Botox injections: common mistakes aesthetic clinicians make!

Aesthetic clinicians can often get it wrong when injecting botulinum toxin (Botox®) cosmetically for the reduction of lines and wrinkles. Injecting incorrectly can result in undesirable side effects and complications from an unbalanced appearance, to Spock brow, or a more serious ptsosis.

In this blog, Dr Tim Pearce will review the common mistakes that he sees being made by aesthetic practitioners when injecting Botox, how you can avoid them and achieve better results for your patients.

Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>

Do not leave EXTRA safety margins when injecting Botox

This might shock you to read, notes Dr Tim, but leaving ‘extra safe’ safety margins can make things much worse. For example, let’s look at treating the glabella. When clinicians first train to inject botulinum toxin, they learn about the risk of causing an eyelid ptosis. We know that the closer you get towards the eyes, the more likelihood there is of causing an eyelid ptosis. Therefore, many practitioners will take the normal safety boundary and shift it up another centimetre. However, with a muscle like the corrugator, if you move a centimetre from where you think that muscle is, you move out of it and typically into the frontalis muscle. This approach results in many newer injectors causing a central brow-drop and a lateral brow-lift, often known as a Spock brow. With the best of intentions, they have caused another side effect, which could have been avoided by injecting in the right place using an appropriately sized safety margin.

Read best Botox brow lift injection patterns to avoid ptosis and Spock brow for more insight.

Another example considers the orbicularis oculi muscle. Those who move their injections further away from the eye can end up more inferior in the cheek. This can cause a saggy appearance as the patient smiles because the cheek is no longer elevated by the lower orbicularis oculi muscle, or even worse, if you are deep and inferior with your injections, you may affect the zygomaticus major causing a droopy smile.

To avoid making these mistakes, consider the safety margins and learn about the impact of injections even in areas that you do not want to treat, to understand the face better and avoid causing additional side effects. Always assess the increasing risks as you move away from one area and into another, think about what other structures could be affected. Injecting is a balancing act, there is no absolute safe position, we must strive for the best compromise with minimal risks for the best results, maintains Dr Tim.

Do not inject too deeply when injecting Botox

It is crucial that you learn the layers of the face when you are injecting botulinum toxins, warns Dr Tim, because you can inject at the right point according to your training diagrams and the product leaflet, but if you are too deep you will be injecting underneath the muscle.

As an illustration, let’s consider the previous mention of treating the orbicularis oculi and impacting the zygomaticus major. Dr Tim explains that it is very common for newer injectors to inject deeply, going straight through the orbicularis oculi muscle into the origin of the zygomaticus major, which will leave your patients unable to smile properly after the procedure.

Similarly, depth is critical in the tail of the corrugator. As you inject the corrugator muscle to decrease frown lines, if you inject a full depth injection laterally you will miss the corrugator completely and be placed near the foramen which could lead to an eyelid ptosis.

Dr Tim believes that the tendency to inject too deeply for new aesthetic injectors may be partly down to how injection delivery is taught in mainstream medicine. Typically, healthcare professionals do not vary the tissue layer of their needle placement, a full needle goes in, and the injection is given for a vaccination or local anaesthetic, for example. Injection precision is much more acute in aesthetic medicine.

As another illustration, if you consider the corrugator muscle where we are trying to avoid injecting into the orbit. We know that laterally, the muscle inserts into the surface of the skin which would be a superficial injection with the first one third of the needle. On the other side of the muscle, the deep part of the corrugator, the muscle is near the bone necessitating approximately two-thirds of the needle placed into the skin.

To avoid making mistakes related to needle depth, facial anatomy knowledge is vital, including an understanding of the layers or tissue planes, as you pass through the skin, fat pads, muscles, and other adjacent structures. You need to know which muscle you are aiming for and whether it is in the more superficial plane or a deeper plane. Additionally, familiarise yourself with needle length and its correlation to different positions in the face, Dr Tim recommends thinking about injections as deep, medium, or superficial.

For more insight from Dr Tim, check out:

• Upper face muscle anatomy: how to avoid Botox side effects and
• Know your muscle anatomy to avoid side effects from Botox in the lower face

Recognise the benefit of movement when injecting Botox

Some movement is desirable, but patients often push aesthetic clinicians to chase their goal for a frozen look. Being frozen does not always mean being more attractive. In fact, it is quite often the opposite, warns Dr Tim, and can impact on the ability to connect with others.

Faces are a tool for communication and collaboration with others. Although removing negative expressions can aid that process, some of the expressions that you remove with Botox treatments are important for building trust, such as a flick of the eyebrows. This is a key sign that humans look for when you first see someone, particularly from a distance, it registers that the person that you know has entered the room and you make a small connection, an acknowledgement. With zero eyebrow movement, people must use other facial expressions to convey that connection, which can negatively affect their social interactions.

To avoid making this mistake, start appreciating movement and why it matters.

You will probably need to educate your patients – many have a misconception that the best Botox result is a frozen result. They can fixate upon this because they want to look like a photograph; you must sell the benefits of some movement and its important in human connections, trust, and relationship building.

Do not overlook accessory muscles when injecting Botox

It is common to overlook the benefits of a muscle that is contracting in terms of its impact on overall beauty. You may look at a patient and determine that they have lines around their eyes which if you stop the muscle from moving will create a clearer complexion with fewer distractions and a more beautiful look. The downside, however, if we consider the orbicularis oculi as an example in this case, is that this muscle is lifting the cheek on smiling. If you over treat, it results in a situation where the patient smiles and they have no wrinkles around the eyes, but their cheek does not rise, and they appear a little stunned which is less attractive.

Similarly, it is important to be mindful where a muscle is doing another function. For example, the platysmal bands are an accessory muscle for breathing, often involved during high intensity exercise or in a patient with COPD who might use this muscle to aid deep inspiration. If you completely stop that muscle from moving, you could cause a knock-on effective and an inability to ventilate quite as effectively.

Impacting accessory muscles is more obvious in muscles that we know are functional but are also used as communication tools. For example, the orbicularis oris around the mouth causes vertical lip lines. If you treat it with botulinum toxin without considering the impact on the function of the muscle, it can result in the patient being unable to drink through a straw or pronounce certain letter sounds, like words beginning with P.

Be cautious of patients who have a mild tendency for incompetent mouth who seek botulinum toxin treatment for a golf ball or dimpled chin. They appear to try very hard to close their mouth at rest and if treated, it can cause further incompetence in their ability to close their mouth and you have created a ‘mouth breather’. This makes patients very upset if they do not naturally do this.

To preserve the necessary function of muscles and avoid making these mistakes, Dr Tim advocates that, as part of the consultation, you encourage patients to accept moderate aesthetic improvements whilst describing the function that they may lose if you remove all movement from a particular muscle. This avoids them focusing on a perfect aesthetic result at the expensive of function.

For more guidance on the best botulinum toxin injection patterns, why not download

• Dr Tim Pearce’s 26 essential injection patterns for botulinum toxin and
• How to get a great result with Botox in older patients

Dr Tim loves to hear from his followers; if you have any questions or ideas for topics he can cover in future videos, please drop him a comment on social media; you can find Dr Tim Pearce on Instagram.

Botox® is a registered trademark of Allergan Aesthetics plc.

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Facial muscle anatomy in 10 minutes

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