Best tried and tested BOTOX® injection patterns and mistakes to avoid

If you are struggling to get good results when treating patients with botulinum toxin or BOTOX® injections, particularly in the forehead, then you have come to the right place.

Dr Tim Pearce is here to discuss his go-to injection patterns, what he thinks about dosing and how best to approach a patient’s face so you can give them the best BOTOX® treatment for them. He also talks about the mistakes to avoid making and the simple strategies to getting your injection techniques right and tailored to your patients.

Dr Tim regularly will discuss medical aesthetic training tips in his upcoming, so if you’re looking to increase your CPD-certified learning and want reassurance about how you’re treating patients, then step one is to register for Wednesday’s free webinar by Dr Tim.

Is there a one-size-fits all approach to delivering BOTOX® injections?

When you first embark on your career as an aesthetic practitioner, it is not surprising that you will find yourself searching for the universal formula to solve a problem like delivering botulinum toxin or BOTOX® injections. We all seek that ‘best way’, a core set of principles to apply to solve the problem, or a quick and easy, one-size-fits-all approach that is somehow fail safe.

Sorry to disappoint you, but Dr Tim Pearce is not here to give you that. What he is here to talk about it his tried and tested techniques and learning over more than twelve years in aesthetic practice.

When you first learn about delivering BOTOX® injections to the forehead, such as in our foundation botulinum toxin training course, you will be taught about the five places to place your toxin, usually a combined dose of 20 units of Allergan’s BOTOX® with 4 units at each marked location. This is the advised placement, as per the manufacturers’ guidance, for the majority of patients, and this is what you learn to do for all. However, you will soon realise that not everyone conforms to the average face shape, size, or layout, so out the window goes your universal formula!

This is not a time to panic however, what you need to do is rethink what you will do when you meet those people whose faces do not conform to the average. This is where we learn and grow as aesthetic practitioners.

When manufacturers of botulinum toxins are applying for their medical licensing for a product, they are looking for consistent results to demonstrate in their clinical trial data. Consistent results come from consistent product placement in the average patient. Once licensed, this becomes the noted guidance in the product SPC (Summary of Product Characteristics) and the standardised technique taught in all introductory product training. This also applies to the dose, which again is advised based on consistent results in clinical trials from consistent dosing patterns, but often you will find that you start to adapt your dosing, as well as your placement. For example, Dr Tim Pearce uses a lower dose of BOTOX® in the forehead than the one detailed in the licensing approval for the product.

When is it okay to deviate from the licensed dose?

Adjusting your treatment approach and BOTOX® injection patterns

The forehead

The forehead is one of the most complex areas to treat with botulinum toxin, particularly when we compared it to other areas such as the glabella.

When treating the glabella, for example, you are trying to reduce movement and relax the area where frowning is occurring. To achieve this, you have three muscles to focus on, the corrugator supercilii above each eyebrow, the depressor supercilii to the side of the orbicularis oculi and the procerus between the eyebrows, and you simply relax them all, that’s it.

When approaching the forehead, it is very different because you don’t want to relax ALL the muscles. Movement is still required in the forehead to support the eyebrows and to avoid a brow ptosis, as well as allowing the individual to continue to show emotions without a frozen look. So, with forehead BOTOX® treatment the aim is to partially relax the muscles in the area. Put simply, we want to have a line of treated muscle and a line of untreated muscle, but where that line runs is the crucial element. A small difference in the separation of injection points can make a big difference to the result. For example, should you place your injections points on the left and right side of the face at half a centimetre difference between them, you risk creating an eyebrow asymmetry which the patient will most certainly not thank you for when they try and raise their eyebrows and one goes higher than the other!

As noted, the licence for BOTOX® states 4 units placed in 5 locations, giving a total of 20 units. Dr Tim tends to use 1 unit per injection and spread this out of over more injection sites, leading to a similar overall dose (where required), but creating a more tailored approach to reduce movement and create lift.

By creating a smaller dose and wider spread of your injections, you avoid putting a full 4 units in one single place which would ‘knock out’ a larger area of the frontalis muscle. If you were to put another 4-unit dose on the other side of the face, yet a full millimetre in a different direction, then you risk asymmetry. By spreading out a lower dose, your delivery becomes a more blended approach and any inconsistencies in the exact injection placement will not manifest so severely in the result.

It is also worth noting that not all foreheads are the same. There is a considerable variation in the size and shape of the forehead, both within the same gender and between men and women. This means that you need to adapt your treatment accordingly, if you are covering a larger forehead you will need to spread out your injections more because bigger foreheads often mean bigger muscles too. Men especially tend to have a differently shaped frontalis muscle which goes much higher up than on a woman. You must take this into account as otherwise you risk under treating the men and creating a ‘horned’ effect at either side of their hairline, again you won’t be thanked for that!

Crow’s Feet

Crow’s feet are otherwise known as lateral canthal lines and are the lines which come out laterally from the edges of the eyes. They often appear when a person smiles, but can also be quite ageing, particularly if they are still present as fine lines and wrinkles around the eyes when the face is at rest.

Using BOTOX® to treat crow’s feet is very common, but it’s also a risky area aesthetically as it can be one of the easiest places to make someone look ‘done’ or ‘Botoxed’ if you don’t apply a subtle approach to your treatment. Although, it is not an area that causes a frozen or stiff look, the muscle interaction with the rest of the face can cause a change in emotional expression which is noticeable as ‘odd’ to those familiar with the individual. Still being able to appear to be laughing at someone’s jokes or smiling naturally and meaningfully, with a visible narrowing of the white part of the eye is very important, so the ideal outcome is to retain the expression of emotion but without the lines.

Bunny Lines

Although some people naturally have bunny lines around the top of their nose if they scrunch up their face, they are not as common to see at rest, although they can indirectly become prominent once you start treating other areas of the face with BOTOX® . For example, if you treat the orbicularis oculi, often the medial part of the face becomes more active as a compensatory side effect to reduced movement elsewhere.

The key to not accentuating bunny lines is either a conservative approach when treating the glabella or lateral canthal lines, or a very superficial dose to knock out the bunny line formation at the same time, being mindful not to cause further complications by affecting the lip elevators if you inject too inferior laterally, causing lip asymmetry when smiling.

Why not download Dr Tim Pearce’s 26 essential patterns for BOTOX® for more specific information on product placement when treating the forehead and other areas with botulinum toxin.

Planning your BOTOX® treatment and understanding your patient’s anatomy

The first part of the process is to find out about your patient, learn about their story, ask them, and let them tell you what bothers them about their face.

For example, if a patient comments that they think they look tired all the time, this is your cue to deciding if an eyebrow lift would benefit your patient. Armed with this new information, which you will not discover if you do not dig deeper into your patient’s story, you can adjust your treatment strategy to achieve this, rather than simply focusing on their lines and wrinkles which you can visibly see. This is where individual tailoring of treatment becomes more evident and you need to learn how to find out more about your patients.

As well as discussing their concerns, it is important to see a full range of facial movement. Have them move all areas of their face, not just the area that you plan to treat. Ask them to smile, frown, raise their eyebrows, pull all sorts of faces so that you can see the full animation of their face. Remember, it is likely that they will not conform to the textbook, average patient!

By doing this, it allows you to see the full interaction between all the facial muscles so that for example, you can understand both the lifting force of the frontalis in contrast to the depressing force of the orbicularis oculi. If a patient has a strong orbicularis oculi muscle when they are smiling, then you will know not to treat heavily in the brow so that you can reduce your risk of ptosis. Understanding their individual facial animation, will save you from an unhappy patient at their two-week follow-up.

A Redaelli et al noted in a paper entitled ‘how to avoid brow ptosis after forehead treatment with botulinum toxin’ published in the Journal of Cosmetic Laser Therapy in 2003 that, “Brow ptosis appears in many studies with a frequency of around 1-5%. This is caused, often, by using incorrect injection sites, too high dosages, and by an inappropriate selection of patients”.

It is important to apply the patient’s desires for the treatment outcome to their anatomy. If for example, we work on the concept of the eyebrow lift, you should mark out the risky areas where you don’t want to inject, including those which may cause a brow ptosis such as the central part of the forehead, as well the lateral muscles which you want to leave untreated to achieve the eyebrow lift. Once marked out accordingly, both in notes and on the patient, with your dosing strategy, it’s important to take a photograph to help you to review your original plan when you follow-up the patient after two weeks so you can further understand the interaction between placement and dose and the effect it has and amend your plan accordingly. Then you are good to go and can work to treat the areas earmarked for injection and hopefully achieve the mutually desired outcome.

Dr Tim always recommends that aesthetic practitioners enrol in a cadaveric masterclass which will help you to truly understand the architecture of the face including muscles, nerves and vessels which present risks when delivering cosmetic injectables.

How far does BOTOX® spread?

The consensus opinion on the spread of BOTOX® specifically is a 1.5-2 cm radius from the injection point when placed in the forehead. Armed with this information you immediately have an idea of the product placement required to relax a particular muscle. All you then need to ask yourself is – how much of the muscle do you want to relax?

We already know that you need to leave some muscle functioning in the forehead to support the brow and avoid ptosis, but if you want to achieve an eyebrow lift, then you need to leave even more of the lateral muscles functioning.

Understanding the placement and the spread means that you can start to formulate a plan for treatment. Sometimes it’s easier to decide where you’re not going to inject!

Things to avoid when injecting BOTOX® into the forehead

It is great to have an idea of which injection patterns to follow to achieve certain outcomes, but it is important to also know what to avoid doing.

The general rule is that it is better to treat the forehead conservatively, making sure that you do not cause a brow ptosis, than to worry about leaving every patient with ‘spock’ eyebrows. As Star Trek’s Dr Spock would say himself, “it is illogical” to place toxin above every patient’s eyebrows as a precaution against creating spock eyebrows, because whilst being fixated on not causing that side effect you run a very real risk of inducing a brow ptosis in some of them instead.

A spock eyebrow is much easier to resolve with a small top up of toxin when they come back to you for their two-week follow-up appointment, whereas a brow ptosis which will take many weeks to resolve and cause much more anxiety for the patient.

We must start to think of delivering treatments as going on a journey – we are trying to find the safest route to the destination, not the quickest or shortest route from A to B. This is especially true with new patients as you discover their face and how it reacts to treatment. Once you establish this through slow, cautious treatment delivery to achieve your goal, you will have found the consistent approach that will give you consistent results for that patient and they will keep coming back to you – rush and give them a brow ptosis and you risk blowing your chances of a long-term relationship. Patients will thank you more for your honestly and desire to see how a treatment goes and follow-up to add more or tweak the result than if you offer a one-size-fits-all solution which goes wrong for them.

Are you still anxious about getting your injection techniques spot on?

If you want to learn more about mastering medical aesthetic treatments or conquering the anxiety of where to place your needle, then register for Wednesday’s Dr Tim webinar.