Aesth Plast Surg
https://doi.org/10.1007/s00266-018-1157-3
ORIGINAL ARTICLE
Muscle Insertion and Strength of the Muscle Contraction
as Guidelines to Enhance Duration of the Botulinum Toxin Effect
in the Upper Face
Antonio Carlos Abramo1
Received: 21 March 2018 / Accepted: 12 May 2018
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2018
Abstract
Background In this series of patients the cutaneous inser-
tion and strength of voluntary contraction of the muscles in
the upper third of the face were used as guidelines for
botulinum toxin application named ‘‘BTA Codes.’’
Method Anatomical dissection of fresh cadavers identified
the shape and cutaneous insertions of the muscles in the
upper third of the face. Patient voluntary contraction of the
muscles in the upper third of the face created different
patterns of skin lines classified by the 4-grade Facial
Wrinkle Scale. For botulinum toxin application injections
points followed the muscle cutaneous insertion and dose
the 4-grade Facial Wrinkle Scale.
Results Injection points ranged from 3 to 23 points per
patient, average of 9.4 points. Dose per point varied from
2.5 to 7.5 U, ranging from 12.5 to 72.5 U per patient,
average of 33.82 U. Skin lines resulting from the voluntary
contraction of the muscle prior to toxin application were
stated as baseline 1. The absence of skin lines and muscle
activity on day fifteen after toxin application defined
baseline 2. Skin lines resulting from the recovered volun-
tary contraction of the muscle after toxin application like
those of baseline 1 established baseline 3. The botulinum
toxin effect was the time elapsed between baselines 2 and
3, ranging from 171 to 204 days, average of 183.72 days,
greater than the 3 or 4 months reported in the literature.
& Antonio Carlos Abramo
acabramo@abramo.com.br; alessandra@abramo.com.br
1
Post-Graduate Course of Plastic Surgery of the Institute of
Assistance in Plastic Surgery of São Paulo, Endorsed by the
Brazilian Society of Plastic Surgery and Brazilian Medical
Association, General Hospital São Luiz – Jabaquara, Rua
Afonso de Freitas, 641, São Paulo, SP 04006-052, Brazil
NON-SURGICAL AESTHETICS
Conclusion ‘‘BTA Codes’’ is a set of rules to apply botu-
linum toxin supported by muscle anatomy and degree of
voluntary contraction to enhance the duration of its effect.
Level of Evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Botulinum toxin
Injection points
Dose

Muscle insertion
Strength of voluntary contraction

‘‘BTA Codes’’
Introduction
The anatomy of the upper facial expression is complex, as
the muscles are very close together and interface at dif-
ferent levels and depths, creating a network of hyperdy-
namic skin lines. Despite having a single origin, the
corrugator supercilii originates several patterns of glabellar
skin lines due to three different cutaneous insertions [1].
Different patterns of skin lines are also created by muscles
with the same attachments and distinctive arrangements of
fibers, such as the frontalis muscle [2]. The number, length
and depth of the skin lines depend on the strength of the
muscle contraction. Correction by using botulinum toxin
requires proper understanding of the anatomical shape and
insertion of the facial muscles [3]. Botulinum toxin action
is more effective when applied by an objective muscle
identification approach [4]. Sundaram et al. [5] report that
inadequate injection points cause none or partial response
to the application of the botulinum toxin. Successful aes-
thetic outcomes have been reported by increasing injection
points and reducing the dose per point of botulinum toxin
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when combined with fillers [6]. However, duration of the

botulinum toxin effect is not described in the reports. The
typical duration of the botulinum toxin effect in the upper
third of the face is 3–4 months, depending on several
factors, including dose [7]. Low number of units by
injection point, regardless of the number of points, can
decrease duration of the botulinum toxin effect. Carruthers
et al. [8] reported that a higher botulinum toxin dose results
in greater efficacy and longer duration of effect. The
number, depth and length of the skin lines on the upper
third of the face are indicators of the botulinum toxin dose.
The 4-grade Facial Wrinkle Scale is a clinical tool for
assessing the depth and length of skin lines [9]. It is a
4-point scale of wrinkle severity that guides the appropriate
dose of botulinum toxin.
To enhance the duration of the botulinum toxin effect in
the upper third of the face, injection points into the muscle
cutaneous insertion and dose according to the strength of
its contraction are proposed. This system is named ‘‘BTA
Codes’’ because it represents a set of rules about how the
author applied botulinum toxin.

Anatomy

Frontalis muscle—Four types of muscle fiber arrangements

inserted along the forehead skin originate four muscle
shapes, establishing four patterns of cutaneous lines [2].
The full type (Fig. 1) creates horizontal straight lines across
the forehead (Fig. 2a); V-shaped type (Fig. 3), horizontal Fig. 2 a Forehead furrows caused for a frontalis full type. Injection
gull wing-shaped lines across the forehead (Fig. 4a); cen- points F1, F2, F4, F5 and F6 were distributed from line 2 to line 10 on
both sides of the forehead. Injection point F3 only on line 6. b Dose
tral type (Fig. 5), a column of short horizontal lines in the
for injection points was 2.5 U. At day 151 after baseline 2 a smooth
middle of the forehead (Fig. 6a); and lateral type (Fig. 7a), forehead during voluntary contraction of frontalis

Fig. 1 Cadaver dissection showing full type of frontalis and narrow Fig. 3 Cadaver dissection with V-shaped type of frontalis, and fan-
ribbon-shaped of both corrugator supercilii. The dotted line represents shaped for the right corrugator supercilii and rectangular-shaped for
the eyebrow location the left. Eyebrows marked by dotted line

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Fig. 5 Cadaver dissection with central type of frontalis, and narrow

ribbon-shaped for the right corrugator supercilii and rectangular-
shaped for the left. Eyebrows marked by dotted line

Fig. 4 a A frontalis V-shaped type created severe horizontal gull

wing-shaped lines and excessive lift of eyebrows. Points F1, F2, F4
and F5 received 2.5 U, bilaterally. b At day 159 after baseline 2,
despite a few lines, a noticeable reduction in the gull wing-shaped
lines remains with natural eyebrows lift during the voluntary
contraction of the frontalis

two lateral columns of short horizontal lines on the fore-

head (Fig. 7b).
Corrugator supercilii muscle—A single origin in the
frontal process of the maxilla with three different insertions
underneath the medial half of the eyebrow creating three
muscle patterns [2]. Fan-shaped (Fig. 7a) along the medial
half of the eyebrow, causing vertical hockey stick-shaped
lines on the medial end of eyebrows (Fig. 8a); rectangular-
shaped (Fig. 9) in the lateral two-thirds of the medial half
of eyebrows causing vertical parallel straight lines on the
glabella (Fig. 9); and narrow ribbon-shaped (Fig. 1) at the
medial end of the eyebrows causing a single vertical line on
the glabella (Fig. 10a). Six patterns of lines can be found Fig. 6 a Voluntary contraction of central type of frontalis showing a
on both sides of the glabella, three symmetrical and three column of short horizontal lines in the middle of the forehead. Points
F2, F3, F4 and F5 received 2.5 U of botulinum toxin. b At day 138
asymmetrical, according to the muscle shape on each side after baseline 2 a smooth forehead is achieved during voluntary
[2]. contraction of the frontalis

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Fig. 7 a Cadaver dissection with lateral type of frontalis and fan-
shaped of both corrugator supercilii. Eyebrows marked by dotted line.
b Voluntary contraction of the frontalis lateral type shows two lateral
columns of short horizontal lines on forehead
Orbicularis oculi muscle—In the upper eyelid, runs
under the corrugator supercilii with the thick peripheral
fibers inserted at the lateral end of the eyebrow, and the
central thinner palpebral fibers spread around both eyelids
[2]. Peripheral fibers shift the lateral end of the eyebrow
downward, whereas the thinner palpebral fibers cause
crow’s feet (Fig. 11a).
Procerus muscle—It is located between and below the
eyebrows [2]. Its activity creates horizontal lines on the
roof of the nose and ‘‘bunny lines’’ (Fig. 12a).
Method
Twenty-five females with age ranging from 41 to 59 years
underwent application of botulinum neurotoxin type A in
the frontalis, corrugator supercilii, orbicularis oculi and
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Aesth Plast Surg
Fig. 8 a Severe vertical hockey stick-shaped lines on the medial end
of eyebrows caused by fan-shaped corrugator supercilii. Injection
points C1, C2 and C3 received 7.5, 5.0 and 2.5 U, respectively, on
both eyebrows. b Glabellar skin lines or muscle activity is not
observed during voluntary contraction at day 134 after baseline 2
procerus muscles. Exclusion criteria included scars,
smokers, prior cosmetic procedures, soft tissue augmenta-
tion, pregnancy, lactation and neuromuscular disease.
Preparation of a botulinum neurotoxin type A from the
same manufacturer was applied in all patients of this series.
Dilution of the botulinum neurotoxin type A in saline
solution was established at 5 U per 0.1 mL of the solution.
Injection points were distributed according to the cuta-
neous insertion of the target muscle. The dose per injection
point was established by the number, depth and length of
the skin lines resulting from the voluntary contraction of
the muscle. The 4-grade Facial Wrinkle Scale measured
depth and length of the skin lines resulting from the muscle
contraction setting: FWS1 as none, FWS2 as mild, FWS3
as moderate and FWS4 as severe. The duration of the
botulinum toxin effect was measured in days, considering
three assessments. Baseline 1: skin lines resulting from the
voluntary contraction of the muscle prior to toxin
Aesth Plast Surg
Fig. 9 Rectangular-shaped of both corrugator supercilii. Voluntary
contraction of the muscles exhibited severe vertical lines on the
glabella
application. Baseline 2: day fifteen after toxin application
with the absence of skin lines and muscle activity. Baseline
3: skin lines resulting from the recovered voluntary con-
traction of the muscle after the toxin application, like those
exhibited in baseline 1. All patients signed an informed
consent form agreeing to the proposed treatment that was
performed according to the 1964 Declaration of Helsinki
and Medical Research Involving Human Subjects.
Dose
Dilution of botulinum toxin in saline solution was estab-
lished at 5 U per 0.1 mL of the solution, making easy
application of fractional doses as 2.5 or 7.5 U. The dose per
injection point for FWS2 was 2.5 U, for FWS3 was 5.0 U
and for FWS4 was 7.5 U.
Injection Points
Frontalis muscle—Eleven vertical parallel lines, with the
same distance among them and numbered from the right to
the left, split the forehead between both lateral ends of the
eyebrows. Injection point F1 was marked on lines 2 and 10,
point F2 on lines 4 and 8 and point F3 on line 6, all of them
2.0 cm above the eyebrow; point F4 on lines 3 and 9 and
point F5 on lines 5 and 7, both 2.5 cm above the eyebrow;
and point F6 on lines 4 and 8, located 3.0 cm above the
eyebrow (Fig. 2a).
Corrugator supercilii muscle—The medial half of the
eyebrow was split by four vertical parallel lines, the same
distance between them, resulting in three compartments
numbered from the medial end of the eyebrow. Injection
points were applied above the eyebrow hairline with the
Fig. 10 a Severe single vertical line on the glabella during voluntary
contraction of a narrow ribbon-shaped corrugator supercilii muscle.
Point C1 received 7.5 U of botulinum toxin. b No muscle activity
during voluntary contraction at day 148 after baseline 2
needle toward the forehead. Point C1 was in compartment
one; point C2 in compartment two; and point C3 in com-
partment three (Fig. 8a). Point C3 is an alternative appli-
cation only for a fan-shaped muscle with severe contraction
strength, creating several vertical lines in the medial half of
the eyebrow associated with the vertical hockey stick-
shaped line. At points C2 and C3, pressing with one finger
inferior to the injection point helped to avoid dispersion of
the toxin to the levator palpebrae superioris muscle.
Orbicularis oculi muscle—Lateral half of the eyebrow
was split by four vertical parallel lines, the same distance
between them, resulting in three compartments numbered
from the lateral end. Point O1 was in compartment one,
below the hair line of the eyebrow; point O2 in compart-
ment one, 1.0 cm above the lateral canthus; point O3 in the
compartment two, at the level of the lateral canthus; point
O4 in compartment two, 1.5 cm below the lateral canthus;
and point O5 in compartment three, 2.0 cm below the
ciliary edge (Fig. 11a).
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Fig. 11 a Voluntary contraction of orbicularis showing crow’s feet
on both eyelids. Lateral half of the eyebrow was split in 3
compartments. Injections points O1, O2, O3, O4, O5 received
2.5 U each one. b Smooth eyelids during voluntary contraction of the
muscle at day 140 after baseline 2
Procerus muscle—The nose was split by five vertical
parallel lines from one nostril to the other with the same
distance between them, numbered from the right to left.
Point P1 was applied on lines two and four, 1.0–1.5 cm
below the medial canthus (Fig. 12a).
Results
Twenty-five females with ages ranging from 41 to
59 years, mean age of 48.43 years, had improvement of
hyperdynamic skin lines on the forehead, glabella, nose
and periorbital area after application of botulinum toxin. In
addition, the height and shape of the eyebrows recovered.
The real-time duration of the botulinum toxin effect was
established in days by the time elapsed between baselines 2
and 3, ranging from 171 to 204 days, average of
183.72 days. Table 1 summarizes the distribution of
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Fig. 12 a Severe bunny lines and horizontal lines on the root of the
nose during voluntary contraction of the procerus. Nose was split in
four compartments. Injection points P1 received 5.0 U applied into
the compartments 2 and 3 below the medial canthus. b Voluntary
contraction at day 138 after baseline 2 without skin lines on the nose
patients, location of the injection points, dose per injection
point and duration of the botulinum toxin effect.
Injection Points and Dose
Injections points were performed at the intramuscular level
distributed according to the extension and location of the
cutaneous insertions of each muscle. Twenty-five female
patients received 236 injection points, ranging from 3 to 23
points per patient, average of 9.4 points. The dose followed
the FWS for each target muscle. A total of 848 U of
botulinum toxin was applied, ranging from 12.5 to 72.5 U
per patient, average of 33.92 U. Thirteen points received
7.5 U, 76 points 5.0 U and 147 points 2.5 U.
Frontalis—Injection points improved forehead furrows,
and height and symmetry of the eyebrows. Points F1, F2,
F3, F4, F5 and F6 were used for full type muscles (Fig. 2a,
b); points F1, F2, F4 and F5 for V-shaped type muscles
 Aesth Plast Surg

Table 1 Patients distribution and outcomes

Age Frontalis Corrugator Orbicularis oculi Procerus Effect duration
Baseline
R* L* Center* R* L* R* L* R* L* 3 - baseline 2
(days)
F1 F2 F4 F5 F6 F1 F2 F4 F5 F6 F3 C1 C2 C3 C1 C2 C3 O1 O2 O3 O4 O5 O1 O2 O3 O4 O5 P1 P1

1 41 – – – – – – – – – – – – 5 – – 5 – – 5 2.5 2.5 – – 2.5 2.5 2.5 – – – 196 - 15 = 181

2 42 – – – – – – – – – – – 7.5 5 2.5 – 5 – – 5 – – – 5 5 – – – – – 188 - 15 = 173
3 41 2.5 2.5 – 2.5 – 2.5 2.5 – 2.5 – 2.5 5 2.5 – 5 2.5 – 5 2.5 2.5 2.5 2.5 5 2.5 2.5 2.5 2.5 2.5 2.5 191 - 15 = 176
4 45 – – – – – – – – – – – – 5 – – 5 – 5 2.5 2.5 – – 2.5 2.5 2.5 – – – – 201 - 15 = 186
5 59 – – – – – – – – – – – – – – – – – 5 – – – – 5 2.5 – – – – – 197 - 15 = 182
6 49 – – – – – – – – – – – 5 – – 5 – – – 5 2.5 – – – 2.5 2.5 2.5 2.5 – – 204 - 15 = 189
7 53 – – – – – – – – – – – – 5 – 7.5 5 – 5 – – – – 5 – – – – – – 199 - 15 = 184
8 57 – – – – – 2.5 5 5 2.5 2.5 – – – – – – – – – – – – – – – – – – – 199 - 15 = 184
9 47 – – – – – – – – – – – 5 2.5 – – 5 – – 5 2.5 – – – 2.5 2.5 2.5 2.5 2.5 2.5 199 - 15 = 184
10 44 – – – – – – – – – – – – 5 – – 5 – – 2.5 – – – – 2.5 – – – – – 199 - 15 = 184
11 42 – – – – – 2.5 2.5 2.5 – – – 5 2.5 – 5 2.5 – – 2.5 2.5 2.5 2.5 – 2.5 2.5 – – – – 194 - 15 = 179
12 58 – – – – – – – – – – – 7.5 5 2.5 – 5 – 2.5 – – – – 5 – – – – – – 204 - 15 = 189
13 52 – – – – – – – – – – – 7.5 5 – – 5 – 5 5 2.5 2.5 2.5 5 2.5 2.5 – – – – 219 - 15 = 204
14 52 – – – – – – – – – – – 7.5 5 – 7.5 2.5 – 5 – – – – 5 – – – – 2.5 5 186 - 15 = 171
15 57 2.5 2.5 2.5 2.5 – – – – – – 2.5 – – – – – – – – – – – – – – – – 200 - 15 = 185
16 53 – – – – – – – – – – – 7.5 5 2.5 – 5 – 5 – – – – 5 – – – – 5 5 212 - 15 = 197
17 44 2.5 2.5 2.5 2.5 – 2.5 2.5 2.5 2.5 – 2.5 7.5 – – 7.5 – – 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 195 - 15 = 180
18 46 – – – – – – – – – – – – 5 – – 2.5 – 2.5 2.5 2.5 – – 2.5 2.5 2.5 2.5 2.5 – – 195 - 15 = 180
19 52 – – – – – – – – – – – 5 2.5 – 5 5 – 2.5 – – – – 5 – – – – – – 194 - 15 = 179
20 54 2.5 2.5 – – – – – – – – 2.5 – 5 – – 5 – – 2.5 2.5 – – 2.5 5 2.5 – – – – 207 - 15 = 192
21 48 – 2.5 – 2.5 – – 2.5 – 2.5 – 2.5 7.5 5 2.5 7.5 5 2.5 5 2.5 2.5 2.5 – 5 2.5 2.5 2.5 – 2.5 2.5 192 - 15 = 177
22 46 – – – – – – – – – – – 5 5 2.5 5 5 2.5 – – – – – – – – – – – – 198 - 15 = 183
23 59 – – – – – – – – – – – 7.5 5 2.5 5 5 2.5 5 5 2.5 2.5 5 2.5 2.5 – – 2.5 2.5 196 - 15 = 181
24 49 – – – – – – – – – – – 7.5 5 2.5 – 5 – 2.5 – – – – 5 – – – – 198 - 15 = 183
25 58 – – – – – – – – – – – 5 – – – 5 – 2.5 – – – – 2.5 – – – – – – 205 - 15 = 190
*U international unit

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(Fig. 10a, b); points F1, F2 and F4 for lateral type muscles;
and points F2, F3, F5 and F6 for central type muscles
(Fig. 11a, b). Thirty-four points on both sides of the fore-
head received 2.5 U, and two points, F2 and F3, on left side
of the forehead received 5.0 U.
Corrugator supercilii—Injection points annulled
glabellar vertical lines and resulted in adequate height of
the medial half of the eyebrow. Points C1, C2 and C3 were
applied to fan-shaped muscle (Fig. 4a, b); C2 to rectan-
gular-shaped muscle; and C1 to narrow ribbon-shaped
muscle (Fig. 12a, b). Thirteen points C1 received 7.5 U
and thirteen 5.0 U; thirty-one points C2 received 5.0 U and
eight 2.5 U; and ten points C3 received 2.5 U.
Orbicularis oculi—Points O1 settled the lateral height of
the eyebrow; and points O2, O3, O4 and O5 annulled the
crow’s feet (Fig. 11a, b). Twenty points O1 received 5.0 U
and eleven 2.5 U; eight points O2 received 5.0 U and
twenty-one 2.5 U; twenty-four points O3 received 2.5 U;
fourteen points O4 received 2.5 U; and nine points O5
received 2.5 U.
Procerus—Point P1 annulled horizontal lines on the roof
of the nose and bunny lines (Fig. 12a, b). Three points
received 5.0 U and eleven 2.5 U.
Discussion
Injection points and dose per point of the botulinum toxin
in the upper third of the face must be individualized [10].
The morphology of each muscle, topographic relationship
with surrounding muscles and the expressiveness of the
corresponding skin lines are relevant to optimize outcomes.
Classification of the facial skin lines, particularly in the
glabella, has been used as a guide for botulinum toxin
injection points. However, application over the skin lines
can recruit adjacent muscles besides the target muscle [11].
To prevent recruitment of adjacent muscles, the ‘‘BTA
Codes’’ distributed the injection points along the cutaneous
insertions of the target muscle and not in the skin lines
resulting from its voluntary contraction. Nevertheless,
standardized injection techniques, when all the subjects
receive the same injection points and equal doses per point,
regardless of the cutaneous insertion and contraction
strength of the muscle, are still being used for botulinum
toxin [12]. Standard injection protocol techniques are
unimportant as long as it remains standardized [13]. In the
‘‘BTA Codes’’ injection points are not standardized,
changing among individuals and on each side of the same
individual, attending the patterns of the muscle shape and/
or its cutaneous insertions. In the forehead, injection points
follow the patterns of the frontalis muscle created by the
arrangement of its fibers, avoiding application of the toxin
in the aponeurotic galea where it has no effect. Injection
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Aesth Plast Surg
points F1, F2, F3, F4 and F5 weaken the frontalis muscle
preserving its activity, minimizing forehead furrows with
minimal downward displacement of the eyebrow. Injection
point F6 is usually applied to residual furrows near the
forehead hair line. The lack of antagonism resulting from
the annulment of the eyebrow depressor muscles stimulates
the automated movement of the frontalis, which reduces
the expressiveness of forehead furrows, holding the eye-
brow in a natural balanced position [14]. Injection points
C1, C2 and C3 for corrugator supercilii can be applied
separately or together according to the three distinct pat-
terns of the muscle and the strength of the voluntary con-
traction. A single point in the center of the glabella has
been reported to annul skin lines due to the activity of the
procerus muscles [15]. However, as the procerus muscles
are inserted into the skin between and below the eyebrows
on either side of the glabellar midline, a single glabellar
central injection point cannot annul the activity of both
muscles. Injection point P1 is applied on either side of the
nose at the level of the medial canthus involving both
procerus muscles to annul skin lines on the roof of the nose
and bunny lines. Duration of the botulinum toxin effect in
facial aesthetic applications has been reported as approxi-
mately 4 months. The treated muscles gradually regain
function, and generally, the skin lines return to their former
appearance 3–4 months after the treatment [16]. In this
series of patients, duration of botulinum toxin effect was 6
months or slightly more. It lasted from baseline 2, day
fifteen after application, and not from baseline 1, day of
application, which establishes the real-time duration of
effect. The dose per point in the ‘‘BTA Codes’’ is not
standardized, changing with the number, depth and length
of skin lines representing the strength of the voluntary
contraction of the muscle. Although a very strong dosage,
the association of 7.5, 5.0 and 2.5 U distributed in different
points of the same muscle extended the duration of the
botulinum toxin effect for about 6 months or more without
side effects, in this series of patients. There were two
factors contributing to the elongated duration of the botu-
linum toxin effect in the ‘‘BTA Codes.’’ First, the injection
points were distributed specifically along the cutaneous
insertion of the target muscle, and second, the dose
according to the strength of the muscle contraction.
According to Maas et al. [17], the size of the field of effect
is difficult to define and it is related to the volume applied.
In this series of patients, 5.0 U of botulinum toxin in
0.1 mL of the solution provided high doses, such as 7.5 and
5.0 U, with minimal volume, restricting its dispersion.
Therefore, it limited the size of the effect field to the
cutaneous insertion of the muscle. This was particularly
important in the injection points C1, C2 and C3 of the
corrugator supercilii muscle, to avoid the drop of the upper
eyelid.
Aesth Plast Surg
Conclusion
‘‘BTA Codes’’ is a practical strategy following the patterns
of muscular dynamics in a selective manner. Duration of
the botulinum toxin effect is dose dependent in relationship
to the strength of the muscle contraction. It is also injection
point dependent, due to the different patterns of the cuta-
neous insertion of each muscle.
Acknowledgements To the cadavers of selfless dedication.
Compliance with Ethical Standards
Conflict of interest The author has no financial interest or conflict of
interest to declare in relation to the content of this article.
References
1. Abramo AC (1995) Anatomy of the forehead muscles: the basis
for the video-endoscopic approach in forehead rhytidoplasty.
Plast Reconstr Surg 95(6):1170–1177
2. Abramo AC, do Amaral TPA, Lessio BP, de Lima GA (2016)
Anatomy of forehead, glabellar, nasal and orbital muscles, and
their correlation with distinctive patterns of skin lines on the
upper third of the face: reviewing concepts. Aesth Plast Surg
40(6):962–971
3. Trévidic P, Sykes J, Criollo-Lamilla G (2015) Anatomy of the
lower face and botulinum toxin injections. Plast Reconstr Surg
136(5S):84S–91S
4. Guerrerosantos J, Eduardo PGC, Arriola JM, Manzano AIV,
Villarán-Muñoz B, Benavides LG, Vazquez MG (2015) Effec-
tiveness of botulinum toxin (type-A) administered by the fixed-
site dosing approach versus the muscle area identification. Aesth
Plast Surg 39(2):243–251
5. Sundaram H, Liew S, Signorini M et al (2016) Global aesthetics
consensus: hyaluronic acid fillers and botulinum toxin type A—
recommendations for combined treatment and optimizing out-
comes in diverse patient population. Plast Reconstr Surg
137:1410–1423
6. Carruthers J, Glogau RG, Blitzer A, Facial Aesthetics Consensus
Group Faculty (2008) Advances in facial rejuvenation: botulinum
toxin type A, hyaluronic acid dermal fillers, and combination
therapies-consensus recommendations. Plast Reconstr Surg 121(5
Suppl):5S–30S (quiz 31S-36S)
7. Hexel DM, Klein AW (2010) Botulinum toxin. Section 51. In:
Baran R, Maibach HI (eds) Textbook of cosmetic dermatology,
4th edn. Informa Healthcare, New York, pp 443–452
8. Carruthers A, Carruthers J, Cohen J (2007) Dilution volume of
botulinum toxin type A for the treatment of glabellar rhytides:
Does it matter? Dermatol Surg 33:S97–S104
9. Carruthers J, Rivkin A, Donofrio L et al (2015) A multicenter,
randomized, double-blind, placebo-controlled study to evaluate
the efficacy and safety of repeated onabotulinumtoxinA treat-
ments in subjects with crow’s feet lines and glabellar lines.
Dermatol Surg 41(6):702–711
10. Carruthers J, Fagien S, Matarasso SL, Botox Consensus Group
(2004) Consensus recommendations on the use of botulinum
toxin type A in facial aesthetics. Plast Reconstr Surg 114(6
Suppl):1S–22S
11. de Almeida AR, da Costa Marques ER, Banegas R, Kadunc BV
(2012) Glabellar contraction patterns: a tool to optimize botuli-
num toxin treatment. Dermatol Surg 38(9):1506–1515
12. Kaufman J, Green JB (2016) Injection techniques: forehead and
eyebrow shaping. Chapter 3. In: Beer KR (ed) Handbook of
botulinum toxins for aesthetic indications. Theory and practice.
London, Philadelphia, Panama City, New Delhi: JP Medical,
pp 15–22
13. Gart MS, Gutowski KA (2016) Overview of botulinum toxins for
aesthetic uses. In: Rothaus KO (ed) Minimally invasive rejuve-
nation of face and neck. Elsevier, Philadelphia, pp 459–472
14. Abramo AC, Dorta AA (2003) Selective myotomy in forehead
endoscopy. Plast Reconstr Surg 112(3):873–879
15. Rzany B, Ascher B, Fratila A et al (2016) Efficacy and safety and
3-and-5 injection patterns (30 and 50 U) of botulinum toxin A
(Dysport) for the treatment of wrinkles in the glabella and central
forehead region. Arch Dermatol 142:320–326
16. Small R (2014) Botulinum toxin injection for facial wrinkles. Am
Fam Physician 90(3):168–175
17. Maas C, Kane MA, Bucay VW et al (2012) Current aesthetic use
of abobotulinumtoxinA in clinical practice: an evidence-based
consensus review. Aesthet Surg J 32(1 Suppl):8S–29S
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