Operative Techniques in Otolaryngology (2007) 18, 248-253

Cosmetic use of botulinum toxin in the upper face

Benjamin A. Bassichis, MD, FACS

From the Advanced Facial Plastic Surgery Center, Dallas, Texas.

KEYWORDS The use of Botox for upper facial rhytids and dynamic line applications (most commonly for the
Botox Cosmetic; treatment of glabelar lines, horizontal forehead lines, and crow’s feet) continues to increase in
Botulinum toxin type A; popularity. This chapter details the use of Botox for the effective treatment of upper facial rhytids.
Facial rejuvenation; Although Botox injections are not technically challenging, an essential understanding of the facial
Facial injection; analysis, Botox dosages, potential adverse outcomes, and preventative techniques and treatments allows
Minimally invasive the physician to optimize patient outcomes.
procedure; © 2007 Elsevier Inc. All rights reserved.
Clostridium
botulinum;
Botox

The benefits of Botulinum toxin type A (Botox) have
been well known to the otolaryngologist for many years and
has in the past been used to temporarily treat vocal cord
movement disorders, such as adductor and abductor spas-
modic dysphonias. In addition, the use of Botox cosmeti-
cally to treat facial rhytids has been in practice for several
years after official U.S. Food and Drug Administration
(FDA) approval to treat the glabelar region occurring in
2002. With significant media attention for a low-risk treat-
ment with quick, natural results, Botox has taken the cos-
metic industry by storm. Its use for upper facial rhytids and
dynamic line applications (most commonly for the treat-
ment of glabelar lines, horizontal forehead lines, and crow’s
feet) is particularly widespread.1,2 Although initially less
indicated for the lower face because of unpredictable re-
sults, the use Botox in the lower face has become more
accepted and used in a broad range of locations. The safety
and convenience of Botox therapy combined with the fee-
for-service income generated has incited many physicians to
incorporate Botox into their practice; however, caution
needs to be advised to the inexperienced physician. Botox
injections are not technically difficult to master, but there
are essential prerequisites that need to be learned before
expecting consistent, acceptable results. Important issues to
consider include a complete understanding of the effects of
Address reprint requests and correspondence: Benjamin A. Bas-
sichis, MD, FACS, Advanced Facial Plastic Surgery Center, 14755 Preston
Road, Suite 110, Dallas, TX 75254.
E-mail address: DrBassichis@advancedfacialplastic.com.
1043-1810/$ -see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2007.08.004
Botox, evaluation of a patient’s underlying anatomy, and
developing a proper diagnosis.
Indications
Botox indications vary from proven functional treatments,
particularly in laryngology and ophthalmology, to the newer
cosmetic applications. The cosmetic uses of botulinum
toxin in the face are indicated primarily for furrows or lines
that are bothersome to the patient. Studies have shown
improvement in the appearance of existing fine lines and
wrinkles of the face following Botox treatments.2-4 The
most commonly treated areas include horizontal forehead
rhytids, glabelar “frown lines,” and lateral periorbital wrin-
kles (crow’s feet). Because lines in the skin related to
inelasticity or actinic damage do not respond well to Botox,
it is recommended that simply spreading the skin can help
predict the outcome. If the skin smoothes out when stretch
is applied at a direction antagonistic to the offending mus-
cles, then a good response can be expected. Smoking or
excessive sun exposure can cause premature signs of aging,
prompting women in their late 20s and early 30s to request
Botox. Its use in younger patients might lessen the severity
or prevent wrinkles from occurring. In theory, prophylactic
Botox injections may intermittently weaken muscular ten-
sion, thus preventing line formation. As the popularity of
Botox injections has increased, so has the number of pa-
tients who present with strange asymmetries and tension
lines reflecting improper injection technique. These patients
Bassichis Cosmetic Use of Botulinum Toxin in the Upper Face
can often be corrected with a small amount of precisely and
thoughtfully placed product.5
Contraindications to Botox use
Botox should not be used in patients who have known
neuromuscular disorders or known sensitivity to any of the
ingredients in the formulation. Given the risk of prolonged
effects, Botox is not recommended in patients with neuro-
logical disorders such as myasthenia gravis, amyotrophic
lateral sclerosis, and Lambert Eaton syndrome.6 Although
there is no evidence of teratogenic effects in humans, treat-
ment of pregnant women and nursing mothers is generally
contraindicated. Patients taking aminoglycoside antibiotics,
quinine, and calcium channel blockers should not be in-
jected if avoidable, because these may potentiate the effect
of the Botox toxin.7,8 Relative contraindications include
patients who rely heavily on their expressions, such as
actors and politicians. Patients with a preexisting lid ptosis
should be made aware of it before treatment and not injected
if exacerbation would be intolerable. For those patients who
have previously developed lid ptosis more than once after
Botox injections, no further attempts should be made at
treating the area in question. Patients who have previously
undergone surgical procedures that may have repositioned
or weakened the target muscles must also be considered
suboptimal candidates for Botox treatment, although some-
times they can still obtain wonderful results. Last, as with
any type of intervention, patients who have unrealistic ex-
pectations, such as patients who are looking for improve-
ment even though they are still fully paralyzed from a recent
injection, should not be given further Botox treatments.
Instead, it should be explained to such patients that the goal
of treatment is to minimize the lines, not eradicate all
movement. Furthermore, injecting more Botox only in-
creases the chance for complications and does little or
nothing to improve appearance.
Technique
Although there are several brands of Botulinum toxin A
available and used for esthetic purposes around the world,
Botox (also known as Botox Cosmetic, Vistabel, and Vist-
abex; Allergan, Irvine, CA) is the most well known brand of
Botulinum toxin A worldwide and is the only brand avail-
able in the United States. For the purposes of this article, all
units and dosing refer to the Botox Cosmetic formulation
and will be referred to as Botox.
Botox is packaged in vials containing 100 U of vacuum-
dried toxin, which should be kept frozen until the time of
use. Although manufacturer guidelines recommend recon-
stitution of Botox with sterile 0.9% saline solution without
preservatives and discarding of the solution after 4 hours,8
some clinicians report no loss of efficacy when the prepa-
ration is used for up to 6 weeks following reconstitution.9,10
Moreover, data suggests that reconstitution with preserved
saline does not impair the stability of Botox,9,11 and causes
less discomfort on injection than preservative-free saline.12
249
Currently, the range of diluent volume, selected based on
the desired concentration of the injection solution, depends
on clinician preference and the number of units to be in-
jected,13 varies from 1.0 to 3.0 mL per vial.9,14,15 Evidence
indicates that higher doses of Botox delivered in smaller
volumes keep the effects more localized and allow for the
precise placement of the toxin with minimized diffusion.16
Conversely, a highly concentrated solution is hard to work
with in larger areas, such as the central forehead, and may
lead to more waste. Some authors have indicated that injec-
tion of Botox in low concentration and higher volume contrib-
utes to a wider diffusion and area of effect, a shorter duration
of effect, and a possible increase in side effects.17,18
Once reconstituted, Botox should be refrigerated between
usages. There is controversy regarding the amount of time it
should be stored, ranging from 4 hours to 6 weeks.19 The
concern is not only about the relative effectiveness of the
product, but also about sterility.
Injection technique
After reconstitution of the Botox with preserved saline
containing 0.9% benzyl alcohol,12 the author uses a 1.0-mL
syringe (Injeckt-F 1 mL, Braun) in which the plunger comes
all the way to the tip (there is no hub), to minimize product
waste. This syringe has no luer lock; therefore, it is impor-
tant to ensure that the needle is tightly applied to prevent
dislodging during injection. After drawing up the desired
amount of Botox, a 32-gauge needle (a Becton-Dickinson
Ultra-Fine II short needle) is placed and the air removed
from the syringe. To minimize discomfort on injection, the
author utilizes reconstitution with preserved saline, and in-
jections of small volumes of relatively concentrated solu-
tion. Injected local anesthesia is not recommended, although
topical anesthetic applied at least 45 minutes before injec-
tion may be used.
Injection techniques are site specific and vary consider-
ably from patient to patient according to individual charac-
teristics. In fact, the success of Botox injections is contin-
gent on recognition of the individuality of each patient and
their target areas, which can be best identified by examina-
tion of muscles at rest and during maximal contraction. In
general, intramuscular injections achieve optimal and some-
times dramatic results, particularly for larger facial muscles,
whereas shallow intradermal injections tend to yield unsat-
isfactory effects owing to toxin dispersion into the muscle
fiber alone. Injection sites are chosen to target the muscle
responsible for facial expression and are typically located in
the mass of the target muscle rather than at the exact site of
maximal dermal depression.
The effects of Botox typically appear 1 to 4 days after
treatment and peak between 1 and 4 weeks after injection,
with a gradual decline in results after 3 to 4 months. The
onset of effect is generally consistent from patient to patient,
although the duration of effect varies considerably.
Treatment of glabelar rhytids with Botox
The most common—and the best known to cosmeti-
cally improve with Botox injections—are the deep verti-
250 Operative Techniques in Otolaryngology, Vol 18, No 3, September 2007
Figure 1 Muscular anatomy for glabelar Botox treatments. The
paired corrugator supercilii muscles are primarily responsible for
causing the glabelar furrows, with additional contribution from the
frontalis, orbicularis, and procerus muscles.
cal creases between the eyebrows or glabelar area.8 The
paired corrugator supercilii muscles are primarily respon-
sible for causing the glabelar furrows, with additional
contribution from the frontalis, orbicularis, and procerus
muscles (Figure 1).
The glabelar creases are best evaluated with the patient at
rest followed by frowning or “squeezing their eyebrows
together.” The corrugator muscle bellies are palpated as the
patient is in motion. This technique will help determine the
location, size, and power of the muscles, and to what extent
they are contributing to the vertical creases. It is important
to evaluate the superior–medial orbicularis muscles, which
might augment deep creases. The procerus muscle is pal-
pated and examined at rest and in motion. Contraction of the
procerus contributes to the horizontal creases located over
the root of the nose. Assessment of the dermal insertion of
the corrugator muscle will determine placement of the lat-
eral extent of Botox injections. Proper evaluation of the
brow position is crucial to obtaining an acceptable outcome
in the upper third of the face. The generally recognized ideal
Figure 2 To effectively treat glabelar creases, the recommended
dose of five to ten units is placed into each corrugator and three
units are placed into the procerus muscle.
Figure 3 Patients who are noted to have an appropriate brow
position during pretreatment assessment also receive three units 1
cm above the orbital rim in the midpupillary line. Care must be
taken to remain at least 1 cm above the brow lateral to the
midpupillary line to avoid denervation of the levator palpebral
muscle, causing undesirable eyelid ptosis.
brow position in a female is a high-arched brow above the
superior orbital rim with the brow tail located 1 to 2 mm
above the medial brow head. In the male patient, the brow
is more horizontally directed with less of an arch. It is
positioned lower on the forehead approximately at the level
of the superior orbital rim.20,21
The upper eyelids are also evaluated for asymmetry or
ptosis, which might need to be demonstrated to the unaware
patient. The position and symmetry of the brows and eyelids
will affect the technique employed during the treatment of
the glabelar creases.
To effectively treat glabelar creases, the recommended
dose of five to ten units is placed into each corrugator and
three units are placed into the procerus muscle (Figure 2).
Appropriate doses and injection sites vary from patient to
patient and depend on individual physical characteristics
such as the strength and size of muscles of the glabelar
complex, brow arch or asymmetry, brow ptosis, or the
amount of regional muscle mass. Men (who typically have
larger brows and greater muscle mass in the brow than
women) often require greater doses for optimal results.15,22
Patients who are noted to have an appropriate brow
position during pretreatment assessment also receive three
units 1 cm above the orbital rim in the midpupillary line.
The contribution of the orbicularis muscle to the glabelar
complex can be clearly defined when the patient “squeezes
their eyebrows together.” Care must be taken to remain at
least 1 cm above the brow lateral to the midpupillary line
(Figure 3). Injection closer to the brow might increase the
risk for Botox migration into the orbit and denervation of
the levator palpebral muscle, causing undesirable eyelid
ptosis. According to the manufacturer’s insert, the risk of
eyelid ptosis is about 3%; however, the author’s experience
is less than that. Eyelid ptosis should be preventable with
proper technique and diagnosis. By avoiding the area just
above the brow at midpupillary line, ptosis of the eyelid is
unlikely.7 The effect of the toxin persists for 3 to 6 months
in most patients, although some patients may require
touch-up injections 2 to 3 weeks after treatment.
Bassichis Cosmetic Use of Botulinum Toxin in the Upper Face
Treatment of horizontal forehead rhytids
Treatment of horizontal forehead lines caused by con-
traction of the frontalis requires thoughtful evaluation of
brow position. Excessive weakening of the frontalis without
a corresponding weakening of the depressors will lead to
brow ptosis. While a broad range of doses and dilutions
have been described for the treatment of horizontal forehead
lines, the author advocates conservative, individualized
treatments for optimal outcome. The recommended dose for
effective forehead treatment is 10 to 15 U divided among
four or five sites distributed horizontally across the mid-
brow, 2 to 3 cm above the eyebrows. Care is taken to not
deposit excessive amounts of Botox over the lateral brow,
which might cause a drop in the lateral brow position and a
flattened brow. Patients who desire a motionless or frozen
forehead must be advised that it may come at the expense of
lowering brow position.5 Some patients desire a “Botox
Browlift” involving elevation of the lateral brow, the tem-
poral area of the frontalis muscle is not treated, which
allows the brow elevators to remain intact and contribute to
brow elevation.23-26 Elevation of the lateral portion of the
eyebrow can result in a subtle, yet satisfying change in the
appearance of the face. Most patients can expect a modest 2
to 3 mm elevation of the lateral brow; however, it might be
at the expense of an incomplete reduction in the forehead
and glabelar creases. In patients with hyperactive or prom-
inent lateral brow elevators, an over-elevation of the lateral
brow can occur, resulting in an undesirable sinister appear-
ance.5,27 Effects typically last from 3 to 6 months.
Treatment of lateral periorbital rhytids
One of the first signs of aging is the formation of lateral
periorbital rhytids, or crow’s feet. Depending on the indi-
vidual’s skin type, muscle activity, and previous sun expo-
sure, these lines may begin to appear as early as 20 years of
age.28 With frequent, repetitive contraction of the perior-
bital muscles, including orbicularis oculi, risorius, and zy-
gomaticus muscles, with smiling, closing the eyes, and
various facial expressions, these lines become increasingly
noticeable with time. Although these lines may initially appear
only during animation, they eventually become a permanent
feature of the skin. As such, this area is often identified as a
problem area for patients who seek facial rejuvenation.
The application of Botox safely denervates targeted mus-
cles that contribute to the formation of hyperfunctional
periorbital lines.28 Although injection sites for crow’s feet
are identified while the patient is smiling, the injections
themselves are performed when the patient is not smiling, or
the toxin may affect the ipsilateral zygomaticus complex,
causing upper lip ptosis.29 The author advocates 8 to 12 U
of Botox per side, distributed among two to four injection
sites (Figure 4). The injections are performed lateral to the
lateral orbital rim, as more medial injections can result in a
temporary lower eyelid droop. However, the greatest risk in
treating this area is an unacceptable bruise.30 Care is taken to
inject into the dermis or just subdermally and to avoid
superficial venous structures that are highly prominent in
this region. At times, it is difficult to identify subcutaneous
251
Figure 4 To accomplish treatment of lateral periorbital rhytids,
or crow’s feet, inject 8 to 12 U of Botox per side, distributed
among two to four injection sites.
vessels, especially in patients who have dark or tanned skin.
If a blood vessel is punctured, quickly applied pressure will
limit the bruise to a minimal and more acceptable pinpoint
lesion. An unattended, pierced vessel has potential to cause
an expanding hematoma throughout the loose areolar tissues
of the periorbital region. Superficial injections can also help
avoid placing Botox deep to the orbital septum, which could
migrate toward the ocular muscles resulting in possible
diplopia.31 Following treatment, most patients report a soft-
ening to the look of their eyes and a more open and awake
appearance. Results last approximately 3 months, and ha-
bitual treatments may minimize the formation of new lateral
periorbital rhytids.
Complications
Botox injections in the upper face are remarkably safe and
effective. With the small amounts used for cosmetic appli-
cations, serious adverse events are rare and occur far less
often than with the larger doses often necessary for thera-
peutic applications (Figures 5 and 6).32 Adverse effects of
cosmetic Botox are usually mild and transient and include
bruising, swelling, and pain around the injection site, mild
headache, and flu-like symptoms.33 Ecchymosis at the in-
jection site is the most common complication with nearly
15% of patients experiencing some bruising.8 Bruising usu-
ally resolves in ten days and can be avoided by injecting
into the subcutaneous layer and avoiding the vasculature
superficial to the orbicularis oculi.
Side effects tend to occur more frequently with greater
concentrations and overenthusiastic doses; a careful injector
will target appropriate muscles, allowing for a diffusion of
1 to 1.5 cm from the injection point.17 Possible complica-
tions in the upper face include eyelid ptosis, lower eyelid
laxity, epiphora, diplopia, brow ptosis, a quizzical or cock-
252 Operative Techniques in Otolaryngology, Vol 18, No 3, September 2007
Figure 5 A 47-year-old woman before (A) and after (B) Botox
Cosmetic injections, with full frown attempt. (Color version of
figure is available online.)
eyed appearance, dry eyes, and an asymmetric smile owing
to toxin diffusion into the zygomaticus major muscle.
Of these complications, brow and eyelid ptosis are the
most serious adverse effects that can occur. Brow ptosis
Figure 6 A 34-year-old woman before (A) and after (B) Botox Cosmetic injections. (Color version of figure is available online.)
attributable to diffusion of Botox into the frontalis muscle,
causing excessive weakening and can persist for up to three
months. Avoiding the frontalis in patients who have existing
significant brow ptosis can help avoid this outcome.
Upper eyelid ptosis, which may become evident as early
as 48 hours or as late as 14 days after treatment, most
commonly occurs when Botox injections intended for the
glabelar complex diffuse through the orbital septum, affect-
ing the upper eyelid levator muscle. The condition usually
resolves over the first week as the Botox takes effect;
however, true eyelid ptosis may require 2 to 12 weeks for
resolution. The patient will appear asymmetric and will
most likely be disappointed with the outcome. Continued
reassurance that the ptosis will completely resolve is nec-
essary. If the patient cannot resume their lifestyle or is
insistent on treatment, there are available options. Topical ␣
adrenergics such as aproclonidine 0.5% eyedrops (Iopidine,
Alcon, Alcon Laboratory, Fort Worth, TX) and naphazo-
loine (Naphcon, Alcon, Alcon Laboratory) will directly
stimulate Mueller’s muscle (a sympatomimmetic muscle of
the upper eyelid). Phenylephrine (Neo-Synephrine) 2.5%
can be used as an alternative in patients who are sensitive to
apraclonidine. Neo-Synephrine is contraindicated in pa-
tients with narrow-angle glaucoma or aneurysms. Drops
should be used three times daily until ptosis resolves.33
Eyelid ptosis can be avoided by using higher Botox con-
centrations, injecting no closer than 1 cm above the bony
orbital rim, and advising patients to remain upright and
refrain from manipulating the treated area for several hours
after injection.
Zygomaticus major palsy can rarely result in lip drop
after Botox injection for crow’s feet. Limiting inferior
crow’s feet injections to the superiormost aspect of the
zygomatic arch and avoiding deep injections can prevent
this complication.31
There have been no reported long-term adverse events or
systemic effects with Botox Cosmetic treatments. A recent
review of the long-term safety for cosmetic purposes re-
Bassichis Cosmetic Use of Botulinum Toxin in the Upper Face
vealed no serious adverse events in more than 850 treatment
sessions for up to 9 years.34
Discussion
Botox has become a household name with widespread pop-
ularity based almost entirely on its cosmetic application in
the upper face. It is essential for any medical practitioner
dealing with esthetics to have an understanding of when and
how to apply this neurotoxin. Patient expectations of Botox
treatments vary and need to be managed in accordance with
the diagnosis. It is imperative for patients to realize their
uniqueness and that their personal results might vary from
those of their peers. The underlying facial muscle anatomy
might, at times, hinder or prevent the desired result. At other
times, the patient’s esthetic desires will be inconsistent with
the physician’s practices and judgment. Patient individual-
ity prohibits treating each patient in exactly the same man-
ner. This chapter describes the use of Botox for the effective
treatment of upper facial rhytids. An understanding of facial
analysis, Botox dosages, potential adverse outcomes, and
preventative techniques and treatments all allow the physi-
cian to optimize patients’ outcomes and ultimately assume
their satisfaction.
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