used to relax facial muscles, primarily above the nose on the upper face. Paralyzing muscles below the nose would affect the mouth, making smiling, speaking and eating difficult. Fillers, not botulinum toxin, are primarily used for anti-aging wrinkle therapy below the nose. In some instances, botulinum toxin can be used to relax the wrinkles above the upper lip or below the chin, but very small amounts are used in the hands of a skilled injector.

The most effective and most popular use of botulinum toxin is to relax frown-line wrinkles between the eyes. This is actually the original cosmetic use of botulinum toxin that was approved by the FD. The injection points correspond with the muscles that pull to allow the contraction of the skin between the eyes. There is significant variability between individuals in facial muscle movement and attachment, thus the injecting physician must customize the injections for each face. This is the art of using botulinum toxin. Failure to customize the treatment may result in unusual, unattractive results.

Botulinum toxin can also be used to relax other facial muscles. Areas for treatment include the crow’s-feet around the eyes, as well as forehead wrinkles. Care must be taken not to place the botulinum toxin too close to the eyes or vision may be affected. Additionally, some individuals use their forehead muscles to keep redundant eyelid skin out of their eyes. If the forehead muscles are over-relaxed, the eyebrows and eyelids will descend, creating an unattractive appearance and vision problems. Watching the patient carefully for muscle use is key before performing any injections, or problems may occur.

More advanced techniques for botulinum administration can result in other subtle facial improvements. For example, injections of very small amounts under the eye can relax the lower eyelid muscles and decrease crepey skin texture, but only if the patient has excellent skin elasticity. Under-eye injections can result in huge under-eye bags if the skin is lax. Injections can also be performed on either side of the nose to relax wrinkles known as “bunny lines,” which are considered unattractive when smiling. Again, small amounts must be used. The eyebrow can also be lifted in certain individuals by injecting at the lateral eyebrow, but this may not work in all females and is not aesthetically pleasing in males. These examples point out the art of patient selection, injection location and injection amount in obtaining the optimal anti-aging result.

Botulinum toxin off the face