FILLERS AND

BOTOX
Aging
◦ intrinsic (soft-tissue maturation, skeletal
change/atrophy, genetics, and muscular
hyperactivity)
◦ extrinsic (gravity, solar damage, smoking and
weight fluctuation)
◦ smooth curvy appearance -replaced by sharp
angles, fine and deep wrinkles, and abrupt
hollows and bulges
◦ Superficial lines that course at the upper
level of the dermis -dermabrasion, chemical
peels, and lasers.
◦ Mimetic wrinkles -muscle inactivation with
neuromodulators (Botox, Dysport, Xeomin,
Jeuveau, and Daxxify) or myotomy/myectomy
or fillers.
◦ Folds during their early stages- fillers, as an
adjuvant modality to surgery
FILLERS
Fillers history
◦ 1893 - Neuber -fat transplanted from the arms to correct facial defects
◦ 1911- Brunning first injected fat
◦ 1899- Robert Gersuny - first injected Vaseline
◦ Eckstein- used paraffin to correct fistulas and hernias and to attain aesthetic soft-
tissue augmentation
◦ 1947- Dr. James Barrett Brown - first used silicone for the correction of soft-tissue
deficits.
◦ highly purified medical grade silicone oil (AdatoSil 5000, Silikon 1000) - treatment
of retinal detachment and off-label for volume augmentation
◦ 1981- bovine collagen- first filler for soft-tissue augmentation-rapid resorption and
allergenic
◦ 2 decades later- HA dermal fillers - gold standard in cosmetic soft-tissue
augmentation
 Classification

autolog syntheti
biologic
ous c
material
material material
s
s s
Autologous fillers
◦ derived from the patient’s own tissues
◦ Ideal soft tissue filler in terms of safety
◦ two-step procedure – harvesting of tissue and injection
◦ donor site scar, infection, migration, inflammatory reactions, loss of
persistence, and unreliable reproducibility
◦ Autologous fillers include
◦ dermis, fascia, cartilage, superficial musculoaponeurotic system (SMAS) grafts ,
breast implant capsule
◦ Fat grafts
◦ Platelet -rich fibrin matrix (PRFM) – 20 months
◦ Platelet -rich plasma (PRP)
◦ cultured fibroblasts (LAVIV or Azficel-T)- 6 months
◦ Bone marrow-derived and adipose-derived stem cells.
Biologic fillers
◦ Derived from organic sources (humans,
animals, or bacteria) offer the benefits
of ready, “off-the-shelf” availability
◦ allergenicity, immunogenicity, and
transmission of disease
◦ Temporary effect
◦ Do not correct the wrinkles or creases
completely
◦ Types of biologic tissue fillers
◦ acellular soft-tissue matrix
◦ Collagen
◦ hyaluronic acid (HA) products
◦AlloDerm
◦acellular, structurally intact sheet of human dermal
graft
◦cells responsible for immunogenicity are removed
◦first used in treatment of full-thickness burns.
◦grafted material acts as a template for recipient cell
repopulation
◦applications - lip augmentation, nasolabial fold
correction, glabellar wrinkle softening,
rhinoplasty(dorsum and tip), septal perforation, Frey
syndrome, liposuction defect, and scar treatments.
◦Complications - infection, persistent palpability or
lumpiness, and variable “take”
◦Cymetra
◦Lyophilized acellular collagen matrix derived from human
cadaver dermis, in a particulate form.
◦Application- lips, nasolabial folds, and deep wrinkles

◦Zyderm and Zyplast

◦ Bovine collagen
◦first commercially marketed injectable approved by the FDA
◦Hyaluronic acid or HA
◦anionic, hydrophilic, nonsulfated glycosaminoglycan
◦component of synovial fluid, connective tissues of the skin,
cartilage, and bone.
◦adds bulk and acts as a shock absorber and lubricant.
◦Unprocessed – t ½ =2 days - rapidly degraded and metabolized by
the liver.
◦cross-link HAs- more stable compounds with significantly longer
degradation times
◦hydrophilic, maintains its volume by binding water from
the interstitial fluids around it.
◦1g of HA can bind an impressive 6L of water.
◦Isovolumetric degradation - HA is progressively
degraded by the surrounding tissues, so underlying
molecules of HA bind more water and therefore
maintain the initial filling volume.
◦can maintain a virtually constant fill volume until the
product is almost completely degraded.
◦Elastic modulus or G′ -is a measure of its firmness
and resistance to deformation.
◦ differs in source, concentration, type and degree of cross-
linking, amount of free unmodified HA present, and
whether the product is monophasic (cohesive gel) or
biphasic (particulate).
◦ Good choice for novice injectors, treatment-naïve patients, and
for patients with moderate aging changes.
◦ Lidocaine, present in many of the recent fillers but, can be mixed
with most fillers to obtain analgesia during injection but can
change the viscosity and certain properties
Restylan NASHA (non-animal stabilized hyaluronic acid)
e
use in the correction of facial wrinkles
Brands within this group that differ by viscosity

Juvéder comes in various concentrations and viscosities and its cross-linking technology is
m termed Hylacross and Vycross
Vycross ◦ homogeneous smooth gels that are used for both lift and lines
◦ incorporates short- and long-chain HA leading to more efficient cross-linking than
Juvéderm Ultra, which only has long-chain HA.
◦ More stability
◦ longer lasting
◦ more viscose gel
◦ a greater lift capacity

◦ Beloter softer (lower G′)

o longer lasting
Balanc useful for superficial injections of fine lines
e low viscosity allows it to spread evenly throughout the soft tissues, which makes for a
soft, smooth fill.

Revanes used for lift as well as lines.

Synthetic fillers
can offer
permanence.
Radies mixture of calcium hydroxyapatite (30%) and polysaccharide gel (70%)
se polysaccharide gel is very white- inappropriate for use in the dermis.
nasolabial and labiomental crease correction, for the dorsum of the hand.
last between 1 and 2 years.
Hyperdilute Radiesse has shown neocollagenesis and is frequently used as a
biostimulatory filler- neck
Sculpt biocompatible, biodegradable material
ra composed of PLLA (poly-l-lactic acid), sodium carboxymethylcellulose, and
non-pyrogenic mannitol.
reconstituted with 5–10mL of sterile water at least 2 hours before injection and
does not require a skin test.
induce the production of fibroblasts leading to collagen production.
degraded in the skin to carbon dioxide and water in 6-24mon
correction of (HIV)-associated facial lipoatrophy and is also for cosmetic use
last up to 2 years after three consecutive treatment sessions, approximately 1
month apart.
 Injection technique
◦ Nerve blocks/Direct infiltration with lidocaine
◦ Direct infiltration can distort anatomic structure, and thus potentially to over- or
undercorrection.
◦ epinephrine in the infiltration can decrease bruising, can blanch areas of injection which mask
vascular compromise.
◦ Needles
◦ Less viscous -30–31G needles.
◦ More viscous -slowly injected through either a small needle such as a 30G or a larger 28G needle
◦ Microcannulas -decrease in risk of vascular occlusion.
◦ Anterograde injection technique can be helpful in areas where soft fluid filler product moves the
subcutaneous tissues away to decrease the risk of vascular injection.
◦ injection technique - simple linear threading ,serial linear threading, radial fanning,
cross-hatching, and serial puncture deposition.
simple linear threading to deposit a small aliquot
◦linear threading or tunneling technique involves injection either
intradermally or into the subcutaneous level
◦Once the needle is inserted, the product is injected in a
retrograde or anterograde fashion.
◦most commonly used to correct wrinkles and furrows.
◦when deeper creases are treated, multiple parallel linear
threads at different levels have to be used to accomplish the
desired volumetric augmentation
◦Examples of where this technique is commonly used include the
glabellar lines, the nasolabial folds, the lips, and the tear troughs
◦Radial fanning is a variation of the linear threading
technique
◦Just before the needle is completely withdrawn from the skin,
it is reinserted in a different direction and the product is again
injected in a retrograde fashion.
◦This process is repeated multiple times in different directions
until adequate correction is accomplished.
◦decreased bruising
◦useful in malar augmentation, correction of the prejowl
sulcus and the nasolabial fold
◦ Cross-hatching -in the correction of large surface areas such as the marionette
lines/prejowl sulcus or the hollowing of the lower cheek
◦ Two independent radial fanning injections oriented perpendicular to each other

◦ depot or droplet technique -needle is inserted deep into the tissue and an
aliquot of product is laid down
◦ Large volumes deposited in this fashion can lead to palpable nodules and
irregularities.

◦ serial puncture technique - small droplets are deposited in a serial fashion

◦ These aliquots have to be close together to prevent irregularities.
◦ If any irregularities appear they can be managed by massaging.
◦ This technique is frequently used for tear trough correction and in lip
augmentation, but also in the treatment of all other wrinkles and creases.
Indications and applications
Glabellar lines
Forehead lines
Eyebrows
Tear troughs
Nasolabial folds
Malar augmentation
Marionette lines
Jawline augmentation
Perioral and mandibular filling
Chin
Lip
Nasal reshaping
Panfacial augmentation
Scars and deformities
Hand rejuvenation
Glabellar lines
◦ Commonly, the glabellar furrow is successfully treated with neuromodulators.
◦ toxin-naïve patients or in patients with heavy solar damage, these lines are static –
requiring a combination approach with lasers or with fillers
◦ Informed consent -risk of arterial occlusion, blindness
◦ Prior to injection, photographs and marking of the supratrochlear and supraorbital
arteries.
◦Position - head at a 45°
◦Use of a needle in this area is
preferrable to a cannula
◦ depot of filler in the subgaleal
vascular safe zone and then massage
over the subgaleal glide plane.
◦ deeper component of the glabellar
furrow - hyaluronic acid placed at the
dermal–epidermal junction using a
serial linear threading fashion in an
retrograde motion.
◦ fanning injection technique not used
◦ Toxin and filler are not placed in this area
on the same day and toxin is used first
followed by filler 2 weeks later if indicated
◦ When combined with neuromodulators, the
effect can last more than 6 months
◦ follow-up at 1 month as some patients may
require additional filler for ideal correction
 Forehead lines
◦direct injection into the lines /bolus of filler in the forehead
concavity to give support.
◦combination of neuromodulator (done first) and filler can be ideal.
◦If the patient has a very dynamic forehead, then neuromodulators
will be very helpful in achieving a better result and increase
longevity of the filler.
◦injection technique similar to that used for the glabellar lines.
◦More commonly, low-viscosity fillers are used, and these are
placed at the dermal–epidermal junction using a serial
droplet or linear threading technique
◦ Reflation should begin at the central forehead and progress laterally.
◦ Because several injection points are used, needles should be changed
every 6 to 7 injections.
◦ Fanning technique is discouraged.
◦ Edema – upto 48 hours and patients are encouraged to sleep with their
head elevated and to avoid exercise for 48 hours.
Eyebrows
◦ With age, the brow position drops more laterally than medially leading to a flat
appearance and loss of projection.
◦ goal - achieve a larger look in the vertical dimension to the upper lid and a
repositioning of tissue such that light reflection gives the illusion of a wider eye
and more projected and contoured eyebrow.
◦ Those with brows that have even descent or brows in which the medial
supraorbital crease peaks medially are ideal candidates
◦ Filler above the lateral eyebrow line will worsen the appearance of an orbital
hollow.
◦ Ideally, filler is placed at the line of the brow at the lateral tail.
◦ Injection in this area must be slow and a bolus technique is not advised.
◦ Sandwich the brow between the thumb and first finger
◦ using a 30G ½-inch needle, 0.5 cc of filler in total, injected from laterally and plan
three longitudinal fills across the brow in a linear fashion moving the needle slowly
but constantly with low-pressure flow.
◦ inject small volumes with each pass to prevent emboli and injury to the sensory
nerves.
◦ The filler is placed at a level that is not mobile.
 Tear troughs/infraorbital hollow
◦ one component of the infraorbital
hollow
◦ nasojugal fold and the
palpebromalar groove comprising
the other components
◦ requires a lower lid
blepharoplasty for a prominent
and herniated infraorbital fat pad.
◦ Indications for HA filler - Patients
with thick smooth minimal laxity
and moderate tear troughs
◦ Often reflation of the midface
medially is also required
◦ One approach to filling this area is to place hyaluronic acid filler deep on the bone
and periosteum.
◦ This ensures that the product is not palpable or visible, especially with animation.
◦ Another technique - using a cannula at one insertion point lateral to the lateral
canthus and using a serial linear threading technique
◦ ½-inch 30G needle with an insertion point at the upper medial cheek.
◦ The needle is pointed toward the medial canthus and using a slow flow injection
technique, filler is placed in the suborbicularis oris fat (SOOF).
◦ Discontinuous aliquots of 0.1mL are deposited along the length of the infraorbital
hollow and milked upwards toward the trough and medially.
◦ 0.5 cc of filler is used per side, depending on the severity of the tear trough and
the desired projection of the malar prominence.
◦ If swelling and bruising are noticed immediately after filler injection, pressure and
cold compresses should be applied.
◦ Overcorrection - massaged down for up to 2–3 weeks.
◦ If the overcorrection persists, the HA filler can be partially dissolved with
hyaluronidase.
◦ If placed in the SOOF (suborbicularis oculi fat), filler does not need to be repeated
more than once a year.
◦ Post-procedure edema can last up to 3 weeks.
◦ most severe complications - retrograde embolus into the periorbital vasculature as
the filler inadvertently slips behind the orbital septum.
◦ check filler placement with the patient animating at the end of the treatment – to
check for “sausage roll” underneath the eye at the conclusion of correction
 Nasolabial folds
◦ The gradation system (Dr. Lemperle) is useful in
evaluating and discussing goals of correction with
patients.
◦ assess whether the fold is being contributed to by
midface descent.
◦ Midface defect -concomitant correction of the cheek
area.
◦ approximately 50% correction of the depth of the fold
◦ Fillers can be used to soften the broader portion of the
fold, which is usually the upper two-thirds down to the
lateral oral commissure.
◦ at the level of the mid to deep dermis.
◦ filler is placed at angles to the fold in order to decrease the risk
of intra-arterial facial artery injection.
◦ Layering performed to enhance longevity
◦ very deep folds- more viscous products or
permanent/semipermanent products placed deep under less
viscous fillers
◦ Taping of the fold after the injection - help the product bind into
scar tissue and prevent lateral displacement of the product to
the nasolabial fold when the patient smiles
Malar augmentation
◦ semipermanent and permanent fillers used
◦ HA fillers can be applied from the deepest layers to the most superficial
◦ Medium-viscosity (MV) HAs can be used over bone, into deep tissue, and in the
dermis.
◦ high-viscosity (HV) HAs can be used deep, with MVHAs placed more superficial
◦ The most appropriate technique for malar augmentation is the radial fanning
technique, with entry points first lateral and then inferior to the malar prominence
◦ Pressure over the augmented area should be avoided over the first week post-
treatment.
◦ The goal in this area is to reposition light reflection rather than to create the same
apple cheek for each patient.
Marionette lines
◦ extend from the oral commissure in a
downward oblique fashion, giving a sad
appearance.
◦ prejowl sulcus - volume deficit medially
extending to the level of the jawline.
◦ correction of the marionette lines combined
with correction of the prejowl sulcus.
◦ Semipermanent filler into the prejowl sulcus
can achieve excellent results especially when
molded over the jawline.
◦ More permanent viscous fillers are used for
deeper correction, with less viscous, finer
products for more superficial correction.
◦ The area to be filled is triangular, extending from the
marionette line to the lower lateral lip vermilion to
the superolateral aspect of the chin
◦ radial fanning technique from two independent
injection sites, superior and inferior, can lead to a
smooth correction of the area.
◦ A layering technique with more viscous hyaluronic
acids
◦ massage aliquots
◦ partial to complete correction is possible,
overcorrection can lead to lumps that are visible or
felt intraorally under the oral mucosa, and a strange
appearance upon animation.
◦ Bruising is very common in this area.
Jawline augmentation
◦ filler is best placed deep plane on the bone or subcutaneously to allow
augmentation similar to a solid implant
◦ usually combined with marionette/prejowl sulcus correction.
◦ HA is placed in the deepest point of the hollow.
◦ Using the thumb, massaging and molding the filler into place so that it
appears congruous with the bony jawline
Panfacial volumetric augmentation
and Facial lipoatrophy
◦ Correction of the temporal hollowing, lifting of the brow, filling of the periorbital
hollowing, and malar, jawline, and perioral enhancement
◦ more viscous HA fillers in the deep tissues may be used instead for an immediate
effect and more predictable results
◦ Alternatively, fat can be used for panfacial volumetric augmentation, with “finer”
fillers used to obtain a more superficial correction.
◦ The idea is not to fill the entire area of atrophy but to soften the contours so that
the wasting does not appear too severe.
◦ Linear threading or a fanning technique may be used, and a gradual and
consistent result can be achieved.
◦ Volumes of 0.5–1.5 cc per area may be used, on average.
◦ Repeated injections on a 2–4-week basis may help to contour areas that have a
large volume deficiency
 Lips
◦ Hyaluronic acids –can be reversed ,filler for both the
vermilion border and the body of the lip
◦ baseline asymmetry to their lips between the sides to
be marked and address other components of the
perioral area if required
◦ If the patient has a very active depressor anguli oris
muscle - addition of low-dose botulinum toxin may be
necessary.
◦ Begin injections at the oral commissure and vermilion
lip at the white roll first.
◦ anterograde pushing forward technique was
demonstrated to cause less bruising and pain.
◦The philtral columns -filler placed in the mid-dermal , placed
at an angle as the columns are less vertical and more like the
Leaning Tower of Pisa, Deposit more filler in the lower two-
thirds of the philtral column as to enhance and peak the
Glogau–Klein points
◦Injection from the wet–dry junction to the vermilion border
may also be carried out just deep to the mucosa within the
orbicularis oris muscle.
◦Placement posterior to the wet–dry junction along the wet
mucosa may enhance the lip volume as well as the projection.
◦ Frequently the upper lip is atrophied above the vermilion border, particularly the
lateral aspects, and restoration is done with MVHA placed at the mid-dermal level
to improve volume and projection of the upper lip.
◦ use minimal volume in the upper lip above the vermilion border as any added
volume may cause lengthening of the upper lip.
◦ limit the amount of filler placed in the upper lip skin adjacent to the nasolabial fold
because this will result in an awkward animation of the upper lip and nasolabial
fold, particularly during smiling, and can give the appearance of a “joker-type”
upper lip or create an unusual fold at the lateral edge of the upper lip.
◦ Patients with long, thin lips(while smiling) and very broad smiles - limited
results because of tissue tension.
◦ Patients with lips that are tight to the dentition or a class II occlusion
should be augmented with conservative volumes, since irregularities of
dentition leads to prominent or “duck-like”.
◦ Approximate volumes for augmentation of the lips - 0.5–1.0mL per lip.
◦ MVHAs last for a period of 4–6 months and when it is repeated, - 8–12
months.
◦ Less viscous HAs first be injected along the vermilion border, which
provides augmentation of the white roll.
◦ Edema can last for up to 72hours and patients should be advised to ice at
10minute intervals per hour to minimize this.
Perioral and mandibular filling
◦ Fillers that are soft and malleable give the best functional result in the perioral area.
◦ Nonpermanent crosslinked fillers are ideal for lip lines
◦ Use of a thin needle (31G or 32G) is ideal and massage is critical to avoid beads-on-a-
string appearance in this area.
◦ Palpate the anterior border of the masseter to understand where the facial artery is so
as to avoid it during injection.
◦ A high G′ filler is ideal which is done by pinching the skin upward and injecting in an
anterograde fashion away from the periosteum.
Chin
◦ A high G′ filler or CaHa are successful products to be used in this area.
◦ Injections should be placed deep and as a bolus in the center of the mentum
between the arches of the mental arteries.
◦ Massage is carried about by rocking the chin in the cupped palm of the injector’s
hand.
◦ Additional amounts of 0.2 to 0.4mL of HA filler can be injected superior and lateral
to the mentum in order to create a continuous arc with filler in the marionette
lines
 Nasal reshaping (off-label)
Indications mild hump, short nose, saddle nose and irregularity of the nasal dorsum at
lateral view
Fillers used HA fillers and calcium hydroxyapatite fillers
high viscoelasticity and low water-absorbing
permanent fillers have a higher risk of becoming visible or palpable

Injection serial threading or tunneling techniques

technique Cannula used
Subcutaneous layer
pushing cannula to radix and begin injection in a retrograde fashion
double-layer approach
Once the height of the nose is achieved, lateral sides of the nasal sidewall
should be injected
Correction of the nasal tip -filler in the interdomal area.
columella projection - placement of 0.2mL of filler into the subcutaneous
columella
Complications alar skin and nasal tip necrosis, especially post rhinoplasty
Scars and deformities
acne, chickenpox, and traumatic scars
 Hand rejuvenation
Indications decreases the appearance of veins,
extensor tendons, and bony
prominences, which become
pronounced with aging.
Fillers Fat
used
Injection Multiple fanning subcutaneous
technique injections with cannula
Avoid the vessels, tendons, and
nerves Postprocedure massage is
critical
Complicati Postprocedure edema
ons not to wear rings for 72 hours.
Use and dosage of
hyaluronidase
75–150 units of hyaluronidase
◦dose-related allergic reactions like
redness, angioedema, and rarely
anaphylactic shock.
◦starting with small doses of 5–15
units per site, with repeated
treatment 2 weeks later if needed.
 Contraindications and
considerations
Unrealistic patient expectations.
Transient bacteremia can create
delayed nodules of filler. So
Infection dental procedures avoided post-
filler placement for one month.
Injection of more superficial HA
Foreign-body reaction or inflammation
and collagen fillers should be
done at a later date following
blood thinners can lead to significant laser treatment
ecchymoses.
very thin skin - higher risk of
Avoided/used with caution - pregnancy,
breastfeeding, patients under 18 years of palpability or visibility- deep
age (no data to suggest adverse effects injection of small amounts of filler
of dermal filler use) is important.
Can be used in diabetes, autoimmune
disease, HIV, or immunosuppression
 Complications and their
treatment
swelling resolves in 2–3 weeks
Common complications -
massive oral steroids
lumps, bumps, and irregularities, swelling
pain, ecchymoses or hematoma,
overcorrection and asymmetry. lump, bump, dilute steroid injection and
or irregularity massage
rare and extremely serious - allergic local steroid injection/oral
Soft-tissue necrosis and embolic reaction steroid
phenomenon (HA- 0.03%.)

vascular occlusion and sterile up to 2 weeks after the initial

immediate blindness- (HA, abscess and injection, treated with I&D
CaH, PLLA, collagen, and dermal telangiectasia
-
matrix) most common sites - nose
(32.8%), glabella (26.2%) and herpetic patients with a previous history
nasolabial fold outbreak of herpes simplex outbreak -
prophylactic treatment with an
BOTOX
◦Wrinkles are formed by dermal atrophy and repetitive
contraction of underlying facial musculature.
◦Injection of botulinum toxin into specific overactive muscles
causes localized muscle relaxation that smooths the overlying
skin and reduces wrinkles.
◦It exerts its effect at the neuromuscular junction
produced by
Clostridium botulinum, Both types A and B are
an anaerobic, gram- currently US Food and
positive, spore-forming Drug Administration
rod. (FDA) approved

Only type A toxin has

The bacterium
indications for cosmetic
produces eight use
distinguishable
neurotoxins.
 Mechanism of action
by cleaving a docking
protein
(synaptosomal-
associated protein of
25 kDA [SNAP-25]) o
n
the internal surface o
f
neuronal membranes
inhibits vesicle fusion
and release of
acetylcholine
SNAP-25
regenerates, and
neuromuscular
signaling and temporary
muscle chemical
contractility are denervation.
restored
 frontal
Horizontal is
forehead lines
temporali
Frown corruga s
proceru
lines tor
Depressor
s
Crows
Bunny
supercili OO
feet
lines
nasal LLS
LLS
Nasolabi is AN ZMn&
al folds M
Radial lip
lines M risorius
platysma
Marionette
lines Chin DLI DAO
lines
Mentali
s
 Upper face- Forehead
◦ Ideal brow position - top of the brow to lie 2.5cm lateral to the mid-pupillary
point, with the brow to-hairline position 5 cm in women and 6cm in (men- at
the level of the supraorbital rim, women-above the rim)
◦ Females- arched brow
◦ bidirectional movement of the skin of the forehead- lower forehead cranially,
and upper forehead caudally.
◦ Both motions met at a static, nonmoving line termed the line of convergence
(C-line).
◦ The C-line was identified clinically at the second horizontal forehead line
when counting from superior to inferior.
◦ Injecting neurotoxin above the C-line can mitigate the risk of eyebrow ptosis
Considerations
◦Over-injection -frozen forehead, brow asymmetry, or medial and/or lateral
eyebrow ptosis.
◦Injection sites should be extended far enough laterally to avoid excessive
elevation of the lateral part of the eyebrow (“Spock” appearance)
◦Eyebrow position results from a balance between eyebrow elevator
muscles (primarily frontalis) and depressor muscles, (procerus and
corrugator muscles, which make up the glabellar complex) as well as the
superolateral fibers of the orbicularis oculi muscle.
◦To avoid eyebrow ptosis, treat the depressors of the glabellar complex in
both men and women and the tail of the brow for arched appearance in
women.
Dosing
◦ women, -10 to 20 U, Men-
20–30 U.
◦ done in 4–6 sites
◦ 1–5U per injection site
◦ at least 2.5–3.0 cm above
the orbital rim.
◦ 1–3 units into the lateral
orbicularis, particularly in
women, to allow eyebrow
elevation.
◦ Glabellar complex - Two corrugator Glabella
supercilii, depressor supercilii,
procerus, medial fibers of orbicularis
oculi and frontalis
◦ Vertical glabellar lines - corrugators.
◦ Oblique glabellar lines - depressor
supercilii
◦ Transverse glabellar lines-procerus
◦ Dose - 20 U (10 to 80 U)
◦ 5- to 7- point injection
◦ Corrugators- 1cm above the orbital rim to
prevent diffusion into the levator palpebrae
superioris.
◦ For the tail of the corrugator, identifying the
most lateral aspect of the corrugator
(presence of dimpling) and placing the
lateral injections just medial
◦ 4 patterns of lateral canthal lines at rest and at
maximal smile: lower-fan, central-fan, full-fan,
Periocular
and upperfan patterns. region
◦ The muscle is targeted by neurotoxin to achieve
widening of the eye aperture at rest and on
smiling

◦ Dose - 8 to 16 U/side in women and 12 to 16

U/side in men.

◦ three injections -at the level of the lateral

canthus, 1cm lateral to the orbital rim and the
other two are placed 1.0–1.5cm both superiorly
and inferiorly, angled at 30° anterior to the first
injection

◦ inject superficially, because the zygomaticus

major may be as shallow as 0.41-cm deep to the
◦ nasalis muscle has an alar and a transverse portion. Midface -
◦ alar nasalis (dilator naris)-nasal flaring.
◦ transverse nasalis-nasal oblique lines (bunny lines). Nose
◦ depressor septi nasi- downward movement of the nasal tip
◦ LLSAN, procerus,OOc, and ZM&m -in nasal movements
and wrinkling
◦ bunny lines -total of 2–5 U in females and up to 10 U in
males
◦ nasal tip ptosis- neurotoxin to the base of the depressor
septi nasi may help with the downward pull, and
treatment of the dilator nasi bilaterally may help with
the superolateral pull of the bilateral nasal ala
◦ 2–6 U injected in the columella, just above its junction with the
cutaneous upper lip
◦ For nasal flaring -5 U of neurotoxin per side into alar
nasalis
◦ Intradermal injection into tip and supratip -sebaceous
hyperplasia and in refining and narrowing the
appearance of nasal tip.
 Gingival show/ gummy smile
◦ exposure of more than 2mm of gingiva when smiling.
◦ LLSAN, LLS, LAO, ZM&m, risorius, and depressor septi nasi interact with the OOr to elevate and
laterally retract the lip.
◦ Anterior gummy smiles -gingival show primarily between the two canines, by activity of the
LLSAN.
◦ posterior gummy smile-gingival show is present posterior to the canines, by zygomaticus major
and minor
◦ Mixed gummy smile has both anterior and posterior involvement
◦ Asymmetric gummy smile has excessive exposure only on one side.
◦ Treatment goals -correct the gingival show without causing asymmetric smile, collapse of the oral
commissure, lengthening of the upper cutaneous lip, or difficulty smiling, speaking, or eating.
◦ Dose-2 to 4 U per side.
◦ To target the LLSAN, an injection can be placed 1 cm lateral to and below the nasal ala
◦ Side effects-smile asymmetry, lowering of the oral commissure, and difficulty with mouth functions.
 Lower face-Masseter muscle
◦
prominence
Hypertrophic masseter - square-angled lower face, pain,
dental attrition, maxillary and mandibular bone resorption,
and accelerated aging process of the lower face.
◦ Treatment goal –
◦ restore more youthful female proportions by reducing the lower
third of the face, thereby allowing the middle third of the face to
be proportionally larger.
◦ improvement of bruxism and jawline pain.
◦ decrease oxidative stress and its impact on bone resorption and
aging of the lower face.
◦ Dose -15–40 U per masseter.
◦ safety zone - below an imaginary line connecting the earlobe
to the oral commissure and between palpable posterior
border of the masseter and 1 cm posterior to the palpable
anterior border of the muscle
◦ 3 points-at the angle of the mandible, point 1cm
superomedially and point 1cm superolaterally
◦ Orbicularis oris contraction leads to the formation of
Perioral
lines perpendicular to the vermilion border. lines
◦ Excessive immobilization leads to difficulties with
phonation, drinking, kissing, and playing musical
instruments.
◦ start with lower doses and avoid treatment in
musicians and singers.
◦ Dosing and technique -total of 1–5 U to the upper and
lower lips (0.5–1 U per injection point).
◦ injection points 2-4 upper lip and 2 in lower lip.
◦ Dermal injections are placed along or up to 2mm
away from the vermilion border
◦ 1cm medial to the oral commissures in order to avoid
diffusion of the toxin into the modiolus.
Chin
◦ Loss of mandibular bone and subcutaneous fat, along with hyperactivity of the
mentalis muscle, lead to peau d’orange appearance of the chin and an accentuated
horizontal chin crease.
◦ most important aesthetic aspect of the chin is that the most horizontal projection
point is closest to the mandible, if higher, it looks like a weak chin.
◦ Dose-4–10 U, either with one injection point in the mandibular symphysis where
the two bellies insert or with two separate injections into each muscle belly, about
5mm from the center of the chin
Depressor anguli oris (DAO)
◦ hyperactive DAO- accentuation of the melo-mental fold (marionette line) and
causes a downward pull of mouth
◦ It functions in drawing the angle of the mouth inferiorly and laterally.
◦ Dosing - 2 U per DAO
◦ injection point should be at least 1 cm lateral to the line where the nasolabial fold
meets the mandible
◦ injection is kept inferior to the mental foramen.
 Platysmal bands
◦ platysma pulls the clavicle upward and depresses the lower cheek and oral
commissures.
◦ hyperactivity of the platysma - vertical platysmal bands, radial cheek lines, blunting
of the cervicomental angle, and lowering of the corners of the mouth.
◦ careful selection of patients who have platysmal bands with good cervical skin
elasticity is needed for this treatment.
◦ injecting masseter with neurotoxin can result in the platysma acting unopposed,
causing greater downward pull of the face.
◦ Dose- injections can be spaced 2 cm apart along each muscle cord, superficially,
using 2–4 U per injection site
◦ High total doses and excessively deep injections - weakness of the neck flexors,
dysphagia, and dystonia.
◦In 2007, Levy described the Nefertiti lift,
named after the Egyptian queen.
◦In addition to vertical injections into the
platysmal bands, a horizontal line of four
injections are placed along the superior
platysma immediately below the mandibular
bone.
◦Injection points are spaced 1–2 cm apart,
starting at least 1 cm posterior to where a
line drawn from the nasolabial fold meets
the mandible avoiding DLI
◦should not exceed a total of 50 U per
injection session to avoid complications.