Techniques in Ophthalmology 1(1):45–52, 2003
T E C H N I Q U E
BoTox: Ironing Out the Wrinkles in
Your Technique
NANCY TUCKER, M.D.
Illinois Oculoplastics Associates, Tinley Park, Illinois

ABSTRACT
BoTox has become the most commonly performed facial
cosmetic procedure. A thorough understanding of the in-
fluence of facial musculature on lines, anatomy, and sym-
metry can help fine-tune injection technique to optimize
results.

HISTORICAL PERSPECTIVE
Botulinum toxin, a potent neurotoxin produced by
Clostridium botulinum, blocks the release of acetyl-
choline from the presynaptic terminal of the neuromuscu-
lar junction, thereby preventing neurotransmitter-induced
muscle contraction.1,2 There are seven subtypes of the
bacterial toxin,: A through G. Types A, B, E, F, and G can
cause illness in humans (food-borne infection, wound in-
fection, and infant botulism3). Type A and B can be man-
ufactured in a purified form for clinical use. Botulinum
toxin A is available under the trade name of BoTox and
BoTox Cosmetic (Allergan Inc., Irvine, CA) in North
America and as Dysport (Ipsen Limited, Berkshire, Eng-
land) in Europe. Botulinum toxin B is marketed by Elan
Pharmaceuticals (San Francisco, CA) as Myobloc in the
North America and as Neurobloc in Europe.
BoTox was approved by the FDA in 1989 for the treat-
ment of strabismus and blepharospasm, and in 2000 for the
treatment of cervical dystonia. More recently (April 2002),
BoTox Cosmetic was granted FDA approval for tempo-
rary improvement in the appearance of moderate to severe
glabellar lines in adult men and women 65 years or
younger. Myobloc is approved for the treatment of cervi-
cal dystonia. Both products have been used “off label” for
cosmetic treatment in the face, as well as for a wide vari-
ety of neuromuscular disorders related to hypertonicity
and spasticity. Some examples include headaches,4,5 spas-
tic cerebral palsy, post-stoke spasticity,6 cricopharyngeal
dysphagia,7 hyperhydrosis,8 and genitourinary and gas-
Address correspondence and reprint requests to Dr. Nancy Tucker,
16650 South Harlem Ave., Tinley Park, IL 60477; e-mail: nancytucker
@attbi.com
Volume 1, Issue 1
© Lippincott Williams & Wilkins, Inc.
trointestinal disorders.9 Ophthalmologists have also used
botulinum toxin to treat Graves-associated upper eyelid re-
traction,10 crocodile tearing,11 and exposure or neu-
rotrophic keratitis by inducing a protective ptosis.12
BoTox and Myobloc are not equivalent in their phar-
macokinetics, dosing, or side effect profile. BoTox is
available as a sterile vacuum-dried powder (stored at

5C). Each vial contains 100 U toxin. The manufacturer
suggests diluting with unpreserved saline (0.9%). Recon-
stitution using benzyl alcohol-preserved saline has been
reported without adverse effect.13 Once diluted, it will
maintain full potency for 4 hours, after which it can
slowly lose its activity at an unpredictable rate. It is rec-
ommended that any unused BoTox be discarded after 4
hours. If kept longer, BoTox should be stored at 2 to 8C.
The beneficial effect is typically evident within 3 to 7 days
following injection, with a duration averaging 3 to 4
months.
Myobloc is much more stable. It is a clear aqueous so-
lution that can be stored in the refrigerator for many
months and used repeatedly. Vials are available in three
sizes (2,500, 5,000, 10,000 U; concentration 5,000
U/mL). Activity per unit does not correspond directly be-
tween serotypes, or even within a single serotype. The
strength of all botulinum toxin serotypes is measured in
biologic units (U), defined by the LD50 in mice. By defi-
nition, 1 U is the dose that kills 50% of female Swiss-
Webster mice weighing 18 to 20 g when injected in-
traperitonially.14 Recommended doses for clinical use are
based strictly on the effect and degree of neuromuscular
blockade observed in humans. One unit of BoTox is clin-
ically equivalent to 3 to 5 U Dysport15 and 50 to 100 U
Myobloc.16 These doses reflect the difference in pharma-
cokinetics of the various subtypes in mice and humans.
Compared to BoTox, Myobloc is more painful on injec-
tion and has a more rapid onset of action and a shorter du-
ration of action. BoTox is used much more commonly for
facial esthetics. Myobloc can be useful when patients are
refractory to BoTox, for small touch-ups, or when a more
rapid onset of action is desirable. This article pertains
specifically to experience and expertise in the use of
BoTox.
45
 N. Tucker
Optimal use of BoTox to improve facial esthetics re-
quires finesse, experience, and a keen understanding of
the interplay of individual muscles on facial rhytides, ex-
pression, anatomic position, and symmetry. Facial asym-
metry is often related to differences in the strength of the
underlying muscles of facial expression. Careful inspec-
tion in most patients will reveal some degree of facial
asymmetry, evident by either a difference in the anatomic
position (most commonly appreciated in the brows) or by
the depth and pattern of facial wrinkles (most commonly
seen in the forehead, glabella, and perioral regions). This
is often easier to appreciate in older patients with more ob-
vious lines. Asymmetries can be diminished or eliminated
by adjusting the injection site and treatment dose. Pre-
existing asymmetries should be discussed with the patient
and documented carefully. Photographs of each area at
rest and with maximal facial expression are an important
part of the patient record. This helps avoid any confusion
or misunderstanding that can arise if asymmetries are first
noticed only postinjection.
The optimal dose of BoTox in each area depends on
the strength of the underlying muscles and the amount of
weakening desired. In general, more prominent rhytides
require higher doses of BoTox. The goal is to achieve the
desired effect using the smallest dose possible. The pa-
tient is made aware that the initial dose may be adjusted
on subsequent injections to achieve the best result. The
patient should be actively involved in this decision-
making process. I generally see patients in follow-up 2
weeks postinjection to discuss the results in each area; ad-
justments can then be planned for the next treatment in 3
to 4 months. I prefer not to reinject at the 2-week follow-
up because of the potential risk of antibody formation.
Neutralizing antibodies have been reported as a complica-
tion of BoTox treatment in approximately 5% of patients
with cervical dystonia.17 It has been shown to be dose-
related18 and occurs more frequently with shorter injection
intervals.19 There have been no reports of reduced BoTox
activity related to antibody formation in patients treated
for facial esthetics.
BoTox has two important benefits. The initial benefit,
seen at 4 to 7 days following injection, is a reduction in dy-
namic wrinkles. The second effect is a long-term benefit
in reducing static wrinkles, best seen when BoTox is used
regularly for a prolonged period of time. The extent to
which lines will disappear depends on the initial depth of
the wrinkle, the amount of dermal restructuring that has al-
ready taken place prior to BoTox treatment, and the depth
of paralysis achieved. BoTox is best for relatively young
patients with early wrinkles, who can enjoy excellent re-
sults with small doses of BoTox that interfere minimally
with facial expression. Older patients with deeper furrows
will require larger doses that are certain to reduce facial
expression in order to reduce the static component of the
46 Techniques in Ophthalmology
wrinkles. These patients will often achieve a better result
with surgery and/or laser in combination with BoTox. As
patient awareness and education improves, I hope we will
see a trend toward initiating BoTox treatment in the 30s
and 40s rather than the 50s and 60, achieving better, more
natural results with smaller doses. In younger patients, ex-
cessive facial expression (particularly in the forehead and
glabellar regions) can be softened and future rhytides pre-
vented with appropriate BoTox treatment.
There are few contraindications to the use of botu-
linum toxin. Both BoTox and Myobloc are classified as
category C medications, meaning that there are not
enough data available to advocate their use during preg-
nancy or lactation. Treatment should be avoided if infec-
tion is present at the planned injection site. It should be
used cautiously in patients with neuromuscular disorders
and with coadministration of aminoglycosides or other
agents interfering with neurotransmission. Due to the
presence of human albumin, there is an extremely remote
risk of viral disease transmission, although no cases have
been identified.

TECHNIQUE
There are many variations in injection technique, with re-
ported outcomes that are generally excellent.20–24 I usu-
ally mark the planned injection sites using a fine marking
pen with the patient seated, particularly when treating
multiple areas (Fig. 1). Although some authors have ad-
vocated injecting into the mounds on either side of the
rhytid, I prefer injecting directly into the line itself. This
is based on the fact that BoTox diffuses up to 1 cm from
the injection site;1,2 the underlying muscle anatomically is
continuous; and it facilitates adjusting the dose and injec-
tion site when treating facial asymmetry. In general,
therefore, I treat the lines, except in areas that are likely to
influence the brow position, in which case I treat sym-
metrically, regardless of any pre-existing asymmetry in
the length or depth of the wrinkle line, to avoid unwanted
asymmetry in the position or shape of the brow.
After marking the injection sites, the patient is re-
clined to a supine position. A cool compress is placed over
the planned treatment areas for 3 to 5 minutes. A separate
ice compress is kept handy to apply directly to each area
for 5 seconds prior to injection. BoTox is prepared by
adding 2 cc nonpreserved sterile saline to each vial (50
U/cc), being careful to avoid denaturing the protein by let-
ting the saline enter forcefully under vacuum pressure.
The desired volume is drawn up in a 1-cc TB syringe with
a 20-gauge needle and injected using a 30-gauge needle.
Alternatively, Flynn et al. have recommended a 0.3-cc in-
sulin syringe (short Ultra-Fine II needle) to minimize
wastage.25 This design is also available in a 1-cc size. In
areas with thick skin (such as the brow, forehead, and pe-
 BoTox: Ironing Out the Wrinkles
FIG. 1. Suggested sites for BoTox injection in the follow-
ing areas: glabella *, crow’s feet and lower eyelid , fore-
head , brow position •, perioral area 
rioral areas), I inject directly into the muscle, as these ar-
eas do not tend to bruise, even when there is bleeding at
the needle puncture site. In areas with thinner skin (such
as the crow’s feet, lower eyelid, under the lateral brow,
and nose), I inject subcutaneously, being careful to avoid
any visible vessels. I warn the patient about the possibil-
ity of a small bruise when I am treating these areas and
recommend stopping aspirin for 7 to 10 days preinjection
in patients who wish to minimize this small risk. Follow-
ing BoTox treatment, I replace the cool compress (or ap-
ply pressure over areas of bleeding) for 2 to 3 minutes. For
frontalis and mentalis injections only, I massage the area
immediately following injection. When injecting above
the lateral canthal tendon, for either high crow’s feet or to
adjust brow position, I keep the patient supine for 15 to 20
minutes to minimize the risk of inducing lid ptosis by
gravity-related inferior tracking of BoTox to the levator
or Muller’s muscle.
Glabella
The glabella is the easiest area to treat and often the most
rewarding. The underlying muscles causing wrinkles in
this area are the procerus and the corrugator supercilii,
which produce horizontal and vertical furrows respec-
Volume 1, Issue 1
tively. These lines tend to be associated with negative
connotations such as anger or worry. Besides their effect
on facial expression, they have no functional purpose. For
this reason they can be treated aggressively with excellent
results (Table 1). The aim in most patients is complete or
almost complete paralysis. The starting dose depends on
the depth of the furrows. These muscles are strong and
generally require between 10 and 40 U BoTox. I recom-
mend using 5 U per injection site into the furrow, spacing
the injections 1 cm apart the length of the furrow. Treat-
ment of glabellar lines that extend laterally over the brow
or inferiorly toward the nose can be complicated by mild
ptosis. Carruthers et al. have reported a 5.4% incidence of
eyelid ptosis complicating treatment of glabellar lines.20
Ptosis is usually mild and generally resolves within 2 to 3
weeks. It can be treated with 0.5% apraclonidine (tid) un-
til spontaneous resolution occurs.26
Crow's Feet
Treating crow’s feet requires more consideration. The un-
derlying muscle causing rhytides in this area is the orbic-
ularis oculi. Not only does this muscle cause crow’s feet,
but more importantly it is responsible for complete eyelid
closure with each blink and when sleeping. Significant
impairment of orbicularis function may cause or worsen
dry eye symptoms and even result in lagophthalmos. In-
jection of crow’s feet above the lateral canthal tendon
(LCT) can be complicated by eyelid ptosis. For crow’s
feet, I start with 1 to 2 U per injection (in four or five sites),
injecting in each major crow’s feet line 1 to 1.5 cm lateral
to the orbital rim. Injecting above the LCT can cause lat-
eral brow elevation. Even minimally asymmetric brows
can be very noticeable. For this reason, injections above
the LCT should be performed symmetrically regardless of
any asymmetry in the number or depth of the crow’s feet
lines. The dose can then be incrementally increased on
subsequent injections until the desired effect is achieved
or until dry eye symptoms obviate higher doses. When dry
eye symptoms develop and are not associated with reflex
tearing, punctal plugs can be inserted to allow further dose
increase if necessary. Although diplopia has been re-
TABLE 1. Glabella
• Usual starting dose 10–25 U (5 U per injection site)
• Look for preexisting Asymmetry
• Treat conservatively Smaller lines (deeper, longer
glabellar lines require more
BoTox)
• Caution Treatment of glabellar lines that
extend below brow, and above
medial brow can cause lid
ptosis
47
 N. Tucker

TABLE 2. Crow's feet TABLE 4. Forehead

• Usual starting dose 5–10 U per side (1–2 U per injection)
• Look for preexisting Dry eye, brow asymmetry
• Treat conservatively Early/minimal dynamic wrinkles, dry
eye patients
• Caution Above LCT: inject symmetrically (to
minimize risk of inducing brow
asymmetry)
Inject subcutaneously to minimize
bruising
ported following lower eyelid BoTox injection, this is
avoided by injecting subcutaneously (Table 2).
• Usual starting dose 5–10 U (0.5–2 U per injection)
• Look for pre-existing Asymmetry in brow position, and
forehead wrinkles
• Treat conservatively Always: aim to soften, not elimi-
nate, especially lower forehead
• Caution Asymmetric result noticeable: min-
imize with multiple injection
sites; massage; small doses
Can induce brow ptosis (especially
when treating lower forehead
lines)
In lower forehead inject symmetri-
cally (to minimize asymmetric
brow ptosis); consider injecting
brow depressors (to offset in-
duced brow ptosis)

Medial Lower Eyelid

Only limited treatment of medial lower eyelid wrinkles is
possible to avoid inducing punctal ectropion and lower
eyelid laxity. If these findings are already present and as-
sociated with secondary epiphora, it is best to avoid in-
jecting the medial eyelid. For medial lower lid lines, I start
with a very conservative dose of 1 U. Younger patients
with good lid tone can usually tolerate a starting dose of 2
U (Table 3).
ment in the lower forehead will result in brow ptosis. I en-
courage patients to accept lower doses in this area to
achieve a more natural result, realizing that it will take
longer to have a visible impact on deeper static wrinkles.
Using this approach, dynamic wrinkles will be noticeably
improved and static wrinkles may continue to improve
over a 1- to 2-year period.

Forehead Brow Position

Treatment of forehead rhytides generally requires more fi- Understanding the influence of facial musculature on the
nesse. Improper technique can result in asymmetric fur- position of the brow is critical to allow fine-tuning of
rowing, which is very noticeable and can give a peculiar brow position and shape. Pre-existing brow asymmetry is
and unnatural appearance. It can also cause a change in very common. The amount of brow elevation that can be
brow position or shape or excessive loss of facial expres- achieved depends on the extent to which the brow eleva-
sion in the forehead area. The key is to carefully assess tors and depressors influence the position of the brow in
the patient for pre-existing asymmetry in brow position, any given patient (Table 5). In general, 1 to 3 mm of brow
depth and length of forehead wrinkle lines, and to start lift can be obtained. Laterally the brow is elevated by a
with small doses in multiple injection sites (Table 4). The rather weak frontalis and depressed by the orbicularis and
amount of BoTox needed is highly variable (5–20 U). I gravity. Medially the brow is elevated by a stronger
usually inject 2 to 2.5 U per site in the middle and upper frontalis and depressed by the orbicularis, procerus, and
forehead and 1 to 2 U per site in the lower forehead. Wrin- corrugator supercilii. Having the patient elevate and lower
kles in the upper forehead can be treated more effectively the brow voluntarily can help delineate the influence of
than wrinkles in the lower forehead, as aggressive treat- these individual muscles on brow position. To elevate the
lateral brow, inject just inferior to the temporal brow in
one or two sites using 2.5 to 5 U per injection. To elevate
the medial brow, inject just above the brow in one or two
TABLE 3. Medial lower lid sites using 2.5 to 5 U per injection. To lower the brow, in-
• Usual starting dose 1–2 U each side ject 1.5 cm above the brow, using 2.5 U in each of one to
• Look for preexisting Lower lid laxity, punctual three injection sites. Using BoTox to elevate the brow can
ectropion (may be associated be complicated by eyelid ptosis. To minimize this risk,
with secondary epiphora) avoid injections in the central brow. Also, I keep patients
• Treatment conservatively When preexisting conditions
are present supine for 15 minutes following BoTox treatment.
• Caution Can cause, or worsen epiphora
Limited effect Perioral
Inject subcutaneously to
minimize bruising Use of BoTox in the perioral area is gaining popularity. It
is important to proceed cautiously in this area. Often the

48 Techniques in Ophthalmology
 BoTox: Ironing Out the Wrinkles
TABLE 5. Brow
• Usual starting dose 2.5–10 U per side (2.5 U–5 per
injection)
• Look for preexisting Asymmetry in brow position. Con-
sider how injections already
done for crow's feet, forehead,
and glabella will influence brow
position
• Treat conservatively When treating unilaterally
• Caution Easier to elevate lateral brow than
medial brow
Avoid center of brow to minimize
risk of lid ptosis
lines descending on either side of the mouth toward the
jaw line (melomental folds) are particularly distressing to
patients. This line is caused by gravity- and age-related
descent of the midface and overaction of the depressor
anguli oris. If rhytides disappear almost completely with
the patient supine, BoTox will likely have very little ef-
fect. In fact, significant improvement in most patients usu-
ally requires a facelift procedure. However, many patients
are very pleased with the subtle to moderate improvement
that can be achieved with BoTox if they are properly in-
formed of the limitations from the outset (Table 6). Avoid
injecting within 1 cm of the lips, as paralysis of the orbic-
ularis oris can result in functional problems related to ex-
cessive loss of lip tone. I start with 2 U placed 1 cm in-
ferolateral to the corner of the mouth. Dimpling of the
chin (peau d’orange) caused by overaction of the mentalis
can be treated with a single injection in the chin (2–4 U)
followed by massage to achieve even spread of BoTox.

SUMMARY
According to the American Society for Aesthetic Plastic
Surgery’s 2001 statistics on cosmetic surgery, BoTox is
the fastest-growing cosmetic treatment performed by sur-
geons in the United States. BoTox cosmetic treatments
have increased 46% since 2000 and were rated number
one among the 8.5 million surgical and nonsurgical cos-
metic procedures performed in 2001. These numbers
speak for themselves in terms of patient satisfaction. Un-
derstanding the interplay between the effect of facial mus-
TABLE 6. Perioral region
• Usual starting dose 2.5 U per side (1–2 U per injection)
• Look for pre-existing Asymmetry
• Treat conservatively Always
• Caution Avoid injecting within 1 cm of
corner of lips (to avoid excessive
weakening of orbicularis oris)
Volume 1, Issue 1
cles on lines, function, and anatomic position is key to
providing patients with the best results. Patients appreci-
ate an honest approach when discussing the advantages
and limitations of BoTox in facial esthetics. For many
younger patients, BoTox alone will provide excellent re-
sults. For older patients, BoTox can help achieve mild to
moderate improvement while allowing the patient to feel
comfortable and gain a better understanding of the vari-
ous options available to improve facial esthetics. The trust
developed in the physician–patient relationship can help
the patient proceed more confidently to other procedures
(e.g., collagen injectables, chemical peels, laser resurfac-
ing, or surgery), which in combination with Botox may
provide the best result.

REFERENCES
1. Gonnering RS. Pharmacology of botulinum toxin. Int Oph-
thalmol Clin 1993;33:203–226.
2. Valtorta F, Arslan G. The pharmacology of botulinum
toxin. Pharmacol Res 1993;27:33–44.
3. Hambleton P. Botulinum toxin: structure and pharmacol-
ogy. Eur Arch Otolaryngol 1994:S200–S202.
4. Klein AW. Treatment of migraine. N Engl J Med 2002;347:
764–766.
5. Rollnik JD, Dengler R. Botulinum toxin (DYSPORT) in
tension-type headaches. Acta Neurochi Suppl 2002;79:
123–126.
6. Pandyan AD, Vuadens P, vanWijck FM, et al. Are we un-
derestimating the clinical efficacy of botulinum toxin (type
A)? Quantifying changes in spasticity, strength and upper
limb function after injections of BoTox to the elbow flexors
in a unilateral stroke population. Clin Rehabil 2002;
16654–660.
7. Parameswaran MS, Soliman AM. Endoscopic botulinum
toxin for cricopharyngeal dysphagia. Ann Otol Rhinol
Laryngol 2002;111:871–874.
8. Tan SR, Solish N. Long-term efficacy and quality of life in
the treatment of focal hyperhydrosis with botulinum toxin
A. Dermatol Surg 2002;28:495–499.
9. Ezzeddine D, Jit R, Katz N, et al. Pyloric injection of botu-
linum toxin for the treatment of diabetic gastroparesis. Gas-
trointest Endosc 2002;55:920–923.
10. Uddin JM, Daviers PD. Treatment of upper eyelid retrac-
tion associated with thyroid eye disease with subconjuncti-
val botulinum toxin injection. Ophthalmology 2002;109:
1183–1187.
11. Yavuzer R, Basterzi Y, Akata F. Botulinum toxin A for the
treatment of crocodile tears. Plast Reconstr Surg 2002;110:
369–370.
12. Ellis MF, Daniell M. An evaluation of the safety and effi-
cacy of botulinum toxin type A (BOTOX) when used to
49
 N. Tucker
produce a protective ptosis. Clin Experiment Ophthalmol
2001;29:394–399.
13. Garcia A, Fulton JE Jr. Cosmetic denervation of the mus-
cles of facial expression with botulinum toxin. A dose-
response study. Dermatol Surg 1996;22:39–43.
14. Benedetto AV. The cosmetic uses of botulinum toxin type
A. Int J Dermatol 1999;38:641–655.
15. Foster JA, Wulc AE, Holck DE. Cosmetic indications for
botulinum A toxin. Sem Ophthalmol 1998;13:142–148.
16. Brashear A, Lew MF, Dykstra DD, et al. Safety and efficacy
of Neurobloc (botulinum toxin type B) in type A-responsive
cervical dystonia. Neurology 1999;53:1439–1446.
17. Zuber M, Sebald M, Bathien N, et al. Botulinum antibodies
in dystonic patients treated with type A botulinum toxin: Fre-
quency and significance. Neurology 1993;43:1715–1718.
18. Rollnik JD, Wohlfarth K, Dengler R, et al. Neutralizing bot-
ulinum toxin type A antibodies: clinical observations in pa-
tients with cervical dystonia. Neurol Clin Neurophysiolo
2001;3:2–4.
19. Dressler D. Clinical features of antibody-induced complete
secondary failure of botulinum toxin therapy. Eur Neurol
2002;1:26–29.
C L I N I C I A N ’ S
BoTox Injection Technique
RICHARD L. ANDERSON, M.D., F.A.C.S.
Medical Director, Center for Facial Appearances,
Salt Lake City, UT.
JEAN CARRUTHERS
Vancouver, British Columbia, Canada.

WHAT IS YOUR CURRENT
INJECTION TECHNIQUE?
Dr. Anderson: I feel that it is important to inject patients
in a sterile area. I inject my patients in a minor room in a
surgery chair at around 30. If patients desire topical or
Address correspondence to Richard L. Anderson, Center for Facial Ap-
pearances, 1002 East South Temple, Suite 308, Salt Lake City, UT
84102; or Jean Carruthers, 943 W. Broadway, #740, Vancouver, British
Columbia, V5Z 4E1 Canada.
Dr. Anderson is a paid consultant for Allergan (manufacturer of BoTox).
Dr. Carruthers is a paid consultant for Allergan (manufacturer of BoTox)
and Elan (manufacturer of Myobloc).
50 Techniques in Ophthalmology
20. Carruthers JA, Lowe NJ, Menter MA, et al. A multicenter,
double blind, randomized, placebo-controlled study of the
efficacy and safety of botulinum toxin type A in the treat-
ment of glabellar lines. J Am Acad Dermatol 2002;46:
840–849.
21. Frankel AS. BoTox for rejuvenation of the periorbital re-
gion. Facial Plast Surg 1999;15:225–226.
22. Alan M. Botulinum A Exotoxin for hyperfunctional facial
lines: Where not to inject. Arch Dermatol 2002;38:
1180–1184.
23. Carruthers A. Botulinum Toxin A: History and current cos-
metic use in the upper face. Dis Mon 2002;48:229–322.
24. Carruthers J, Carruthers A. BOTOX use in the mid and
lower face and neck. Sem Cut Med Surg 2001;20:85–
92.
25. Flynn CF, Carruthers A, Carruthers J. Surgical Pearl: The
use of the Ultra-Fine II short needle 0.3-cc insulin syringe
for botulinum toxin injections. J Am Acad Dermatol 2002;
46:931–933.
26. Matarasso SL. Complications of botulinum A exotoxin
for hyperfunctional lines. Dermatol Surg 1998;24:1249–
1254.
C O R N E R
preinjection cold compresses, I have them come in a half-
hour early (this is rare). I carefully wipe the area to be
treated with alcohol swabs. I suggest the following pearls
for injection: Mark injection sites with a fine-tip marker;
use a 30-gauge 1/2-inch needle; pinch up skin at the in-
jection site; use loupes or reading glasses to detect and
avoid vessels; relax muscles during injection; direct the
needle nearly horizontal through pinched skin (don’t jab);
inject just under the skin in most sites (this helps avoid
pain and hematoma from hitting muscle, blood vessels,
nerves and periosteum. Neurotoxins diffuse into the mus-
cle); hold firm pressure immediately on any hematoma. If
hematoma occurs, suggest avoiding aspirin and so forth
 BoTox: Ironing Out the Wrinkles
immediately prior to the next injection. Chart injections in
a diagram for future reference. I feel that asking patients
to contract muscles injected or not contract or avoid ac-
tivity is unnecessary.
Dr. Carruthers: If patients are taking nonsteroidal, as-
pirin, or anti-inflammatory medications, we do routinely
use preinjection cold compresses as well as topical Beta-
caine anesthetic ointment. We always have our patients
sitting and we use the Becton-Dickinson superfine II 7-
mm 30-gauge needle on a 0.3-cc syringe. Serendipitously,
my husband Alastair discovered that if you dilute the
BoTox 1 cc of preserved saline in the vial, one Botox unit
is the same as 1 diabetic unit. Our injection technique is
to go into the muscle in the brow, to be intradermal in the
horizontal forehead lines and lateral crow’s feet areas if
the skin is rather thin and there is a big plexus of veins that
need to be avoided.
We use frozen peas as our postinjection cold com-
presses, and then we have the patients stay upright for at
least 4 hours after the injection. We make a joke of it and
say, “No shoe shopping!”
In addition, we ask the patients to repeatedly contract
the muscles we have injected for 30 minutes, as this has
been shown to improve the binding and thus to improve
the results. We usually see the patients back in 2 weeks
and then evaluate them and photograph them again and
see if there is any need to enhance their results.

IS THERE ANYTHING ABOUT YOUR
CURRENT TECHNIQUE THAT HAS
EVOLVED OVER THE LAST YEAR?
Dr. Anderson: In the last year I have tried to establish a
more natural, youthful appearance in patients. I still treat
the glabellar region heavily but have in general lessened
the forehead total dose and spread it over more sites to al-
low minimal but even forehead function. I have in general
treated crow’s feet with higher doses. I am injecting nasal
scrunch lines, lips, mentalis scrunch, and melolabial folds
much more frequently. My suggested doses are noted in
Table 1.
TABLE 1. Average Botox Cosmetic Requirements
Forehead 20–30 units in 4–7 sites
Glabella 20–40 units in 5–6 sites
Crow's feet 15–25 units in 6 sites
Nasal scrunch lines 4–8 units in 2 sites
Upper lip 3–5 units in 2 sites
Lower lip 3–5 units in 2 sites
Melolabial fold 4–8 units in 2 sites
Mentalis scrunch 4–10 units in 2 sites
Platysmal bands 20–100 units in multiple sites
Volume 1, Issue 1
Dr. Carruthers: In the last year I have injected more
and more patients in the depressor anguli oris and men-
talis. The mouth frown is a potent negative facial expres-
sion, and I think that this injection, along with the injection
of filler and nonablative resurfacing, really does help re-
store the mouth area in a way that gives no downtime. I like
to be sure that I inject just anterior to the anterior border of
the masseter at the angle of the jaw so that BoTox gets into
the depressor anguli oris by diffusion. If you inject more
anteriorly, in other words right into the muscle, what you
see is diffusion into the depressor labii, and this gives
lower lip elevation, which is an impediment to speech and
also cosmesis. This is photographically documented both
in our upcoming book (ready at the American Academy of
Dermatology March 2003) and also in our video series,
which can be accessed at videos@Carruthers.net.

WHAT DO YOU DO WITH UNUSED
BOTOX AT THE END OF THE DAY?
Dr. Anderson: I have used BoTox on my family and my-
self after several days of refrigeration with little loss of
strength. I usually use the daily unused on staff or family.
Dr. Carruthers: Unused BoTox at the end of the day is
injected into my staff members and into individuals such
as receptionists in other doctors’ offices who send us a lot
of patients. We have kept the vial over the weekend with
the plug in to prevent evaporation, but largely we try to use
it as a promotional event rather then leaving it in the fridge.
We have used it up to 1 month after recomposition and not
found there to be any significant decrease in the potency.

IN WHAT CLINICAL SETTING
ARE YOU CURRENTLY USING
MYOBLOC?
Dr. Anderson: I use Myobloc for touch-ups on BoTox pa-
tients. If one area doesn’t take or wears off before the sur-
roundings, I use Myobloc. Myobloc has advantages in this
situation: No fear of immunization to botulinum A toxin
from short repeat dosing; more rapid onset to smooth out
uneven areas; shorter duration of action so it wears off be-
fore the next BoTox injection; stable in solution so a vial
can be kept in the refrigerator for touch-ups for long time
periods. As a primary treatment, Myobloc has the disad-
vantages of a much shorter duration, more painful injec-
tions, dry mouth, and 50 to 100 times unit dosage re-
quired.
Dr. Carruthers: I use Myobloc when I am looking for
a very fast effect—within 7 to 8 hours after injection the
process starts. Myobloc is a fabulous alternative. I partic-
ularly like it for the extra diffusion it gives in the forehead
and in the crow’s feet areas. In addition I find it very help-
ful in the axilla and palms for hyperhidrosis.
51
 N. Tucker

WHAT OTHER PEARLS
WOULD YOU OFFER FOR
THE OPHTHALMOLOGIST
JUST STARTING TO USE BOTOX?
Dr. Anderson: I feel that ophthalmologists beginning to
use BoTox should start with glabellar folds until they are
comfortable with the injections. Patients note the greatest
response in this area and there are fewer negative effects.
Stronger muscles require more BoTox. In general, males
require more than females and old more than young. Tell
patients that you would prefer not to overtreat at the first
injection, and if they require more you can increase the
dose at the next visit.
Dr. Carruthers: The ophthalmologist starting to use
BoTox should understand global facial anatomy and not
just that of the periorbital region. I think it is a good plan
to go to your local university department of anatomy and
review the anatomy and physiology of the muscles prior
to starting cosmetic injections.

52 Techniques in Ophthalmology