88 COSME TIC MEDICINE 2.

24 R E V I E W S

Ten mistakes to avoid

when injecting botulinum toxin*
R. RUIZ-RODRIGUEZ AND A . MARTIN-GORGOJO

However, when used prudently and rigorously by a doc-

KEY WORDS: Botulinum toxin type A, facial muscles, tor who understands the anatomy and functionality of
skin aging, rejuvenation the facial muscles, botulinum toxin injection is clearly,
for both doctor and patient, the most gratifying tech-
SUMMARY: nique used in the fascinating field of cosmetic dermatol-
Injection of botulinum toxin is currently the most com- ogy. Moreover, in our experience, botulinum toxin has an
mon cosmetic procedure in the United States, and in recent “educating” effect on the facial muscles and therefore
years it has become – together with dermal fillers – the also helps to prevent the appearance of certain expres-
mainstay of therapy for the prevention and treatment of sion lines.
facial aging. However, in some cases the treatment may Proper technique is essential to achieving good
lead to a somewhat unnatural appearance, usually caused results with botulinum toxin. In this article, we ana-
by loss of facial expression or other telltale signs. In the lyze the mistakes that doctors should avoid in order to
present article, we review the 10 mistakes that should be achieve optimal results with botulinum toxin injection.
avoided when injecting botulinum toxin. We also reflect on
how treatment with botulinum toxin influences us through
our facial expressions, both in terms of how we feel and FIVE ERRORS OF ACTION
what others perceive.
Using an excessively high dose
Result: Lack of Expression
Some articles and textbooks recommend using a dose of
20–40 U of botulinum toxin type A (Vistabel) in the gla-
INTRODUCTION bella, 15–30 U in the forehead, and 12–30 U in the crow‘s
feet [2, 3].
According to the American Society of Plastic Surgeons, We use 30 % less in the glabella, 50 % less in the fore-
injection of botulinum toxin is currently the most com- head, and the same dose in the crow‘s feet. On the lower
mon cosmetic procedure in the United States. The use of third of the face, we usually use 50 % less than the gener-
botulinum toxin to eliminate expression lines by relaxing ally recommended dose. With this approach, the results
the facial muscles has become – together with dermal are more natural and side effects are less frequent;
fillers – the mainstay of therapy for the prevention and however, patients should be informed that the effect of
treatment of facial aging [1]. the procedure will last for a shorter time (approximately
Patients considering injectable treatments generally 3–4 months).
want natural-looking, minimally detectable results. How- In our protocol, we ask patients to return for a fol-
ever, a nonnegligible portion of the population believes low-up appointment 2 weeks after the initial treatment.
that the use of botulinum toxin – or Botox, as it is com- At this visit, we reassess the patient and, if necessary,
monly known – produces unnatural and, in many cases, administer additional injections in certain areas. How-
grotesque results. In our opinion, there are 2 general ever, it is important to educate patients to help them
reasons why some people hold this opinion: understand that “less is more” (ie, the goal is not to
completely paralyze the facial muscles).
• In some cases, the results of the technique
can be too “paralyzing,” leading to a loss of facial
expressiveness.

• In other cases, an unnatural eyebrow shape and new * Please cite this article as: Ruiz-Rodriguez R, Martin-Gorgojo A.
telltale wrinkles signal that a patient has received Diez errores a evitar en la inyección de toxina botulínica.
botulinum toxin injections. Actas Dermosifiliogr. 2015; 106: 458–464.
 COSME TIC MEDICINE 2.24 89

Fig. 1: The 5 traditional injection sites for treatment of the Fig. 3: Injection at point 2 can result in the Mephisto effect.
glabellar region. Doctors attempting to inject the corrugator Injection at point 3 lifts the lateral portion of the brow; in some
supercilii muscle often inject the lower portion of the fronta- patients, it may lift the brow excessively. Injection at point 4 can
lis muscle instead, causing the medial portion of the brow to relax the frontalis muscle; in some patients, it can cause eyelid
descend and the lateral portion of the brow to arch upward ptosis. Injection at point 5 can relax the orbicularis oculi muscle
unnaturally, generating a Mephisto effect. and exacerbate the undereye bags.

Fig. 2: Typical Mephisto effect or “devil brow.” Fig. 4: After treatment with botulinum toxin, improvement is
observed in the crow‘s feet but a new contraction of the nasalis
muscle also appears, resulting in “bunny lines.”

Injecting the Frontalis Muscle Instead

of the Corrugator Supercilii Muscle
Result: Mephisto Effect medial portion of the brow to descend and lifts the lat-
The 5 traditional glabellar injection sites appear in many eral portion of the brow as a result of the compensatory
articles and textbooks (Fig. 1). In reality, however, the 2 contraction of the lateral fibers of the frontalis muscle.
most superior of these injection sites are not located on The result is the well-known Mephisto effect (Fig. 2).
the corrugator supercilii muscle – for which the insertion In some cases, we use a higher concentration of
site is almost at eyebrow level – but rather on the fronta- botulinum toxin in order to achieve greater precision
lis muscle. Relaxation of the frontalis muscle causes the and relax only the corrugator supercilii muscle. In our
90 COSME TIC MEDICINE 2.24 R E V I E W S

Injecting the frontalis muscle in patients

who use it to raise the eyelids
Result: Brow and/or eyelid ptosis
In our experience, we have observed that many patients
aged 65 years or older use the frontalis muscle to keep
their eyes open. In these patients, relaxation of the fron-
talis muscle with botulinum toxin (Fig. 3) results in ptosis
of the brows and/or eyelids. Therefore, in patients aged
65 years or older, the physician should examine the fron-
talis muscle and avoid injecting it if the patient uses it to
open the eyes.

Injecting Too Low in the Crow‘s Feet

Result: Exacerbation of Undereye Bags
Fig. 5: The face appears more rested after botulinum toxin Some patients have undereye bags as a result of herniated
injection in the upper, middle, and lower thirds. fat or fluid retention. In either case, botulinum toxin injec-
tion can exacerbate these bags if the inferior fibers of the
orbicularis oculi muscle are relaxed excessively. Therefore,
in patients with a tendency to develop undereye bags,
injection of the most inferior portion of the crow‘s feet
should be avoided in order to preserve the tone of the cor-
responding region of the orbicularis oculi muscle.

FIVE ERRORS OF OMISSION

Failure to inject the lower third of the face

Result: Less effective overall result
When administering botulinum toxin injections, the physi-
Fig. 6: The glabella is more relaxed. The corners of the mouth cian should consider the patient‘s face as a whole, with the
have also been lifted by the relaxation of the depressor anguli aim of relaxing the main depressor muscles in both the
oris muscle. upper third – where the results are most gratifying – and
the lower third. The problem is that undesired effects in
the lower third of the face can lead to both cosmetic and
experience, this approach allows us to inject a smaller functional deficiencies. It is therefore essential to use
volume of liquid, thereby decreasing the likelihood low doses in order to avoid complications.
of diffusion to unintended muscles (in this case, the In the lower third of the face, we can relax the plat-
frontalis). ysma muscle at the jawline (a technique known as the
“Nefertiti lift”) [5], the depressor septi nasi muscle (in
Always injecting the superior-lateral portion patients who have a plunging nasal tip when they smile)
of the orbicularis oculi muscle [6], the depressor anguli oris muscle (to lift the corners
Result: excessively elevated eyebrows of the mouth) [7], the mentalis muscle (to relax the “peb-
Infiltration of botulinum toxin into the superior-lateral bly” effect caused by the insertion of this muscle on the
fibers of the orbicularis oculi muscle (Fig.   3) relaxes skin) [8] etc.
those fibers and lifts the lateral portion of the brow. The masseter muscle, which is used for chewing, is
The problem is that, in many patients, the position of hypertrophied in some patients, causing both functional
the eyebrows moves upward with age as a result of the alterations (bruxism) and cosmetic alterations (square
physiological contraction of the frontalis muscle. face). Injecting botulinum toxin into this muscle not only
In one study, 4 photographs were analyzed in order improves the symptoms of bruxism but also transforms
to compare eyebrow position in young patients and in a square face into a more oval shape [9, 10]. When inject-
patients 30 or 40 years older. Paradoxically, the study ing the masseter muscle, the location of the risorius
found that a physiological elevation of the eyebrows muscle should be taken into account because diffusion
tends to occur with age in most patients. Therefore, for of the toxin into this muscle can result in an asymmetri-
natural results, the superior-lateral fibers of the orbicu- cal smile [11].
laris oculi muscle should only be injected in patients in
whom the lateral portion of the brow has descended.
 COSME TIC MEDICINE 2.24 91

Failure to inject wrinkles caused by botulinum toxin

Result: “Unnatural” wrinkles
When certain muscles are relaxed with botulinum toxin,
the adjacent muscles increase in tone as they compen-
sate for the inactivity of the treated muscles. This com-
pensation has a desirable lifting effect, but it can also
lead to new telltale wrinkles. The classic wrinkles caused
by botulinum toxin – “bunny lines” – are caused by the
contraction of the nasalis muscle (Fig. 4) [12] but the con-
traction of fibers in the inferior portion of the orbicularis
oculi muscle, in the frontalis muscle just above the eye-
brows or at the hairline, etc., can also cause new wrin-
kles. These wrinkles should be corrected with botulinum
toxin treatment.
Fig. 7: These photographs show the relaxation of the crow‘s feet,
Lack of familiarity with muscle contraction patterns the lifting of the lateral portion of the brow, and a reduction in
Result: Unnatural appearance gingival display.
The appropriate injection sites vary from patient to
patient. The “one size fits all” approach does not work in
botulinum toxin treatment. Physicians should be familiar
with the basic contraction patterns of the glabella [13–
15], the forehead [16], and the crow‘s feet [17] so that they
can personalize the injection pattern for each patient,
thereby achieving more natural results and using a
smaller amount of botulinum toxin.

Failure to differentiate between men‘s

and women‘s eyebrows
Result: Masculinization of women‘s appearance
and feminization of men‘s appearance
The “seagull wing” is the classic eyebrow shape in
women, whereas men‘s eyebrows are straighter and
closer to the upper eyelids. The eyebrows can be shaped Fig. 8: A side view shows the improvement in the crow‘s feet,
by relaxing the frontalis muscle, which lowers the brow the lifting of the nasal tip, and the better-defined jawline.
at the injection site, or by relaxing the superior-lateral
fibers of the orbicularis oculi muscle, which lifts the lat-
eral portion of the brow. To lift the medial portion of
the brow, botulinum toxin should be injected into the 3 therapy – a “3-dimensional” approach – achieves the
depressor muscles in this area: the procerus, the corru- most natural results. By combining this approach with
gator supercilii, and the depressor supercilii. fractional laser treatment, focused ultrasound treat-
ment, and laser treatment of pigmented and vascular
Failure to combine botulinum toxin lesions, it is possible to safely and effectively correct
with other treatments the various signs of facial aging [19].
Result: Suboptimal results
Botulinum toxin is an excellent treatment for control-
ling certain expression lines and adjusting the position REFLECTIONS ON BOTULINUM TOXIN
of certain facial features, including the brows, the nose,
and the mouth. However, in the interest of achieving an In order to achieve natural results with botulinum toxin,
excellent outcome, physicians should explain to patients the physician should have exhaustive knowledge of the
that a prudent combination of botulinum toxin injection anatomy and functionality of the facial muscles. In our
and other cosmetic treatments yields the best results. experience, cadaver anatomy courses and the treatment
One of the most important signs of facial aging is of patients with facial paralysis provide excellent oppor-
the loss of volume caused by changes in the fat com- tunities to learn about the anatomy and functionality of
partments and bones of the face [18]. In light of these the facial muscles; this knowledge can help physicians
changes, it is easy to see why the combination of bot- to optimize the cosmetic results of botulinum toxin
ulinum toxin, dermal fillers, and collagen induction treatment.
92 COSME TIC MEDICINE 2.24 R E V I E W S

Many patients tell us that they do not recognize them- Conflicts of Interest:
selves in the mirror – that the face ages more quickly The authors declare that they have no conflict of interest.
than the mind. They seek treatment in order to align their
appearance with how they feel. Curiously, the transfor-
mations that our faces undergo with age mimic those
which occur when we make an expression of sadness – Address of Correspondence:
in other words, the action of the depressor muscles is Dr. Ricardo Ruiz Rodríguez, MD
predominant [20]. Botulinum toxin is an effective tool C. del Marqués de Villamagna, 8, Salamanca
for relaxing the depressor muscles of the entire face, ES-28001 Madrid
thereby reactively strengthening the levator muscles.
Facial rejuvenation treatment is currently based on a
global 3-dimensional approach. However, there is also a
fourth dimension: our expressions (in other words, the
information transmitted by facial muscle movements).
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not help their patients pursue ideal beauty at all costs; linum toxin-A in the treatment of hypertrophic masseteric muscle
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