Aesth. Plast. Surg.
25:73–84, 2001
DOI: 10.1007/s002660010100
Botulinum Toxin A and Facial Lines: The Variable Concentration
Claude Le Louarn
59 rue Spontini, 75116 Paris, France
Abstract. Our improved understanding of the functional
anatomy of the face and of the action of the botulinum toxin A
leads us to determine a new injection procedure which conse-
quently decreases the risk of eyebrow and eyelid ptosis, and
increases the toxin injection’s possibilities and efficiencies.
Variable toxin injection concentrations adapted to each injected
area are used. Thanks to the new procedure in the upper face,
toxin A action is quite close to an endoscopic surgical action.
In addition, interesting results are achievable on the nose, upper
part of the nasolabial fold, jawline and neck regions. Lastly, a
smoothing effect on the skin is obtained by the anticholinergic
action of the toxin A on the dermal receptors.
Key words: Botulinum toxin A—Variable concentration—
Injection technique
Two types of botulinum toxin A are used in this study,
the DYSPORT toxin distributed by BEAUFOUR-IPSEN
laboratory (Each vial contains 500 Speywood units of
toxin A), and the BOTOX toxin distributed by ALLER-
GAN laboratory (Each vial contains 100 Allergan units
of toxin A).
The toxin equivalence seems to be 3 to 4 Speywood
units (Dysport) 4 1 Allergan unit (Botox) [7]. A Dys-
port vial contains 25% to 40% more usable product than
one Allergan vial.
To correct dystonia and spasm, injections must be re-
peated at a constant frequency to maintain the desired
effect [10]. This seems to be related to the high intensity
and frequency of nerve stimulation in such disorders.
In the cosmetic field (facial lines) injection frequency
can be progressively decreased because of 2 factors: a
mild long-term muscle atrophy, and a change in facial
animation patterns with a lower intensity and in the fre-
quency muscle nervous stimulation [1,2].
The following study describes the new possibilities of
the botulinum toxin A when using new injection tech-
niques which limit its migration.
© 2001 Springer-Verlag New York Inc.
Migration Factors
The main concern with the use of toxin A lies in the risk
of migration. Three injection sites are specifically asso-
ciated with the risk [6].
An injection above the eyebrow into the corrugator
muscle can cause eyelid ptosis. The migration distance
between the injection site and the levator palpebrae
muscle is 2 cm.
An injection in the lateral part of the orbicularis oculi
muscle, just below the eyebrow, can allow the toxin to
migrate into the levator palpebrae muscle or into the
extraocular muscles. Migration distance is 2 cm.
Injection in the upper part of the frontalis muscle can
migrate into the lower part of the frontalis muscle. As
described in Fig. 5, lower frontalis muscle paralysis in-
duces eyebrow ptosis. Migration distance is 2 cm.
The migration is specially due to injection volume,
injection orientation, and injection bleeding.
Injection Volume
When following the instructions of the Dysport package
insert, 500 units of Dysport are mixed with 2.5 ml of
non-preserved saline: 20 units equals a volume of 0.1 ml
which is frequently larger than the volume of muscle to
be injected. Obviously, the risk of side effects is high.
In order to obtain a more precise effect, the contents of
a vial are diluted in 0.7 ml of saline (nearly a quarter of
the recommended quantity) thus the volume to inject will
be smaller than the volume of the muscle injected (Fig.
1). The risk of migration in the periorbital region is thus
drastically diminished.
For Botox toxin, 100 Allergan units are usually mixed
with 4 ml of saline [4]. The proposed dilution is 100
Allergan units mixed with 1 ml of non-preserved saline.
It is better to use a 0.5 ml diabetic syringe to inject
a high concentration solution of toxin A rather than a
1 ml syringe. The 0.5 ml diabetic syringe is twice as
74
Fig. 1. Volume of 15 units of Dysport in case of dilution of the
vial with 2.5 ml, 1.25 ml, 0.62 ml of saline.
precise as the 1 ml, but also the 0.07 ml loss of solution
per use between the syringe and the needle doesn’t exist
with the smaller syringe. Indeed, the 0.5 ml diabetic sy-
ringe has a 29 gauge needle directly inserted in the cavity
with no empty space. The performing syringe we found
for this use is the BD 4-100 Insulin microfine 8 mm 0.5
ml with 50 units (Fig. 2).
Injection Orientation
Not only is the bevelled angle of the needle directed to
the desired target exactly like in Collagen injection tech-
niques, but also any dangerous adjacent muscle direction
of the injection is to be avoided.
In case of corrugator muscle injection, the bevelled
angle of the needle is directed opposite to the levator
palpebrae muscle.
Bleeding Induced with Injection
A needle injection creates a micro-tissue trauma, micro-
bleeding, sometimes an ecchymosis. This ecchymosis
downward migration due to gravity, carries along the
botulinum toxin. This risk is minimized with the help of
the following procedure: Any injection on a vascular axis
such as the supraorbital bundle, should be avoided [3]; an
appropriate digital pressure is realized when the needle is
removed from the injection site. This action is mainly
important in case of corrugator muscle injection, as well
as in the case of frontal and orbicularis oculi muscles
such as previously described, and in any case of ecchy-
mosis; adrenaline is added to the non-preserved saline
with a dilution of 50 m gr/per ml (like xylocaïne 1%
adrenaline).
Injection Technique
There are three causes of the injection imprecision that
can explain different results with the same patient and
the same technique at different injection sessions: a par-
allax error vision due to an axis of vision which is not
perpendicular to the axis of the syringe; imprecision in
the digit pressure on the piston of the syringe due to the
Varying Botulinum Toxin A Concentrations
Fig. 2. The 0.5 ml insulin syringe with 50 units.
use of the tip of the thumb and not of its base; lastly, the
unit number in each vial of Dysport or of Botox is subject
to a variation of 20%. This unavoidable variation results
from the toxin manufacturing processes. A good injec-
tion technique limits problems 1 and 2.
Variable Toxin Concentration
The concentration of a motor end-plate near the injection
point depends on each type of muscle. A flat and thin
muscle like the platysma muscle has a medium motor
end-plate concentration, and, on the contrary, a short and
thick corrugator muscle has a high concentration of mo-
tor end-plates near the injection point. On this basis, we
describe 3 different toxin concentrations, high, medium
and low depending upon the action we look for.
The high toxin concentration. 0.7 ml of saline are used
to dilute 500 units of Dysport or 1 ml of saline for 100
units of Botox. The action is strong and precise, on thick
muscles of the peri orbital area: the corrugator muscle,
the orbicularis oculi muscle pars orbitalis, the depressor
supercilii muscle and the lower part of the frontalis
muscle. This high concentration diminishes the volume
of injection and prevents migration.
Medium concentration toxin. To obtain a medium con-
centration toxin, two volumes of saline including adrena-
line is added to the volume of high concentrated toxin
which is already in the syringe (Fig. 3).
The action is clear and spread over a larger surface
with the same number of units of toxin. The muscles
concerned are the frontalis, the orbicularis oculi temporal
and malar pars, the platysma and the chin muscles.
The low concentration toxin. 3 volumes of saline includ-
ing adrenaline are added to the volume of toxin already
in the syringe. The action of the injection is partial and
localised. It is useful for injecting spots in the vermillon
border of the lip or in the orbicularis oculi pars orbitalis
in the lower eyelid area. The variable concentration can
be adapted to each physician’s experience and to each
patient’s reaction. A patient with a long duration effect
on the periorbital area and too short an effect on the
frontal area, will benefit from a higher concentration of
toxin injection in the frontal area at a further session.
C. Le Louarn
Fig. 3. The sterile cap of the syringe is filled with the same and
volume solution of saline, plus adrenaline, used to dilute the
toxin. The syringe is filled with the necessary amount and
volume of toxin to weaken the target muscles. Two volumes of
the saline are added to the syringe to obtain medium-
concentration toxin, and 3 volumes of saline are added to the
syringe to obtain a low-concentration toxin. In special cases
(alcoholism or diabetes, for instance) dilution can be more
important—five times the volume already in the syringe may
be needed.
Injection sites
The injection sites we are going to study are periorbital
and peribuccal (Fig. 4).
Periorbital Sites
Periorbital sites include the following muscles: corruga-
tor, depressor supercilii, procerus, frontalis, and orbicu-
laris oculi.
Corrugator muscle. The corrugator muscle originates
from the bone of the lower part of the arcus superciliaris.
The volume of the arcus superciliaris depends on the
strength of the contraction of the underlying corrugator
muscle. A strong contraction creates a progressively
more important volume of the arcus superciliaris. The
palpation of the arcus superciliaris gives information on
the location and strength of the corrugator muscle. The
muscle belly is oriented transversally and inserted in the
skin above the eyebrow, creating the characteristic “cor-
rugator dimple” on a forceful contraction, at the junction
middle third, lateral third of the eyebrow [9]. The middle
third of the eyebrow is then strongly depressed.
Injection of the medial part of the corrugator muscle.
From an aesthetic point of view, the induction of medial
brow ptosis from vertical glabella frown lines treatment
should be avoided. This side effect results from the cor-
rugator muscle injection through the frontalis muscle. In
this usual technique the frontalis muscle receives com-
pulsorily some of the injected product and thus is weak-
ened. In order to avoid this common problem, injection
into the deep corrugator muscle is realized while the
surgeon’s digit raises the medial part of the eyebrow,
through the orbicularis oculi muscle.
75
Seven to 14 units of Dysport or 3 to 5 units of Botox
are injected. The tip of the needle is on the arcus super-
ciliaris bone, the bevelled opening oriented to the gla-
bella area and not to the levator palpebrae muscle. The
bony insertion of the muscle is injected, not its skin
insertion. The injection of the medial part of the corru-
gator muscle decreases the vertical glabella frown lines.
Injection of the lateral part of the corrugator muscle.
This injection is realized in case of non-sufficient action
of the injection of the medial part of the corrugator
muscle to decrease the glabella frown lines, or too low a
location of the middle third of the eyebrow. This injec-
tion produces the elevation of the middle third of the
eyebrow. The product is injected deeply, near the bone at
the lateral extremity of the corrugator muscle, which
means at the lateral extremity of the bony arcus super-
ciliaris. That is also the lateral extremity of the corruga-
tor dimple. Only 3 units of Dysport or 1 unit of Botox are
used. This very small quantity of toxin will not concern
the overlying frontalis muscle. The injection is far from
the supraorbital nerve and its vacular bundle, a source of
possible hematoma and migration.
Depressor supercilii muscle
The depressor supercilii muscle originates from the nasal
process of the nasal portion of the frontal bone, 1 cm
above the medial canthal ligament. The belly is oriented
transversally and located behind the orbicularis oculi
muscle. The depressor supercilii muscle penetrates the
skin of the top of the eyebrow. Its contraction depresses
the head of the eyebrow. Consequently, its injection
slightly elevates the head of the eyebrow. The tip of the
needle penetrates 2 mm behind the orbicularis oculi
muscle plane. Three units of Dysport or 1 unit of Botox
are used.
Procerus muscle
The procerus muscle originates from the aponeurosis of
the transverse nasalis, from the periosteum of the nasal
bones and the perichondrium of the upper lateral carti-
lages. The muscle inserts in the skin over the lower re-
gion of the forehead between the eyebrows. The procerus
muscle contraction is responsible for the transverse radix
lines. The injection is placed in the vertical fibers of the
belly of the muscle. The tip of the needle penetrates 2
mm at the root of the nose. Seven units of Dysport or 2
units of Botox are used.
Frontalis muscle
The frontalis muscle originates from a split in the galea
under the anterior hairline and inserts into the forehead
skin just above the eyebrow. At this level, corrugator,
orbicularis oculi, procerus and depressor supercilii
muscles are mixed with the frontalis muscle. Physiologi-
cal studies have determined three vertical, functional,
independent units on each frontalis muscle (right and
left): medial, medium, and lateral [5].
76
As demonstrated in Fig. 5, the contraction of the upper
part of the frontalis muscle moves forward the anterior
hair line and the contraction of the lower part elevates the
eyebrow.
Toxin injection of the frontalis muscle in its lower part
favors brow ptosis. Toxin injection in its upperpart fa-
vors fading of the upper frontal rythids without inducing
brow ptosis. Fading of the rythids of the lower part of the
frontal area can be decided during a further injection
session, when elevation of the eyebrow is sufficient and
authorizes injection of the lower part of the frontalis
muscle.
In most cases, the eyebrow line presents a mild degree
of concavity at the supra orbital notch level. Any injec-
Varying Botulinum Toxin A Concentrations
Fig. 4. Approximate areas of injection
of Botulinum Toxin: h (orange dots)
are areas of high toxin concentration,
m (blue dots) areas of medium toxin
concentration, l (yellow dots) areas of
low toxin concentration. The location
of each injection point depends on
static and dynamic study of the
patient. Each injection point is useful
for various problems. (Note: not all of
these injections can be performed on
one patient.)
tion in the frontalis muscle above this area would in-
crease this local concavity. Association of the medial
eyebrow depression with important elevation of the me-
dium third of the eyebrow creates the Mephisto look. In
order to avoid the Mephisto look when injecting the eye-
brow depressor muscles the lateral frontalis muscle must
also be injected to minimize the eyebrow medium third
elevation, and no frontalis muscle injection should be
done above the supra-orbital nerve bundle (to avoid eye-
brow head depression).
Injections of the medial part of the frontalis muscle,
associated with procerus muscle injection, fades medial
frontal lines. These medial injections are safe, without
any side effects. One unit of Botox or 3.5 units of Dys-
C. Le Louarn 77

Fig. 5. Patient with a post-traumatic frontal paralysis of his right

side. The lift frontalis muscle contraction creates the elevation
of the eyebrow in its lower part and the descent of the hairline
in its upper part.
Fig. 6. (A) A 43 year-old woman, pre-injection, at rest. (B)
Aspect 2 months post-injection with elevation of the eyebrows,
fading of the frontal rythids, and disappearance of the excess of
skin.
Fig. 7. (A) A 40 year-old woman’s pre-injection aspect with this
permanent frontal contraction. (B) 2 months post-injection with
the frontal rythids fading, and a good design in the eyebrow arch.
Fig. 8. (A) A 68 year-old woman, pre-injection, at rest with
frontal rythids, eyebrows located low on her face, and crows
feet. (B) 2 months post-injection with elevation of the whole
eyebrow. Frontal and temporal area are cleaned.
78
Fig. 10. (A) A 45 year-old woman with this permanent facial
mimic: elevation of the right eyebrow, lowering of the inner
part of the left one, and frontal, and crows feet rythids. (B) 2
Fig. 11. Dissection of the levator cutaneous malaris muscle.
Varying Botulinum Toxin A Concentrations
Fig. 9. (A) A 55 year-old woman,
pre-injection. She had a face lift 8 years
ago and asked for a new face lift. (B) 2
months post-injection, without any
additional surgery. The entire face is
improved, and the eyebrows are well
located with elevation of their inner part.
months post-injection with correction of each abnormal eye-
brow position. The harmony of the face is improved.
port are used in each injection site. Vertical veins have to
be checked before injection so as not to create a hema-
toma.
Orbicularis oculi muscle
The orbicularis oculi muscle is divided in three parts, the
orbital portion, the preseptal portion, and the pretarsal
portion. The orbital portion extends superiorly from
above the eyebrow, 3.4 cm lateral to the lateral canthus,
and inferiorly far down onto the cheek. The orbital por-
tion is the sphincter of the eye. The preseptal and the
pretarsal portions have finer muscular fibers involved in
the blink reflex.
Injection of the pars orbitalis in its lateral portion 1
mm deep fades the crowfeet rythids, and, in its cheek
portion, diminishes low located crowfeet rythids.
C. Le Louarn
Fig. 12. (A) A 49 year-old woman with a plunging tip, a nasolabial fold, and a short upper lip. (B) Aspect 2 months post-injection:
the paralysis of the levator labii oris alaquae nasi induces the tip elevation, and improves the nasolabial fold, and the upper lip.
Injection of the orbicularis oculi muscle in its lateral
part can be done just beneath the eyebrow tail to induce
its moderate elevation. To avoid medial migration to the
levator palpebrae muscle, the injection point has to be as
lateral as possible under the eyebrow tail. One unit of
Botox or 3.5 units of Dysport are used.
Two to eight injection points of toxin are realized in
each crowfoot area in one or two parallels rows, depend-
ing on the number and length of wrinkles. The medial
injection row is at least 1 cm from the lateral orbital rim.
Deep injection in the cheek area at the bony insertion
of the zygomaticus muscle, decreases its contraction. It
can be useful in reducing the effects of broad smiles on
the recruitment of the lower eyelid and cheek rythids.
Injection intradermally made in the preseptal portion
of the lower eyelid reduces those specific fine wrinkles.
To avoid creating on ectropion, the high concentration
injection is here changed for a low concentration injec-
tion. Seven units of Dysport or 2 units or Botox are used
for each lower eyelid area.
Indications in lower eyelid wrinkles with no real ex-
cess of skin or of fat are: either wrinkles are appearing
and surgery is no longer necessary, eyelid surgery has
already been done and there is no more excess of skin
and fat but, loss of skin elasticity creates fine wrinkles, or
a furrow between the orbicularis oculi muscle septal part
and the inferior orbital rim induced by lower eyelid sur-
gery, including fat removal. Toxin injection fades the
orbital contour and improves the aesthetic result. For
examples, see Figs. 6–10.
To decrease the depth of the tear-trough, 3 units of
Dysport or 1 unit of Botox are injected in its lower relief.
The lower relief of the tear-trough is due to the volume
of the muscle. This muscle originates from the frontal
process of maxilla bone, crosses over the medial canthal
ligament, and inserts into the skin of the lateral and in-
ferior quarter of the malar area. The contraction of this
individualized part of the orbicularis oculi muscle is ef-
fective on forcefull elevation of the malar area (Clint
Eastwood mimic) and creates the submalar dimple. The
contraction of this levator cutaneous malaris muscle is
79
associated with the contraction of the levator labii supe-
rioris muscle (Fig. 11).
Peribuccal Sites
Peribuccal sites include the following muscles: levator
labii oris alaquae nasi, dilatator naris, constrictor naris,
depressor anguli oris, orbicularis oris, depressor labii in-
ferioris, mentalis, and platysma.
Levator labii oris alaquae nasi. This muscle originates
from the frontal process of the maxilla bone and inserts
into the skin of the posterior part of the nostril. The
muscle is the medial part of the levator labii superioris
measure.
Its contraction elevates the nostril vertically, deepens
the upper part of the nasolabial fold, and makes the tip of
the nose plunge. When the contraction of this muscle is
associated with the transverse nasalis muscle contraction,
oblique wrinkles of the nasal bones are obtained.
The injection is made 1 cm under its bony insertion.
One unit of Botox or 3.5 units of Dysport are used. The
effect on the shape of the nose is obvious in Fig. 12,
without any other treatment. An injection test before
nose surgery is done to be sure the levator labii oris
alaquae nasi muscle section has to be realized.
Dilatator naris muscle
The dilatator naris muscle originates from the nasolabial
fold and inserts at the inferior border of the nostril. Its
contraction increases the frontal diameter of the nostril.
The injection is realized in the medial part of the nostril.
One unit of Botox or 3.5 units of Dysport are used. The
frontal diameter of the nostril is decreased and the usual
surgical incision at the nostril base can be avoided (Fig.
13).
80
Fig. 13. (A) This is a patient seeking rhinoplasty. (B) Post
operative result. (C) The patient was happy with her result, but
she desired to diminish her alar base. The usual alar base re-
section was not possible because of the patient’s tendency to-
ward hypertrophic scars. (D) Injection of the dilatation naris
muscle shortened her alar base.
Fig. 14. (A) A 55 year-old woman with a permanent contrac-
Constrictor naris muscle
The constrictor naris muscle originates from the bony
process of the dentis canini and inserts into the posterior
border of the nostril. Its contraction lowers the nostril
and decreases its sagittal diameter. Consequently, the
upper lip anterior projection is increased. Its injection is
useful to elevate the nostril insertion and to diminish a
permanent contraction of the constructor naris muscle
Varying Botulinum Toxin A Concentrations
tion of the depressor anguli oris muscle, associated with the
contraction of the mentalis muscle. This combined contraction
creates the typically sulky look. (B) Injection of the upper part
of the mentalis muscle, and the main part of the depressor
anguli oris muscle, advances the chin and elevates the corner of
the mouth. Underlying wrinkles have disappeared. The vermil-
lon border, injected, is also improved.
projecting the upper lip. One unit of Botox or 3.5 units of
Dysport are used.
Depressor anguli oris muscle
The depressor anguli oris muscle originates from the
middle part of the linea obliquae mandibula and runs into
the skin in the corner of the mouth. The anterior skin
insertion of its belly fibers creates the bitterness furrow.
C. Le Louarn
Fig. 15. (A) A 52 year-old woman, pre-injection. (B) The injection of the vermillon border decreases the importance of the peribuccal
wrinkles.
An injection is made in the body of the muscle, lateral
to the bitterness furrow and at mid-height, between the
mandibular border and the corner of the mouth. A second
injection can be done near its bony insertion on the linea
obliquae mandibula. This toxin injection lightly lifts the
corner of the mouth and decreases the sad appearance of
the bitterness furrow. One unit of Botox or 3.5 units of
Dysport are used on each injection site (Fig. 14). An
injection that is too high near the corner of the mouth can
induce an orbicularis oris muscle paralysis causing feed-
ing difficulties.
Too medial an injection could induce a depressor labii
inferioris muscle paralysis causing speaking difficulties.
Orbicularis oris muscle
To minimize functional problems and to improve the
aesthetic result, a toxin injection is made in the vermillon
border exactly like a collagen injection. The low concen-
tration solution is used and three to four injection points
are used in each lip.
One unit of Dysport or 0.3 units of Botox are used on
each injection point. Those injection points are made at
least 1.5 cm from the corner of the mouth to eliminate
feeding problems (Fig. 15).
Depressor labii inferioris muscle
The depressor labii inferioris muscle originates from the
medial part of each linea obliquae mandibula and inserts
in the whole chin skin. Its contraction depresses the me-
dial part of the lower lip, lowers and spreads laterally the
whole chin skin. If a patient has a permanent and strong
concentration of the depressor labii inferioris muscle, a
witch chin appears. To cure this spasm, injections of
Botulinum Toxin A are located in the cutaneous chin
insertions of the muscle, specifically laterally (Fig. 16).
Mentalis muscle
The mentalis muscle originates from the bony process of
the dentis incicivi and caninini and inserts into the whole
chin skin. Its contraction elevates the medial part of the
81
lower lip and the whole chin skin. If a patient has a flat
chin due to a constant mentalis muscle contraction, su-
perficial medial injections in the upper part of the muscle
maintains the lower part contraction and creates a chin
advancement with softening of the skin of the upper part
of the mentalis area.
A common type of chin mimic is the mentalis muscle
contraction and contraction of the two depressor angu-
loris muscles. When these three muscles are injected
(Fig. 13) the sulky look disappears.
Platysma muscle
The platysma muscle originates from the superficial fas-
cia of the upper chest, clavicle, and acromial regions.
The posterior fibers of the muscle are forward and blend
with the depressor anguli oris, the risorius, and the lateral
part of the orbicularis oris muscles to terminate in the
skin of the oral commissure. The anterior medial fibers
insert into the periosteum of the medial part of the body
of the mandible. It is these anterior fibers that cause
medial bands when platysma muscle contracts. Three to
five injections are spaced vertically at 1.5 cm intervals
from the jawline to the lower neck, in each band.
Injections can be made in a necklace pattern across the
platysma. Currently, the two large platysma bands pre-
sent in most patients are injected with up to 60 units of
Dysport or 20 units of Botox each (Fig. 17). Only a few
number of units can be injected above the chin/cervical
angle to prevent migration to the deglutition muscles.
As stated by Matarasso et al., conditions such as
lipodystrophy, cutaneous laxity, and extremely flaccid
muscle cords are not appropriate for consideration [8].
Those authors report an elevation of the lower face after
platysma cords injection. However, patients in this series
had multiple sites on the face injected with the maximum
total dose of 400 units of Botox (near 1200 units of
Dysport).
Skin Softening
The botulinum toxin injection improves the aspect of the
skin. The toxin blocks eccrine sweat glands which are
82 Varying Botulinum Toxin A Concentrations

Fig. 16. (A) A 52 year-old woman with a permanent contraction of the depressor labii inferioris muscle which creates a witch chin.
The patient underwent many operations to try to solve this problem. (B) 2 months post-injection. Toxin (20 units of Dysport or 6 units
of Botox, medium concentration) injections advance and relax the chin, and hyaluronic acid (Perlane, Q-Med Laboratory) injections
fill the residual posterior depression.

Fig. 17. (A) A 49 year-old woman before injection in her platysma bands. (B) The platysma result post-injection.

innervated by cholinergic sympathetic nerve fibers. This
effect is used to treat focal hyperhydrosis. Apocrine
sweat glands, supplied by adrenergic sympathetic nerve
fibers remain unaffected by botulinum toxin. This anti-
cholinergic dermal effect of the botulinum toxin, associ-
ated with an action on the skin trophicity, explains the
smooth skin aspect obtained after injection. A mild and
diffuse effect can be obtained on the skin of the jaw
without paralysing the sublying muscles with a very low
concentration of the toxin.
Patients and methods
This study includes 613 patients. One quarter of the pa-
tients were treated with toxin injection of Botox for one
year. Three quarters of the patients received injections of
Dysport for 4 years. Eighty-nine percent of the patients
are women, and eleven percent are men. The mean age
treated was 45 for woman, and 40 for men. Neither topi-
cal anesthesia or oral anxiolytics were used. Clinical ex-
amination of the patient is done at rest and during the
mimic. Pictures are taken at each session.
Injection frequency
Injections are usually made every 3–5 months. Result
stability can be obtained after 5–10 sessions. A stable
result is defined as the disappearance of the injected
area’s wrinkles for a long period of time. Result stability
depends on each patient and also on each muscular area.
C. Le Louarn
Fig. 18. (A) A 55 year-old woman before a lower face lift surgery and an upper face toxin injection. (B) Frontal wrinkles have
disappeared and the whole face is harmoniously younger.
In our experience, factors that have influenced the result
stability are: sex of patient (better stability for women),
skin thickness (better with thin skin), facial expression
pattern (better with moderate facial expression patterns)
and patient activity (better with non-athletic patient).
Sex and skin thickness are generally related. Patients
with extreme facial expressions or who are very active
are trained to control the muscles. A fifth factor that
increases the result stability is the peripheric neuropathy
induced by even a moderate alcoholism.
Regarding muscular areas, the interbrow muscular
area can be stabilized in one patient at the fourth injec-
tion session although in the same patient the orbicularis
oculi muscle can still noticeably contract two months
after the last injection. Doses in this area have to be
increased for a larger period to obtain the desired effi-
ciency. After each session, patients are asked to move the
injected muscles vigorously in the following days in or-
der to favor toxin fixation on those motor end plates.
Contraindication for use of botulinum toxin include:
pregnancy or attempts at pregnancy, quinine, calcium
channel blockers, penicillamine, aminoglycosid antibiot-
ics (they can potentiate the effects of botulinum toxin),
preexisting neuromuscular conditions like Myasthenia
Gravis or Eaton Lambert syndrome, and peripheric neu-
ropathy, such as diabetes, or alcoholism (neuropathies
only need one third of the typical quantity).
Botulinum toxin has to be an adjunctive treatment in
facial aesthetic surgery and medicine. Stabilization in
good position of the frontal endoscopic lift is favored by
a presurgical treatment with toxin injection of depressor
muscles and of the upper part of the frontalis muscle. The
only risk is that the patient may be pleased by the results
of this treatment, and may therefore cancel the surgical
appointment. Of course, toxin injection can also be use-
83
ful to complete an endoscopic surgery. Harmonization of
the whole face after a cervical and jugal lift can be ob-
tained when injecting the frontal area with toxin. Abra-
sion or chemabrasion, more devoted to treat actinic
wrinkles, can be used along with toxin injection to treat
dynamic wrinkles and to obtain a more complete result.
Fat grafting in mobile areas, like the vermillon border is
helped by pre-treatment with toxin.
Complications
Immunization. As stated by Matarasso [8], to avoid the
potential complication of immunization it is important to
use the smallest possible effective dose, extend the in-
terval between treatments (at least 3 months), and avoid
booster injections. One case was reported in the glabella
area after frequent booster injections. Neutralizing anti-
bodies last for at least ten years.
Migration. This is a temporary complication that can
cause browptosis, blepharoptosis, lagopthtalmia, and ec-
tropion. Blepharoptosis can be partially cured with eye-
drops containing an adrenergic agent like neosynephrin.
A temporary contraction of Muller’s muscle elevates the
upper eyelid margin. A specific ocular complication us-
ing an adrenergic agent includes glaucoma. A consulta-
tion with an ophthalmologist is mandatory before using
neosynephrin.
Dysphagia. There have been 718 cases of adverse reac-
tions to the generally approved use of Botox made to the
FDA between 1989 and 1997. Of these cases 142 were
84
qualified as serious. They are mainly dysphagia. The
potential gravity of the dysphagia suggests it is wise to
decrease the doses injected to treat platysma bands, al-
though Matarasso et al. [8] describe no migration of the
50 to 100 units of Botox injected in the neck to the
deglutition muscles.
Poisoning. Not a single case of poisoning by intravas-
cular injection with the doses used for facial rejuvenation
has been reported. The median lethal dose is estimated to
be one hundred times larger than the maximum total
recommended dose for one session.
Dry eye syndrome. Worsening of a dry eye syndrome is
encouraged by the anticholinergic effect of the toxin on
the lacrymal gland.
Conclusion
Thanks to an improved understanding of the functional
anatomy, a performing syringe, the addition of adrena-
line to the saline solution making the use of digital pres-
sure more precise, and the variable concentration provid-
ing the ability to adapt the number of toxin units to the
type of muscle and to the desired effect, we have a better
and more reliable result.
Varying Botulinum Toxin A Concentrations
References
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