Feature: Injecting Botox: Tips from a Master - Dr. Arnold Klein demonstrates his technique for using this newly approved cosmetic agent. Plus, read about other cosmetic uses and how to reduce pain for this procedure from Skin & Aging’s Cosmetic Clinic columnist Dr. Lance Brown and co-author Dr. Ronald Brancaccio. B otulinum toxin has come a long way since 1895 when the microbe Clostridium botulinum was first isolated by Professor Emile van Ermengem after nearly 3 dozen people in Belgium fell ill, three of whom died, after eating raw, salted ham. Attempts to purify the toxin, which is released from the intact bacterium in culture, began in 1920. By 1946, type A toxin — the type used in Allergan’s recently approved Botox Cosmetic — was purified in crystalline form. It wasn’t until 1978 that the pioneer Dr. Alan Scott began clinical experiments on humans with the purified form of the toxin. And, he first used botulinum toxin type A for cosmetic purposes in the mid 80s. Drs. Jean and Alastair Carruthers, other early pioneers of using botulinum toxin type A for cosmetic purposes, first noted the possible applications of the substance in the late 80s when a patient who underwent treatment for blepharospasm subsequently also noticed that her glabellar area appeared smooth and relaxed. Fast forward to this past April when the FDA granted approval to botulinum toxin type A (Botox Cosmetic) to be used as a temporary treatment for moderate to severe glabellar lines in men and women aged 65 or younger. Bolstered by this approval and Allergan’s $50 million ad campaign that’s underway, procedures are sure to sykrocket. For help in improving your technique, read on to learn about Botox Cosmetic injection tips from veteran clinician Dr. Arnold Klein, who has performed this procedure for more than a decade. Dr. Klein most recently demonstrated his technique in early June during the 6th Annual International Symposium on Aging Skin in Chicago. Storing and diluting botox Before dilution, vials of Botox Cosmetic are stored in a freezer at a temperature of -5 degrees Centigrade or lower. Dr. Klein uses 3 ml of diluent to dilute each vial of Botox Cosmetic, and he recommends the following tips: • Make sure any alcohol on the cap has evaporated because alcohol will inactivate the product. • Draw the diluent into the vial by vacuum — not by squirting it. This will prevent foaming. • Don’t shake the vial after adding the diluent to avoid denaturation. • Store the vial of diluted Botox Cosmetic in the refrigerator at a temperature between 2 to 8 degrees Centigrade. Dr. Klein adds that he usually uses the contents of the vial within 24 hours. Dr. Klein’s Upper Face Single Treatment In the diagram above, the numbers represent injection locations and the usual number of units Dr. Klein injects at each site. Preparing For The Procedure The target muscles he aims for include the currugator supercilii and depressor supercilii and the procerus. Also included are portions of the upper medial orbicularis oculi. Before injecting Botox Cosmetic to improve glabellar folds, Dr. Klein cleanses the area with alcohol and allows it to completely evaporate. Then, he prepares a 0.5-inch, 30-gauge metal needle with 3 ml of a new batch of Botox Cosmetic, which he dilutes with preserved saline. He also uses electromyography (EMG) to help guide him. The EMG locates active or contracting muscles. Next, he inserts approximately one-third to one-half of the needle and then asks the patient to frown as he injects the Botox Cosmetic. He first places 6 units on either side of the central frown, just superior to a line vertically above the inner canthus and the superior margin at the bony orbit above the brow. He directs the injection upward and outward, parallel to the direction of the currugator. He also places 3 units above the brow injected almost perpendicularly to the skin but also directed slightly upward at the midpupillary site bilaterally — if muscle movement in the area is contributing to the glabella. Finally, he injects 3 units into the procerus where the lines join the medial brow and the inner canthus of the opposite eye intersect. Afterward, he massages the site horizontally across the upper nasal bridge to massage the Botox Cosmetic toward the depressor supercilii. He’s found no complications associated with this technique thus far. Additional Tips In cases where a female patient has more horizontal brows, deeper frown lines or larger, stronger muscles, a stronger dose is necessary. In these cases, Dr. Klein injects an additional 3 units (up to a total of 24 units) into the procerus between the brows. If the patient is male, the muscles that cause frowning are usually greater in mass than a female’s. For a male patient, Dr. Klein would use higher doses of toxin — typically, about 21 to 32 units. He injects the Botox using the same diagram as for female patients. While injecting into the currugator muscle, Dr. Klein uses his fingers to place pressure at the border of the supraorbital ridge. This reduces the chance that the Botox will extravasate and potentially result in lid ptosis. Treating Periorbital Wrinkles To treat the periorbital site, Dr. Klein first measures 1.5 cm from the lateral canthus or 1 cm lateral to the orbital rim. He injects 3 units of Botox Cosmetic at this site. Using the same dosage, he then makes the next injection 1 cm inferior and slightly medial to the first injection site. Next, he gently massages the sites in a direction away from the orbital rim to help prevent ecchymoses. Another tactic he uses to avoid bruising is to inject the Botox Cosmetic in a series of blebs, with each subsequent site at the border of the previous injection in order to avoid hitting blood vessels. He typically injects a range of 6 to 18 units per side, more if necessary. Post Treatment After he completes procedures with Botox Cosmetic, Dr. Klein instructs his patients to remain upright for at least 4 hours, although this is controversial. He also encourages patients to use the treated muscles 10 times an hour for the first 4 hours to increase uptake of Botox. Botox — Other Uses -By Lance H. Brown, M.D., and Ronald R. Brancaccio, M.D. Although Botox is most commonly used to improve the lines and furrows of the upper one-third of the face, there are a number of other cosmetic uses for Botox that are gaining increasing popularity. • Infra-orbital Rhytides Injecting Botox into the area below the eyelid margin can treat infraorbital rhytides. A recent study by Flynn and Carruthers evaluated the use of infraorbital injections of Botox. For the study, 15 women had botox injected into the obicularis oculi muscle. One lower eyelid had 2 units placed subdermally in the midpupillary line 3 mm below the ciliary margin. The opposite eye received 2 units in the lower eyelid, but also received 12 units to the lateral orbital area (“Crow’s Feet”). The results revealed that 2 units of Botox injected into the lower eyelid orbicularis oculi muscle improves infraorbital wrinkles, especially in combination with Botox treatment of the lateral orbital area. • Bunny Lines These creases, created by the contraction of the transverse portion of the nasalis muscle, create a “bunched-up” appearance on the sides of the nasal bridge. These lines can be improved by injecting 2 to 4 units of Botox into the transverse portion of the nasalis muscle 2 to 3 mm lateral to the nasal bridge. • Peri-Oral Area Botox has also been used for the lower third of the face, particularly the peri-oral area. Injecting 3 units of Botox into the depressor anguli oris muscle at the angle of the jaw can elevate the corners of the mouth. By following the nasolabial fold inferiorly to the angle of the jaw, you can inject 3 units of Botox superficially at the insertion site of the muscle. Reducing Pain -By Lance H. Brown, M.D., and Ronald R. Brancaccio, M.D. The issue of how to reduce the pain associated with Botox injection has remained controversial. However, a recent study by Alam, Dover and Arndt, has supported the use of preservative-containing saline to reconstitute Botox in order to reduce pain upon injection. Traditionally, Botox has been reconstituted with preservative-free saline. The study design had two arms — a retrospective study as well as a double-blind randomized prospective trial. The retrospective arm revealed that 90% of patients reported that treatment with Botox reconstituted with preservative-containing saline was less painful than prior treatment with the preservative-free reconstituted Botox. Similarly, 100% of patients reported feeling less pain in the side of the face treated with the Botox reconstituted with preservative-containing saline. The study confirmed that the use of preservative-containing saline to reconstitute Botox can significantly reduce patient discomfort upon injection. Skin & Aging - ISSN: 1096-0120 - Volume 10 - Issue 06 - June 2002 - Pages: 38 - 44