Botox: correct injection points for crow’s feet (lateral canthal lines)

Crow’s feet, or to give them their correct medical name – lateral canthal lines, are a common complaint from aesthetic patients who start to notice them appearing around their eyes every time they smile. Understanding how to optimally approach the aesthetic treatment of crow’s feet very much depends on an understanding of the anatomy.

In this blog, Dr Tim Pearce explains the correct technique and injection points to use when treating lateral canthal lines with Botox or botulinum toxin, and the anatomy to consider so you are safe and can create the best results for your patients.

To be among the first to receive exclusive updates on the launch of Dr Tim’s new movement, featuring an immersive 3D learning experience, comprehensive Botox lessons, and much more, simply sign up here to join the priority waiting list.

Why accurate Botox injection point placement is vital for lateral canthal lines

When treating lateral canthal lines with botulinum toxin, dose placement via injection, as defined by the manufacturer, is performed at three points laterally to the eye, but have you ever stopped to wonder about the difference between the placement of each injection point?

Depending on accurate placement, each of the injection points can cause subtle or dramatic differences that you must understand, affirms Dr Tim. Knowing the outcomes is a good way to understand the anatomy, with an appreciation that millimetre accuracy matters considerably when it comes to injecting botulinum toxin, and you must carefully consider the exact placement of the three points to avoid some common mistakes.

Let’s consider the first or top point of the three. If you place it low and too far inwards, you will be too medial to the eye and will miss the bulk of the orbicular oculi muscle. More importantly, it would place you too close to important and vulnerable structures in the eye including the lateral rectus muscle and the lacrimal gland.

Remember to leave approximately 1.5 to 2cm from the lateral canthus – the lateral junction of the upper and lower eyelid margins – when placing your injection points.

The aim of the second or middle point of injection is to target the bulk of the orbicularis oculi muscle. This muscle arcs away from the eye but comes back in inferiorly, hence this placement is an important injection point to soften lateral canthal lines. However, you must be careful, warns Dr Tim, because it is an accessory muscle to cheek elevation. Therefore, overtreating can sometimes make patients look a little sad because they do not achieve the upward pull in their cheek area when smiling.

The final injection point ought not to be too low because if you inject too deeply, through the subcutaneous fat, the needle will come to rest on the origin of the zygomaticus major muscle which elevates the cheeks on smiling. If you relax that muscle, even a little bit, it will result in asymmetry and potentially a droopy smile, highlights Dr Tim. Your patients will look and feel very unhappy if that happens.

Get further insight from this blog on Treating orbicularis oculi with Botox: what can go wrong?.

Why do aesthetic clinicians use incorrect injection placement?

Sadly, inaccurate injection points are more commonplace than you might think when treating crow’s feet, especially amongst newer aesthetic clinicians, and why Dr Tim warns that being a few millimetres out can lead to problems and side effects. As you develop as an aesthetic injector, you will start with a much lower resolution for the anatomy. This does not mean that you do not know the anatomy, it is the resolution that is poor, meaning that 5mm in one direction or another does not look out of place until you develop improved anatomical understanding.

Similarly, it can be very easy to be 5 to 10 mm out of position when there are distractions on the face. For example, if the patient has a large orbicularis oculi muscle with lots of lines and wrinkles, it may create some confusion about the best placement, compared to a neat and discrete muscle where you can see more clearly where to inject.

Many other factors might inadvertently affect your injection placement – for example, your injection angle, especially if room space is compromised, or patient demands that can cause you to change your injection points to “chase lines” that bother them – and can lead to side effects. As you develop as an aesthetic injector, you will quickly learn not to submit to patient requests and instead be guided by the anatomy.

Dr Tim also highlights a common occurrence in the career path of an aesthetic injector which is identified by the Dunning-Kruger effect. This manifests as a burst of confidence whereby you believe the aesthetic specialty is easy. You begin to think less as you practice and inject more, resulting in your first wave of complications. This experience grounds you, in a new state of fear around your patients, but will make you think much more clearly about where you inject, improving your resolution for injecting and your anatomical knowledge. When you start to think more when you are injecting, you will experience fewer side effects.

For additional guidance on botulinum toxin injection points, including treating lateral canthal lines:

• Download Dr Tim Pearce’s 26 essential injection patterns for botulinum toxin
• Read up on the best tried and tested BOTOX® injection patterns and mistakes to avoid

Dr Tim is always keen to hear about the experiences of his followers and guide newer practitioners with educational content. So, if you have any questions, case studies, or discussion points for him, you can find Dr Tim Pearce on Instagram.

Aesthetics Mastery Show

Correct Injection Points for Crow’s Feet – Crow’s feet Botox Technique

Dr Tim says:

“Crow’s feet are a common complaint for patients. In this episode I talk through the correction injection points for treating this area and the anatomy you need to know to stay safe and create great results for your patients.”

Watch the full Aesthetics Mastery Show here.

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BOTOX (Botulinum Toxin) eLearning Courses

If you want to increase your confidence in botulinum toxin injections, or learn how to avoid and handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

• BOTOX® Foundation Course
• Botulinum Toxin Complications Mastery

Both give CPD and certificates on completion.

In addition, browse our FREE downloadable resources on complications.

3D anatomy learning experience movement

In the next few weeks, Dr Tim Pearce is going to be launching something amazing that involves an incredible 3D learning experience for injectors, a community of clinicians on the same mission as you to help you achieve your goals, and exclusive online access to him and his team, to help you become a pro injector. Be the first to join the movement by joining the priority waiting list.

Botox® is a registered trademark of Allergan Aesthetics plc.

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.