Introduction Best Practices Upper Face MidFace Lower Face Submental Area Injection Codes

Overview
A Coded Approach to Injecting
With the ALLERGAN® Facial
Aesthetics Portfolio
PRESENTS
 Introduction
The Allergan Medical Institute (AMI) Mission

Best Practices
Our mission is to provide world-class medical education through a progressive continuum of
learning for healthcare specialists in the fields of facial aesthetics, plastic and regenerative
medicine, body contouring, and skincare.

We are dedicated to advancing scientific knowledge and techniques, with the goal of
optimizing patient outcomes and pursuing practice excellence.

Upper Face
MidFace
Injector Resources
Allergan Direct 1-855-AGN-DRCT (1-855-246-3728)
• D
 irect-to-physician web support line where existing Allergan customers can purchase
products, pay bills, and access detailed reports

Lower Face
BrandBox (AllerganBrandBox.com)
• O
 fficial assets and educational materials for the ALLERGAN® Aesthetics Portfolio

Brilliant Distinctions® Program

• S
 avings program where patients can earn points on all Allergan treatments and products
in the Brilliant Distinctions® portfolio

Submental Area
• S
 imple for practices to enroll and facilitate

For answers to medical-related questions, to contact a Medical Science Liaison (MSL),

or to report an adverse event with an Allergan product, call 1-800-678-1605.
• Allergan is dedicated to the safety of its products and monitors postmarketing
reports closely
Injection Codes
Overview

Contact your Allergan Business Development Manager (BDM) if you would like to learn
about the ALLERGAN® Portfolio of Products.

2
 Introduction
Introduction to Injection Codes

Best Practices
The injection codes are a blueprint for treatment with Allergan facial injectables, identifying
needle placement and recommended sequences for injecting each product.

The codes were derived from a variety of factors:

• E
 ach product’s approved injection pattern as stated in its Prescribing Information or
Directions for Use
• Clinical trial experience

Upper Face
Anatomy and patient individuality
Of course, no 2 patients are alike, and each patient requires an individual assessment and
treatment recommendation. The injection codes should be considered in conjunction with a
patient’s anatomy and treatment goals. The injection codes are designed to help injectors:
• C
 onsider both anatomy and injection patterns when planning treatment in the upper,
mid, and lower face (including lips and perioral area), and submental area
• Optimize product placement, thereby optimizing efficiency of product use

MidFace
• Avoid areas of caution
• Educate patients about treatment and treatment goals
• Achieve the desired outcome

Injection techniques
The injection codes are 1 factor in treatment. This guide also includes information on injection

Lower Face
techniques, including injection depth and areas of caution, as well as general best practices
and product-specific tips. It is intended as a comprehensive resource to help injectors.

Submental Area
Injection Codes
Overview

3
 Introduction
Table of Contents

Best Practices
Introduction to the ALLERGAN® Portfolio of Products.............................................................................5

Best Practices..............................................................................................................................................................6-9

Upper-Face Treatment....................................................................................................................................... 10-19

 — Forehead lines.................................................................................................................................................12-13

 — Glabellar lines................................................................................................................................................. 14-15

 — Lateral canthal lines......................................................................................................................................16-17

Upper Face
Midface Treatment..............................................................................................................................................20-27

Lower-Face Treatment......................................................................................................................................28-39

 —Wrinkles and folds.......................................................................................................................................28-33

 —Lips and perioral area............................................................................................................................... 34-39

MidFace
Submental Area Treatment........................................................................................................................... 40-44

Injection Codes Overview......................................................................................................................................45

Indications and Important Safety Information....................................................................................46-50

Lower Face
Submental Area
Injection Codes
Overview

4
 Introduction
ALLERGAN® Portfolio of Products BOTOX® Cosmetic (onabotulinumtoxinA)
Important Information

Best Practices
Indications
BOTOX® Cosmetic (onabotulinumtoxinA)
Upper Face is indicated in adult patients for
the temporary improvement in the
appearance of:
- Moderate to severe glabellar lines
associated with corrugator and/or
procerus muscle activity
- Moderate to severe lateral canthal lines
associated with orbicularis oculi activity
- Moderate to severe forehead lines
associated with frontalis activity
Midface
JUVÉDERM® Collection of Fillers

Upper Face
Important Information
INDICATIONS
JUVÉDERM VOLUMA® XC injectable gel
is indicated for deep (subcutaneous and/
or supraperiosteal) injection for cheek
augmentation to correct age-related
volume deficit in the mid-face in adults
Lower Face over the age of 21.
JUVÉDERM® Ultra XC and JUVÉDERM®
Ultra Plus XC injectable gels are indicated
for injection into the mid-to-deep dermis
for correction of moderate to severe
facial wrinkles and folds (such as

MidFace
nasolabial folds).
JUVÉDERM VOLLURE™ XC injectable gel
is indicated for injection into the mid-to-
deep dermis for correction of moderate
to severe facial wrinkles and folds (such
as nasolabial folds) in adults over the
age of 21.
JUVÉDERM® Ultra XC injectable gel is
indicated for injection into the lips and
Lips perioral area for lip augmentation in
adults over the age of 21.

Lower Face
JUVÉDERM VOLBELLA® XC injectable
gel is indicated for injection into the lips
for lip augmentation and for correction
of perioral rhytids in adults over the age
of 21.

KYBELLA® (deoxycholic acid) injection

10 mg/mL Important Information

Submental Area INDICATION

KYBELLA® (deoxycholic acid) injection
is indicated for improvement in the

Submental Area
appearance of moderate to severe
convexity or fullness associated with
submental fat in adults.
The safe and effective use of KYBELLA®
for the treatment of subcutaneous
fat outside the submental region
has not been established and is not
The safety and efficacy of these products for recommended.
combined use have not been studied.

Please see Indications and Important Safety Information about BOTOX® Cosmetic
Injection Codes

(onabotulinumtoxinA), including Boxed Warning, on pages 46 to 47. Please see

Overview

Indications and Important Safety Information for the JUVÉDERM® Collection of Fillers on
pages 48 to 49. Please see Indication and Important Safety Information about KYBELLA®
(deoxycholic acid) injection 10 mg/mL on page 50.
5
 Introduction
Best Practices

Best Practices
Anatomy and assessment
Treatment recommendations should always begin with a full-face, individualized assessment.
Consider assessing the face in fours:
• U
 pper face
• Midface
• L
 ower face, including lips and perioral area
• S
 ubmental area

Upper Face
Upper face

MidFace
Midface

Lower Face
Lower face

Submental area

During the assessment, consider each patient’s unique anatomy, the patient’s stated concerns, Submental Area
and the alignment of appropriate products to treatment goals.

Please see Indications and Important Safety Information about BOTOX® Cosmetic
Injection Codes

(onabotulinumtoxinA), including Boxed Warning, on pages 46 to 47. Please see

Overview

Indications and Important Safety Information for the JUVÉDERM® Collection of Fillers
on pages 48 to 49. Please see Indication and Important Safety Information about
KYBELLA® (deoxycholic acid) injection 10 mg/mL on page 50.
6
 Introduction
BOTOX® Cosmetic (onabotulinumtoxinA)
When considering the upper face, remember that BOTOX® Cosmetic is indicated for the

Best Practices
temporary improvement in the appearance of moderate to severe forehead lines, lateral
canthal lines, and glabellar lines in adults.1 Simultaneous treatment of all 3 areas has been
clinically studied, and, in the case of forehead lines, simultaneous treatment with glabellar
lines is recommended.1,2 Some factors to consider during assessment for forehead
lines include1,2:
• Severity of wrinkles in forehead lines
• Assessment of patient-specific anatomy at rest and animation

Upper Face
• Note any upper facial asymmetry on chart and to patient
• Evaluate the risk of eyebrow/eyelid ptosis

JUVÉDERM® Collection of Fillers

Clinical trials and experience have provided specific guidance for all products when
injecting JUVÉDERM®3-7:
• Aspirate the needle to verify it is not intravascular
• Follow the sequence and insert the needle tip at the appropriate depth

MidFace
• Inject slowly, applying even pressure
• Inject to 100%—do not overcorrect
• Gently mold and massage to the contour of the surrounding tissue, as appropriate

Lower Face
Aspirate the Follow the Inject Mold and
needle sequence slowly massage

Submental Area
KYBELLA® (deoxycholic acid) injection 10 mg/mL
When injecting KYBELLA®, treat all fat pockets within approved boundaries. Appropriate
needle depth is also critical.8
• Inject approximately midway into the preplatysmal fat layer8
– Injections that are too superficial (into the dermis) may result in skin ulceration
and necrosis
Injection Codes

• A
 void injections into the platysma, postplatysmal fat, or other structures such as salivary
Overview

glands, lymph nodes, and nontarget tissue such as muscles8

7
 Introduction
Aseptic Technique

Best Practices
While some factors are more pertinent to injecting fillers, the following high-level tips may be
considered, regardless of treatment area or product used.

Preinjection
✓ Screen patients for factors that increase risk of infection, including recent infection,
history of immunosuppression, vaccinations, or dental work9,10

✓ Have patient clean their face and use headband or surgical cap to keep hair back11

Upper Face
✓ If using filler to treat lip/perioral area, ask patient to use chlorhexidine mouthwash10

✓ Disinfect entire face with sterile gauze and antiseptic (repeat after facial marking)10-12

During injection
✓ Avoid unnecessary contact with skin, particularly hairline and hair11
• When injecting filler into lips/perioral area, do not touch mucosal areas11
• If treating multiple areas, inject filler into lips and perioral area last11

MidFace
✓ Do not touch needle

✓ Change needle and gloves often, especially after making contact with nonsterile surfaces11

Post injection
✓ Advise patient to not use make-up for 12 hours and skin care products for 24 hours, and
to postpone dental procedures for at least 2 weeks10,11,13

Lower Face
Whether injecting BOTOX® Cosmetic (onabotulinumtoxinA), the JUVÉDERM® Collection of
Fillers, or KYBELLA® (deoxycholic acid) injection 10 mg/mL, aseptic technique is essential
to minimize the possibility of contamination, which may contribute to an adverse event.9,10,13
This is especially true when injecting fillers, particularly in the lip and perioral area due to the

Submental Area
prevalence of bacteria in the mouth.11

Injection Codes

Please see Indications and Important Safety Information about BOTOX® Cosmetic
Overview

(onabotulinumtoxinA), including Boxed Warning, on pages 46 to 47. Please see

Indications and Important Safety Information for the JUVÉDERM® Collection of Fillers
on pages 48 to 49.
8
 Introduction
Areas of Caution for Facial Injection

Best Practices
Anatomical knowledge is essential for facial injection. Before treating any area of the face,
injectors must understand facial anatomy, including:
• Pathways of arteries and veins
• Location of nerves

Upper Face
Supratrochlear Nerve14 Supraorbital Artery/Vein14

Infratrochlear Nerve14 Supratrochlear Artery/

Vein14

MidFace
Infraorbital Artery/Vein15

Infraorbital Nerve14
Angular Artery14

Superior Labial Artery15

Lower Face
Marginal Mandibular
Nerve14 Facial Artery14

Inferior Labial Artery15

Submental Area
Injection Codes
Overview

9
 Introduction
Upper-Face Treatment

Best Practices
There’s only one BOTOX® Cosmetic
1 2 3 4
#1 IN AWARENESS DAYS INDICATIONS MONTH DURATION
(48 HOURS) IN GLABELLAR
LINES

BOTOX® Cosmetic is
#1 in consumer
awareness among
neurotoxin brands.16,*
*Aided and unaided
awareness, based
on a self-completed
online interview
Upper Face
Patients may begin BOTOX® Cosmetic 80% of patients
to see results within is the first and only (325/405) showed
24 to 48 hours after FDA-approved improvement vs 3%
injection.1 treatment for (4/132) for placebo
the temporary per investigator
improvement in assessment at day
the appearance of 30; 89% of patients
moderate to severe (362/405) assessed
glabellar lines, lateral improvement vs 7%

MidFace
with 206 women canthal lines, and (9/132) for placebo
and men, aged 18 to forehead lines in at day 30 (coprimary
75, who have used adult patients.1 efficacy end points);
a neurotoxin and/ 25% of patients
or filler in the past (102/403) showed
2 years and are improvement vs 2%
considering at least (2/128) for placebo
1 aesthetic treatment per investigator
in the next 2 years.16 assessment at day

Lower Face
120; 39% of patients
(157/403) assessed
improvement vs 1%
(1/128) for placebo at
day 120).1

Precise Control for Individualized Anatomy

Submental Area
The dosing and injection patterns for BOTOX® Cosmetic have been studied in multiple
clinical trials, including simultaneous injection of forehead lines and lateral canthal lines
when treating the glabella.1,2

• It is recommended that glabellar lines be treated in conjunction with forehead lines.
The recommended total dose for treatment of forehead lines (20 Units) in conjunction
Injection Codes

with glabellar lines (20 Units) is 40 Units

Overview

Please see Indications and Important Safety Information about BOTOX® Cosmetic
(onabotulinumtoxinA), including Boxed Warning, on pages 46 to 47.
10
 Introduction
Botulinum Toxins Are Not Interchangeable

Best Practices
Per each botulinum toxin product’s label, Units cannot be
converted, and no dose ratios exist.1
• T
 he injection codes and associated volumes injected are specific to BOTOX® Cosmetic
(onabotulinumtoxinA) and validated in BOTOX® Cosmetic clinical studies

Botulinum toxins are biologic products and, therefore, the result of distinct
manufacturing processes.17

Upper Face
• BOTOX® Cosmetic is manufactured in a state-of-the art facility owned by Allergan
– A
 llergan maintains strict quality and safety standards throughout the supply chain,
from manufacturing through packaging, helping to ensure the reliability and safety
of each vial

Approved Muscles for Proper Upper-Face Injection

MidFace
Frontalis14,18

Procerus14,18

Lower Face
Corrugator14,18

Orbicularis oculi14,18

Submental Area
Injection Codes

Muscles of the upper face are interrelated

Overview

Understanding the relevant anatomy is important for optimal outcomes.

11
 Introduction
Injecting Forehead Lines

Best Practices
Code Injection Site1 Dosage1 Treatment Goal1 Cautions and Considerations1,19

Middle frontalis 4 Units

Upper Face
• T
 reat forehead lines in conjunction with
Left lateral frontalis 4 Units
Temporary glabellar lines to minimize potential for
blockage of brow ptosis
muscle activity, • L
 ateral injection sites can be 0.5 cm
leading to to 1.5 cm medial to the temporal fusion
FH Right lateral frontalis 4 Units improved line, and the distance between the brow
appearance of and lower treatment row should be no
moderate to less than 2 cm

MidFace
severe forehead • W
 hen targeting the corrugator,
lines inadvertently injecting the frontalis
Left medial frontalis 4 Units
too shallowly may lead to brow ptosis

Right medial frontalis 4 Units

Lower Face
Total dosage: 20 Units divided across 5 sites1

Submental Area
Injection Codes
Overview

Please see Indications and Important Safety Information about BOTOX® Cosmetic
(onabotulinumtoxinA), including Boxed Warning, on pages 46 to 47.
12
 Introduction
Forehead Lines Injection Codes

Best Practices
Midline

Superior Margin
of Frontalis Activity

Upper Face
Upper Treatment Row
FH FH
Lower Treatment Row
FH FH FH

0.5 cm- 0.5 cm-

1.5 cm 1.5 cm Eyebrow

MidFace
The distance between
the eyebrow and lower
treatment row should
be at least 2 cm

Temporal Fusion Line

Lower Face
Refer to page 9 to review areas of caution, including location of nerves and blood
vessels, and page 11 for location of approved muscles to consider when injecting
BOTOX® Cosmetic (onabotulinumtoxinA) in the upper face.

For all BOTOX® Cosmetic injections

Epidermis Whenever injecting BOTOX® Cosmetic, ensure Submental Area

Dermis injections aren’t too deep or too superficial in
Subcutaneous fat order to target the approved muscle.
Muscle
Injection Codes

Periosteum
and bone
Overview

13
 Introduction
Injecting Glabellar Lines

Best Practices
Code Injection Site1 Dosage1 Treatment Goal1 Cautions and Considerations1

Procerus 4 Units

Upper Face
Left corrugator • A
 void injection near the levator
4 Units palpebrae superioris, particularly in
muscle-medial
Temporary patients with larger brow depressor
blockage of complexes
muscle activity, • L
 ateral corrugator injections should
leading to be placed at least 1 cm above the
Left corrugator
GL 4 Units improved
muscle-lateral bony supraorbital ridge
appearance of

MidFace
moderate to • E
 nsure the injected volume/dose is
severe glabellar accurate and, where feasible, kept to
lines a minimum
Right corrugator • D
 o not inject toxin closer than 1 cm
4 Units
muscle-medial above the central eyebrow

Right corrugator
4 Units

Lower Face
muscle-lateral

Total dosage: 20 Units divided across 5 sites1

Submental Area
Injection Codes
Overview

Please see Indications and Important Safety Information about BOTOX® Cosmetic
(onabotulinumtoxinA), including Boxed Warning, on pages 46 to 47.
14
 Introduction
Glabellar Lines Injection Codes

Best Practices
Upper Face
GL GL
GL GL

GL

MidFace
Lower Face
Refer to page 9 to review areas of caution, including location of nerves and blood
vessels, and page 11 for location of approved muscles to consider when injecting
BOTOX® Cosmetic (onabotulinumtoxinA) in the upper face.

Submental Area
Injection Codes
Overview

15
 Introduction
Injecting Lateral Canthal Lines

Best Practices
Code Injection Site1 Dosage1 Treatment Goal1 Cautions and Considerations1

Injection Pattern 1

1.5 cm to 2 cm temporal
to the lateral canthus

Upper Face
and just temporal to the 4 Units
orbital rim (A) • If lateral canthal lines are above
and below the lateral canthus,
Lateral orbicularis oculi
use injection pattern 1
CF • Injections should be given with the
CF
needle bevel tip up and oriented
Lateral orbicularis oculi 4 Units
away from the eye

Temporary
blockage of
Lateral orbicularis oculi 4 Units muscle activity,

MidFace
leading to
improved
Injection Pattern 2 appearance of
moderate to
1.5 cm to 2 cm temporal severe lateral
to the lateral canthus canthal lines
and just temporal to the 4 Units
orbital rim (A)
Lateral orbicularis oculi • If lateral canthal lines are primarily

Lower Face
below the lateral canthus, use
CF
CF injection pattern 2
Lateral orbicularis oculi 4 Units

Lateral orbicularis oculi 4 Units

Submental Area
Total dosage: 12 Units divided across 3 sites per side, or 24 Units1

Injection Codes
Overview

Please see Indications and Important Safety Information about BOTOX® Cosmetic
(onabotulinumtoxinA), including Boxed Warning, on pages 46 to 47.
16
 Introduction
Lateral Canthal Lines
Injection Codes (2 Options)

Best Practices
Injection pattern 1

30°

CF

Upper Face
1.5 cm-2.0 cm
A CF

CF

30°

MidFace
Injection pattern 2

Lower Face
A
1.5 cm-2.0 cm
CF

CF

CF

Submental Area

Refer to page 9 to review areas of caution, including location of nerves and blood
vessels, and page 11 for location of approved muscles to consider when injecting
Injection Codes

BOTOX® Cosmetic (onabotulinumtoxinA) in the upper face.

Overview

17
 Introduction
Before and After:
Forehead Lines

Best Practices
Upper Face
Before After day 30
Actual patient. Results may vary.
Photos taken at maximum eyebrow elevation before and 30 days after treatment with BOTOX® Cosmetic.
In 2 clinical studies of healthy adults, 61% and 46% had a ≥ 2-grade improvement at day 30.1,*

MidFace
Before and After:
Lateral Canthal Lines

Lower Face
Before After day 7
Actual patient. Results may vary.

Submental Area
Photos taken at full smile before and 7 days after treatment with BOTOX® Cosmetic. In 2 clinical
studies, 26.1% and 20.3% of adults had a ≥ 2-grade improvement at day 30. In one of these studies,
67.9% had mild or no crow’s feet lines at day 30 after treatment.1,*

*Side effects associated with the injection include localized pain, infection, inflammation, tenderness,
Injection Codes

swelling, redness, and/or bleeding/bruising.

Overview

18
 Introduction
Before and After:
Glabellar Lines

Best Practices
Upper Face
Before After day 30
Actual patient. Results may vary.
Photos taken at maximum frown before and 30 days after treatment with BOTOX® Cosmetic. In
clinical studies, physicians assessed 74% of adults had significant improvement at day 7; and 80%
had significant improvement at day 30.1,*

MidFace
Proven up to 4 months in moderate to severe glabellar lines;
physician-reported response of 25% (102/403) vs 2% (2/128) for placebo1

Lower Face
Before After day 7

Submental Area

After month 3 After month 4

Actual patient. Results may vary.
Injection Codes

Photos taken at maximum frown before and after treatment with BOTOX® Cosmetic at day 7, month 3,
Overview

and month 4. In clinical studies, physicians assessed 74% of adults had significant improvement at day
7; 80% of adults had significant improvement at day 30; 48% of adults had significant improvement at
month 3; and 25% of adults had significant improvement at month 4.1,*
19
 Introduction
Filler Injection Technique Options

Best Practices
When reviewing the midface and lower-face sections of the Injection Codes Guide, the
following injection techniques are referenced.

Tunneling Serial puncture Fanning Vertical puncture

Upper Face
✓
Small boluses recommended
for a lifting effect (0.1 mL-0.2 mL)3 X Large boluses not recommended

MidFace
Injection delivery
Use the following to visualize various product placement and amount.

Lower Face
Very small droplets of filler (0.01 mL to 0.05 mL
Microaliquot
per point)

Static injection of a small amount of filler

Small bolus
(0.1 mL or 0.2 mL)

Submental Area
Linear Antegrade or retrograde

Multiple linear injections via a single entry site,

Fanning
creating a fan-like pattern
Injection Codes
Overview

20
 Introduction
Marking to Guide Midface Treatment

Best Practices
C A
V1
V2

Upper Face
V3
D
V4
B

Use Hinderer's lines to locate the Mark the V1-V4 injection points:

V1-V4 injection points20
• M
 ark the lid-cheek junction as an upper
boundary (dotted line)
MidFace
Locate the suture on the zygomatic arch,
between the zygomatic bone and the
temporal bone:

• D
 raw 2 lines to identify the treatment V1 Lateral to this suture, at the anchor
regions, plan injection sequence, and point of the zygomatic arch
ensure symmetry

Lower Face
V2 Medial to this suture, on the most
– Line 1: Vertical from lateral canthus A prominent point of the zygomatic bone
to oral commissure B
V3 Lateral to the midpupillary line; medial
– Line 2: Horizontal from tragus C to this line is the no-go deep zone
to upper alar lobule D
V4 In the submalar region

Submental Area
Injection Codes
Overview

21
 Introduction
Midface Treatment

Best Practices
JUVÉDERM VOLUMA® XC is the first and only FDA-approved filler to correct age-related
volume loss in the midface for up to 2 years with optimal treatment.3
 pecifically tailored to add volume, creating lift and contour3,21
• S

Treat the midface first when addressing multiple filler areas.

• The impact of volume correction may affect how you approach treatment in the lower face22

Upper Face
MidFace
Midface

Lower Face
Submental Area
Injection Codes

*With optimal treatment.

Overview

Please see Indications and Important Safety Information for the JUVÉDERM® Collection
of Fillers on pages 48 to 49.
22
 Introduction
Midface:
Vascular Cautions and Anatomical

Best Practices
Considerations

Upper Face
MidFace
Transverse Facial Artery14

Infraorbital Neurovascular
Bundle14,15

Angular Artery14

Lower Face
Parotid Duct14

Submental Area
! • Use caution around anatomic structures and vessels
• Do not inject into blood vessels
• For anatomical reference only; not approved for injection Injection Codes
Overview

23
 Introduction
Injecting the Midface

Best Practices
Treatment
Code Injection Site3 Common Techniques3,24 Cautions and Considerations3,20,25,26
Goal3

Volumize the
Zygomatic cheek laterally
V1
arch to provide • A
 dd volume, providing lift
subtle lift Vertical puncture/ laterally along the zygomatic

Upper Face
small bolus in arch before treating the
supraperiosteal anteromedial and submalar regions
Fill the plane (V1, V2)
– This will avoid overfilling
V2
Zygomatic projection
the submalar region and
arch point of the
optimize the ogee curve
cheek
• Inject small boluses (0.1 mL to
0.2 mL over a large area)
• O
 vercorrection can increase
Volumize
Anteromedial likelihood of adverse events
V3 anteromedial

MidFace
cheek • Do not inject into blood vessels
deficit
Fanning,
subcutaneously or – Introduction of product into
intradermally, to the vasculature may lead to
volumize (V3, V4) embolization, occlusion of
Add volume in the vessels, ischemia, or infarction
V4
Submalar
the submalar
region
cheek

Lower Face
Microaliquot Small bolus Linear Fanning

Inject the product slowly and apply the least amount of pressure necessary. Rare, but serious, adverse
events associated with the intravascular injection of soft-tissue fillers in the face have been reported
and include temporary or permanent vision impairment, blindness, cerebral ischemia or cerebral
hemorrhage leading to stroke, skin necrosis, and damage to underlying facial structures. Immediately

Submental Area
stop the injection if a patient exhibits changes in vision, signs of a stroke, blanching of the skin, unusual
pain during or shortly after the procedure.3

Injection Codes
Overview

Please see Indications and Important Safety Information for the JUVÉDERM® Collection
of Fillers on pages 48 to 49.
24
 Introduction
Midface
Injection Codes

Best Practices
Upper Face
V1
V2
V3

V4

MidFace
Lower Face
Refer to page 23 to review areas of caution, including location of blood vessels, when
injecting JUVÉDERM VOLUMA® XC in the midface.

SUBCUTANEOUS OR

Submental Area
SUPRAPERIOSTEAL V1-V2 INJECTION SUBCUTANEOUS V3-V4 INJECTION

Epidermis Epidermis

Dermis Dermis

Subcutaneous Subcutaneous

Periosteum Periosteum
Injection Codes
Overview

25
 Introduction
Before and After:
Midface

Best Practices
Upper Face
MidFace
Before After 1 month At 2 years

Actual patient. Results may vary.

Unretouched photos of paid patient taken before treatment, 1 month after treatment, and at 2 years
after treatment. A total of 3.5 mL of JUVÉDERM VOLUMA® XC was injected into the zygomatic arch,
anteromedial cheek, and submalar region.

In the JUVÉDERM VOLUMA® XC clinical trial, the total volume injected ranged from 1.2 mL to 13.9 mL,
with a median of 6.6 mL, to achieve optimal correction for all 3 subregions.3

Lower Face
The first and only FDA-approved filler to correct age-related volume loss
in the midface for up to 2 years with optimal treatment.3

Submental Area
Injection Codes
Overview

26
 Introduction
Before and After:
Midface (cont.)

Best Practices
Upper Face
MidFace
Before After 1 month

Actual patient. Results may vary.

Unretouched photos of paid patient taken before treatment and 1 month after treatment. A total of
4.0 mL of JUVÉDERM VOLUMA® XC was injected into the zygomatic arch, anteromedial cheek, and
submalar region.

In the JUVÉDERM VOLUMA® XC clinical trial, the total volume injected ranged from 1.2 mL to 13.9 mL,
with a median of 6.6 mL, to achieve optimal correction for all 3 subregions.3

Lower Face
Submental Area
Injection Codes
Overview

27
 Introduction
Lower-Face
Treatment

Best Practices
Wrinkles and folds

• JUVÉDERM VOLLURE™ XC is the first and only FDA-approved hyaluronic acid (HA) filler
to correct moderate to severe facial wrinkles and folds for up to 18 months4,*
– Specifically tailored with a unique balance of firmness and cohesivity27
– Appropriate for adding subtle volume to correct moderate to severe facial wrinkles and

Upper Face
folds, such as nasolabial folds28
• JUVÉDERM® Ultra Plus XC is a more robust gel to correct moderate to severe facial
wrinkles and folds beyond 1 year6,*
• JUVÉDERM® Ultra XC is also indicated for wrinkles and folds, with results lasting
up to 1 year7,*

MidFace
Lower Face
Lower face

Submental Area
Injection Codes

*With optimal treatment.

Overview

Please see Indications and Important Safety Information for the JUVÉDERM® Collection of
Fillers on pages 48 to 49.
28
 Introduction
Lower Face:
Vascular Cautions and

Best Practices
Anatomical Considerations

Upper Face
MidFace
Angular Artery15

Lower Face
Superior Labial Artery15

Inferior Labial Artery

and Vein15

Submental Area
! • Use caution around anatomic structures and vessels
• Do not inject into blood vessels
• For anatomical reference only; not approved for injection Injection Codes
Overview

29
 Introduction
Before and After:
Lower Face

Best Practices
Upper Face
Before After 1 month After 18 months

Actual patient. Results may vary.

Unretouched photos of paid patient taken before treatment, 1 month after treatment, and 18 months
after treatment. A total of 2.3 mL of JUVÉDERM VOLLURE™ XC was injected into the nasolabial folds,

MidFace
oral commissures, and marionette lines.

Lower Face
Before After 1 month After 18 months

Submental Area
Actual patient. Results may vary.
Unretouched photos of paid patient taken before treatment, 1 month after treatment, and 18 months
after treatment. A total of 3.75 mL of JUVÉDERM VOLLURE™ XC was injected into the nasolabial folds,
oral commissures, and marionette lines.

Results last up to 18 months with optimal treatment.4

Injection Codes
Overview

30
 Introduction
Before and After:
Lower Face (cont.)

Best Practices
Upper Face
MidFace
Before After 2 weeks

Actual patient. Results may vary.

Unretouched photos of paid patient taken before treatment and 2 weeks after treatment. A total of
2.2 mL of JUVÉDERM® Ultra Plus XC was injected into the nasolabial folds, oral commissures, and
marionette lines. A total of 1.0 mL of JUVÉDERM® Ultra XC was also injected into the nasolabial folds,

Lower Face
oral commissures, and marionette lines.

Submental Area
Injection Codes
Overview

31
 Introduction
Injecting Wrinkles
and Folds

Best Practices
Injection Treatment
Code Common Techniques4,6,7 Cautions and Considerations4,6
Site4,6 Goal4,6

• M
 id-to-deep
dermis
JUVÉDERM®
Fill the Ultra Plus XC

Upper Face
Nasolabial
J1 nasolabial Most common
folds
folds techniques:
• Serial puncture
• Tunneling
Other common
techniques: • Injection
 techniques may vary by
• Fanning angle and orientation of the bevel,
• Cross-hatching depth of injection, and volume
administered

MidFace
JUVÉDERM®
J2
Oral Smooth oral Ultra XC • Do not inject into blood vessels
commissures commissures
Most common – Introduction of products into
techniques: the vasculature may lead to
• Tunneling embolization, occlusion of the
• Linear threading vessels, ischemia, or infarction
• Serial puncture
• Fanning

Lower Face
• Cross-hatching
Remove the JUVÉDERM
J3 Marionette mouth frown VOLLURE™ XC
lines in marionette • May be injected
lines using serial
puncture,
tunneling, fanning,
or cross-hatching

Submental Area
Microaliquot Small bolus Linear Fanning

Inject the product slowly and apply the least amount of pressure necessary. Rare, but serious, adverse
events associated with the intravascular injection of soft-tissue fillers in the face have been reported
and include temporary or permanent vision impairment, blindness, cerebral ischemia or cerebral
hemorrhage leading to stroke, skin necrosis, and damage to underlying facial structures. Immediately
stop the injection if a patient exhibits changes in vision, signs of a stroke, blanching of the skin, unusual
pain during or shortly after the procedure.4,6,7
Injection Codes
Overview

Please see Indications and Important Safety Information for the JUVÉDERM® Collection of
Fillers on pages 48 to 49.
32
 Introduction
Lower-Face
Injection Codes

Best Practices
J1

Upper Face
J2

J3

MidFace
Refer to page 29 to review areas of caution, including location of blood vessels, when
injecting JUVÉDERM VOLLURE™ XC, JUVÉDERM® Ultra Plus XC, and JUVÉDERM® Ultra XC
in the lower face.

Lower Face
Evaluate wrinkle type during patient assessment

Moderate
wrinkle or fold Severe
wrinkle or fold

Submental Area
Injection Codes
Overview

Epidermis Dermis Subcutaneous

33
 Introduction
Lower-Face
Treatment (cont.)

Best Practices
Lips and perioral area

• JUVÉDERM VOLBELLA® XC is the first and only FDA-approved filler proven to

increase lip fullness and correct perioral lines for up to 1 year5,*
– Specifically tailored to be a soft, smooth gel5
• JUVÉDERM® Ultra XC is also indicated for lip augmentation and can be used to

Upper Face
plump the lips for up to 1 year7,*

MidFace
Lower face
LIPS AND

Lower Face
PERIORAL AREA

Submental Area

*With optimal treatment.

Injection Codes
Overview

Please see Indications and Important Safety Information for the JUVÉDERM® Collection of
Fillers on pages 48 to 49.
34
 Introduction
Lips and Perioral Area:
Vascular Cautions and

Best Practices
Anatomical Considerations

Upper Face
Superior Labial Artery15

MidFace
Inferior Labial Artery15

Lower Face
! • Avoid injection into the inferior and superior labial arteries
• For anatomical reference only; not approved for injection

Muscles Arteries

Submental Area
Alar Rim29 Superior Labial Artery15

Orbicularis Oris29 Inferior Labial Artery15

Injection Codes

Safety Information
Overview

Introduction of these products into the vasculature may lead to embolization, occlusion of the vessels, ischemia, or
infarction. Rare, but serious, adverse events associated with the intravascular injection of soft-tissue fillers in the face
have been reported and include temporary or permanent vision impairment, blindness, cerebral ischemia or cerebral
hemorrhage leading to stroke, skin necrosis, and damage to underlying facial structures.

35
 Introduction
Injecting Lips and
Perioral Area

Best Practices
Injection Common Cautions and
Code Treatment Goal5,7,30-32
Site5,7 Techniques5,7,33 Considerations5,34

Increase overall fullness. JUVÉDERM

Add volume to the tubercles/ VOLBELLA® XC
Vermilion
L1 pillows to increase fullness, • T
 unneling,
body/red
enhance projection, and serial puncture,
vermilion • Injection techniques
improve lip proportions/

Upper Face
or fanning
balance may vary by angle and
techniques, or a
orientation of the bevel,
combination of
depth of injection, and
Add volume to the transition the 3, have been
Vermilion volume administered
L2 line between the vermilion used to achieve
border
and the white vermilion optimal results • W
 hen injecting into the
in lips perioral area:
Add volume to support the • F
 or perioral – Inject perpendicular
L3 Cupid’s bow central projections of the rhytids, to the line
upper lip. Do not overcorrect tunneling was – Inject perpendicular

MidFace
most common; to the skin
fanning was
Inject to form an inverted V. – Inject parallel
Philtral also used
L4 These columns should not be to the line
columns – Intradermal
parallel to each other
was the most • D
 o not inject into
common blood vessels
Oral injection plane – Introduction of
L5 Inject oral commissures
commissures in clinical trials product into the
JUVÉDERM® vasculature may

Lower Face
Ultra XC lead to embolization,
Inject the perioral region occlusion of the
to soften the appearance of • In most sites, vessels, ischemia,
perioral lines with JUVÉDERM injections were or infarction
Perioral administered
L6 VOLBELLA® XC
rhytids primarily by
Inject the perioral area serial puncture
for lip augmentation with or tunneling
JUVÉDERM® Ultra XC

Submental Area
Microaliquot Small bolus Linear Fanning

Aseptic technique is particularly important when injecting the lips and perioral area to
minimize contamination due to the prevalence of bacteria in the mouth. See page 8 for
aseptic technique information, including:
• Do not touch mucosal areas11
• Change needles and gloves often11
Injection Codes

• If treating multiple areas, treat lips and perioral area last11

Overview

Please see Indications and Important Safety Information for the JUVÉDERM® Collection of
Fillers on pages 48 to 49.
36
 Introduction
Lips and Perioral Area
Injection Codes

Best Practices
L4 L6
L3

Upper Face
L1 L5

L2

MidFace
Refer to page 35 to review areas of caution, including location of blood vessels,
when injecting JUVÉDERM VOLBELLA® XC and JUVÉDERM® Ultra XC in the lips
and perioral area.

Lower Face
Submental Area
Injection Codes
Overview

37
 Introduction
Before and After:
Lips and Perioral Area

Best Practices
Upper Face
MidFace
Before After 1 month

Lower Face
Actual patient. Results may vary.
Unretouched photos of paid patient taken before treatment and 1 month after treatment. A total
of 2.05 mL of JUVÉDERM VOLBELLA® XC was injected into the perioral lines and into the oral
commissures and lips (vermilion body, vermilion border, Cupid's bow, and philtral columns) for
lip augmentation.

Submental Area

Before After 1 month After 1 year

Injection Codes

Actual patient. Results may vary.

Overview

Unretouched photos of paid patient taken before treatment, 1 month after treatment, and 1 year after
treatment. A total of 1.1 mL of JUVÉDERM VOLBELLA® XC was injected into the oral commissures and
lips (vermilion body, vermilion border, Cupid's bow, and philtral columns) for lip augmentation.

38
 Introduction
Before and After:
Lips

Best Practices
Upper Face
MidFace
Before After 1 month After 1 year

Lower Face
Actual patient. Results may vary.
Unretouched photos of paid patient taken before treatment, 1 month after treatment, and 1 year after
treatment. A total of 1.2 mL of JUVÉDERM® Ultra XC was injected into the oral commissures and lips
(vermilion body and vermilion border) for lip augmentation.

Results last up to 1 year with optimal treatment.7

Submental Area
Injection Codes
Overview

39
 Introduction
Submental Area Treatment

Best Practices
KYBELLA® (deoxycholic acid) injection 10 mg/mL is the first-of-its-kind injectable, FDA
approved to treat moderate to severe submental fat in adults.8

The safe and effective use of KYBELLA® for the treatment of subcutaneous fat outside the
submental region has not been established and is not recommended.8

Upper Face
• INDIVIDUALLY TAILORED* injectable treatments administered according to the amount
of submental fat and aesthetic goals
• PERMANENTLY DESTROYS FAT CELLS in the submental treatment area for an
improved chin profile
*Multiple injections under the chin per treatment; up to 6 treatments at least 1 month apart.8

Injection Into the Preplatysmal Fat Layer

MidFace
Lysis of Adipocytes

Healthy
Adipocytes

Lower Face
• Injections that are too superficial
(into the dermis) may result in
skin ulceration and necrosis8

Submental Area
Submental
Fat
Injection Codes
Overview

Please see Indication and Important Safety Information about KYBELLA® (deoxycholic
acid) injection 10 mg/mL on page 50.
40
 Introduction
Identify the Treatment Zone

Best Practices
Marginal Mandibular
Nerve15

Upper Face
“No-Treatment Zone”8
Submandibular Gland15
Inferior Border of
KYBELLA® the Mandible15
Digastric Muscle15 treatment
area
Hyoid Bone15
KYBELLA® Treatment Zone
(Marking shown
Anterior Border of the
approximately 1 cm-1.5 cm
Sternocleidomastoid Muscle15
below the inferior border

MidFace
of the mandible8)
Thyroid Notch15

Thyroid Gland15

Lower Face
Submental Area
Injection Codes
Overview

41
 Introduction
Injecting the
Submental Area

Best Practices
Injection
Code Dosage8 Common Technique8 Cautions and Considerations8
Site8

• D
 o not withdraw the needle from
the subcutaneous fat during
injection. This could increase
• Inject perpendicular to
the risk of intradermal exposure,
the skin, approximately

Upper Face
leading to potential skin ulceration
midway into the
Treatment and necrosis
0.2 mL per preplatysmal fat layer
K Zone in the
injection site – If resistance is met, • A
 void injection into other tissues,
submental
withdraw the needle such as the muscle, salivary glands,
area
to an appropriate and lymph nodes
depth before injecting
• T
 reat all fat pockets; mark lateral
areas in the approved Treatment
Zone not covered by the grid in a
1-cm grid pattern

MidFace
0.2 mL

Lower Face
0.2 mL
per injection
site1 Translating dots to vials8
pe 8
1 dot = 0.2 mL
r in e
jectio n sit

Number of Dots Total Dose (mL) Number of KYBELLA® Vials

10 2 1
20 4 2

Submental Area
30 6 3
40 8 4
50 10 5
Per treatment session: up to a maximum of 50 injections of
0.2 mL each (up to 10 mL total), spaced 1 cm apart.
Injection Codes
Overview

Please see Indication and Important Safety Information about KYBELLA® (deoxycholic
acid) injection 10 mg/mL on page 50.
42
 Introduction
Submental Area
Injection Codes

Best Practices
Inferior Border of
the Mandible15

KYBELLA® Treatment Zone

Upper Face
(Marking shown
approximately 1 cm-1.5 cm
below the inferior border
of the mandible8)
“No-Treatment Zone”8
K

MidFace
Thyroid
Notch

Treatment area
No injections

Lower Face
Injection Grid

Submental Area
First mark the treatment area, then apply the injection grid and use alcohol to remove any grid dots or
skin markings that do not fall within the approved Treatment Zone for injection.
The grid is to be used as a spacing tool. The Treatment Zone should be carefully demarcated according
to anatomical landmarks prior to application of the grid.
Injection Codes
Overview

43
 Introduction
Noticeable Results for an
Improved Chin Profile

Best Practices
Nikki, aged 35

Upper Face
MidFace
Before After 4 treatments
Jason, aged 36

Lower Face
Submental Area

Before After 6 treatments

Injection Codes
Overview

Unretouched photos of paid models. Individual results may vary.

Not all treatments are shown; 59% of adults received 6 KYBELLA® treatments in clinical studies.8
*Multiple injections under the chin per treatment; up to 6 treatments at least 1 month apart.

44
 Introduction
Injection Codes Overview

Best Practices
Upper Face

FH FH

Midface
FH FH FH

Upper Face
GL GL
GL GL
GL
Lower Face CF

CF

CF

MidFace
V1
V2
V3
V4
J1
L4
L6
Lips L3

L1 L5

Lower Face
J2

L2 J3

Submental Area K

Submental Area
The safety and efficacy of these products for
combined use have not been studied.

Please see Indications and Important Safety Information about BOTOX® Cosmetic
Injection Codes

(onabotulinumtoxinA), including Boxed Warning, on pages 46 to 47. Please see

Overview

Indications and Important Safety Information for the JUVÉDERM® Collection of Fillers on
pages 48 to 49. Please see Indication and Important Safety Information about KYBELLA®
(deoxycholic acid) injection 10 mg/mL on page 50.
45
 Introduction
BOTOX® Cosmetic (onabotulinumtoxinA) Important Information
Indications

Best Practices
BOTOX® Cosmetic (onabotulinumtoxinA) is indicated in adult patients for the temporary improvement in the appearance of:
- Moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity
- Moderate to severe lateral canthal lines associated with orbicularis oculi activity
- Moderate to severe forehead lines associated with frontalis activity

IMPORTANT SAFETY INFORMATION, INCLUDING BOXED WARNING

WARNING: DISTANT SPREAD OF TOXIN EFFECT
Postmarketing reports indicate that the effects of BOTOX® Cosmetic and all botulinum toxin products may spread from the area of

Upper Face
injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized muscle weakness,
diplopia, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence, and breathing difficulties. These symptoms have been
reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening and there have been reports
of death. The risk of symptoms is probably greatest in children treated for spasticity, but symptoms can also occur in adults
treated for spasticity and other conditions, particularly in those patients who have an underlying condition that would predispose
them to these symptoms. In unapproved uses, including spasticity in children, and in approved indications, cases of spread of
effect have been reported at doses comparable to those used to treat cervical dystonia and spasticity and at lower doses.

CONTRAINDICATIONS

MidFace
BOTOX® Cosmetic is contraindicated in the presence of infection at the proposed injection site(s) and in individuals with known hypersensitivity to any botulinum
toxin preparation or to any of the components in the formulation.
WARNINGS AND PRECAUTIONS
Lack of Interchangeability Between Botulinum Toxin Products
The potency units of BOTOX® Cosmetic are specific to the preparation and assay method utilized. They are not interchangeable
with other preparations of botulinum toxin products and, therefore, units of biological activity of BOTOX® Cosmetic cannot be
compared to nor converted into units of any other botulinum toxin products assessed with any other specific assay method.

Lower Face
Spread of Toxin Effect
Please refer to Boxed Warning for Distant Spread of Toxin Effect.
No definitive serious adverse event reports of distant spread of toxin effect associated with dermatologic use of BOTOX® Cosmetic at the labeled dose of 20
Units (for glabellar lines), 24 Units (for lateral canthal lines), 40 Units (for forehead lines with glabellar lines), 44 Units (for simultaneous treatment of lateral
canthal lines and glabellar lines), and 64 Units (for simultaneous treatment of lateral canthal lines, glabellar lines, and forehead lines) have been reported.
Patients or caregivers should be advised to seek immediate medical care if swallowing, speech, or respiratory disorders occur.
Serious Adverse Reactions With Unapproved Use

Submental Area
Serious adverse reactions, including excessive weakness, dysphagia, and aspiration pneumonia, with some adverse reactions associated with fatal outcomes,
have been reported in patients who received BOTOX® injections for unapproved uses. In these cases, the adverse reactions were not necessarily related to
distant spread of toxin, but may have resulted from the administration of BOTOX® to the site of injection and/or adjacent structures. In several of the cases,
patients had pre-existing dysphagia or other significant disabilities. There is insufficient information to identify factors associated with an increased risk for
adverse reactions associated with the unapproved uses of BOTOX®. The safety and effectiveness of BOTOX® for unapproved uses have not been established.
Hypersensitivity Reactions
Serious and/or immediate hypersensitivity reactions have been reported. These reactions include anaphylaxis, serum sickness, urticaria, soft-tissue edema, and
dyspnea. If such reactions occur, further injection of BOTOX® Cosmetic should be discontinued and appropriate medical therapy immediately instituted. One fatal
Injection Codes

case of anaphylaxis has been reported in which lidocaine was used as the diluent and, consequently, the causal agent cannot be reliably determined.
Overview

46
 Introduction
BOTOX® Cosmetic (onabotulinumtoxinA) IMPORTANT SAFETY INFORMATION (continued)
WARNINGS AND PRECAUTIONS (continued)

Best Practices
Cardiovascular System
There have been reports following administration of BOTOX® of adverse events involving the cardiovascular system, including arrhythmia and myocardial
infarction, some with fatal outcomes. Some of these patients had risk factors including pre-existing cardiovascular disease. Use caution when administering to
patients with pre-existing cardiovascular disease.
Increased Risk of Clinically Significant Effects With Pre-existing Neuromuscular Disorders
Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis, or neuromuscular junction disorders (eg, myasthenia gravis or Lambert-
Eaton syndrome) should be monitored when given botulinum toxin. Patients with neuromuscular disorders may be at increased risk of clinically significant effects
including generalized muscle weakness, diplopia, ptosis, dysphonia, dysarthria, severe dysphagia, and respiratory compromise from onabotulinumtoxinA (see
Warnings and Precautions).

Upper Face
Dysphagia and Breathing Difficulties
Treatment with BOTOX® and other botulinum toxin products can result in swallowing or breathing difficulties. Patients with pre-existing swallowing or breathing
difficulties may be more susceptible to these complications. In most cases, this is a consequence of weakening of muscles in the area of injection that are
involved in breathing or oropharyngeal muscles that control swallowing or breathing (see Boxed Warning).
Pre-existing Conditions at the Injection Site
Caution should be used when BOTOX® Cosmetic treatment is used in the presence of inflammation at the proposed injection site(s) or when excessive weakness
or atrophy is present in the target muscle(s).
Dry Eye in Patients Treated With BOTOX® Cosmetic

MidFace
There have been reports of dry eye associated with BOTOX® Cosmetic injection in or near the orbicularis oculi muscle. If symptoms of dry eye (eg, eye irritation,
photophobia, or visual changes) persist, consider referring patients to an ophthalmologist.
Human Albumin and Transmission of Viral Diseases
This product contains albumin, a derivative of human blood. Based on effective donor screening and product manufacturing processes, it carries an extremely
remote risk for transmission of viral diseases and variant Creutzfeldt-Jakob disease (vCJD). There is a theoretical risk for transmission of Creutzfeldt-Jakob
disease (CJD), but if that risk actually exists, the risk of transmission would also be considered extremely remote. No cases of transmission of viral diseases, CJD
or vCJD have ever been identified for licensed albumin or albumin contained in other licensed products.

Lower Face
ADVERSE REACTIONS
The most frequently reported adverse reactions following injection of BOTOX® Cosmetic for glabellar lines were eyelid ptosis (3%), facial pain (1%), facial
paresis (1%), and muscular weakness (1%).
The most frequently reported adverse reaction following injection of BOTOX® Cosmetic for lateral canthal lines was eyelid edema (1%).
The most frequently reported adverse reactions following injection of BOTOX® Cosmetic for forehead lines with glabellar lines were headache (9%), brow ptosis
(2%) and eyelid ptosis (2%).

Submental Area
DRUG INTERACTIONS
Co-administration of BOTOX® Cosmetic and aminoglycosides or other agents interfering with neuromuscular transmission (eg, curare-like compounds) should
only be performed with caution as the effect of the toxin may be potentiated. Use of anticholinergic drugs after administration of BOTOX® Cosmetic may
potentiate systemic anticholinergic effects.
The effect of administering different botulinum neurotoxin products at the same time or within several months of each other is unknown. Excessive
neuromuscular weakness may be exacerbated by administration of another botulinum toxin prior to the resolution of the effects of a previously administered
botulinum toxin.
Excessive weakness may also be exaggerated by administration of a muscle relaxant before or after administration of BOTOX® Cosmetic.
Injection Codes

USE IN SPECIFIC POPULATIONS

Overview

There are no studies or adequate data from postmarketing surveillance on the developmental risk associated with use of BOTOX® Cosmetic in pregnant women.
There are no data on the presence of BOTOX® Cosmetic in human or animal milk, the effects on the breastfed child, or the effects on milk production.
Please see BOTOX® Cosmetic full Prescribing Information including Boxed Warning and Medication Guide.
47
 Introduction
JUVÉDERM® Collection of Fillers Important Information
INDICATIONS

Best Practices
JUVÉDERM VOLUMA® XC injectable gel is indicated for deep (subcutaneous and/or supraperiosteal) injection for cheek augmentation to correct age-related
volume deficit in the mid-face in adults over the age of 21.
JUVÉDERM® Ultra XC and JUVÉDERM® Ultra Plus XC injectable gels are indicated for injection into the mid-to-deep dermis for correction of moderate to severe
facial wrinkles and folds (such as nasolabial folds).
JUVÉDERM VOLLURE™ XC injectable gel is indicated for injection into the mid-to-deep dermis for correction of moderate to severe facial wrinkles and folds
(such as nasolabial folds) in adults over the age of 21.
JUVÉDERM® Ultra XC injectable gel is indicated for injection into the lips and perioral area for lip augmentation in adults over the age of 21.
JUVÉDERM VOLBELLA® XC injectable gel is indicated for injection into the lips for lip augmentation and for correction of perioral rhytids in adults over the

Upper Face
age of 21.
IMPORTANT SAFETY INFORMATION
CONTRAINDICATIONS
These products should not be used in patients who have severe allergies, marked by a history of anaphylaxis or history or presence of multiple severe allergies,
and should not be used in patients with a history of allergies to Gram-positive bacterial proteins or lidocaine contained in these products.
WARNINGS
• D o not inject into blood vessels. Introduction of these products into the vasculature may lead to embolization, occlusion of the vessels, ischemia, or
infarction. Take extra care when injecting soft-tissue fillers; for example, inject the product slowly and apply the least amount of pressure necessary.

MidFace
Rare, but serious, adverse events associated with the intravascular injection of soft-tissue fillers in the face have been reported and include temporary
or permanent vision impairment, blindness, cerebral ischemia or cerebral hemorrhage leading to stroke, skin necrosis, and damage to underlying facial
structures. Immediately stop the injection if a patient exhibits any of the following symptoms: changes in vision, signs of a stroke, blanching of the skin,
unusual pain during or shortly after the procedure. Patients should receive prompt medical attention and, possibly, evaluation by an appropriate healthcare
professional specialist should an intravascular injection occur
• Product use at specific sites in which an active inflammatory process (skin eruptions such as cysts, pimples, rashes, or hives) or infection is present should
be deferred until the underlying process has been controlled

Lower Face
PRECAUTIONS
• In order to minimize the risk of potential complications, these products should only be used by healthcare professionals who have appropriate training,
experience, and knowledge of facial anatomy
• Healthcare professionals are encouraged to discuss the potential risks of soft-tissue injections with their patients prior to treatment and ensure that patients
are aware of signs and symptoms of potential complications
• The safety and effectiveness for the treatment of anatomic regions other than the mid-face with JUVÉDERM VOLUMA® XC; facial wrinkles and folds with
JUVÉDERM® Ultra XC, JUVÉDERM® Ultra Plus XC, and JUVÉDERM VOLLURE™ XC; and the lips and perioral area with JUVÉDERM® Ultra XC and JUVÉDERM

Submental Area
VOLBELLA® XC have not been established in controlled clinical studies
• As with all transcutaneous procedures, dermal filler implantation carries a risk of infection. Follow standard precautions associated with injectable materials
• The safety for use during pregnancy, in breastfeeding females, and in patients with known susceptibility to keloid formation, hypertrophic scarring, and
pigmentation disorders has not been studied
• The safety for use of JUVÉDERM VOLUMA® XC in patients under 35 or over 65 years, JUVÉDERM® Ultra XC and JUVÉDERM® Ultra Plus XC in patients under
18 years, and JUVÉDERM VOLLURE™ XC and JUVÉDERM VOLBELLA® XC in patients under 22 years has not been established
• Use with caution in patients on immunosuppressive therapy
• Patients who are using products that can prolong bleeding (such as aspirin, nonsteroidal anti-inflammatory drugs, and warfarin) may experience increased
bruising or bleeding at treatment sites
Injection Codes

• If laser treatment, chemical peel, or any other procedure based on active dermal response is considered after treatment, or if these products are
Overview

administered before the skin has healed completely, there is a possible risk of an inflammatory reaction at the treatment site
• Patients who experience skin injury near the site of implantation may be at a higher risk for adverse events

48
 Introduction
JUVÉDERM® Collection of Fillers IMPORTANT SAFETY INFORMATION (continued)
PRECAUTIONS (continued)

Best Practices
• The safety of JUVÉDERM VOLUMA® XC injectable gel for use in patients with very thin skin in the mid-face has not been established
• Patients may experience late onset nodules with use of dermal fillers, including JUVÉDERM VOLUMA® XC
• Patients may experience late onset adverse events with use of dermal fillers
ADVERSE EVENTS
The most commonly reported side effects for JUVÉDERM® injectable gels were injection-site redness, swelling, pain, tenderness, firmness, lumps/bumps, bruising,
discoloration, and itching. For JUVÉDERM VOLBELLA® XC, dryness was also reported. For JUVÉDERM VOLUMA® XC, side effects were predominantly moderate in severity,
with duration of 2 to 4 weeks; for JUVÉDERM® Ultra XC, JUVÉDERM® Ultra Plus XC, or JUVÉDERM VOLLURE™ XC, they were mostly mild or moderate in severity, with
duration of 14 days or less; and for JUVÉDERM VOLBELLA® XC, they were predominantly mild or moderate, with duration of 30 days or less.

Upper Face
To report an adverse reaction with any product in the JUVÉDERM® Collection, please call Allergan at 1-800-433-8871. Please visit
JuvedermDFU.com for more information.
Products in the JUVÉDERM® Collection are available by prescription only.

MidFace
Lower Face
Submental Area
Injection Codes
Overview

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 Introduction
KYBELLA® (deoxycholic acid) injection 10 mg/mL Important Information
INDICATION

Best Practices
KYBELLA® (deoxycholic acid) injection is indicated for improvement in the appearance of moderate to severe convexity or fullness associated with submental
fat in adults.
The safe and effective use of KYBELLA® for the treatment of subcutaneous fat outside the submental region has not been established and is not recommended.
IMPORTANT SAFETY INFORMATION
CONTRAINDICATIONS
KYBELLA® is contraindicated in the presence of infection at the injection sites.
WARNINGS AND PRECAUTIONS
Marginal Mandibular Nerve Injury

Upper Face
Cases of marginal mandibular nerve injury, manifested as an asymmetric smile or facial muscle weakness, were reported in 4% of subjects in the clinical trials;
all cases resolved spontaneously (range 1-298 days, median 44 days). KYBELLA® should not be injected into or in close proximity to the marginal mandibular
branch of the facial nerve.
Dysphagia
Dysphagia occurred in 2% of subjects in the clinical trials in the setting of administration-site reactions, eg, pain, swelling, and induration of the submental area;
all cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days). Avoid use of KYBELLA® in patients with current or prior history of dysphagia
as treatment may exacerbate the condition.
Injection-Site Hematoma/Bruising

MidFace
In clinical trials, 72% of subjects treated with KYBELLA® experienced hematoma/bruising. KYBELLA® should be used with caution in patients with bleeding
abnormalities or who are currently being treated with antiplatelet or anticoagulant therapy as excessive bleeding or bruising in the treatment area may occur.
Risk of Injecting Into or in Proximity to Vulnerable Anatomic Structures
To avoid the potential of tissue damage, KYBELLA® should not be injected into or in close proximity (1 cm-1.5 cm) to salivary glands, lymph nodes,
and muscles.
Injection Site Alopecia
Cases of injection site alopecia have been reported with administration of KYBELLA®. Onset and duration may vary among individuals and may persist. Consider

Lower Face
withholding subsequent treatments until resolution.
Injection Site Ulceration and Necrosis
Injections that are too superficial into the dermis may result in skin ulceration and necrosis. Cases of injection site ulceration and necrosis have been reported
with administration of KYBELLA®. Do not administer KYBELLA® into affected area until complete resolution.
ADVERSE REACTIONS
The most commonly reported adverse reactions in the pivotal clinical trials were: injection site edema/swelling, hematoma/bruising, pain, numbness,
erythema, and induration.

Submental Area
Please see KYBELLA® full Prescribing Information.

Injection Codes
Overview

50
 Introduction
References:
1. BOTOX® Cosmetic Prescribing Information, November 2019.

Best Practices
2. Data on file, Allergan, September 19, 2016; Clinical Study Report 191622-143.
3. JUVÉDERM VOLUMA® XC Directions for Use, September 2016.
4. JUVÉDERM VOLLURE™ XC Directions for Use, March 2017.
5. JUVÉDERM VOLBELLA® XC Directions for Use, July 2017.
6. JUVÉDERM® Ultra Plus XC Directions for Use, May 2016.
7. JUVÉDERM® Ultra XC Directions for Use, May 2016.
8. KYBELLA® Prescribing Information, January 2018.
9. Wagner RD, Fakhro A, Cox JA, Izaddoost SA. Etiology, prevention, and management of infectious complications
of dermal fillers. Semin Plast Surg. 2016;30(2):83-86.
10. De Boulle K, Heydenrych I. Patient factors influencing dermal filler complications: prevention, assessment and

Upper Face
treatment. Clin Cosmet Investig Dermatol. 2015;8:205-214.
11. Urdiales-Gálvez F, Delgado NE, Figueiredo V, et al. Preventing the complications associated with the use of dermal
fillers in facial aesthetic procedures: An expert group consensus report. Aesthetic Plast Surg. 2017;41(3):667-677.
12. Cohen SR, Berner CF, Busso M, et al. Five-year safety and efficacy of a novel polymethylmethacrylate aesthetic
soft tissue filler for the correction of nasolabial folds. Dermatol Surg. 2007;33(suppl 2):222S-230S.
13. Collier H. The role of bacterial biofilms in aesthetic medicine: prioritising prevention. J Aesthetic Nurs.
2014;3(10):476-481. https://www.magonlinelibrary.com/doi/abs/10.12968/joan.2014.3.10.476. Published
November 27, 2014. Accessed April 9, 2018.
14. Standring S, ed. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 40th ed. London, England: Churchill
Livingstone; 2008.
15. Drake RL, Vogl AW, Mitchell AWM, Tibbitts RM, Richardson PE, eds. Gray’s Atlas of Anatomy. 2nd ed. Philadelphia,

MidFace
PA: Churchill Livingstone; 2015.
16. Data on file, Allergan, April 2018; Neurotoxin Facial Injectables Consumer A&U.
17. Brin MF, James C, Maltman J. Botulinum toxin type A products are not interchangeable: a review of the evidence.
Biologics: Targets and Therapy. 2014;8:227-241.
18. Beer JI, Sieber DA, Scheuer JF III, Greco TM. Three-dimensional facial anatomy: structure and function as it relates
to injectable neuromodulators and soft tissue fillers. Plast Reconstr Surg Glob Open. 2016;4(suppl 12):e1175.
19. Small R. Botulinum toxin injection for facial wrinkles. Am Fam Physician. 2014;90(3):168-175.
20. Swift A, Remington K. BeautiPHIcation™: a global approach to facial beauty. Clin Plast Surg. 2011;38(3):347-377.
21. JUVÉDERM VOLUMA® XC Patient Label, May 2016.

Lower Face
22. Data on file, Allergan.
23. Pinsky MA, Thomas JA, Murphy DK, Walker PS; for JUVÉDERM® vs ZYPLAST® Nasolabial Fold Study Group.
JUVÉDERM® injectable gel: A multicenter, double-blind, randomized study of safety and effectiveness.
Aesthetic Surg J. 2008;28(1):17-23.
24. Hoffmann K; JUVÉDERM VOLUMA® Study Investigators Group. Volumizing effects of a smooth, highly cohesive,
viscous 20 mg/mL hyaluronic acid volumizing filler: prospective European study. BMC Dermatol. 2009;9:1-9.
25. Gladstone HB, Cohen JL. Adverse effects when injecting facial fillers. Semin Cutan Med Surg. 2007;26(1):34-39.
26. Alam M, Gladstone H, Kramer EM, et al. ASDS guidelines of care: injectable fillers. Dermatol Surg.

Submental Area
2008;34(suppl 1):115S-148S.
27. Pierre S, Liew S, Bernardin A. Basics of dermal filler rheology. Dermatol Surg. 2015;41(suppl 1):120S-126S.
28. JUVÉDERM VOLLURE™ XC Patient Label, March 2017.
29. Lee SH, Gil YC, Choi YJ, Tansatit T, Kim HJ, Hu KS. Topographic anatomy of the superior labial artery for dermal
filler injection. Plast Reconstr Surg. 2015;135(2):445-450.
30. Sarnoff DS, Gotkin RH. Six steps to the “perfect” lip. J Drugs Dermatol. 2012;11(9):1081-1088.
31. de Maio M, Rzany B. The most common indications. In: de Maio M, Rzany B, eds. Injectable Fillers in Aesthetic
Medicine. Berlin, Germany: Springer; 2006:32-65.
32. Jordan DR, Klapper SR. Soft tissue fillers for facial aesthetics. In: Yen MT, ed. Surgery of the Eyelids, Lacrimal
System, and Orbit. 2nd ed. New York, NY: Oxford University Press; 2011:443-476.
Injection Codes

33. Data on file, Allergan, May 29, 2015; CSR JUVÉDERM VOLBELLA® XC-004 Final Report.
Overview

34. Data on file, Allergan; Facial Assessment & Injection Guide.

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Best Practices
Upper Face
MidFace
Lower Face
Submental Area
Injection Codes
Overview

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