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Consensus Recommendations on the Use ofBotulinum Toxin Type A in Facial AestheticsJean Carruthers, M.D., Steven Fagien, M.D., Seth L. Matarasso, M.D., and the Botox Consensus GroupVancouver, Canada; Boca Raton, Fla.; and San Francisco, Calif.

The use of botulinum toxin type A for facial en-hancement is the most common cosmetic procedurecurrently undertaken in the United States. Overall clin-ical and study experience with botulinum toxin type Atreatment for facial enhancement has confirmed that itis effective and safe in both the short and long term.Nevertheless, consistent guidelines representing theconsensus of experts for aesthetic treatments of areasother than glabellar lines have not been published.Therefore, a panel of experts on the aesthetic uses ofBotox Cosmetic (botulinum toxin type A; Allergan,Inc., Irvine, Calif.) was convened to develop consensusguidelines. This publication comprises the recommen-dations of this panel and provides guidelines on generalissues, such as the importance of the aesthetic evalua-tion and individualization of treatment, reconstitutionand handling of the botulinum toxin type A, proceduralconsiderations, dosing and injection-site variables, andpatient selection and counseling. In addition, specificconsiderations and recommendations are provided bytreatment area, including glabellar lines, horizontalforehead lines, “crow’s feet,” “bunny lines” (downwardradiating lines on the sides of nose), the perioral area,the dimpled chin, and platysmal bands. The review ofeach area encompasses the relevant anatomy, specificson injection locations and techniques, starting doses(total and per injection point), the influence of othervariables, such as gender, and assessment and retreat-ment issues. Factors unique to each area are presented,and the discussion of each treatment area concludeswith a review of key elements that can increase the like-lihood of a successful outcome. Summary tables are pro-vided throughout. (Plast. Reconstr. Surg. 114 (Suppl.): 1S,2004.)

OVERVIEW AND GENERAL PRINCIPLES

The aesthetic use of botulinum toxin type Ais governed by general principles as well asspecific considerations for each treatmentarea. This supplement will review the generalprinciples of botulinum toxin type A use inaesthetics and then provide specific guidelinesfor each potential treatment area. These sec-tions will include information on the targetmuscles, the injection sites, total starting dosesby gender and amount per injection site, re-sponse assessment, and potential retreatmentintervals. Techniques and guidance to mini-mize side effects and maximize efficacy will beprovided. Finally, special considerations foreach area will be addressed.

Reconstitution and Handling

Clostridium botulinum toxin type A (Botox;Allergan, Inc., Irvine, Calif.) is supplied in avial containing 100 U of vacuum-dried neuro-toxin complex. According to the prescribinginformation, powder in each vial should bereconstituted with 2.5 ml of 0.9% nonpre-served saline to a final concentration of 4.0U/0.1 ml.1 A literature review noted that mostclinicians use a dilution of 2.5 to 3.0 ml pervial.2 The members of the consensus panelagreed that a range of dilutions and injection

From the Department of Ophthalmology, University of British Columbia; private practice; and the Department of Dermatology, Universityof California School of Medicine, San Francisco. Received for publication July 19, 2004; revised August 20, 2004.

Drs. Carruthers, Fagien, and Matarasso are executive editors of this supplement.This statement is sponsored by an unrestricted educational grant from Allergan, Inc., Irvine, Calif.The members of the Botox Consensus Group are listed in the Appendix at the end of this article.Off-Label Statement: It should be noted that the results reported in this article refer to the Allergan formulation of botulinum toxin type A (Botox,

Botox Cosmetic, Vistabel) and cannot be generalized to other formulations or serotypes of botulinum toxin. Botulinum toxin type A is indicatedfor the temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activityin adult patients less than or equal to 65 years of age. All other uses are considered off-label. The full prescribing information should be viewedprior to using any products discussed here.

DOI: 10.1097/01.PRS.0000144795.76040.D3

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volumes is acceptable and depends primarilyon the number of units to be injected and thepreference of the practitioner. Currently, nodata from well-controlled studies support theidea that volume of injection contributes sig-nificantly to diffusion. In a dose-dilution studyin which a total dose of 30 U was reconstitutedin 1, 3, 5, or 10 ml, no between-group differ-ences in efficacy or safety were observed intreating glabellar rhytids.3 The effects of dilu-tion at higher volumes and in other regionsremain to be investigated systematically. Anec-dotal and published reports suggest that vol-ume may influence duration of effect: thegreater the volume, the shorter the duration ofeffect.4 In general, physicians should choose adilution that minimizes the likelihood of diffu-sion to neighboring muscle groups.

The full prescribing information also statesthat botulinum toxin type A should be usedwithin 4 hours of reconstitution.1 Clinical ex-perience and recently published data, how-ever, suggest that potency can be maintainedfor up to 6 weeks with proper storage. Forexample, the results of a multicenter, double-blind study demonstrated that reconstitutionwith nonpreserved saline up to 6 weeks beforeuse did not diminish efficacy in the treatmentof glabellar frown lines.5 Reconstituted vialswere stored at 4°C. It has also been reportedthat botulinum toxin type A reconstituted 30days before use did not decrease in efficacy.6Other studies and reports have also noted re-tention of potency over varying durations, asreviewed by Hexsel et al.5 A survey of the con-sensus panel members revealed that 73 percentstore botulinum toxin type A for more than 4hours. The other members do so occasionally.

The consensus panel members agreed thatpreserved saline can be used to dilute botuli-num toxin type A. The results of a bilateral,comparative, prospective study showed that100 percent of patients (n � 15) reported lesspain with preserved isotonic saline than withnonpreserved isotonic saline (p � 0.001).7 Inan additional analysis, patients who receivedbotulinum toxin type A in preserved salinewere asked to compare the pain relative toprevious injections with nonpreserved saline.Of 20 patients, 90 percent reported less painwith the preserved saline preparation. Oncereconstituted, botulinum toxin type A shouldbe clear, colorless, and free of particulate mat-ter, regardless of the diluent.1

Concerns about loss of botulinum toxin typeA potency at the air/solution interface have ledto recommendations to avoid agitation andfoam during reconstitution.1,8,9 To examinethis issue, Trindade de Almeida and col-leagues8 reconstituted two vials of botulinumtoxin type A simultaneously, vigorously agitat-ing only one vial until bubbles appeared. Sixfemale patients received injections in the gla-bellar and periocular areas bilaterally. Theright side was treated with the gently reconsti-tuted botulinum toxin type A and the left sidewas treated with the agitated solution. Blindedobservers compared pretreatment and post-treatment photographs. No differences in mus-cle relaxation between the two treatment sideswere detected (p � 0.0013). Effects were main-tained through 16 weeks on both treatmentsides (p � 0.0025). This report supports theclinical experience of the consensus panelmembers that suggests the fragility of botuli-num toxin type A is not as problematic aspreviously reported. The results, however,need to be confirmed in larger studies and inmouse lethality assays.

Recommendations for reconstitution andhandling are summarized in Table I.1 Pleasealso refer to the approved package insert be-fore using Botox Cosmetic.

Procedural Considerations: Type of Syringe and PainManagement

Prescribing information for botulinum toxintype A (Botox)1 suggests a tuberculin syringe,which was preferred by 44 percent of consen-sus panel members. Insulin syringes were used

TABLE IRecommendations for Reconstitution and Handling*

Parameter Recommendation

Diluent ● Preserved 0.9 percent saline(preferred)

● Nonpreserved 0.9 percent saline*Concentration ● 4 U/0.1 ml* or any convenient

concentration to deliver requiredunits per injection site

StorageBefore reconstitution ● 2°C to 8°C for up to 24 months*After reconstitution ● 4 hours at 2°C to 8°C

● Up to 6 weeks at 4°C†Handling ● Special precautions not required

* Please refer to the approved package insert before using Botox Cosmetic.Allergan. Botox Cosmetic (botulinum toxin type A) purified neurotoxincomplex (Package Insert). Irvine, Calif.: Allergan, Inc.

† From Hexsel, D. M., de Almeida, A. T., Rutowitsch, M., et al. Multi-center, double-blind study of the efficacy of injections with botulinum toxin typeA reconstituted up to six consecutive weeks before application. Dermatol. Surg.29: 523, 2003.

2S PLASTIC AND RECONSTRUCTIVE SURGERY, November Supplement 2004

by 32 percent of consensus panel members,and another 12 percent reported using bothtypes of syringes. Plastic, single-use syringes arerecommended; the insulin syringe, with no po-tential space at the hub, may waste less solu-tion. A 30-gauge needle is standard, but severalpanel members have reported on their experi-ences of reduced pain with the use of a 32-gauge needle. The choice of syringe dependsprimarily on practitioner preference.

Topical anesthesia can be beneficial in help-ing to reduce any discomfort associated withthe injections. Botulinum toxin type A pre-scribing information does not provide recom-mendations on the use of topical anesthesia,but the use of such agents may provide a morecomfortable, positive experience for some pa-tients. A total of 65 percent of the consensuspanel members agreed that the use of a topicalanesthetic, including ice, could be beneficialfor some patients.

Dosing and Injection-Site Considerations

For any facial area treated with botulinumtoxin type A, a number of variables, includingspecific aesthetic goals, influence the startingand total doses, as well as the placement andnumber of injections (Table II). Here again,the distinction between wrinkle effacementand facial shaping is critical. Patient evaluationwithin the framework of facial enhancementwill lead to a treatment plan that incorporatesthe creation of harmony and balance ratherthan wrinkle removal in isolation.10

Understanding the variables that contributeto the patient’s appearance will aid in the de-velopment of an individualized treatment plandesigned to achieve the patient’s and physi-cian’s agreed-upon aesthetic goals. Foremost, a

thorough understanding of the underlying fa-cial musculature and the physiologic interac-tions of the muscles is critical to success. Thenumber of units to be injected depends on thespecific region and the characteristics of theinvolved muscles, including their masses. Inturn, muscle mass is influenced by gender andindividual variation. Generally, the muscles ofmen are greater in mass and require higherdoses of botulinum toxin type A. The requireddose and the sites to be injected are also basedon an assessment of how the muscles behave inrepose, in normal animation, and during max-imal contraction. Skin thickness and texturemay also contribute to dosing decisions. Al-though injections are generally intramuscular,the thickness of the dermis may influence theinjection technique. For example, the skin ofAsians tends to be thicker and have more col-lagen fiber than the skin of Caucasians.11 Ingeneral, thicker skin requires a higher dose ofbotulinum toxin type A than thinner skin doesfor an equivalent outcome.11 The amount willdepend on muscle bulk. With the exception ofthe periocular and perioral areas (in whichinjections should be superficial), intramuscu-lar injections should be made perpendicular tothe skin and directed to the belly of the mus-cle. Where skin is thin, injections should bemade superficially in the subcutaneous plane.

Aesthetic Considerations

Aesthetic planning involves understandingand assessing the patient’s desires and prefer-ences in the context of an overall treatmentplan. The evolving emphasis on facial shapingand enhancement argues against treating anyone area in isolation, without regard to its ef-fect on other areas. Correspondingly, the mus-cles of facial expression do not act in isolationbut have complex anatomic and physiologicinteractions. For example, treatment of glabel-lar lines, “crow’s feet,” or forehead lines canalter eyebrow shape and position, which areconsidered central to aesthetic evaluations ofthe upper face. Therefore, potential effects oneyebrow shape and position should be consid-ered in advance of any and all treatments inthe upper face. Gender differences are impor-tant for eyebrow shape: typically, women have amore arched eyebrow, which is considered tobe aesthetically pleasing; the male brow is flat-ter. Just as the eyebrows are central to theappearance of the upper face, the lips are fun-damental to the appearance of the mid- and

TABLE IIVariables Influencing Treatment Plan

Variable Effect

Aesthetic goals Development of overall treatmentplan

Region(s) to be injected Dose, injection sites, retreatmentinterval

Gender Usually higher doses for men;aesthetic goals

Muscle mass Higher doses for larger musclesEthnicity Aesthetic ideals, skin thickness,

functional anatomySkin thickness Higher doses may be needed for

thicker skinAnatomic variation Injection sites and dosingAnimation Illustrates functional anatomy;

injection sites

Vol. 114, No. 6 Supplement / BOTULINUM TOXIN AND FACIAL AESTHETICS 3S

lower face. Thus, treatment of the perioral areaor dimpled chin needs to consider the shapeand position of the mouth and the type ofsmile.

Patient Selection, Education, and Counseling

The quality of the botulinum toxin type Atreatment experience depends to a certain ex-tent on proper patient selection and educa-tion. Patients who present with severe, deepwrinkles may have unrealistic expectations asto the outcome of botulinum toxin type Atreatment. Clinicians can help avert dissatisfac-tion by setting overall aesthetic goals with pa-tients, developing an overall treatment plan,and establishing realistic expectations for theoutcome. Photographing the patient beforetreatment and at follow-up is also useful indocumenting the effect and in planning anytouch-ups or retreatments.

An accurate medical history can uncover po-tential problem areas and functional effects.The physical examination presents an oppor-tunity to watch the patient in a dynamic settingand to observe how the potential areas of treat-ment behave as well as to reveal any contrain-dications to treatment.

Although adverse events with botulinumtoxin type A treatment are rare,1,12 a few pre-procedural and postprocedural instructionsand precautions, as well as technical nuances,can increase the probability of a successful out-come. For example, the potential for bruisingcan be reduced by advising patients to avoidmedications that inhibit clotting, such as vita-min E, aspirin, aspirin-containing products,and nonsteroidal anti-inflammatory drugs, fora period of 10 to 14 days before treatment.Even though specific posttreatment instruc-tions differ by treatment area, several universalrecommendations were made by consensuspanel members (Table III). In addition, theuse of loupe magnification by the injectormakes it easier to detect areas in which veinand venous plexi are evident through the thinperiorbital skin, thereby avoiding bleeding andbruising to this region.

Patients need to receive information aboutpotential adverse effects of botulinum toxintype A, but they should be made aware of thelong history of safe use, the low probability ofany of these effects occurring, and the fact thatmost adverse effects are mild and transient.1,12

The results of a recent retrospective study con-firmed the long-term safety of botulinum toxin

type A in all facial areas.13 Fifty subjects re-ceived a total of 853 injection sessions. Tenadverse events occurred in total, but only fiveevents were considered to be definitely orprobably related to the use of botulinum toxintype A. These events were bilateral eyebrowptosis (n � 2), right brow ptosis (n � 1), righteyelid ptosis (n � 1), and dysphagia (n � 1).Other adverse events, pain at injection site, andbruising were associated with the injectiontechnique but not with the toxin itself. Thelikelihood of ptosis can be minimized by care-ful selection of injection sites in the eye area.

In double-blind, controlled clinical trials forthe use of botulinum toxin type A in the treat-ment of glabellar lines, the overall rate of ad-verse events was similar in placebo-treated(41.5 percent) and botulinum toxin typeA–treated patients (43.7 percent). Headacheoccurred in 17.7 percent of placebo-treatedpatients and in 13.3 percent of botulinumtoxin type A–treated patients, suggesting thatthis adverse event may be caused by the injec-tion and technique rather than the toxin.1

TABLE IIIGeneral Posttreatment Instructions for Patients

InstructionConsensus

(% of panel) Remarks

1. Massagetreatment area?

Patients should never massagethe treatment area. Some

a. Yes 0 regions benefit by gentleb. No 100 massage by the physician,

performed at the time ofinjection. The direction ofthe massage is important; seespecific areas

2. Contract treatedmuscles?

Patients should be advised tocontract the injected area for

a. Yes 78 approximately 90 minutes tob. No 22 2 hours, which may expedite

uptake of the toxin3. Limit activity? Limiting activity may reduce

a. Yes 30 unwanted diffusion, butb. No 70 agreement has not been

reached on this nor havecontrolled studies beenconducted

4. Avoid bending? This may also reduce unwanteda. Yes 29 diffusion, but the sameb. No 71 limitations apply as above

5. Avoid exposureto heat for 2hours aftertreatment?a. Yes 20b. No 80

6. Avoid flying for2 hours?a. Yes 13b. No 88


Botulinum toxin type A is contraindicated inthe presence of infection at the proposed in-jection site(s) and in individuals with knownhypersensitivity to any ingredient in the formu-lation, including albumin.1 Caution in the useof botulinum toxin type A is recommended inseveral circumstances, including but not lim-ited to the following1,14:

• Treatment of patients with peripheral motorneuropathic diseases or neuromuscularfunctional disorders; for example, patientswith myasthenia gravis or Eaton-Lambertsyndrome may be at increased risk of clini-cally significant systemic side effects.

• Coadministration with aminoglycoside an-tibiotics or other agents that interfere withneuromuscular transmission, which maypotentiate the effect of botulinum toxintype A.

• Treatment of patients with inflammatoryskin conditions at the injection site.

• Pregnancy (pregnancy category C), al-though inadvertent use has not resulted inany reported teratogenicity or pregnancyproblems.

• Lactation, because it is not known whetherthe toxin is excreted in human milk or hasany effect on the infant’s nervous system.

Physicians must consider the suitability ofbotulinum toxin type A treatment for eachpatient based on the complete evaluation. Thepatient’s comfort level with the procedure andexpectations are important variables.14

THE GLABELLAR COMPLEX AND VERTICAL

FROWN LINES

The musculature of the glabellar complex, re-sponsible for vertical frown lines, is the mostcommon site for botulinum toxin type A injec-tion, and published experience is extensive.11,15–36

Anatomy

The primary muscles of the glabellar com-plex are the corrugator supercilii, the pro-

FIG. 1. The muscles of the glabellar complex. Reprintedwith permission from Sommer, B., and Sattler, G. BotulinumToxin in Aesthetic Medicine. Berlin: Blackwell Wissenschafts-Verlag, 2001.

TABLE IVMuscles of the Glabellar Complex*

Muscle Location Origin/Insertion/Orientation Primary Function

Corrugator Bilateral, deep to frontalismuscle; superficial toperiosteum, directly onfrontal bone of the uppermedial orbits

Frontal bone medial to eyebrows;inserts into underside of galea,just above medial head ofeyebrow; runs approximately30 degrees above horizontal

Brow adductors (depressors);moves the eyebrowdownward and medial

Procerus Vertical midline; flat muscleon bridge of nose

Lower part of nasal bone andupper lateral nasal cartilage;insets on skin overlying nasalroot; interdigitates with frontalis,corrugators, and orbicularisoculi; vertically oriented

Brow depressor; depressesmedial head of theeyebrows; results intransverse lines on nasaldorsum

Orbicularis oculi (medial);sometimes considered tobe separate and called thedepressor supercilii

Bilateral, thin muscle, lyingsuperficial to thecorrugators

Superior upper dorsum; inserts onunderside of galea, near themedial aspect of the corrugator;vertically oriented

Brow depressors

* From Wieder, J. M., and Moy, R. L. Understanding botulinum toxin: Surgical anatomy of the frown, forehead, and periocular region. Dermatol. Surg. 24: 1172,1998; and Kaminer, M. S., and Hruza, G. J. Botulinum A exotoxin injections for photoaging and hyperhidrosis. In M. S. Kaminer, J. S. Dover, and K. A. Arndt (Eds.),Atlas of Cosmetic Surgery, 1st Ed. Philadelphia: Saunders, 2002. Pp. 292–309.


cerus, and the depressor supercilii (Fig. 1).37

In addition, the medial fibers of the orbicu-laris oculi and the frontalis can contribute, asfibers from these muscles may interdigitatewith those of the corrugator. The main func-tions of these muscles are summarized inTable IV.38,39 The treatment plan needs totake into account the interdigitation of mus-cle fibers and the degree to which their ac-tivities are in opposition to anticipate theeffect of botulinum toxin type A injection.For example, treatment of the depressor su-percilii fibers will allow a slight elevation ofthe medial brow because the majority offrontalis activity will be unopposed.38

Injection Technique

Prescribing information for botulinum toxintype A recommends five injection sites. Whenindicated by muscular anatomy, however, twoadditional bilateral points above the superiororbital rim may be injected. Members of theconsensus panel noted that the exact numberof injection points depends on individual pa-tient variables, as discussed. Gender is particu-larly important, as men have larger musclemasses on average. The shape of the male browtends to the horizontal, whereas the femalebrow is characterized by a gentle arch. Mostmembers of the consensus panel recom-mended the injection of five to seven points,with men undergoing a greater number of in-jections than women (Table V).38,39 In individ-ual cases, as few as three sites or as many as 10to 12 sites may be treated. Asian skin, for ex-ample, may require more conservative treat-ment, and three starting points may be suffi-cient. Typical injection sites for “average” menand women are depicted in Figure 2.

Total Starting Doses

The recommended total treatment doseaccording to the Botox Cosmetic prescribing

information is 20 U.1 A review of the litera-ture revealed that total starting doses rangedfrom 10 to 80 U, with a median total dose ofapproximately 20 U.11,15,16,18 –29,31–33,35

Gender. The majority of studies have beenconducted in women, who require a lower start-ing dose than men. A recent dose-ranging studyin female subjects confirmed that 10 U was lesseffective than 20 U, 30 U, or 40 U injected inseven points in the glabellar complex.21 Amongmembers of the consensus panel, 96 percentbegan treating women with either 20 or 30 U ofbotulinum toxin type A, evenly divided betweenthe two doses.

In men, a dose-ranging study evaluated totaldoses of 20, 40, 60, or 80 U administered in theglabellar complex.23 As expected, on the basisof clinical experience and gender differencesin anatomy, the 20-U dose was significantly lesseffective than the other doses. Many consensuspanel members begin treatment with 30 U (50percent) in women and 40 U (38 percent) inmen. Thirty percent of the panel members

FIG. 2. Injection sites for the glabellar complex in women(above) and men (below). There are five injection points forwomen and seven for men. This is a general starting point;additional (or fewer) injections may be given depending onthe patient. Only one central injection is indicated in thisfigure, but to more densely affect the procerus muscle, severalinjections above and below this central injection might beadministered that would be influenced by the desired effect(result). Additional injections could be given just peripher-ally and slightly below this central injection point that wouldaffect the medial aspect of the orbicularis muscle and thedepressor supercilii for the desired effect. Courtesy of StevenFagien, M.D. Please note: avoid injecting too low over theorbit; in general, to be ultimately safe, injecting should bedirected “outside” the orbital rim.

TABLE VRecommendations for Treating Glabellar Lines

Target Muscles

Usual No. ofInjection Points

(range)

TotalStarting Dose*(usual range)

Corrugator, procerus,depressor supercilii,orbicularis oculi,frontalis

5 to 7; men mayrequire moresites

Women: 20 to 30 UMen: 30 to 40 U

* Higher starting doses may be used depending on individual patient vari-ables.


frequently started with higher doses in men(45 to 120 U).

Other variables. In treating Asian women, amore conservative approach may be warrantedbecause of their epicanthal folds and the effectson their ability to apply makeup. In these cir-cumstances, consensus panel members recom-mended starting with a 10-U total dose andreevaluating in 2 weeks. Thicker, sebaceous skinotherwise generally requires somewhat higherdoses of botulinum toxin type A.

Units per injection point. The total dose is di-vided among the total number of injectionpoints, but not necessarily equally. For exam-ple, when injecting seven sites, Carruthers andpanel members used the following distribution:procerus, 20 percent; each corrugator, 15 per-cent; and the orbicularis oculi, 50 percent, with15 percent at each of two sites above the medialcanthus and 10 percent at each of two sitesabove the midpupillary line. Final dosing anddistribution depend on individual assessmentof muscle function and aesthetic goals. Mem-bers of the consensus panel injected a range ofaliquots from 1 U to 10 U.

Assessment and Retreatment

In assessing response to a starting treatment,consensus panel members recommended see-ing patients at 14 days after treatment, but onlyif there is a problem or if response is inade-quate. At that time, adjustments in dosing ortouch-ups can be made based on patient pre-sentation. When an interim assessment is notdeemed necessary, the typical interval for re-treatment is 3 to 4 months. The duration ofeffect may depend on the total unit dose ad-ministered, which is supported by some pub-lished data for both men and women.21,23 Re-treatment, in some cases, may not take placebefore 5 to 6 months have elapsed.

Special Considerations for Treating the GlabellarComplex

Botulinum toxin type A is being used withincreasing frequency in combination withother procedures and materials, such as resur-facing and surgery, and in conjunction withfillers. Some experts believe that botulinumtoxin type A treatment 1 to 2 weeks before laserresurfacing and other procedures can providebetter overall outcomes. At times, however, thismay be impractical because of the need forfrequent visits. Moreover, some physicians be-lieve the duration of results may be reduced.

Botulinum toxin type A treatment can takeplace either before or after a face lift, but atleast 2 to 4 weeks should intervene after facialsurgery. Botulinum toxin type A treatment andfillers should be considered complementarytools in achieving overall aesthetic goals. It isimportant to understand that botulinum toxintype A treatment may have an effect on facialfeatures other than those treated directly (i.e.,eyebrow position). Such effects need to be con-sidered in advance of treatment, to achieve anoptimal and satisfactory result (Table V).

Key Elements

1. Assess facial expression at rest and duringanimation.

2. Evaluate the range of motion of involvedmuscles.

3. Palpate muscles during repose andcontraction.

4. Assess brow position. In women, be sure toconsider whether the brows have beenplucked or tattooed.

5. Evaluate any asymmetries and assess poten-tial effects of botulinum toxin type Ainjection.

6. Avoid injecting too low over the orbit; ingeneral, to be ultimately safe, injectionsshould be directed “outside” the orbital rim.

7. Use caution with lateral brow injections; staywell above the superior orbital rim.

8. It is not necessary to insert the needle toperiosteum and “back off” to administer ef-fective treatment to the central brow depres-sors; however, the desired effect on browposition will dictate the plane of injection.

9. Exercise caution in patients who have under-gone surgery that can alter the underlyinganatomy.

10. Recognize the variables that affect requireddosage in individuals.

11. Begin with the recommended starting dosesand add more units or additional sites ifnecessary at a 2-week evaluation.

12. Do not completely paralyze the muscles.13. Consider patient expectations as well as cul-

tural viewpoints in planning the overalleffect.

14. Assess the need for treatment with other mo-dalities, such as soft-tissue augmentation orsurgical intervention.

HORIZONTAL FOREHEAD LINES

The frontalis muscle of the forehead elevatesthe brow and is associated with the develop-


ment of horizontal forehead rhytids. The goalin treating the forehead is to maintain somemovement of the frontalis muscle and avoidcomplete paralysis. Although the effects of bot-ulinum toxin type A for treating horizontalrhytids are less well studied than those forfrown lines, the results consistently indicatethat botulinum toxin type A is safe and effec-tive for this use.11,18,27,31,34–36,40–45 Many mem-bers of the consensus panel noted, however,that the frontalis muscle presents significantchallenges for the more inexperienced user forseveral reasons41: (1) interindividual variabilityin frontalis structural anatomy; (2) interindi-vidual variability in frontalis functional (habit/expression) anatomy; (3) difficulty in treatingin isolation because of the potential for eye-brow ptosis on the one hand and failure toefface lines on the other; and (4) the potential

for overtreating and producing an inanimateappearance.

Anatomy

The frontalis, a large, vertically orientedmuscle, is illustrated in Figure 337 and dis-cussed in Table VI.38,39 Members of the consen-sus panel noted that clinical experience sug-gests considerable interindividual variation inthe structural features of the frontalis. Al-though usually depicted as two somewhat fan-shaped bands, the midline fibers overlap sub-stantially in some individuals.39 In addition, themedial fibers of the frontalis may be morefibrous than the lateral fibers.38 Foreheadshape also differs between individuals in bothvertical and horizontal directions. In addition,some individuals have numerous fine foreheadlines, whereas others have a single deep hori-zontal furrow. Moreover, individuals will alsodemonstrate a spectrum of variations in habit-ual facial expression, causing furrows and in-fluencing eyebrow shape. The totality of theseanatomic features and their variations play animportant role in determining the treatmentplan for horizontal forehead rhytids.

Injection Technique

The number of injection points varies basedon the aesthetic goals and the individual pa-tient characteristics. Figure 4 illustrates the po-tential injection points based on possible pre-sentations of horizontal forehead lines andanatomic variation in forehead shape and eye-brow position.

Among members of the consensus panel, thenumber of injection points ranged from two to12. The most frequent number of injectionpoints cited by the panel members was a range offour to six (Table VII). Regardless of the numberof injection sites, it is important that all injectionsremain 1 to 2 cm above the orbital rim to reducethe potential for brow ptosis in selected individ-

FIG. 3. The frontalis muscle. Reprinted with permissionfrom Sommer, B., and Sattler, G. Botulinum Toxin in AestheticMedicine. Berlin: Blackwell Wissenschafts-Verlag, 2001.

TABLE VIThe Frontalis Muscle*

Muscle Location Origin/Insertion/Orientation Primary Function

Frontalis, but muscleinteracts withprocerus, corrugators,and orbicularis oculi

Forehead, superior toeyebrows and inferiorto scalp

Galea aponeurotica, variably near the coronalsuture/inserts on the supraciliary ridge ofthe frontal bone; also inserts onto fibers ofthe procerus, corrugator, and orbicularisoculi muscles; vertically oriented

Brow elevation

* From Wieder, J. M., and Moy, R. L. Understanding botulinum toxin: Surgical anatomy of the frown, forehead, and periocular region. Dermatol. Surg. 24: 1172,1998; and Kaminer, M. S., and Hruza, G. J. Botulinum A exotoxin injections for photoaging and hyperhidrosis. In M. S. Kaminer, J. S. Dover, and K. A. Arndt (Eds.),Atlas of Cosmetic Surgery, 1st Ed. Philadelphia: Saunders, 2002. Pp. 292–309.


uals who wish to maintain or elevate brow posi-tion. The upper two thirds of the forehead wasalso suggested as a landmark. Again, for women,

care should be taken to assess the natural posi-tion of the eyebrows and whether they areplucked or tattooed. Panel members suggestedthat injections should avoid the first horizontalline above the brows. In addition, a filler maybe needed to soften the inferior lines, wherebotulinum toxin type A injections should beavoided.

Some of the consensus panel members sug-gested that forehead lines not be treateduntil 2 weeks after treatment of verticalfrown lines, to achieve aesthetic harmony inthe upper face. However, a careful dynamicaesthetic and functional evaluation of the

FIG. 4. Possible injection sites for horizontal forehead rhytids in men (above)and women (below). (Left) Brows raised before injection; (right) brows in attemptto raise after injection. Note that male patients who desire complete eradicationof forehead rhytids will accept the inevitable induction of significant brow ptosis(that may be unacceptable for most female patients) in exchange for maximumreduction of rhytids. A reduced induction of brow ptosis may be achieved withcoincident injection to the corrugators as shown. Photographs of male patientreprinted from Fagien, S. Botulinum toxin type A for facial aesthetic enhance-ment: Role in facial shaping. Plast. Reconstr. Surg. 112 (Suppl.): 6S, 2003; pho-tographs of female patient courtesy of Rod Rohrich, M.D.

TABLE VIIRecommendations for Treating Horizontal Forehead Lines

Target Muscles

Usual No.of Injection

Points (range)

TotalStarting Dose(usual range)

Frontalis, but considerinteractions withprocerus, corrugators,and orbicularis oculi inoverall facial shape

4 to 8; more or fewermay be requiredbased on anatomicand aestheticevaluations

Women: 15 U;10 to 20 U

Men: 20 to 30 U


forehead, in most cases, would allow for si-multaneous treatment.


For women, 94 percent of consensus panelmembers recommended a total starting dose of10 to 20 U, with 61 percent recommending thelower dose. For men, 32 percent of the panelrecommended starting with 20 U, and 46 per-cent recommended starting with 30 U. Thecalculated typical starting dose was 15 U forwomen and 20 U for men. Gender differencesin muscle mass allow a higher starting dose inmen. Also, men accept and prefer a flatter, lessarched brow. Some of the members of theconsensus panel recommended 1- to 3-U ali-quots into the lateral orbicularis (depressormuscle), particularly in women, to allow eye-brow elevation. This application also tends toneutralize the potential brow depression thatcan occur when individuals receive frontalisinjections that extend inferiorly toward theeyebrow proper or laterally toward the line oftemporal fusion. The total dose for eyebrowelevation rarely exceeds 30 U, especially inwomen, although a somewhat higher dose maybe necessary in patients with a very high brow.

Units per injection point. The total dose is di-vided by the number of planned injectionpoints, starting with a low dose. Typically, eachpoint is injected with 1- to 5-U aliquots, withhigher doses used in men. As with other areas,the dosing depends on the pretreatment aes-thetic analysis.


Because the starting dose is low and balanceof the upper face depends on eyebrow posi-tion, reassessment in 2 weeks for additionaltreatments or subtle corrections is highly rec-ommended. At that time, eyebrow position canbe reassessed and adjusted with small amountsof properly placed botulinum toxin type A.Before and after photographs can be veryhelpful.

Retreatment intervals for horizontal fore-head lines range from 3 to 6 months. Usually,retreatment is needed less often for this areathan for the glabellar complex. Some panelmembers have also suggested that a slightlyreduced dose to the frontalis can be advanta-geous when the glabella and lateral canthusare also being treated. This may allow retreat-ment of all the periorbital regions to be more“in sync” with regard to harmonious dissipa-

tion of effects. Approximately 80 percent of thepanel members observed benefits to last for 4to 6 months.

Special Considerations for Treating HorizontalForehead Rhytids

Older patients may use the frontalis to in-crease their visual field.46 Therefore, caution isneeded in these circumstances. Men may bemore willing to tolerate forehead lines thanwomen, and they are not always good candi-dates for this procedure. When they do desiretreatment, they may need higher doses thanwomen do, but overtreatment should beavoided in all cases. If laser treatment isplanned, botulinum toxin type A treatmentscan be undertaken 1 to 2 weeks before resur-facing. Botulinum toxin type A injection canalso be combined with fillers, and many of thepanel members apply these treatmentssimultaneously.

Key Elements

1. Less experienced injectors of botulinumtoxin type A should stay at least 2 cm abovethe brow.

2. Assess for asymmetries in brow position. Asfew as two injections high up in the foreheadcan help bring the eyebrows into symmetry.

3. Ensure that injection sites are lateral enoughto avoid a quizzical eyebrow appearance, butavoid the lower lateral forehead. A high lat-eral injection can modulate a severe lateralbrow elevation.

4. A small amount of botulinum toxin type Aadministered in the procerus can help pre-vent brow ptosis.

5. A midline injection should be consideredbecause many patients have frontalis fibers inthat area, even though some schematic draw-ings fail to depict them.

6. Some consensus panel members recommendthat the frontalis and brow depressors shouldbe treated at the same time for a harmoniousresult. Others recommend injecting these ar-eas separately to decrease the amount of bot-ulinum toxin type A used. Diffusion andoverlap can result in immobilization. If treat-ments are undertaken separately, treat thedepressors first, followed 2 weeks later by thefrontalis treatment. The selected approachshould be undertaken in the context of thepretreatment aesthetic evaluation.

7. Start with a low dose in the frontalis andavoid using a dose of botulinum toxin type A


that will cause forehead immobilization. Thismay also facilitate a more uniform dissipa-tion of effects to the upper face and accen-tuate facial harmony throughout the treat-ment period.

8. Distribute the injection points according tothe observed animation and muscle functionof the individual patient.

9. If injections are too centralized, a “quizzical”eyebrow shape can result.

10. Centrally focused injections can allow lateralbrows to elevate.

CROW’S FEET

Lateral orbital wrinkles, commonly termedcrow’s feet, result from muscle activity incombination with photoaging.47 The goal isto ameliorate or soften wrinkles and to pro-vide a relaxed look, not to cause immobility.In the published literature, botulinum toxintype A has been used in relatively low dosesto achieve these goals safely and effective-ly.11,16,19,27,30,31,34 –36,43,45,48 –52 Patient counselingis particularly important in making patientsaware of the inadvisability of attempts toeliminate crow’s feet because of the impor-tant functions of the orbicularis oculi—voluntary and involuntary closing of the eye-lids. Treatment of this area should be avoidedin patients with laxity of the canthal tendonand/or with lower lid retraction as well as inindividuals who recruit their zygomaticus majormuscle to animate their crow’s feet.

Anatomy

The orbicularis oculi is a sphincter-like mus-cle encircling the eyes (Fig. 5).37 The muscle isgenerally broad and thin. It is usually catego-

rized into two or three regions, which are sum-marized in Table VIII.38,39,53–55 Botulinum toxintype A treatment for crow’s feet is generallydirected to the lateral orbital portions of themuscle.

Injection Technique

Despite the commonality of the underlyinganatomy, crow’s feet lines occur in several dis-tinct patterns and may require different treat-ment strategies.53

The usual number of injection points is twoto five per side (Table IX). Occasionally moresites are injected, which is influenced by other

TABLE VIIIThe Orbicularis Oculi*

Muscle Location Origin/Insertion Primary Function

Palpebral portion Covers eyelid Palpebral ligament/palpebral raphe Involuntary action to close eye; workswith other portions

Orbital portion Surrounds the orbit, from bottomof forehead to front of cheek

Frontal process of maxilla/insertsnear its own origin; upper fibersblend with occipitofrontalis andcorrugator supercilii

Moves eyebrow medially; lateralportion of this muscle depresseslateral brow58; may also serve as anaccessory upper cheek elevator

Lacrimal portion Smallest and innermost portion,at the medial side of the orbit

Lacrimal crest inside of bridge ofnose; passes across the lacrimalsac/inserts with the palpebralportion

Interacts with other portions to closethe eye

* From Wieder, J. M., and Moy, R. L. Understanding botulinum toxin: Surgical anatomy of the frown, forehead, and periocular region. Dermatol. Surg. 24: 1172,1998; Kaminer, M. S., and Hruza, G. J. Botulinum A exotoxin injections for photoaging and hyperhidrosis. In M. S. Kaminer, J. S. Dover, and K. A. Arndt (Eds.),Atlas of Cosmetic Surgery, 1st Ed. Philadelphia: Saunders, 2002. Pp. 292–309; Kane, M. A. Classification of crow’s feet patterns among Caucasian women: The key toindividualizing treatment. Plast. Reconstr. Surg. 112 (Suppl.): 33S, 2003; Mythos Anatomy. WebMD Anatomy. Available at http://www.mythos.com/webmd. Accessed June9, 2004; and Gray’s Anatomy Online. Available at http://education.yahoo.com/reference/gray/106.htm. Accessed June 9, 2004.

FIG. 5. The orbicularis oculi. Reprinted with permissionfrom Sommer, B., and Sattler, G. Botulinum Toxin in AestheticMedicine. Berlin: Blackwell Wissenschafts-Verlag, 2001.


desired effects at the lateral canthus.10 Theinjection sites should be kept well lateral, ap-proximately 1 to 1.5 cm from the orbital rim inthe vertically oriented portions of the lateralorbicularis fibers. The precise injection pointswill depend on the pretreatment analysis, in-cluding the activity of the muscle and the ob-served line patterns (Figs. 6 and 7).56


As with horizontal forehead lines, lowerdoses are preferable. The selected dose de-pends on the severity and location of the linesand the number of injection sites per side.Members of the consensus panel typicallystarted treating crow’s feet with 8 to 16 U perside in women (96 percent) and 12 to 16 U perside in men (89 percent), but lower startingdoses may be advisable for less experiencedclinicians.

Units per injection point. The total dose is di-vided by the number of planned injectionpoints, starting with a low dose. Consensuspanel members typically injected approxi-mately 3 to 4 U per injection site. In some cir-cumstances, but not all, men will receive a 1- to2-U higher dose than women. Generally menwill tolerate more smile-associated wrinklesthan women and also may desire less browelevation.


Patients can be reassessed in 2 weeks if reas-sessment is deemed necessary. Duration of ef-fect is usually less than that observed in otherareas of the upper face, at typically 3 months.In some patients, the effect may last 4 months.In one published study, benefits of treatmentwere maintained for 12 weeks after the firstbotulinum toxin type A treatment for crow’sfeet and was sustained in 65 percent of patientsat 16 weeks after a second injection.50 Lessfrequently, the treatment effect may endurefor up to (and rarely beyond) 6 months. Anec-dotal evidence suggests that as in all otherareas, duration is dose-dependent, with thehigher (saturation) dosages yielding the long-est-lasting effects.

TABLE IXRecommendations for Treating Crow’s Feet

Target Muscles


(per side)

Total StartingDose*

(usual range)

Lateral portions of thelateral orbicularis

2 to 5 (higher inselected cases)

12 to 30 U

* Gender differences in muscle mass are balanced by gender differences inaesthetic goals. Women generally prefer fewer lateral canthal rhytids than men.

FIG. 6. Typical injection pattern; all others can be mod-ified from this pattern. The figure shows a typical patient whomight receive injections at four sites in the lateral canthusregion. These sites will also change (slightly) depending onthe patient presentation and the desired effect. Courtesy ofSteven Fagien, M.D.

FIG. 7. Treatment of crow’s feet. (Above) Hypertrophy ofthe lateral fibers of the orbicularis oculi muscle, resulting inhorizontal crow’s feet (white dots indicate injection points).(Below, below) Eradication of rhytids after three intramuscularinjections of 2.5 U of Botox spaced approximately 1.0 cmfrom each other. Reprinted from Matarasso, S. L., and Mat-arasso, A. Treatment guidelines for botulinum toxin type Afor the periocular region and a report on partial upper lipptosis following injections to the lateral canthal rhytids. Plast.Reconstr. Surg. 108: 208, 2001.


Special Considerations for Treating Crow’s Feet

It is very important to inject superficially inthis area using intradermal subdermal blebs toavoid or minimize bruising. The needle shouldbe oriented away from the orbit. Applying pres-sure and/or ice after the injection can alsominimize bruising.

In this region, botulinum toxin type A injec-tions are useful in combination with fillers andresurfacing techniques. Botulinum toxin typeA can be used 2 weeks before laser resurfacingor chemical peels to enhance collagen remod-eling. Denervation treatment may prolong theresults of the resurfacing procedures. Botuli-num toxin type A treatment should be ap-proached with greater caution in patients whohave undergone recent blepharoplasty or vi-sion/refractive procedures such as laser-assisted in situ keratomileusis (LASIK)procedures.

Key Elements

1. Ask the patient to animate to enable assess-ment of the line patterns and dynamic eye-brow and cheek positions.

2. Treat crow’s feet around the lower third ofthe canthal area with caution.

3. Evaluate lid laxity with a snap test. Laxityindicates the potential for developing an ec-tropion, and lower injections may beavoided.

4. Exercise caution in patients who have under-gone surgery.

5. Avoid, in most patients, the area below thezygomatic arch and the zygomaticus majormuscle. Injection into this area has the po-tential to cause lip and cheek ptosis.

6. Start with low doses to avoid overtreatmentand potential lid ptosis; Asian patients whowish to have a wider eye look may be treatedwith doses up to 50 percent higher thanthose used for other patients.

7. Asking patients to animate during injectioncan be helpful, especially in individuals withsignificant rhytids.

8. Avoid veins, when possible, in the lateral can-thus; they may be revealed under appropri-ate lighting and magnification.

9. Proceed with caution when treating patientswho have a history of dry eyes.

10. Keep injections superficial; use intradermalor subdermal blebs with the needle orientedaway from the orbit.

11. Use ice to help avoid ecchymoses.

“BUNNY LINES”

Bunny lines appear on the sides of the noseand radiate downward from the sides, as shownin Figure 8. They should be differentiated fromtransverse lines resulting from procerus activ-ity. Bunny lines occur from regular wrinklingof the nose and should be evaluated in thepreoperative analysis. A literature review re-vealed only one published article that ad-dressed the treatment of bunny lines. Themembers of the consensus panel, however,noted that they typically treat bunny lines, ifthey are present, in conjunction with the gla-bellar complex.

Anatomy

Bunny lines result from contracting thetransverse portion of the nasalis. This portionarises from the maxilla and runs diagonallyacross the bridge of the nose. It expands into athin aponeurosis and is continuous with that ofthe muscle of the opposite side and with theaponeurosis of the procerus.54,55

Injection Technique

A low-dose midline injection is often suffi-cient to soften bunny lines. If necessary, onelow-dose injection on each side may be admin-istered as well, for a total of one to three injec-tion points (Fig. 7). The injections should berelatively superficial.

FIG. 8. Nasalis muscle injection sites for bunny lines(downward radiating lines on the sides of the nose). Courtesyof Steven Fagien, M.D.

TABLE XRecommendations for Treating Bunny Lines

Target Muscle

Usual No. ofInjection

PointsTotal Starting Dose

(usual range)

Nasalis 1 per side 2 to 5 U, dividedevenly

Procerus (for transverse nasal) 1 in midline 1 U, if needed


Total Starting Doses and Units per Injection Point

The usual total starting dose for the mem-bers of the consensus panel was 2 to 5 U (TableX). As little as 1 U per site may be adequate.Men do not receive treatment for bunny linesas often as women do, so gender differencesare not an important variable. When treated,men may receive a dose that is slightly higherby 1 U.


Assessment will be part of the overall evalu-ation, as bunny lines are not typically treated inisolation. The usual retreatment interval is 3months.

Special Considerations for Treating Bunny Lines

Few special considerations apply other thanthose discussed for the glabellar complex.Treatments may be less effective in patientswho have had rhinoplasty.

Summary for Treating Bunny Lines

Use low doses on the upper part of the na-salis. A total of two injections—one on eachside—should suffice. A midline procerus injec-tion will address transverse nasal lines.

Key Elements

1. Ensure that injections avoid the levator labiialaeque nasi and the levator labii superioris toprevent drooping of the upper lip.

2. Do not massage vigorously or in a downwarddirection, which could also result in lip ptosis.

3. Consider including an injection of 1 to 2 Uper side of the upper nasalis when treating theglabellar area, to prevent recruitment.

4. Keep injections superficial in this vascularizedarea to avoid bruising.

PERIORAL TREATMENT

As the eyebrows are central to the aestheticappearance of the upper face, the lips are central

to the lower face. Aging, smoking, and expres-sion result in substantial changes in the appear-ance of the lips, including vertical perioral rhyt-ids. The normal actions of the orbicularis orisaccentuate these lines, which are a commonsource of patient dissatisfaction with appearance.Fine wrinkles of the upper lip are often treatedwith fillers or resurfacing, but botulinum toxintype A can help improve the appearance of thewrinkles in this area. In addition, careful treat-ment in the perioral area may produce the ap-pearance of fuller lips, because weakening of themuscle results in slight eversion of the upperlip.24 Because of the complex functions of thisregion and the interplay of muscles, treatment ofthe perioral area deserves careful attention andshould be practiced by experienced injectors.

FIG. 9. The orbicularis oris. Reprinted with permissionfrom Sommer, B., and Sattler, G. Botulinum Toxin in AestheticMedicine. Berlin: Blackwell Wissenschafts-Verlag, 2001.

TABLE XIThe Orbicularis Oris and Associated Musculature*

Location Origin/Insertion Primary Function

Surrounds the orificeof the mouth

Buccinator/forms deeper strata of orbicularis oris;caninus/upper lip; depressor anguli oris (trianguli)/lower lip; quadratus labii superioris, zygomaticus,quadratus labii inferioris; orbicularis oris is alsoconnected to the maxillae and septum of the nose andmandible

Direct closure of the lips; applies lips to alveolararch; brings lips together and protrudes themforward; the depressor anguli oris depresses theangle of the mouth (to express sadness)

* From Mythos Anatomy. WebMD Anatomy. Available at http://www.mythos.com/webmd. Accessed June 9, 2004; and Gray’s Anatomy Online. Available at http://education.yahoo.com/reference/gray/106.htm. Accessed June 9, 2004.


Anatomy

The perioral area encompasses several mus-cles, including the orbicularis oris, the depres-sor anguli oris, and the mentalis. The depres-sor anguli oris derive from the lower jaw andinsert into the angle of the mouth. They de-press the angle of the mouth and pull it back-ward. The mentalis raises the skin over thechin. The focus of this section is on the orbic-ularis oris, which is the sphincter muscle of themouth (Fig. 9).37 Fibers derive partially fromother muscles inserted into the lips and frommuscles associated with the lips (Table XI).54,55

Injection Technique

Among members of the consensus panel,treatment of the perioral area with botulinumtoxin type A was highly individualized with re-gard to number of injection points. The aver-age number of injection points was five to six,but ranged from one per side to a total of 11(for example, including four in each lip, one ineach depressor anguli oris, and one in thementalis). Several members of the panel in-jected the upper lip only, whereas others in-jected both the upper and lower lips. In gen-eral, injections should be kept superficial andsymmetrical. The use of ice for topical anes-thetic effect is beneficial for enhanced patientcomfort.

Potential injection sites are depicted in Fig-ure 10 and include both the upper and lowerlips. A reasonably conservative approach is tobegin with one site per quarter lip and reassessin 2 weeks. Regardless of facial asymmetries,consensus panel members recommendedstrongly that injections be placed symmetri-cally. Some experts suggested placing the sitesjust above the vermilion border, while othersrecommended a distance of 5 mm above theborder. Injections that are too cephalad can

cause the upper lip to invert, evert, or becomeptotic temporarily. The midline (or Cupid’sbow) should be avoided. In general, the injec-tion sites need to be adjusted to the patterns ofthe lines and preference of lip shape.


The average total starting dose for the perioralarea was approximately 5 to 6 U (Table XII).Most panel members recommended 1 to 2 U perinjection point. As little as 0.5 to 0.75 U can beused conservatively. If the depressor anguli orismuscles are treated, low doses should be used(e.g., 2 to 5 U).4


It is a good practice to reassess the treatment2 weeks after injection, at which time slightcorrections can be attempted. The duration ofeffect may be less than that of other areasbecause of the low doses, sometimes only 2 to3 months. Patient outcomes can be enhancedwhen botulinum toxin type A treatment is usedin combination with fillers and/or resurfacing.Panel members frequently undertake theseprocedures in the same session.

Special Considerations for Treating the Perioral Area

The treatment of the perioral area is bestmanaged by using botulinum toxin type A inconjunction with laser resurfacing and fillers.When fillers and botulinum toxin type A areused at the same appointment, most physiciansinject the filler first. In principle, this is toprevent the possibility of the filler causing thespread of the botulinum toxin type A along thelip line, with the added advantage of the anes-thetic effect of the filler allowing for a painlessinjection.

Overtreatment of the perioral area can resultin significant dysfunction, including difficultyin pursing the lips; speech impairments, suchas the inability to pronounce “b” and “p”; dif-ficulty eating, brushing teeth, and using a strawfor drinking; and diminished proprioception.Treatment of the depressor anguli oris that is

TABLE XIIRecommendations for Treating the Perioral Area

Target MuscleUsual No. of

Injection Points*Total Starting Dose

(range)

Orbicularis oris 2 to 6; to start: 4 sites,1 site/lip quadrant

4 to 10 U, evenly dividedamong the sites

* All injections in this area should be symmetrical.FIG. 10. Injection sites for the perioral area.


too close to the mouth can result in inadver-tent injection of other muscles and produceoral incompetence, drooling, and an asymmet-rical smile.

Key Elements

1. Patient selection and counseling are critical.Those who rely on their lips in their profes-sions (e.g., some musicians, singers, and pub-lic speakers) are not good candidates for bot-ulinum toxin type A treatment. Patients mayalso have unrealistic expectations about thebenefits of treatment and should be coun-seled or not treated.

2. Treat conservatively with low doses at a mini-mum number of injection sites (one to twosites per side of the upper lip); always injectsymmetrically.

3. Avoid treating the corners of the lips, whichcould result in drooping and drooling.

4. Avoid the midline of the upper lip to avoidflattening the lip.

5. Avoid treating too distantly from the lip mar-gin, that is, not usually more than 5 mm abovethe vermilion border.

6. Keep injections superficial and massagelaterally.

7. Injections in the lower lip area are more likelyto affect function; treat conservatively, if at all.

8. Consider using botulinum toxin type A in con-junction with resurfacing procedures andfillers.

9. Use ice liberally to anesthetize the area, asinjections in the perioral area can be painful.

DIMPLED CHIN (PEAU D’ORANGE)

The dimpled appearance of the chin can bereduced with conservative botulinum toxintype A treatment. The dimpled appearance isthe result of the actions of the mentalis musclecoupled with loss of collagen and subcutane-ous fat in the chin.

Anatomy

The mentalis muscle is shown in Figure 11.37

The mentalis originates from the mandible,covers the chin, and inserts into the skin belowthe lower lip.54,55 The mentalis raises the chin,which can cause wrinkles and dimpling, andprotrudes the lower lip, which expresses sad-ness, anger, disdain, or doubt (Fig. 12).

Injection Technique

Only one injection with botulinum toxintype A is generally necessary to weaken the

muscle, although some experts inject two sites(Table XIII). The injection should be low orjust below the tip or prominence of the chin(Fig. 13). If one injection point is used, itshould be in the midline mass of the muscle.The injection should be angled upward. Themuscle should be massaged in a lateral direc-tion. It is preferable to start with a more con-servative approach of one injection andreassess.


The typical total starting dose among panelmembers was 5 to 6 U, with some experienced

FIG. 12. Dimpled chin. Courtesy of Timothy C. Flynn, M.D.

FIG. 11. The mentalis muscle. Reprinted with permissionfrom Sommer, B., and Sattler, G. Botulinum Toxin in AestheticMedicine. Berlin: Blackwell Wissenschafts-Verlag, 2001.


users going up to 12 U. In general, 5 to 10 Ushould be adequate. Men are treated signifi-cantly less frequently than women. Their chinsmay be less likely to develop dimpling, and itpresents less of an aesthetic problem to them.Dosing is similar in women and men; occasion-ally men who are treated may require a dose 2to 3 U greater than that used for women. Thetotal dose is divided evenly among sites if morethan one injection point is used.


If desired, patients can be seen at 2 weeks.The usual retreatment interval is 3 to 4months, but it can be as long as 6 months insome patients.

Special Considerations for Treating Dimpled Chin

This is an area that responds well to combi-nation treatment with botulinum toxin type Aand fillers. Treatment of this area is also usefulin patients undergoing chin implants and an-ticipating laser resurfacing. It should be noted,however, that the dimpled chin is not as re-sponsive to laser resurfacing as other areas ofthe face.

Key Elements

1. Some patients are unaware of their dimpledchin, which appears on animation. It can bedemonstrated with a mirror.

2. Avoid injecting too high, which can affect theorbicularis oris and cause lower lip incompe-tence and possibly drooling.

3. Care must be taken to avoid the depressorlabii, which can cause the lower lip to depress.

4. Be aware that some individuals who presentwith a dimpled chin may have hypertrophicmentalis muscles, which may be a sign of apredisposition to oral incompetence. Do nottreat with botulinum toxin type A if this issuspected.

PLATYSMAL BANDS

The platysmal bands of the neck may be-come very prominent in some individuals with

aging or after surgical rhytidectomy. Botuli-num toxin type A treatments may be a usefuladjunct in carefully selected patients who haveretained skin elasticity and have a minimal de-scent of submental fat.

Anatomy

The platysma, a broad, thin sheet of muscle,originates in the pectoral and deltoid muscles(Fig. 14).37 It extends upward over the clavicleand inward along each side of the neck andunder the skin near the mandible. Anteriorfibers may interdigitate with the fibers of theopposite side. The platysma depresses thelower jaw and pulls the lower lips and cornersof the mouth sideways and down, partiallyopening the mouth. Banding occurs with agingand changes in the submental space.

Injection Technique

Among the members of the consensus panel,80 percent treated three to five sites per bandwith botulinum toxin type A (Table XIV). An-other 20 percent treated more sites. Usuallyinjections are given at 1-cm intervals (Fig. 15).


In the published literature, a considerablerange of botulinum toxin type A doses has

TABLE XIIIRecommendations for Treating Dimpled Chin

Target MuscleUsual No. of

Injection PointsTotal Starting Dose

(usual range)

Mentalis 1 to 2 (start with one midlineor 2 symmetrical, lateralinjections)


FIG. 13. Injection sites and dosage of Botox for dimpledchin.


been reported for the treatment of platysmalbands.18,45,57–61 Among consensus panel mem-bers, doses per injection point were also quitevariable, resulting in total doses per band of 6 to40� U, depending on the number of injectionsites and doses used. Usually two bands aretreated in a session.


As with other areas, follow-up assessmentscan take place 2 weeks after treatment ifneeded. Retreatment intervals are typically 3 to4 months.

Special Considerations for Treating Platysmal Bands

Treatment of platysmal bands can be com-bined with treatment of the depressor angulioris and the use of fillers to restore volume inthe lower third of the face. Botulinum toxintype A can also be used to treat the platysmal

bands 2 weeks before liposuction of the neckor before resurfacing.

The majority of clinicians recommendedgrasping the band with the nondominanthand and injecting directly into the belly ofthe muscle. A few practitioners injected su-perficially into the skin and allowed for dif-fusion to carry botulinum toxin type A intothe platysma. Although some clinicians con-tinue to use electromyographic guidance toallow for the most accurate placement of thetoxin with the smallest dose, the consensuspanel members generally do not utilize thistechnique.62

Key Elements

1. Select patients with care, as patient selection iscritical. This procedure works best on younger

TABLE XIVRecommendations for Treating Platysmal Bands

TargetMuscle


Total Starting Dose*(usual range)

Platysma Women: 2 to 12/band Women: 10 to 30 UMen: 3 to 12/band Men: 10 to 40 U

* Some experts use total doses of up to 100 U.

FIG. 14. The platysma. Reprinted with permission fromSommer, B., and Sattler, G. Botulinum Toxin in Aesthetic Med-icine. Berlin: Blackwell Wissenschafts-Verlag, 2001.

FIG. 15. Injection sites for platysmal bands. Small injec-tions can be placed at horizontal lines. Photographs courtesyof Rod Rohrich, M.D.


patients with good skin elasticity or postoper-atively for residual bands.

2. Note that botulinum toxin type A injection inthis area can also diminish horizontal (“neck-lace”) lines on the neck in selected patients.

3. Counsel patients about the variability of resultsin the neck area so that they will have realisticexpectations; platysmal band injection does notsubstitute for surgical procedures, and it will notcorrect skin laxity or fat deposits.

4. Use caution to avoid dysphagia, dysphonia, andneck weakness. The strap muscles should beavoided. Grasping of the bands and direct injec-tion and/or the use of electromyographic guid-ance should ensure a more accurate injection.

5. Inject multiple sites per band for the mostsatisfactory results.

SUMMARY

The cosmetic use of botulinum toxin type Ahas continued to expand since its approval by theU.S. Food and Drug Administration for improv-ing the appearance of moderate to severe glabel-lar lines associated with activity of the corrugatorand procerus muscles.1 As the most prevalentcosmetic procedure undertaken in the UnitedStates, botulinum toxin type A injections are nowused to enhance facial appearance in a numberof areas, alone or in combination with otheraesthetic techniques. The consensus panel, con-

vened on April 3 and 4, 2004, met to developguidelines to aid the practitioner in using botu-linum toxin type A in a wide range of aestheticapplications and to help ensure a satisfactory out-come that reflects an aesthetic ideal of harmonyand balance.

The guidelines and recommendations pre-sented in this article include general principlesas well as information on specific use. Perhapsone of the most important perspectives is thatindividualized aesthetic planning is the key tosuccess. This depends on a thorough under-standing of the underlying anatomy and phys-iology of the individual muscles and their in-teractions, as well as on individual patientcharacteristics, including goals and expecta-tions. Engaging the prospective or continuingpatient in the development and refinement ofthe aesthetic treatment plan is critical.

On the basis of their extensive experience,consensus panel members provided injectionand dosing guidelines for using botulinumtoxin type A in the upper, mid-, and lower face,as summarized in Table XV.

Seth L. Matarasso, M.D.Department of DermatologyUniversity of California School of MedicineSan Francisco, California490 Post, No. 700San Francisco, Calif. [email protected]

TABLE XVInjection and Dosing Guidelines

Region and Target Muscle Usual No. of Injection Points (range) Total Starting Dose (usual range)

Glabellar complexCorrugator, procerus, depressor

supercilii, orbicularis oculi5 to 7; men may require more sites Women: 20 to 30 U

Men: 30 to 40 UHorizontal forehead rhytids

Frontalis, but consider interactions withprocerus, corrugators, and orbicularisoculi in overall facial shape

4 to 8; more or fewer may be requiredbased on anatomic and aestheticevaluations

Women: 15 U; 10 to 20 UMen: 20 to 30 U

Crow’s feetLateral portions of the lateral

orbicularis2 to 5 (higher in selected patients) 12 to 30 U

Bunny linesNasalis 1 per side 2 to 4 U divided evenlyProcerus (for transverse nasal) 1 in midline 1 U, if needed

PerioralOrbicularis oris 2 to 6; to start: 4 sites, 1 site/lip quadrant 4 to 10 U evenly divided among the

sitesDimpled chin (peau d’orange)

Mentalis 1 to 2 (start with one midline or 2symmetrical, lateral injections)


Neck, platysmal bandsPlatysma Women: 2 to 12/band Women: 10 to 30 U

Men: 3 to 12/band Men: 10 to 40 U


APPENDIX

Botox Consensus Group

The members of the Botox Consensus Group are asfollows: Jean Carruthers, M.D., Executive Edi-tor, Vancouver, Canada; Steven Fagien, M.D.,Executive Editor, Boca Raton, Fla.; Seth L. Mat-arasso, M.D., Executive Editor, San Francisco,Calif.; Tina S. Alster, M.D., Washington, D.C.;Richard Lee Anderson, M.D., Salt Lake City,Utah; David E. Bank, M.D., Mount Kisco, N.Y.;William Harold Beeson, M.D., Carmel, Ind.;Anthony V. Benedetto, D.O., Philadelphia, Pa.;Andrew Blitzer, M.D., D.D.S., New York, N.Y.;Stephen L. Bosniak, M.D., New York, N.Y.;Alastair Carruthers, M.A., B.M., B.Ch., Vancou-ver, Canada; Sue Ellen Cox, M.D., Chapel Hill,N.C.; Steve Dayan, M.D., Chicago, Ill.; WalterD. Dishell, M.D., Encino, Calif.; Zoe DianeDraelos, M.D., High Point, N.C.; John CharlesFinn, M.D., Durham, N.C.; Timothy C. Flynn,M.D., Chapel Hill, N.C.; Ellen C. Gendler,M.D., New York, N.Y.; Richard G. Glogau,M.D., San Francisco, Calif.; Michael A. C. Kane,M.D., New York, N.Y.; Arnold William Klein,M.D., Los Angeles, Calif.; Nicholas J. Lowe,M.D., Los Angeles, Calif.; Alan Matarasso,M.D., New York, N.Y.; Ada Regina Trindade deAlmeida, M.D., São Paulo, Brazil; WilliamPhilip Werschler, M.D., Spokane, Wash.; Patri-cia S. Wexler, M.D., New York, N.Y.; and JessicaWu, M.D., Los Angeles, Calif.

REFERENCES

1. Allergan, Inc. Botox Cosmetic (botulinum toxin typeA) purified neurotoxin complex (Package Insert). Ir-vine, Calif.: Allergan, Inc.

2. Klein, A. W. Dilution and storage of botulinum toxin.Dermatol. Surg. 24: 1179, 1998.

3. Carruthers, A., Carruthers, J., Cohen, J., and Alain, J.Dose dilution and duration of effect of botulinumtoxin type A (BTX-A) for the treatment of glabellarrhytids. Poster presented at the 2002 Winter Meetingof the American Academy of Dermatology, New Or-leans, La., February 22-27, 2002.

4. Klein, A. W. Complications and adverse reactions withthe use of botulinum toxin. Dis. Mon. 48: 336, 2002.

5. Hexsel, D. M., de Almeida, A. T., Rutowitsch, M., et al.Multicenter, double-blind study of the efficacy of in-jections with botulinum toxin type A reconstituted upto six consecutive weeks before application. Dermatol.Surg. 29: 523, 2003.

6. Garcia, A., and Fulton, J. E., Jr. Cosmetic denervation ofthe muscles of facial expression with botulinum toxin:A dose-response study. Dermatol. Surg. 22: 39, 1996.

7. Alam, M., Dover, J. S., and Arndt, K. A. Pain associatedwith injection of botulinum A exotoxin reconstitutedusing isotonic sodium chloride with and without pre-

servative: A double-blind, randomized controlled trial.Arch. Dermatol. 138: 510, 2002.

8. Trindade de Almeida, A. R., Kadunc, B. V., Di Chiacchio,N., and Neto, D. R. Foam during reconstitution doesnot affect the potency of botulinum toxin type A.Dermatol. Surg. 29: 530, 2003.

9. Carruthers, A., Kiene, K., and Carruthers, J. BotulinumA exotoxin use in clinical dermatology. J. Am. Acad.Dermatol. 34: 788, 1996.

10. Fagien, S. Botulinum toxin type A for facial aestheticenhancement: Role in facial shaping. Plast. Reconstr.Surg. 112 (Suppl.): 6S, 2003.

11. Ahn, K. Y., Park, M. Y., Park, D. H., and Han, D. G.Botulinum toxin A for the treatment of facial hyperki-netic wrinkle lines in Koreans. Plast. Reconstr. Surg.105: 778, 2000.

12. Alam, M., Dover, J. S., Klein, A. W., and Arndt, K. A.Botulinum A exotoxin for hyperfunctional facial lines:Where not to inject. Arch. Dermatol. 138: 1180, 2002.

13. Carruthers, A., and Carruthers, J. Long-term safety re-view of subjects treated with botulinum toxin type Afor cosmetic use. In Proceedings of the 13th Congress of theEuropean Academy of Dermatology & Venereology, Flo-rence, Italy, November 17-21, 2004.

14. Matarasso, S. L. Complications of botulinum A exo-toxin for hyperfunctional lines. Dermatol. Surg. 24:1249, 1998.

15. Carruthers, J. D., and Carruthers, J. A. Treatment ofglabellar frown lines with C. botulinum-A exotoxin.J. Dermatol. Surg. Oncol. 18: 17, 1992.

16. Sommer, B., Zschocke, I., Bergfeld, D., Sattler, G., andAugustin, M. Satisfaction of patients after treatmentwith botulinum toxin for dynamic facial lines. Derma-tol. Surg. 29: 456, 2003.

17. Klein, A. W. Cosmetic therapy with botulinum toxin:Anecdotal memoirs. Dermatol. Surg. 22: 757, 1996.

18. Blitzer, A., Brin, M. F., Keen, M. S., and Aviv, J. E. Bot-ulinum toxin for the treatment of hyperfunctionallines of the face. Arch. Otolaryngol. Head Neck Surg. 119:1018, 1993.

19. Carruthers, A., and Carruthers, J. A. Botulinum toxin inthe treatment of glabellar frown lines and other facialwrinkles. In J. Jankovic and M. Hallett (Eds.), Therapywith Botulinum Toxin. New York: Marcel Dekker, 1994.Pp. 577-595.

20. Carruthers, J. D., Lowe, N. J., Menter, M. A., et al. Dou-ble-blind, placebo-controlled study of the safety andefficacy of botulinum toxin type A for patients withglabellar lines. Plast. Reconstr. Surg. 112: 1089, 2003.

21. Carruthers, A., Carruthers, J., and Said, S. Double-blind, randomized, parallel group, dose-ranging studyof botulinum toxin type A (Botox, Allergan, Inc.) inthe treatment of glabellar lines. Poster presented atthe European Academy of Dermatology and Venere-ology meeting, Munich, Germany, October 10, 2001.

22. Carruthers, J. A., Lowe, N. J., Menter, M. A., et al. Amulticenter, double-blind, randomized, placebo-con-trolled study of the efficacy and safety of botulinumtoxin type A in the treatment of glabellar lines. J. Am.Acad. Dermatol. 46: 840, 2002.

23. Carruthers, A., and Carruthers, J. Botulinum toxin typeA for treating glabellar lines in men: A dose rangingstudy. Poster presented at the 61st Annual Meeting ofthe American Academy of Dermatology, San Fran-cisco, Calif., March 21–26, 2003.


24. Fagien, S. Botox for the treatment of dynamic and hy-perkinetic facial lines and furrows: Adjunctive use infacial aesthetic surgery. Plast. Reconstr. Surg. 103: 701,1999.

25. Frankel, A. S., and Kamer, F. M. Chemical browlift.Arch. Otolaryngol. Head Neck Surg. 124: 321, 1998.

26. Grimes, P. E. A four-month randomized, double-masked evaluation of the efficacy of botulinum toxintype A for the treatment of glabellar lines in womenwith skin types V and VI. Poster presented at the 62ndAnnual Meeting of the American Academy of Derma-tology, Washington, D.C., February 6-11, 2004.

27. Guerrissi, J., and Sarkissian, P. Local injection into mi-metic muscles of botulinum toxin A for the treatmentof facial lines. Ann. Plast. Surg. 39: 447, 1997.

28. Guyuron, B., and Huddleston, S. W. Aesthetic indica-tions for botulinum toxin injection. Plast. Reconstr.Surg. 93: 913, 1994.

29. Hankins, C. L., Strimling, R., and Rogers, G. S. Botu-linum A toxin for glabellar wrinkles: Dose and re-sponse. Dermatol. Surg. 24: 1181, 1998.

30. Blitzer, A., Binder, W. J., Aviv, J. E., Keen, M. S., and Brin,M. F. The management of hyperfunctional faciallines with botulinum toxin: A collaborative study of210 injection sites in 162 patients. Arch. Otolaryngol.Head Neck Surg. 123: 389, 1997.

31. Lew, H., Yun, Y. S., Lee, S. Y., and Kim, S. J. Effect ofbotulinum toxin A on facial wrinkle lines in Koreans.Ophthalmologica 216: 50, 2002.

32. Lowe, N. J., Maxwell, A., and Harper, H. Botulinum Aexotoxin for glabellar folds: A double-blind, placebo-controlled study with an electromyographic injectiontechnique. J. Am. Acad. Dermatol. 35: 569, 1996.

33. Pribitkin, E. A., Greco, T. M., Goode, R. L., and Keane,W. M. Patient selection in the treatment of glabellarwrinkles with botulinum toxin type A injection. Arch.Otolaryngol. Head Neck Surg. 123: 321, 1997.

34. Saray, Y., and Gulec, T. Botulinum exotoxin-A for treat-ment of facial rhytides (Abstract A43). J. Cosmet. Der-matol. 1: 166, 2003.

35. West, T. B., and Alster, T. S. Effect of botulinum toxintype A on movement-associated rhytides followingCO2 laser resurfacing. Dermatol. Surg. 25: 259, 1999.

36. Zimbler, M. S., Holds, J. B., Kokoska, M. S., et al. Effectof botulinum toxin pretreatment on laser resurfacingresults: A prospective, randomized, blinded trial. Arch.Facial Plast. Surg. 3: 165, 2001.

37. Sommer, B., and Sattler, G. Botulinum Toxin in AestheticMedicine. Berlin: Blackwell Wissenschafts-Verlag, 2001.

38. Wieder, J. M., and Moy, R. L. Understanding botuli-num toxin: Surgical anatomy of the frown, fore-head, and periocular region. Dermatol. Surg. 24:1172, 1998.

39. Kaminer, M. S., and Hruza, G. J. Botulinum A exotoxininjections for photoaging and hyperhidrosis. In M. S.Kaminer, J. S. Dover, and K. A. Arndt (Eds.), Atlas ofCosmetic Surgery, 1st Ed. Philadelphia: Saunders, 2002.Pp. 292-309.

40. Bulstrode, N. W., and Grobbelaar, A. O. Long-term pro-spective follow-up of botulinum toxin treatment forfacial rhytides. Aesthetic Plast. Surg. 26: 356, 2002.

41. Carruthers, A., Carruthers, J., and Cohen, J. A prospec-tive, double-blind, randomized, parallel-group, dose-ranging study of botulinum toxin type A in femalesubjects with horizontal forehead rhytides. Dermatol.Surg. 29: 461, 2003.

42. Flynn, T. C., and Clark, R. E. Botulinum toxin type B(Myobloc) versus botulinum toxin type A (Botox)frontalis study: Rate of onset and radius of diffusion.Dermatol. Surg. 29: 519, 2003.

43. Han, K. H., Seo, K. I., Won, C. H., and Eun, H. C. Com-parison of two botulinum toxin type A preparations inthe treatment of hyperkinetic facial wrinkles (Ab-stract). Korean J. Dermatol. 41 (Suppl. 1): 4, 2003.

44. Keen, M., Blitzer, A., Aviv, J. E., et al. Botulinum toxinA for hyperkinetic facial lines: Results of a double-blind, placebo-controlled study. Plast. Reconstr. Surg.94: 94, 1994.

45. Le Louarn, C. Botulinum toxin A and facial lines: Thevariable concentration. Aesthetic Plast. Surg. 25: 73,2001.

46. Klein, A. W., Wexler, P., Carruthers, A., and Carruthers,J. Treatment of facial furrows and rhytides. Dermatol.Clin. 15: 595, 1997.

47. Carruthers, A., and Carruthers, J. Cosmetic uses of bot-ulinum A exotoxin. Adv. Dermatol. 12: 325, 1997.

48. Flynn, T. C., Carruthers, J. A., Carruthers, J. A., and Clark,R. E., II. Botulinum A toxin (Botox) in the lowereyelid: Dose-finding study. Dermatol. Surg. 29: 943,2003.

49. Guerrissi, J. O. Intraoperative injection of botulinumtoxin A into the orbicularis oculi muscle for the treat-ment of crow’s feet. Plast. Reconstr. Surg. 112 (Suppl.):161S, 2003.

50. Lowe, N. J., Lask, G., Yamauchi, P., and Moore, D. Bi-lateral, double-blind, randomized comparison of 3doses of botulinum toxin type A and placebo in pa-tients with crow’s feet. J. Am. Acad. Dermatol. 47: 834,2002.

51. Lowe, N. J., Yamauchi, P., Lask, G., and Moore, D. Bo-tox-A gives adjunctive benefit to periorbital laser re-surfacing (Abstract 267). Lasers Surg. Med. Suppl. 14:73, 2002.

52. Matarasso, S. L. Comparison of botulinum toxin typesA and B: A bilateral and double-blind randomizedevaluation in the treatment of canthal rhytides. Der-matol. Surg. 29: 7, 2003.

53. Kane, M. A. Classification of crow’s feet patterns amongCaucasian women: The key to individualizing treat-ment. Plast. Reconstr. Surg. 112 (Suppl.): 33S, 2003.

54. Mythos Anatomy. WebMD Anatomy. Available at http://www.mythos.com/webmd. Accessed June 9, 2004.

55. Gray’s Anatomy Online. Available at http://education.ya-hoo.com/reference/gray/106.htm. Accessed June 9,2004.

56. Matarasso, S. L., and Matarasso, A. Treatment guide-lines for botulinum toxin type A for the periocularregion and a report on partial upper lip ptosis fol-lowing injections to the lateral canthal rhytids. Plast.Reconstr. Surg. 108: 208, 2001.

57. Brandt, F. S. A prospective, placebo-controlled, ran-domized, parallel group study of botulinum toxin typeA for the treatment of mild to moderate platysmalbands. Poster presented at the 62nd Annual Meetingof the American Academy of Dermatology, Washing-ton, D.C., February 6-11, 2004.

58. Carruthers, J., and Carruthers, A. Aesthetic botulinumA toxin in the mid and lower face and neck. Dermatol.Surg. 29: 468, 2003.


59. Kane, M. A. Nonsurgical treatment of platysmal bandswith injection of botulinum toxin A. Plast. Reconstr.Surg. 103: 656, 1999.

60. Kane, M. A. Nonsurgical treatment of platysma bandswith injection of botulinum toxin A revisited. Plast.Reconstr. Surg 112 (Suppl.): 125S, 2003.

61. Matarasso, A., and Matarasso, S. L. Botulinum A exo-

toxin for the management of platysma bands. Plast.Reconstr. Surg 112 (Suppl.): 127S, 2003.

62. Blitzer, A. Botulinum neurotoxin A for the manage-ment of lower facial lines and platysmal bands. In N. Lowe(Ed.), Textbook of Facial Rejuvenation: The Art of MinimallyInvasive Combination Therapy. London: Martin Dunitz,2002.


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