3 common mistakes when injecting Botulinum toxin


3 common mistakes when injecting Botulinum toxin

Medically Reviewed by Mohsen Talani, MD on November 27, 2023 | Written by CBAM Author


Botulinum Toxin-A was first used cosmetically in the mid-1980s, and its popularity has since skyrocketed. In North America, Botox injections are one of the most popular non-surgical procedures. Botox was the most popular cosmetic procedure searched for online in Canada as of January 2021, with a monthly search volume of over 18 thousand.

Neurotoxin treatment outcomes vary significantly due to a lack of standardized training, pharma company-led marketing, and unregulated practice.
Here we will look at three of the most common mistakes made during neurotoxin practice and how to avoid them:

Mistake #1. Ignoring the Middle and Lower Face Areas

Neurotoxins are fantastic for dynamic upper-third lines. However, as your confidence grows, don’t be afraid to try some of the more unusual botulinum toxin applications in the mid and lower face.

In the lower face, the following three muscles are the most useful to target:

– Depressor Angulae Oris
This muscle is partially responsible for lowering the corners of the mouth at rest.
Effective treatment can be obtained with 2-3 units per side at subcutaneous and moderate muscle levels. Try to avoid deeper, more medial lower lip depressors.

– Levator labii superioris alaeque nasi and nasal tip droop
The elevator labii superiors alaeque nasi originates from the frontal process of the maxilla and inserts into the skin of the nasal ala and the superior aspect of the lip. This muscle is responsible for elevating the superior lip and the nasal ala.
It also works in conjunction with the depressor septum muscle to open the nostrils.
Gummy smiles can be effectively treated with botulinum toxin. 1 unit right at the apex of the nasolabial fold, in the subcutaneous plane, will often be all that is required. This treatment often requires an adjustment dose.
Nasal tip ptosis:
The muscles around the nose are complex and can be divided into lifters, depressors, dilators, and constrictors.
The Levator labii superioris alaeque nasi belongs to the elevator category. The hint is in the name! In fact, the Latin translation is “elevator of the upper lip accompanying the nose.” Injection of 3 units into each LLSAN muscle and 5 units into the depressor muscle of the nasal cavity prevents nose tip drooping, especially when the patient is smiling.

– Masseter

Most muscles treated with botulinum toxin are facial expression muscles, whereas the masseter muscle is the muscle of mastication.
It is a thick rectangular muscle with superficial and deep components, which originate from the zygomatic arch. The superficial part inserts onto the masseteric tuberosity at the outer surface of the mandibular angle. The deep part runs further dorsally onto the outer part of the mandibular ramus.
This muscle can become hypertrophied and cause a square-shaped appearance. It is usually asymptomatic but can lead to temporomandibular joint dysfunction and bruxism (teeth grinding). Neurotoxins can cause muscle atrophy, reducing visibility and narrowing the jawline.

Mistake #2. Over-treating the Frontalis Area

The frontalis is the most difficult area of the face to treat with neurotoxins. It is the only levator muscle on the forehead and requires precise treatment for natural results. There are a few things to keep in mind when treating the frontalis:

– The dose should be adjusted according to the size of the forehead and dynamic lines. For example, a patient with a long forehead may need two injections to properly cover the area. Low doses are also recommended for patients with small and short foreheads, especially in the initial treatment.
– Men usually will require a higher dose of toxins when compared to women.
– If the three depressor muscles (orbicularis oculi, corrugator, and procure) are not treated at the same time, the brows can look heavy or droop.
– Patients with increased upper eyelid skin sagging and drooping eyelids should be treated with caution. The injection should be placed high (at least 3 cm above the orbital rim). And in cases where the frontalis muscle is over-compensating for the increased skin laxity and is required in the opening of the eyes, treatments in the frontalis muscle with toxins should be avoided.
Additionally, when treating the tail of the corrugator muscle, ensure the injection is placed superficially. The muscle inserts into the skin laterally, and superficial placement will avoid inadvertent treatment of the frontalis.

Mistake #3. Believing the myths

Many aftercare instructions are highly anecdotal and speculative. For example, there is no evidence that lifting your head for 6 hours after treatment reduces the likelihood of adverse events. This advice may reflect concerns that ptosis can be an adverse event, however, there is no evidence that changing to a horizontal position or lowering the head influences lid ptosis or diffusion. Indeed, most of the toxins are present in synaptic vesicles within 5-10 minutes after binding. There is no change in the effect of whether or not the injection site is massaged after the treatment.

One study to show that muscle activity in patients may be beneficial after aesthetic treatments is by Wei et al., who showed significantly higher masseter muscle atrophy in patients who exercised their masseters for 2 hours a day after treatment. (so recommending chewing gum after a masseter toxin would be sound clinical advice – although this evidence is very preliminary).
In summary, the below common pieces of aftercare advice have no evidence:
“don’t rub the area after treatment”
“avoid applying make-up after treatment”
“do not lie flat after treatment”
“avoid air travel after treatment”