Module 1, Course B - A Practical Guide To Botulinum Toxin Type A - The Scientific Art of Softening Lines and Wrinkles 2

The Academy for the
Advancement of Aesthetics
Module: Botulinum Toxin Type A
Course B: A Practical Guide to Botulinum Toxin

Type A – The Scientific Art of Softening
Lines and Wrinkles
Patient Assessment:
the Patient Consultation Process
► Careful patient assessment before injecting
BoNT/A is an essential part of the consultation
process.1
► Understanding your patient’s desires and
preferences at the outset enables you to set
realistic treatment goals and manage their
expectations.1,2
1. Carruthers J et al. Dermatol Surg 2013;39:510-525. 2. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment.
Aesthetic Medicine Expert Group: 2014. 2
Patient Assessment:
the Initial Consultation
An effective initial consultation should include the following key steps:
Your patient’s treatment goals
DISCUSS • Ensure patient expectations are in balance with realistic aesthetic outcomes
• Identify patients who may not be suitable candidates for treatment
Facial anatomy, including patterns of aging, skin elasticity, surface landmarks, muscle distribution and mass
ASSESS • Obtain the patient’s medical history and identify any contraindications or previous treatments
Your patients about the planned treatment and provide them with detailed information
INFORM • Include potential adverse events, contraindications, and precautions specific to the indication
• Address any questions and alleviate anxieties
The treatment and identify the muscles(s) to be treated
PLAN • Decide on the quantities of BoNT/A to be injected into the individual muscles
• Take into account any pre-existing asymmetry or natural ptosis
Patient information and the agreed treatment plan
DOCUMENT • Use patient photography and visual scales to record baseline status
• Obtain patient’s informed consent (in writing)
3
Patient Assessment:
Tips for Successful Patient Consultations
► Discussions should be clearly recorded in patients’ notes, including
the information and advice provided and how patients responded.
► You should provide patients with written information to take away
and read, and encourage them to ask questions.
► Once a patient has consented to treatment, include photographs in
the patient’s notes so it is clear what treatment is to be performed.
4
Patient Assessment:
Individualized Treatment
► The aesthetic treatment plan and the extent to which BoNT/A can
provide benefit is dependent on:1
► Physiological factors: patient lifestyle and genetics yield a unique aging
presentation
► Patient preference: the concept of aging and beauty is unique to each
patient
► You must be prepared to recognize and respond to these influences
by developing a treatment plan that is both tailored to your patient’s
aesthetic goals and realistic with respect to aesthetic outcome.
1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 5

Patient Assessment: Individualized Treatment:
Interactive Question
Which of the following factors do you think influence BoNT/A treatment outcomes?
A. Severity and type of wrinkle (static vs dynamic)
B. Baseline skin quality (eg, skin type)
C. Desired degree of clinical effect
D. Size and dynamic action of target muscle
E. All of the above
► Submit answer
6
Patient Assessment:
Key Points for Documentation
► It is important to document the planned treatment.
You can use an indication-specific treatment record form.
► Here are the key points to document in your patient’s
treatment record:
► Patient information and medical history, including any previous
treatments and their effects
► Patient goals, severity and type of lines, any asymmetry or natural
ptosis, skin type, and general skin health
► Discussion of product selection and alternative cosmetic procedures
► ‘Before’ and ‘after’ photographs
► The muscles to be treated (marked on the patient’s picture in the treatment record form)
► The quantities of BoNT/A to be injected into the individual muscles
► The timing of follow-up visits
7
Patient Assessment:
Facial Anatomy
► Pretreatment assessment should include careful evaluation of your patient’s
facial anatomy.1
► For example when treating the upper face with BoNT/A, it is important to
evaluate your patient at rest and during animation to assess:
► Dynamic and static lines
► Position and mobility of brows, eyelid function, presence of excess skin
► Volume loss in the upper face
► Potential asymmetries

Patient Assessment:
Steps in Evaluating Facial Anatomy
Step 1: Ask your patient to frown forcefully:
► Note strength and bulk of the contracting muscles
► Observe muscle origin and insertion
► Identify eyebrow position
► Note asymmetries and discuss them with your patient
Step 2: Mark sites for injection using a soft eyebrow pencil.

Step 3: Explain to your patient what proportion of the frown lines are
dynamic vs static:
► Static lines may also require a filler
Step 4: Observe your patient’s overall facial movements, mannerisms,
smile patterns, and other individual expressions.
9
Patient Assessment:
Importance of Observation
► The muscles of facial expression are part of a complex network of
anatomic and physiologic interactions.
► This means BoNT/A treatment can affect facial features other than those being
treated directly.
► For example, treatment of glabellar lines or periorbital wrinkles can alter
eyebrow shape and position.
► So, it’s important to evaluate the face as a whole in advance of any
aesthetic treatment.1

Patient Assessment:
Regional Diagnostic Tests
► Before treating a patient with BoNT/A, it is important to evaluate
certain features of the face.
► One such feature is eyelid laxity.
► Eyelid laxity indicates the potential for your patient to develop an ectropion
following treatment,1 a condition in which the eyelid is turned outwards away
from the eyeball.
1. Carruthers J et al. Plast Reconstr Surg. 2004;114(Suppl):1-22. 11

Regional Diagnostic Tests:
The Eyelid Snap Test
► This test is performed by pulling the lower
eyelid away and down toward the inferior
orbital rim.
► An eyelid without lower lid laxity will
return to its original position without the
patient blinking.
► An eyelid with lower lid laxity will remain
away from the eye for several seconds.
Nerad JA. Techniques in Ophthalmic Plastic Surgery: A Personal Tutorial. London; Elsevier: 2012. 12
Regional Diagnostic Tests:
The Eyelid Distraction Test
► This is performed by pulling the lower
eyelid away from the eyeball.
► The eyelid is considered to be lax if it
moves more than 6 mm off the
eyeball.1
► Treat patients with lower eyelid laxity with caution.

► You may wish to avoid the lower injection sites that are typically used
when treating periorbital lines with BoNT/A.2
1. Nerad JA. Techniques in Ophthalmic Plastic Surgery: A Personal Tutorial. London; Elsevier: 2012. 2. Carruthers J et al. Plast Reconstr Surg. 2004;114(Suppl):1-22.
Figure from Yoon JM, Kim SA, Roh JH. J Korean Ophthalmol Soc. 2008;49(12):1877-1887. 13
Essential Equipment and Supplies
It is essential that you have the basic equipment necessary for the administration
of BoNT/A in your practice, including the following:
1. Vial of BoNT/A
2. Alcohol or antiseptic wipes
3. 30G needles for injection
4. Vial of sterile, physiological saline (0.9% NaCl)
for reconstitution of BoNT/A
5. Syringe with 25G needle for reconstitution of BoNT/A
6. Syringes for administering BoNT/A eg, 1-mL syringes
7. Gauze pads
8. Ice pack or frozen gel packs for anaesthesia
9. Topical anesthetic cream
14
Emergency Equipment
► Every practitioner should also have emergency equipment on hand in the
treatment room.
► For allergic/anaphylactic reactions, the emergency bag should contain:1
1. Intravenous (IV) antihistamines
2. IV steroids
3. Adrenaline
► Products must be checked regularly to ensure that they are within their
expiry dates.
► Oxygen should also be available in the clinic.
1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. Aesthetic Medicine Expert Group: 2014. 15
Preparing Your Equipment for Use
► Close attention to antisepsis is vital to lower the risk of infection and
related AEs during the injection procedure.
Clean work environment1
• Keep work surfaces clean and tidy
• Use disinfectant wipes between patient visits
• Discard used materials immediately after a procedure
• If using cold packs, ensure they are cleaned with antiseptic wipes and wrapped in gauze awaiting use
Clean equipment1
• Use a single-use dressing pack for each patient
• Keep syringes, needles, and other equipment in a clean area before and during treatment
• Use ‘no touch” technique at all times, restricting any contact to clean zones
Correct Reconstitution and Mixing
of BoNT/As: Overview
► To help avoid suboptimal clinical outcomes by injecting incorrect
doses, it is importnt that the preparation is reconstituted and mixed
correctly.
► Each BoNT/A product needs to be reconstituted differently, as
outlined in the manufacturer’s guidelines.
► For all BoNT/A products, reconstitution should be performed in
accordance with good practice rules, particularly with respect to
asepsis.1-3
1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC; 2015. 2. DYSPORT [highlights of prescribing information]. Fort Worth, TX:
Galderma Laboratories, LP; 2016. 3. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016. 17
Correct Reconstitution and Mixing:
IncobotulinumtoxinA
► 50 U incobotulinumtoxinA is reconstituted for injection in 1.25 mL of 0.9% preservative-free NaCl.
► Once reconstituted, the vial contains a solution at a concentration of 4 U per 0.1 mL.
► The vial should be discarded if the vacuum does not pull the solvent into the vial.
► Once reconstituted, incobotulinumtoxinA is a clear, colourless solution, free of particulate matter.
► If the reconstituted solution has a cloudy appearance or contains floccular or particulate matter,
the vial should not be used.
► Any solution for injection that has been stored for more than 24 hours, as well as any unused
solution for injection, must be discarded.
► For further information on the importance of the correct reconstitution of incobotulinumtoxinA,

see the following article: Carey WD. J Drugs Dermatol. 2014;13:735-738.
NaCl, sodium chloride

XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC; 2015. 18
AbobotulinumtoxinA
► 125 Speywood units of abobotulinumtoxinA should be reconstituted
using 0.63 mL of 0.9% NaCl solution for injection.
► Accurate measurement can be achieved using 1-mL insulin-type
syringes, which have increments of 0.01 mL.
► Reconstitution will provide a clear solution containing 125 Speywood
units of active substance at a concentration of 20 U per 0.1 mL.
DYSPORT [highlights of prescribing information]. Fort Worth, TX: Galderma Laboratories, LP; 2016. 19
OnabotulinumtoxinA
► 50 U onabotulinumtoxinA is reconstituted for injection in 1.25 mL of 0.9%
preservative-free NaCl.
► Once reconstituted, the vial contains a solution at a concentration of
4 U per 0.1 mL.
► The central part of the vial’s rubber cap should be cleaned with alcohol
before the solution is added.
► The solution should then be injected slowly into the vial and gently rotated
to avoid bubble formation.
► The vial should be discarded if the vacuum does not pull solvent into the vial.
► The solution should be inspected before use to ensure that it is colourless
to slightly yellow, with no particles.
BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016. 20

All BoNT/As
► Although the manufacturers of both onabotulinumtoxinA and incobotulinumtoxinA
specify the use of preservative-free NaCl as the diluent, in recent consensus publications
experts agree that the use of preservative-free or preserved NaCl is acceptable for
reconstitution.1,2
► Each vial of onabotulinumtoxinA, abobotulinumtoxinA, and incobotulinumtoxinA is
approved for single-patient use during a single session.
► A consensus panel concluded that a single-use vial can be used for multiple patients, providing that
sterile procedures are carefully followed.2 A clinical study with onabotulinumtoxinA found that the vials
remained sterile under multiple-use conditions.3
► ‘Vial splitting’ is an off-label practice and it is essential to have a clear workplace policy on how products
are to be safely handled and used.
► AbobotulinumtoxinA and incobotulinumtoxinA must be used within 24 hours of
reconstitution; abobotulinumtoxinA must be used within 4 hours.4-6
1. Hexsel D et al. J Drugs Dermatol. 2010;9(Suppl 3):31-37. 2. Kane M et al. J Drugs Dermatol. 2010;9(Suppl 1):7-22. 3. Alam M et al. J Am Acad Dermatol. 2006;55:272-275.
Storage and Safe Disposal of BoNT/As
► Itis important to have a good understanding of how to store and
appropriately dispose of any unused BoNT/A product.
► Historically, recommendations stated that reconstituted BoNT/A
should be used within 24 hours and in a single patient.
► A recent consensus panel concluded that, for facial muscle
indications, a vial of toxin reconstituted appropriately:
► Can be refrigerated or refrozen for at least 4 weeks before injection without
significant risk of contamination or decreased effectiveness1
► Can be used to treat multiple patients, assuming appropriate handling1
1. Alam M et al. Dermatol Surg. 2015;41:321-326. 22

Safe Disposal: IncobotulinumtoxinA
► Once reconstituted, incobotulinumtoxinA can be stored at 2°–8°C for 24 hours
but, from a microbiological point of view, the product should be used
immediately.
► For safe disposal, unreconstituted incobotulinumtoxinA should be reconstituted
in the vial with a small amount of water and autoclaved.
► Any empty vials, vials containing residual solution, syringes or spillage should be
autoclaved.
► Alternatively, the remaining incobotulinumtoxinA can be inactivated with diluted sodium
hydroxide or sodium hypochlorite solution.
► After inactivation, used vials, syringes and materials should not be emptied and
must be discarded into appropriate containers and disposed of in accordance
with local requirements.
XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC; 2015. 23
Safe Disposal: AbobotulinumtoxinA
► Once reconstituted, abobotulinumtoxinA can be stored at 2°–8°C for
4 hours but, from a microbiological point of view, the product should
be used immediately.
► Any unused, reconstituted abobotulinumtoxinA in the vial or syringe
should be inactivated with 2 mL of 0.5% or 1% sodium hypochlorite
solution.
► Used vials, syringes and materials should not be emptied and must
be discarded into appropriate containers and disposed of in
accordance with local requirements.
3. DYSPORT [highlights of prescribing information]. Fort Worth, TX: Galderma Laboratories, LP; 2016. 24
Safe Disposal: OnabotulinumtoxinA
► Once reconstituted, onabotulinumtoxinA can be stored at 2°–8°C for
24 hours, but immediate use is recommended.
► Immediately after use (and prior to disposal) any unused,
reconstituted solution in the vial and/or syringe must be inactivated
with 2 mL of 0.5% or 1% sodium hypochlorite solution and then
disposed of in accordance with local requirements.
. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016. 25

What to Do in Case of Product Spills
► Any BoNT/A spillages must be wiped up using the following methods:1-3
► For incobotulinumtoxinA, use an absorbent material impregnated with a solution
of sodium hydroxide or sodium hypochlorite for the powder, or a dry absorbent
material in the case of reconstituted product.
► For abobotulinumtoxinA, use an absorbent material impregnated with a solution
of sodium hypochlorite for the powder, or a dry absorbent material in the case of
reconstituted product.
► For onabotulinumtoxinA, use an absorbent material soaked in a solution of
sodium hypochlorite in the case of vacuum-dried product, or a dry absorbent
material in the case of reconstituted product.
► Any contaminated surfaces should be cleaned in the same way, and then dried.
What to Do in Case of Skin Contact
► For incobotulinumtoxinA, wash the affected area with a solution of
sodium hydroxide or sodium hydrochlorite then rinse abundantly
with water.
► If the product makes contact with a wound or open skin, rinse with plenty of
water and take appropriate medical steps according to the dose injected.1
► For abobotulinumtoxinA or onabotulinumtoxinA, wash with a
solution of sodium hypochlorite and then rinse thoroughly with
plenty of water.2,3
What to Do in Case of Eye
Contact or Vial Breakage
► Eye contact
► IfBoNT/A comes into contact with the eyes, rinse with plenty of water or
with an ophthalmic eyewash solution.1-3
► Vial breakage
► If a vial breaks, collect the pieces of glass (taking care not to cut the skin) and
wipe up the product as described earlier.1-3
Preparing the Face for BoNT/A Injections
► Before treating your patient with BoNT/A, you should first review your patient’s
notes to check for previous local or systemic infection.
► When you are ready to proceed, thoroughly clean your hands, the area of
injection, and the surrounding skin.
Clean your hands1
• Position the patient and lighting before cleaning hands
• Disinfect your hands prior to using clean gloves
• Do not touch surfaces, lights, non-clean areas before starting treatment and during procedure
Clean your patient’s face1

• Remove all make-up
• Clean the skin with an antiseptic wipe, solution, or spray
• Do not allow patient to touch areas after cleaning
Preparing the Face for BoNT/A Injections
(continued)
► Alcohol can denature BoNT/As.

► After cleaning your patient’s face, it is important to allow the
cleansed area to dry completely before proceeding with injections.
► Scrupulous adherence to aseptic technique is vital to reduce the risk
of infection when treating your patients with BoNT/A.
30
Softening Glabellar Frown Lines with BoNT/A:
Overview
►A sound knowledge of injection techniques, as well as facial
anatomy, is essential to optimize benefits and minimize
complications when using BoNT/A in aesthetic procedures.1
1. Ascher B et al. J Eur Acad Dermatol Venereol. 2010;24:1278-1290. 31

Glabellar Frown Lines:
► When treating glabellar frown lines with BoNT/A, what are the 2 primary target
muscles? Select 2 answers from the options below:
A. Procerus
B. Frontalis
C. Corrugator supercilii
D. Orbicularis oculi
Submit answer
1. Ascher B et al. J Eur Acad Dermatol Venereol. 2010;24:1278-1290. 32

Interindividual Differences
► Interindividual differences in wrinkles generated during animation have been
observed.
► The 5 patterns of lines generated in the glabellar region are the ‘U’, ‘V’, ‘converging arrows’,
‘omega’, and ‘inverted omega’ patterns.
► The most common patterns are ‘U’ and ‘V’, and each pattern should be approached
differently for treatment purposes.1
► Precise analysis of a patient’s age-related changes, patterns of muscle
contraction and facial expressions should precede any treatment with BoNT/As.
► Typically, glabellar lines are characterized by 1, 2, or 3 vertical lines, with or
without a horizontal furrow at the root of the nose.
► Some patients have horizontal furrows only.
► You may still want to treat the corrugator muscles in these patients as they may contribute to
the formation of both horizontal and vertical lines.
33
Locating the Corrugator Supercilii
► When treating glabellar frown lines it is
important to locate the corrugator supercilii
muscle, both by visualisation and palpation.
► The muscle is found at the medial end of the
eyebrow, just above the orbicularis oculi muscle,
and it inserts into the underside of the frontalis
(4.2–4.5 mm from the midline).
► The body of the corrugator supercilii muscle is
deep to the frontalis muscle, becoming more
superficial at its tail.
► Depth of injection needs to be tailored
accordingly and the corrugator muscle located
by palpation along its entire length.
1. de Almeida AR et al. Dermatol Surg. 2012;38:1506-1515. 34

Softening Glabellar Lines:
Injection Sites
► The number of injection sites varies
between patients: consider 1 or 2 injection
sites in the medial portion of the
corrugator.
► The second injection site may be needed
for patients with severe vertical glabellar
lines.
► Red arrows indicate direction of the pull of

the muscles
35
Softening Glabellar Frown Lines with
BoNT/A: Injection Technique
Main target • Corrugator supercilii (mainly vertical furrow between brows)
muscles • Procerus (mainly horizontal furrow at the root of the nose)
Location of • Corrugator supercilii (mainly vertical furrow between brows)
injections • First injection site: medial portion of the muscle, near its origin, at least 1 cm above the bony orbital rim
• Second injection site (optional): in line with the midpupilary line above the eyebrow
• Procerus (mainly horizontal furrow at root of the nose)
• Middle of the muscle belly, found by drawing a line between the medial aspect of the brow to the medial
canthus of the opposite eye
• Expert tip: mark these injection sites (including the potential danger zones) using a soft eyebrow pencil
Recommended • Use a sterile needle, 30–33G (0.3–0.2 mm diameter), 13 mm length
needle
Injection depth • Intramuscular for medial portion of corrugator muscle and intradermal or subdermal for central or tail portion
• The tip of the needle, bevel up, should be directed outside the orbital rim and inserted 4–5 mm to reach the
periosteum and then retracted back 1–2 mm
• Intradermal or subdermal for procerus muscle
Recommended • IncobotulinumtoxinA/onabotulinumtoxinA: 20 units per treatment session, divided into 5 equal injections
standard of 4 units each
dose1-4 • AbobotulinumtoxinA: 50 units per treatment session, divided into 5 equal injections
1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 2. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC; 2015.
3. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016. 3. DYSPORT [highlights of prescribing information]. Fort Worth, TX:
Galderma Laboratories, LP; 2016. 36
BoNT/A: Safety Considerations
• In general, to prevent brow ptosis, avoid injecting laterally past the mid-pupillary line
• However, this should be decided based on the individual patient, as in some cases there will be
corrugator activity lateral to the mid-pupillary line
• In these patients, injections past the mid-pupillary line will be required and should be very superficial
• Ask your patient to contract their corrugator muscles as this will allow you to identify their precise position.
Injecting at the correct depth will avoid recruitment of the frontalis muscle.
• Avoid injecting too high (>1 cm above the orbital rim), as this can block the action of the frontalis
• To avoid lid ptosis and diplopia, do not inject the levator palpebrae superioris, into the cranial portion of the
orbicularis oculi or within the bony orbital rim
• The levator palpebrae superioris muscle can be avoided by injecting above the supraorbital ridge found at
the boundary between the forehead and upper eyelid
• Protect the supraorbital rim with the non-dominant hand
• Direct the needle away from the orbit to minimize the risk of adverse effects
37
BoNT/A: Expected Results
►A 2-point change in the Merz Aesthetics Scales rating for glabellar
frown lines can be expected
► For example, a patient with severe glabellar lines at maximum frown
(a rating of 3) could expect an improvement to mild glabellar lines at
maximum frown (a rating of 1)
Figures reprinted with permission from Flynn TC et al. Dermtol Surg. 2012;38:309-319. 38
Softening Glabellar Frown Lines Mephisto eyebrow
with BoNT/A: Expert Tips

► Recruitment of the frontalis can be avoided by not placing
injections any further lateral than the mid-pupillary line.
► However, if there is recruitment of the frontalis leading to
the ‘Mephisto’ or ‘Spock’ eyebrow, this can be countered by injecting a small amount of
neuromodulator into the frontalis above the point of the highest eyebrow elevation.
► Men typically have larger and longer corrugators than women, and Asian patients
tend to have shorter and broader corrugators than Whites.1
► Injection sites and doses may need to be adjusted to accommodate these differences.
► There are guidelines that include recommendations on the use of BoNT/As to
treat glabellar lines.
► In particular, the publication by Carruthers and colleagues provides consensus guidelines
for treating glabellar lines with BoNT/As.2
Photo courtesy of Kyle K. Seo, MD.

1. Yang HM, Kim HJ. Surg Radiol Anat. 2013;35:817-821. 2. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 39
► What injection depth is used for the lateral side of the corrugator muscle?
A. Superficial
B. Deep
► Submit answer
40
‘Before’ and ‘After’ Photographs
Before After Before After
41
Softening Lateral Periorbital Lines with
BoNT/A: Injection Points
► Skin wrinkling in the lower eyelid results from the hyperkinetic behaviour of the
palpebral portion of the orbicularis oculi muscle.
► The lateral portions of the orbicularis oculi are targeted when treating lateral
periorbital lines with BoNT/A.
Orbicularis oris
42
Target muscle • Orbicularis oris
Location of • The first injection should be ≈1 cm lateral from the bony orbital rim (in the prolongation of the lateral
injections epicanthus); the other 2 injections should be placed ≈1 cm above and below the first injection point
along an arc ≈1 cm from the bony rim

needle
Injection depth • Intradermally above the orbicularis oculi muscle, directly into the dermis; the needle, bevel up, should
be inserted almost parallel to the skin
Recommended • IncobotulinumtoxinA/onabotulinumtoxinA: 24 units total dose (typically 12 units per side), divided
standard among 3 injection points per side
dose1-3 • AbobotulinumtoxinA: based on consensus as not currently approved for this indication
• 20–60 units total dose, divided among 3 injection points, optional fourth injection point of 10
units
1. XEOMIN [highlights of prescribing information]. Raleigh NC: Merz Pharmaceuticals, LLC; 2015. 2. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA:
Allergan; 2016. 3. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 43
BoNT/A: Safety Considerations
• Inject with caution in patients with dry eyes, prominent eye bags, scleral show, or morning eyelid edema
• To avoid spread of toxin and subsequent diplopia, the lateral orbital rim should be protected using the non-
dominant hand
• To avoid lip ptosis, do not inject near the zygomaticus major muscle, which can be avoided by remaining
above the orbicularis oculi muscle and injecting very small doses intradermally, approximately 1–1.5 cm
from the orbital rim
• Where possible, avoid injection into veins in the lateral canthus; these veins may be revealed under
appropriate lighting and magnification
• Keep injections superficial and direct the needle away from the orbit to minimize risk of adverse effects
• Consider the extrusion pressure used during injection – inject slowly to reduce the risk of botulinum toxin
spreading; this can also help prevent diplopia (double vision) when the lateral rectus muscle is affected and
eyelid ptosis when the levator palpebrae superioris muscle is reached
44
BoNT/A: Expected Results
►A 2-point change in the Merz Aesthetics Scales rating for assessing
crows feet can be expected
► For example, a patient with very severe wrinkles at maximum smile (a rating
of 4) could expect an improvement to moderate wrinkles at maximum smile
(a rating of 2)
BoNT/A: Expert Tips
► Injecting along an arc 1 cm from the lateral and inferior orbital rim
mitigates the risk of intraorbital diffusion and inadvertent lid ptosis,
and also preserves natural expressions.
► In Whites, the orbicularis oculi muscle has been found to extend
≈1.4 cm superior, 1.2 cm inferior and 2.5 cm lateral to the orbital rim.
► In White men, the muscle extends significantly further superiorly and
laterally than in women.1
► Anatomical variations in the orbicularis oculi also exist between
individuals.

BoNT/A: Microdroplet Technique
►A microdroplet technique can be used to create a smooth transition
between the treated periorbital area and the non-treated area of the
upper cheek.
► See the article by Imhof and Kuhne to learn more about this
technique.1
1. Imhof M, Kuhne U. J Clin Aesthet Dermatol. 2013;6:40-44. 47

Softening Periorbital Lines with BoNT/A:
Before After
48
Softening Periorbital Lines with BoNT/A:
Treatment Guidelines
► The consensus guidelines for treatment of periorbital lines by
Carruthers and colleagues are particularly relevant1
► The infraorbital crease can be treated with neuromodulators,
providing the patient shows a good response in a ‘snap test’ used to
measure lower skin laxity.
► Treating the lower eyelids is not for the novice injector, due to the delicacy of
this area.

Softening Horizontal Forehead Lines
with BoNT/A: Injection Points
► When treating horizontal forehead lines with neuromodulators, the number of
injections sites and dose should be tailored to your patient and based on their
forehead width and muscle mass. This may also vary with sex and ethnicity.
► Carruthers and colleagues provide more information on this topic.1
1. Carruthers JD et al. Plast Reconstr Surg. 2008;121(5 Suppl):5S-30S. 50

with BoNT/A: Injection Technique
Target muscle • Frontalis
Location of • The most lateral injection sites should be 1–1.5 cm lateral to the temporal fusion line (usually in line
injections with the lateral canthal line)
• Place 4–6 injections across the midline or upper third of the forehead

needle
Injection depth • Intra- or subdermal
Recommended • IncobotulinumtoxinA/onabotulinumtoxinA
standard dose • 5–15 units total dose, divided among 4–10 injection points;1 however, up to 20 units may be
needed in some patients
• Also, to preserve eyebrow movement, lower initial doses are advisable (2–6 units)
• AbobotulinumtoxinA
• 20–60 units total dose, divided among 4–6 injection points1

with BoNT/A: Safety Considerations
• Injecting into the frontalis can cause over-weakening of the muscle, resulting in brow ptosis1
• Variation in the structure, size, and strength of the frontalis muscle means injection sites and toxin volume should be
adjusted based on the individual’s characteristics
• Expert tip: inject into brow depressors to avoid brow ptosis when treating brow elevators
• Care should be taken to avoid blood vessels to reduce the risk of bruising and bleeding
1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London: Aesthetic Medicine Expert Group: 2014. 52
with BoNT/A: Expected Results
►A 2-point change in the Merz Aesthetics Scales rating for forehead
lines can be expected.
► For example, a patient with moderate lines with expression (a rating of 2)
could expect an improvement to no lines with expression (a rating of 0)
with BoNT/A: Expert Tips
► Lateral
recruitment of the frontalis can lead to ‘Mephisto’ or ‘Spock’
eyebrow.
► The risk of this occurring can be minimized by keeping the most lateral
injection sites 1–1.5 cm lateral to the temporal fusion line.
► The temporal fusion line is usually found in line with the lateral canthus.
► You can locate the temporal fusion line by asking the patient to clench their
jaw and then palpating the temple area.
► Intradermal microinjections are effective for treating any small lines
above the lateral eyebrow.
54
with BoNT/A: Interactive Question
► From the video, what is the minimum distance above the eyebrow
that a full dose of BoNT/A should be injected?
Please select an answer from the list below:
A. 1 cm
B. 1.2 cm
C. 1.5 cm
D. 2.2 cm
E. 2.5 cm
► Submit answer
55
Softening Horizontal Forehead Lines with
BoNT/A: ‘Before’ and ‘After’ Photographs
Before After
56
Lateral Eyebrow Elevation with BoNT/A:
Injection Points
► The ideal shape of the eyebrow has been described as having the crest of the arch over
the lateral canthus.
► With age, the shape and vertical position of the eyebrow changes as the muscles weaken.
► BoNT/As can be used to lift the lateral eyebrow but it is important to tailor treatment
based on each patient’s facial shape.
57
Injection Technique
Target muscle • Upper lateral part of orbicularis oculi
Location of • A single injection into the upper lateral fibres of the orbicularis oculi, ≈0.5 cm above the orbital rim in
injections line with the lateral canthus

needle
Injection depth • Intra- or subdermal
standard dose1 • 3–7 units under the tail of the eyebrow, plus inactivation of central depressors
• 5–10 units under the tail of the eyebrow

Safety Considerations
• Care should be taken to avoid blood vessels to reduce the risk of bruising and bleeding.
• Be aware that, in patients with severe blepharochalasis and elastosis, there might be a higher risk of
diffusion and eyelid ptosis.
59
Expected Results
►A 2-point change in the Merz Aesthetics Scales rating can be expected
► For example, a patient with flat arch to the eyebrow (a rating of 3) could
expect an improvement to a medium arch (a rating of 1)
Expert Tips
► Good lighting and stretching the skin may help you avoid blood vessels and
minimize the risk of bleeding and bruising.
► These complications are common because the periorbital skin is thin and contains numerous
blood vessels.
► In practice, injection of the lateral orbicularis oculi under the tail of the eyebrow
to give a lateral brow lift is commonly combined with treatment of the glabellar
frown lines.1,2
► Other techniques used for eyebrow positioning and shaping have been
described; these are advanced techniques.3
1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 2. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment.
London: Aesthetic Medicine Expert Group: 2014. 3. Bistoni G, Figus A. Minimally Invasive Procedures for Facial Rejuvenation. Eds. Giuseppe C, Antonio R. Foster City,
CA; OMICS Group eBooks: 2014. 61
Before After
62
Softening Nasal Rhytides with BoNT/A:
Overview
► Several muscles are responsible for the production of nasal wrinkles.1
► In particular, nasal wrinkles are associated with contraction of the levator labii superioris alaequae nasi
and the transverse portion of the nasalis muscle.
► The levator labii superioris alaeque nasi, a thin muscle lateral to the nose, runs between the
inner margin of the orbit and upper lip and contributes to movement of the upper lip and ala of
the nose.
► The transverse portion of the nasalis muscle arises from the nasal bone, runs inferolaterally
across the bridge of the nose and inserts bilaterally into the skin above the nasal ala.1
► The levator labii superioris muscle and the levator labii superioris alaeque nasi muscle are
responsible for the ‘gummy smile’, an excessive gum line exposure with a full smile where the
gingiva above the canines can be seen.2
► This can be treated by targeting these muscles to drop the upper lip.
► Care must be taken to not weaken the zygomaticus major muscle by injecting too laterally over the
malar mound.
1. Tamura BM et al. Dermatol Surg. 2005;31:271-275. 2. Bistoni G, Figus A. Minimally Invasive Procedures for Facial Rejuvenation. Eds. Giuseppe C, Antonio R.
Foster City, CA; OMICS Group eBooks: 2014. 63
Classifications
Nasal wrinkles have been classified into 4 types according to the
anatomic differences that exist between individuals.1
Type of Nasal Rhytides Location of Wrinkles

Nasalis rhytides Nasal dorsum
Nasoalar wrinkles Around the alar groove
Naso-orbicular wrinkles At the root of the nose and between the eyes
Nasociliary wrinkles At the lower glabellar region and the medial region of the eyes
1. Tamura BM et al. Dermatol Surg. 2005;31:271-275. 64

Injection Points
► Nasal wrinkles(‘bunny lines’) can frequently be treated with BoNT/A injected into
the nasalis muscle.
► However, some nasal wrinkles remain after treatment and understanding nasal
wrinkle patterns allows for more effective wrinkle treatment of the nose.1
1. Tamura BM et al. Dermatol Surg. 2005;31:271-275. 65

Injection Technique
Target muscle • Dorsal nasalis and the levator labii superior alaeque nasi
Location of • Nasalis, 1 per side; occasionally an additional, single injection point on the bridge
injections of the nose may be required
Injection depth • Intramuscular
Recommended • For incobotulinumtoxinA/onabotulinumtoxinA: 1–3 units, bilaterally

standard dose1 • For abobotulinumtoxinA: 2.5–7.5 units, bilaterally
1. Bistoni G, Figus A. Minimally Invasive Procedures for Facial Rejuvenation. Eds. Giuseppe C, Antonio R. Foster City, CA; OMICS Group eBooks: 2014. 66
Expert Tips
► When treating this area it is important to avoid the levator labii superioris, as
chemodenervation of this muscle will cause elongation (and possibly drooping)
of the upper lip.
► For the same reason, activity of the levator labii superioris alaequae nasi should
not be fully obliterated.
► To avoid chemodenervation of the levator labii superioris, draw an imaginary
line from the middle of the nasal side wall and ensure injection points are kept
superior to this line.
► This will avoid injection into the insertion point of the levator labii superioris.
► The medial branches of the angular artery and the dorsal nasal artery are
located at the top of the nose and should also be avoided to reduce the risk of
ecchymosis or hematoma.1
Before After
68
Softening Perioral Lines with BoNT/A:
Injection Points
► The orbicularis oris may be injected to smooth out perioral lines.
► However, great care must be taken to avoid overdosing as this can lead to a
raised or drooped lip, or asymmetry.1
Injection Technique
Target muscle • Orbicularis oris
Location of • Orbicularis oris, within 5 mm of the vermilion border

injections
needle
Injection depth • Subdermal
standard dose1 • 4–6 units total dose, divided across 2–6 injection points
• Upper lip: 5–15 units total dose, divided across 2 or 4 injection points
• Lower lip: 5–15 units total dose, divided across 2 injection points
► Weakening of the orbicularis oris muscle by treating the vermilion border results in slight
eversion of the upper lip. This may produce the appearance of fuller lips.2
1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 2. Bistoni G, Figus A. Minimally Invasive Procedures for Facial Rejuvenation. Eds. Giuseppe C, Antonio R.
Foster City, CA; OMICS Group eBooks: 2014. 70
• Consider how the juxtaposing muscles work together to move the mouth; unbalanced dosing or
asymmetrical injection can lead to loss of the ability to purse the lips and an asymmetrical smile1
• Avoid injecting around the oral commissures and keep injection points 1 cm medial to the oral commissures
• Botulinum toxin type A may spread to, and weaken, the lateral lip elevator muscles; this can result in lip
ptosis and drooling
• Injecting the midline should also be avoided to prevent effacement of Cupid’s bow1
Expected Results
►A 2-point change in the Merz Aesthetics Scales rating can be
expected
► For example, a patient with very severe wrinkles (a rating of 4) could expect
an improvement to moderate wrinkles (a rating of 2)
72
Before After
73
Softening Marionette Lines with BoNT/A:
Overview
► Overactivity of the depressor anguli oris (DAO) can contribute to the appearance of
indentations in the corners of the mouth and lines extending from the corners of the mouth
down to the chin (so called ‘marionette lines’).1
► Treatment with BoNT/A may be useful in weakening the DAO, thus allowing the zygomaticus
major and levator anguli oris muscles to lift the corners of the mouth back to a horizontal
plane, which may improve the appearance of ‘marionette lines.’
Injection Technique
Target muscle • Depressor anguli oris (DAO)
Location of • Lower third of the DAO

injections • Draw a line straight down from the mouth; the injection site should be 1 cm lateral
to this line
needle
Injection depth • Intramuscular/subdermal
Recommended • IncobotulinumtoxinA/onabotulinumtoxinA: 1-7.5 per side
standard dose1 • AbobotulinumtoxinA: 2.5–10 units per side
► It is important to target the most lateral part of the DAO muscle. Precise injection is very
important to ensure symmetry.
► You can check whether the needle is intramuscular by asking your patient to contract the DAO
muscle. You should feel a pull on the needle.

• Complications, such as an asymmetrical smile, as well as difficulties eating, speaking and drinking, can
arise when toxin penetrates too deeply into the DAO or injections are misplaced1
• To avoid such complications, injections into the depressor labii inferioris, orbicularis oris, mentalis and
platysma should be avoided
Expected Results
►A 2-point change in the Merz Aesthetics Scales rating can be
expected
► For example, a patient with severe lines (a rating of 3) could expect an
improvement to mild lines (a rating of 1)
77
Before After
78
Treating Cobblestone Chin with BoNT/A:
Overview
► Repeated contraction of the mentalis can result in ‘orange peel’-like indentations
or ‘cobblestone chin’.
► It is important to take into account the strength of the muscle and tailor the dose
accordingly.
79
Injection Technique
Target muscle • Mentalis
Location of • 2 symmetrical injection sites approximately 1 cm from the midline, or a single site in the
injections midline
needle
Injection depth • Intramuscular
standard dose • 2–5 units per side,1 although doses as low as 2 units may be sufficient2
• 5–25 units total dose, distributed across 1–2 injection sites1
London: Aesthetic Medicine Expert Group: 2014. 80
Safety Considerations and Expected Results
• It is important to avoid injecting too laterally into the depressor labii inferioris to prevent an asymmetrical
smile
• The ‘V’ shape of the muscle should be considered to ensure the injection is within the muscle, and (if
injecting centrally) that spread of toxin occurs to both sides
• If injection is administered too far cranially, lip ptosis may occur by diffusion into the orbicularis oris
• Intramuscular injection just above the periosteum and inferior to the chin crease will avoid undesired oral
incompetence and problems with articulation
• These problems may result from weakening of the orbicularis oris and depressor labii inferioris
► Expected results
► A moderate improvement in the dimples of the chin
81
Expert Tip
► Depending on the strength of the muscle, it is possible to treat the mentalis in
both the superficial and deep layers using 4 injection sites.
82
Before After
83
Treating Masseteric Hypertrophy with
BoNT/A: Overview
► Treatment of the masseter is an established paradigm in Asia where
patients have a tendency for benign masseteric hypertrophy.
► Asian patients may have a larger masseter mass and this may
influence the number of injection sites and dosing.1,2
► Chewing and excessive grinding of the teeth may result in
reactionary masseteric hypertrophy.
1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London: Aesthetic Medicine Expert Group: 2014.
2. Kim NH et al. Plast Reconstr Surg. 2005;115:919-930. 84
Target muscle • Masseter
Location of • 2–5 injection sites per side

injections • Inject low into the masseter, just above the mandible
needle
Injection depth • Deep intramuscular (touch periosteum with needle tip then slightly withdraw needle)
standard • 10–20 units per side; however, doses can be increased to 25–50 units (as needed
dose1,2 and as tolerated)
1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London: Aesthetic Medicine Expert Group: 2014.
2. Carruthers J et al. Plast Reconstr Surg. 2008;121(Suppl):5S-30S. 85
Treating Masseteric Hypertrophy with BoNT/A:
Safety Considerations and Expected Results
• Asymmetric smile can be caused by the diffusion of BoNT/A into the risorius muscle, which is superficially
attached to the anterior part of the masseter muscle1
• Deep intramuscular injection can help avoid diffusion of botulinum toxin type A into the risorius
• Injecting too high into the masseter can result in diffusion of toxin into the zygomaticus, which may result in
drooping of the lip
• Repeated, high-dose injections over several years can result in chronic muscular atrophy
► Expected results
► Bilateral injection of the masseter muscles can decrease their prominence
and produce tapering of the lower face
BoNT/A: Expert Tip
► Locate the masseter muscle by asking
the patient to clench their jaw.
► Draw a line from lip corner to ear tragus
(superior border) and keep injections
below this line.
► Injections should be 1 cm away from
every border. Identify area
of maximum
thickness
87
BoNT/A: ‘Before’ and ‘After’ Photographs
Before After
88
Aftercare
► Patient aftercare is a vital part of ensuring a successful treatment outcome for
you and your patient.
► When BoNT/A is used to treat periorbital lines, the duration of effect is usually
less than that observed in other areas of the upper face, generally lasting up to
3 months.1
► It is important to make your patient aware of what to expect after treatment.

Aftercare: Immediate Posttreatment
Discussion with Patients
Immediately after treatment, you should remind
your patient of the following:
► Onset of effect usually starts within 2–3 days, with
the maximum effect being observed at 2–4 weeks
► The duration of action generally lasts up to 4 months
► The period between each treatment session
should be at least 3 months
► To return for a follow-up visit
► To seek medical help immediately if swallowing,
speech, or respiratory disorders occur
► Whom to contact if they have any concerns
► To expect some mild bruising and swelling that should resolve after a few days
90
Aftercare:
Recommendations to Speed Patient Recovery
► You may wish to apply a cold compress to soothe the area and reduce posttreatment swelling
► Do not lie down for approximately 4 hours after the injection
► Use creams containing vitamin K or arnica on treated areas to help bruises fade more quickly
► Wash the area gently every day
► Should you have any reactions that cause you concern, or any worsening of symptoms, you
should contact your clinician
► Remember to provide your patients with contact details in case they have any concerns
► Do not massage, scrub, or rub the treated area after treatment
► Try not to wear make-up or touch the treated area unnecessarily after treatment
► Try not to drink alcohol as this can increase the risk of bruising
► Try not to exercise strenuously after treatment to allow treatment effects to settle
► Do not use a sauna or steam room, and stay out of strong sun after treatment
Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. Aesthetic Medicine Expert Group: 2014. 91
Follow-up Visits and Repeat Treatments
► To assess response to initial treatment, there is general consensus
that 2 weeks is appropriate for patient follow-up.1
► The follow-up visit provides you with the opportunity to see if the
patient has responded well to their treatment and to check for any
signs of complications, such as infection.

Follow-up Visits and Repeat Treatments:
Lack of Treatment Response
► Most patients re-visit the practice for retreatment after 3–4 months.1
► If no treatment effect occurs within 2 weeks of initial BoNT/A treatment, the
following measures should be taken:
► Consider possible reasons for nonresponse (eg, injection into the wrong muscles, incorrect
injection technique, insufficient dosage, formation of neurotoxin-neutralizing antibodies)
► Re-evaluate BoNT/A treatment as adequate therapy
► An additional treatment may be performed if no AEs occurred during the initial
treatment and under the following conditions:
► Dose adjustment with regard to the analysis of the most recent therapy failure
► Compliance with the minimum interval of 3 months between initial and repeat treatment

Common Mistakes and How
to Avoid Them
► The most common mistakes that occur with BoNT/A treatment are related to the injection strategy.
► Even small errors in dosing or placement of injections can lead to poor aesthetic outcomes.1,2
Unwanted Effect Cause(s) How to Avoid/Manage

‘Mephisto’ or • Too much BoNT/A injected into the glabella • You must understand the variable anatomy of
‘Spock” eyebrow complex and medial frontalis, without the muscles in the upper face; this effect can
treatment of the lateral frontalis be treated with the selective injection of a
• Alternatively, it can be caused by too much small amount of neurotoxin into the lateral
toxin injected into the lateral orbicularis oculi part of the frontalis2
when trying to lift the tail of the eyebrow2
‘Frozen look’ (no • Too much BoNT/A injected into the muscles • A careful patient assessment and injection
natural movement of facial expression such as orbicularis oculi, strategy is essential for avoiding the ‘frozen
in the glabella) frontalis, and corrugator muscles, although look’
for some individuals (dependent on sex and
ethnicity) the ‘frozen look’ might be a
desired outcome
to Avoid Them (continued)
Unwanted Effect Cause(s) How to Avoid/Manage
Drooping eyelids or • BoNT/A injected into the corrugator • A careful injection strategy is essential for
eyebrows/eyelid ptosis superciliary muscle (or rarely avoiding lid ptosis; injections in the glabella
(blepharoptosis)a orbicularis oculi muscle) may diffuse region should be kept at least 1 cm above the
bony orbital rim and should not cross the
into the levator palpabrae superioris
mid-pupillary line
muscle responsible for eye opening • Iopidine 5 mg/mL eye drops may improve
ptosis1
Drooping of the • BoNT/A penetrates the zygomaticus • Inject very small doses intradermally,
corner of the mouth major muscle ≈1–1.5 cm from the orbital rim to avoid
the zygomaticus major
Lower lip • Inaccurate BoNT/A placement into • This effect can be treated by injecting
asymmetry the depressor labii inferioris when neurotoxin into the contralateral
treating the depressor anguli oris or depressor labii inferioris
the mentalis, or inadequate initial
patient assessment
aTrue ptosis is a rate event
to Avoid Them: Expert Tips
► To avoid making these common mistakes, follow the top tips below:
► Make a treatment plan and adhere to it
► Know your anatomy and the danger zones to avoid when injecting
► Read the treatment guidelines, know the treatment guidelines, follow the
treatment guidelines
► Ensure your injection experience is sufficient for the procedure
► Remember, these unwanted effects are usually temporary, but your

patient’s dissatisfaction might not be!
96
The Scientific Art of Softening Lines and
Wrinkles: Summary
You should now have an understanding of the following:
► The importance of careful patient assessment before injecting BoNT/A and why it is an essential part of
the consultation process1
► The key steps to creating an individualized and realistic treatment plan designed to achieve the patient’s
aesthetic goals, including discussion of product selection, dosing, placement of injections, and timing of
follow-up visits2
► The basic equipment necessary for BoNT/A treatment
► Aseptic techniques when preparing equipment and the patient for treatment, and why these techniques
are vital to lower the risk of infection and related AEs2
► The specific reconstitution techniques for each of the BoNT/A products
► Injection techniques and appropriate guidelines relevant to the use of BoNT/A and why these are
essential to optimize benefits and minimize complications1,2
► Patient aftercare and why it is a vital part of ensuring a successful treatment outcome for you and your
patient
► The most common mistakes that occur with BoNT/A treatment, how they relate to injection strategy,
and how they can be managed or avoided1,2

Module 1, Course B - A Practical Guide To Botulinum Toxin Type A - The Scientific Art of Softening Lines and Wrinkles 2

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Module 1, Course B - A Practical Guide To Botulinum Toxin Type A - The Scientific Art of Softening Lines and Wrinkles 2

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The Academy for the

Course B: A Practical Guide to Botulinum Toxin

1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 5

1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 8

Step 2: Mark sites for injection using a soft eyebrow pencil.

1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 10

1. Carruthers J et al. Plast Reconstr Surg. 2004;114(Suppl):1-22. 11

► Treat patients with lower eyelid laxity with caution.

► For further information on the importance of the correct reconstitution of incobotulinumtoxinA,

NaCl, sodium chloride

BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016. 20

1. Alam M et al. Dermatol Surg. 2015;41:321-326. 22

. BOTOX Cosmetic [highlights of prescribing information]. Irvine, CA: Allergan; 2016. 25

Clean your patient’s face1

► Alcohol can denature BoNT/As.

1. Ascher B et al. J Eur Acad Dermatol Venereol. 2010;24:1278-1290. 31

1. Ascher B et al. J Eur Acad Dermatol Venereol. 2010;24:1278-1290. 32

1. de Almeida AR et al. Dermatol Surg. 2012;38:1506-1515. 34

► Red arrows indicate direction of the pull of

with BoNT/A: Expert Tips

Photo courtesy of Kyle K. Seo, MD.

Recommended • Use a sterile needle, 30–33G (0.3–0.2 mm diameter), 13 mm length

1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 46

1. Imhof M, Kuhne U. J Clin Aesthet Dermatol. 2013;6:40-44. 47

1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 49

1. Carruthers JD et al. Plast Reconstr Surg. 2008;121(5 Suppl):5S-30S. 50

Recommended • Use a sterile needle, 30–33G (0.3–0.2 mm diameter), 13 mm length

1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 51

Recommended • Use a sterile needle, 30–33G (0.3–0.2 mm diameter), 13 mm length

1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 58

Type of Nasal Rhytides Location of Wrinkles

1. Tamura BM et al. Dermatol Surg. 2005;31:271-275. 64

1. Tamura BM et al. Dermatol Surg. 2005;31:271-275. 65

Recommended • For incobotulinumtoxinA/onabotulinumtoxinA: 1–3 units, bilaterally

Location of • Orbicularis oris, within 5 mm of the vermilion border

Location of • Lower third of the DAO

1. Carruthers J et al. Dermatol Surg. 2013;39:510-525. 75

Location of • 2–5 injection sites per side

1. Carruthers J et al. Plast Reconstr Surg. 2004;114(Suppl):1-22. 89

1. Carruthers J et al. Plast Reconstr Surg. 2004;114(Suppl):1-22. 92

1. Carruthers J et al. Plast Reconstr Surg. 2004;114(Suppl):1-22. 93

Unwanted Effect Cause(s) How to Avoid/Manage

► Remember, these unwanted effects are usually temporary, but your

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