SUMMARY

ANATOMICAL LANDMARKS FOR

INJECTING WITH BOTULINUM TOXINS
Congratulations on completing course: ‘Anatomical landmarks for injecting with botulinum toxins’.
This course summary will cover the anatomical landmarks that can guide the safe and effective injection
of botulinum toxins when used to rejuvenate the face.

Botulinum toxin type A (BoNT/A) injection techniques for

facial rejuvenation
The most overt signs of aging in the upper face are mimic lines that form as a result of muscle activity.1
BoNT/A injection is the standard non-surgical procedure for upper facial rejuvenation and can soften the
severity of upper facial rhytides by reducing the motility of the mimetic muscles.1
A sound knowledge of injection techniques as well as facial anatomy is essential to optimise benefits and
minimise complications when using BoNT/As in aesthetic procedures.2

Summary of key injection techniques

Treatment Target Location of in- Depth of
area muscle(s) jections injections
© MERZ INSTITUTE Glabellar Corrugator First injection site – Intramuscular for medi-
frown lines supercilii medial portion of the al and central portion
muscle, near its ori- of the muscle belly. 1
gin at least 1 cm The tip of the needle,
above the bony orbi- bevel up, should be
tal rim; second site directed outside the
(optional) – lateral to orbital rim and inserted
the medial bone 4–5 mm to reach the
insertion at least periosteum and then
1 cm above the bony retracted back 1–2 mm.
orbital rim.

Procerus Middle of the muscle Intramuscular

belly, found by dra-
wing a line between
the medial aspect of
the brow to the
medial canthus of
the opposite eye.
© MERZ INSTITUTE Lateral Orbicularis The first injection Intradermally above the
periorbital oculi should be ~1 cm orbicularis oculi muscle,
lines lateral from the bony directly into the dermis.
orbital rim. The other The needle, bevel up,
two injections should should be inserted
be placed ~1 cm almost parallel to the
above and below the skin.
first injection point
along an arc ~1 cm
from the bony rim.

…
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 Treatment Target Depth of
Location of injections
area muscle(s) injections
© MERZ INSTITUTE Lateral Upper lateral A single injection site into the Subdermal
eyebrow part of orbi- upper lateral fibres of the
elevation cularis oculi orbicularis oculi ~0.5 cm
above the orbital rim in line
with the lateral canthus.

© MERZ INSTITUTE Horizontal Frontalis The most lateral injection Subdermal

forehead sites should be 1–1.5 cm
lines medial to the temporal fusion
line. Place 4 –  6 injections
across the midline of the
forehead.
© MERZ INSTITUTE Nasal Dorsal nasalis Nasalis. Intramuscular
rhytides and the leva-
tor labii supe-
rioris alaeque
nasi

© MERZ INSTITUTE Perioral lines Orbicularis Orbicularis oris, within 5 mm Subdermal
oris of the vermillion border.

© MERZ INSTITUTE Marionette Depressor Lower third of the depressor Intramuscular

lines anguli oris anguli oris. Draw a line
straight down from the
mouth – the injection site
should be 1 cm lateral to the
line and 1 cm above the infe-
rior border of the mandible.

© MERZ INSTITUTE ‘Cobblestone Mentalis Two symmetrical injection Intramuscular

chin’ (‘peau sites approximately 1 cm from
d’orange’) the midline, or a single site in
the midline.

© MERZ INSTITUTE Masseter Masseter 2–5 injection sites bilaterally, Intramuscular

low into the masseter, just
above the mandible.

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Anatomical landmarks for BoNT/A injections
Anatomical landmarks in the upper face can help identify target muscles and danger zones when injecting
botulinum toxins. Recognising the anatomical landmarks that can be used when injecting BoNT/A can guide
good injection technique and minimise the risk of complications.

Key anatomical landmarks by treatment area

Treatment Target
Anatomical landmarks
area muscle(s)
© MERZ INSTITUTE Glabellar Corrugator  L ocate the corrugator supercilii muscle
frown lines supercilii and by visualisation and palpation
procerus  – The muscle is found at the medial
end of the eyebrow, just above the
orbicularis oculi muscle, and inserts
into the underside of the frontalis
(4.2– 4.5 mm from the midline)
– The body of the corrugator
supercilii muscle is deep to the
frontalis muscle
  void injection into the frontalis
A
muscle, as this can result in brow ptosis
  void injection into the levator palpe-
A
brae superioris muscle as this can lead
to upper lid ptosis
 – This can be avoided by injecting
above the supraorbital ridge found
at the boundary between the fore-
3
head and upper eyelid
– You can also prevent diffusion by
protecting the supraorbital rim with
the finger of the non-dominant hand
  void injection into the supraorbital
A
artery and nerve

© MERZ INSTITUTE Lateral peri- Orbicularis   void the zygomaticus major to prevent
A
orbital lines oculi lip ptosis, asymmetry and smile impair-
ment
 – This can be avoided by remaining
above the orbicularis oculi muscle;
inject very small doses intradermally,
approximately 1–1.5 cm from the
orbital rim3
– This can also help prevent diplopia
(double vision) when the lateral
rectus muscle is affected, and eyelid
ptosis when the levator palpebrae
muscle is reached

© 2016 MERZ PHARMACEUTICALS GMBH. ALL RIGHTS RESERVED.


Changes to the facial…
© MERZ INSTITUTE
Treatment Target
Anatomical landmarks
area muscle(s)
Lateral Upper lateral   culpting of the eyebrow with BoNT/A
S
eyebrow part of orbi- can be unpredictable in terms of the
elevation cularis oculi amount of elevation achieved in each
individual with a given dose and, there-
fore, this should be carried out by expe-
rienced practitioners
Horizontal Frontalis  Injecting into the frontalis can cause
forehead over-weakening of the muscle, resulting
lines in brow ptosis
– Variation in the structure, size and
strength of the frontalis muscle
means injection sites and toxin
volume should be adjusted based
on the individual’s characteristics3,4
– This includes consideration of diffe-
ring forehead shape, overlapping
fibres in the centre in some individu-
als, and a spectrum of lines due to
variation in habitual facial expression4
Nasal Dorsal nasalis   void the levator labii superioris, as che-
A
rhytides and the leva- modenervation of this muscle will cause
tor labii supe- elongation (and possibly drooping) of
rioris alaeque the upper lip4
nasi  For the same reason, activity of the leva-
tor labii superioris alaequae nasi should
not be fully obliterated
4
 The medial branches of the angular
artery and the dorsal nasal artery are
located at the top of the nose and
should be avoided

© MERZ INSTITUTE Perioral lines Orbicularis   hen treating around the mouth, it is
W
oris important to consider how the juxtapo-
sing muscles work together to move
the mouth
– Unbalanced dosing or asymmetrical
injection can lead to loss of the
ability to purse the lips and an
asymmetrical smile3
  void injecting around the oral commis-
A
sures as toxin may spread to, and
weaken, the lateral lip elevator muscles,
resulting in lip ptosis and drooling
 Injecting the midline should also be
avoided to prevent effacement of
Cupid’s bow5

© 2016 MERZ PHARMACEUTICALS GMBH. ALL RIGHTS RESERVED.

 Treatment Target
Anatomical landmarks
area muscle(s)
© MERZ INSTITUTE Marionette Depressor   omplications, such as an asymmetrical
C
lines anguli oris smile and difficulty in eating, speaking
and drinking, can arise when toxin pene-
trates too deeply into the depressor
anguli oris, or in cases where the injec-
tions have been misplaced3
 – In order to avoid such complications,
injections into the depressor labii
inferioris, orbicularis oris, mentalis
and platysma should be avoided

‘Cobblestone Mentalis   hen injecting symmetrically into the

W
chin’ (‘peau mentalis, ensure the points are medial in
d’orange’) order to avoid the depressor labii infe-
rioris, thus avoiding an asymmetrical
smile3
 onsider the ‘V’ shape of the muscle to
C
ensure the injection is within the muscle
and, if injecting centrally, that the
spread of toxin occurs on both sides3
 If injection is made too far cranially, lip
ptosis may occur by diffusion of toxin
into the orbicularis oris3
 Intramuscular injection just above the
periosteum and inferior to the chin crea-
se will avoid undesired oral incompe- 5
tence and articulation problems that
may result from weakening of the orbi-
cularis oris and depressor labii inferioris
functions5

© MERZ INSTITUTE Masseter Masseter  L ip asymmetry can be caused by injec-

ting into the risorius muscle, which is
anterior to the masseter with a curved
border3
– Deep intramuscular injection can
help avoid diffusion of BoNT/A to
the risorius
 Repeated, high-dose injections over
several years can result in chronic
muscular atrophy
  reatment of the masseter is an esta-
T
blished paradigm in Asia. Asian patients
may have a larger masseter mass than
Caucasians and this may influence the
number of injection sites and dosing6

Remember, for any aesthetic procedure, identifying the key anatomical landmarks and conducting a careful
patient assessment will help you avoid complications and treatment-induced asymmetries.

© 2016 MERZ PHARMACEUTICALS GMBH. ALL RIGHTS RESERVED.

References
1. Carruthers JD, et al. Plast Reconstr Surg 2008;121(Suppl.):5S–30S.

2. Ascher B, et al. J Eur Acad Dermatol Venereol 2010;24:1278–90.

3. Inglefield C, et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler
Treatment. London; Aesthetic Medicine Expert Group: 2014.

4. Carruthers J, et al. Plast Reconstr Surg 2004;11:1S–22S.

5. Bistoni G, Figus A. Minimally Invasive Procedures for Facial Rejuvenation. Eds. Giuseppe C,
Antonio R. Foster City, CA; OMICS Group eBooks: 2014.

6. Kim NH, et al. Plast Reconstr Surg 2005;115:919–30.

© 2016 MERZ PHARMACEUTICALS GMBH. ALL RIGHTS RESERVED.