(Myobloc)

**Table 1.**

**Upper Face** Glabella lines (**Figure 1**)

Lateral canthal lines (Crow's feet) (**Figure 2**)

Forehead Lines1 (**Figure 3**)

Bunny lines (Nasal oblique lines)

**Lower Face** Perioral rhytides (smokers' lines)

Gummy smile2 **Levator labii** 

Marionette lines **Depressor anguli oris**

**Forehead lines/ Cosmetic**

Abobotulinumtoxin (Dysport) Yes Cervical dystonia, blepharospasm Incobotulinumtoxin (Xeomin) Yes Cervical dystonia, blepharospasm

*^Upper limb spasticity, chronic migraine, overactive bladder and urinary incontinence.*

Onabotulinumtoxin (Botox) Yes Cervical dystonia, severe primary axillary

**Other^**

No Cervical dystonia, blepharospasm

**Unites and Technique**

**Procerus:** Intramuscular, single injection point,

**Corrugator:** Intramuscular 1–3 injection points at each side, First injection point 0.5–1 cm above the medial orbital rim, 2nd injection point 1 cm above and lateral to 1st

3 injection points 1–2 cm lateral to the orbital rim, 2–5 U/

forehead lines; the patient ideally can still elevate the eyebrows to a lesser extent than prior to treatment [1, 3, 6]. Intramuscular or intradermal (especially near eyebrow), 4–8 injection points in 1–2 rows, start injection with the upper lateral fibers to the mid forehead inferiorly (stop 2 cm above the brow), 2–4 U/point, total 8–25 U [6]. For narrow forehead less injection points and lower doses

To maintain neutral brow position and arch the corrugator supercilii, procerus and superiolateral fibers of orbicularis oculi are treated at the same time or a few days before

Intramuscular (at the site of levator labii superioris alaeque nasi and zygomaticus minor convergence with the insertion of levator labii superioris, 1–2 injection points, 0.5–2 U/

superficial ones need either resurfacing or hyaluronic fillers Intradermal, 2–5 injection points, 0.5–1 U/ point [3, 6].

Intramuscular, 1–2 points/ side, 2–3 U/ injection point. The main injection point is the posterior aspect of the depressor anguli oris muscle at the superior margin of the mandible, and at least 1 cm lateral to the oral commissure [3, 6].

Intramuscular, 2–3 injection points, 2 U/point [3].

perpendicular to the skin, 2–4 U [3]

injection point, 2–4 U/ point [3]

point, total dose is 6–15 U [3, 5].

**Frontalis** The target is to only soften, not to completely eliminate,

are used.

point [3]

frontalis injection [1, 3].

**Orbicularis oris** BTXN injection is recommended for deep rhytides,

**Orbicularis** oculi Intradermal or SC injection of the lateral muscle fibers,

hyperhidrosis, strabismus, blepharospasm

**32**


**Muscles written in bold** *are the injected muscles. Facial musculature varies between males and females, with increased strength and bulk in men. Thus, higher doses and increased number of injection points are generally required in men in all regions of the face [5].*

1 *Brow position is lowered with age "brow ptosis". Glabellar complex injection (20–40 U) lead to immediate lateral eyebrow elevation, followed by an entire brow lift that peaked 12 weeks post treatment. This effect is due to the toxin diffusion into the lower medial frontalis muscle fibers with subsequent increased tone in the upper and lateral frontalis fibers. Forehead lines is recommended to be done simultaneously with brow lift to maintain a neutral position for the eye brow [6].*

2 *Exposure of* ≥*2 mm of the gingiva on smiling [8]. Done for younger patients with strong lip elevator complex [6].* <sup>3</sup> *Youthful face is a heart shape with fullness in the upper part and tapering toward the mandible [1]. It is essential to exclude parotid gland hypertrophy either primary or secondary to pathology as Sjögren syndrome or bulimia nervosa or parotid gland mass using clinical assessment and CT imaging, or volume loss related masseteric prominence [3, 15].*

#### **Table 2.**

*Botulinum toxin neuromuscular indications in the face.*

### **2. Storage and reconstitution**

The various BTXN products are supplied as lyophilized powder containing vials except for rimabotulinumtoxin which is supplied in a liquid form [1].

#### **Figure 1.**

*Glabellar complex injection. (a) before: Procerus (blue dot) single intramuscular perpendicular to the skin, 2–4 U, corrugators* **(***black dots***):** *2 intramuscular injection points 2–4 U/point; first injection point 0.5–1 cm above the medial orbital rim, 2nd injection point 1 cm above and lateral to 1st injection point. (b) after.*

#### **Figure 2.**

*Lateral Canthal lines injections. (a) before: 3 intradermal injection points 1–2 cm lateral to the orbital rim 2–5 U/ point. (b) After.*

To reconstitute the powdered BTXN, a non- preserved saline, preserved (bacteriostatic) saline or lidocaine can be used as a diluent agent, the laters are associated with less pain on injection [1, 4].

The reconstituted vial can be used for up to 4 weeks safely if kept frozen at – 20°C or refrigerated at 4°C [1, 4].

A single vial can be used for multiple patients, as long as there is safe and sterile reconstitution and injection techniques are followed [1, 16].

**35**

is 20 U/0.1 cc [7].

**Figure 3.**

**3. Clinical considerations**

**3.1 Pretreatment assessment**

including the upper face [16].

contraction [5].

document consent [8].

*Botulinum Toxin for the Face*

*DOI: http://dx.doi.org/10.5772/intechopen.94495*

There are variable methods for BTXN reconstitution. 100 U vial of onabotuliunum A is commonly reconstituted in 2 cc of the diluent, which means there is 5 U/ 0.1 cc. 500 U of abobotulinum toxin A is diluted in 2.5 cc of the diluent so that there

*Forehead lines injection. 4–8 intramuscular - intradermal near eyebrow - injection points in 2 rows, starting* 

*with the upper lateral fibers (stop 2 cm above the brow), 2–4 U/point.*

The key to successful intervention is tailoring the treatment plan to every patient's need and combining different procedures to achieve best outcome [3]. Combination with hyaluronic acid fillers is increasingly utilized to optimize outcomes. The combined treatment with fillers can be considered for all regions,

For esthetic indications, the current trend accepted by both patients and physi-

Muscular and bony landmarks are to be used to identify the injection points [3]. It is recommended to discuss with the patients the black box warning and to

cians is to use BTXN in the least effective dose, injection points, and at longer intervals to achieve muscle activity modulation rather than muscle paralysis [3]. Assessment of the muscles should be performed at rest and at maximum muscle

#### **Figure 3.**

*Cosmetic Surgery*

**Figure 1.**

**34**

**Figure 2.**

*2–5 U/ point. (b) After.*

with less pain on injection [1, 4].

20°C or refrigerated at 4°C [1, 4].

To reconstitute the powdered BTXN, a non- preserved saline, preserved (bacteriostatic) saline or lidocaine can be used as a diluent agent, the laters are associated

*Lateral Canthal lines injections. (a) before: 3 intradermal injection points 1–2 cm lateral to the orbital rim* 

*Glabellar complex injection. (a) before: Procerus (blue dot) single intramuscular perpendicular to the skin, 2–4 U, corrugators* **(***black dots***):** *2 intramuscular injection points 2–4 U/point; first injection point 0.5–1 cm above the medial orbital rim, 2nd injection point 1 cm above and lateral to 1st injection point. (b) after.*

The reconstituted vial can be used for up to 4 weeks safely if kept frozen at –

reconstitution and injection techniques are followed [1, 16].

A single vial can be used for multiple patients, as long as there is safe and sterile

*Forehead lines injection. 4–8 intramuscular - intradermal near eyebrow - injection points in 2 rows, starting with the upper lateral fibers (stop 2 cm above the brow), 2–4 U/point.*

There are variable methods for BTXN reconstitution. 100 U vial of onabotuliunum A is commonly reconstituted in 2 cc of the diluent, which means there is 5 U/ 0.1 cc. 500 U of abobotulinum toxin A is diluted in 2.5 cc of the diluent so that there is 20 U/0.1 cc [7].
