Botox Injection Depth: Advanced Techniques for Upper Face Treatment

The Missing Dimension in Botox Training

Most botulinum toxin training focuses extensively on where to inject, but rarely addresses a critical element of technique: how deep to place the product. This oversight is where many injectors go wrong, particularly in the complex anatomy of the upper face. Understanding the optimal depth for each facial area empowers you to achieve more predictable results while minimizing unwanted side effects.

In every area of the face, you will get subtly different results depending on the depth of your injection. This masterclass explores the nuances of injection depth across the upper face, providing insights that will transform your botulinum toxin technique and help prevent common complications.

The Evolution of Injection Confidence

There’s a pivotal moment in your development as an injector when you stop thinking solely about injection points and begin to understand how risk and reward changes with every shift in angle, depth, and position of your needle. This awareness is when you become truly free to create the results you want because you’re automatically guided by this deeper understanding.

Let’s explore what should go through your mind regarding different injection depths while injecting botulinum toxins and how this awareness guides you to optimize treatment results across the upper face.

Frontalis: Understanding Layer Thickness

The frontalis, in many ways, is one of the simpler areas of the face in terms of injection technique, but there are important differences with different injection depths. If you’ve attended a cadaver course, you may have examined the cross-section of the forehead. What’s surprising to many practitioners is how thick the dermis is, how substantial the hypodermis is, how thin the muscle itself is, and how little space exists underneath.

When you inject intradermally into the forehead, several telltale signs indicate you’re too superficial:

• Visible blanching occurs as the skin turns white
• You’ll feel significant resistance when compressing the plunger
• Patients report more pain than with deeper injections

Intradermal injections are seldom used in aesthetic medicine because they’re not only more painful but also less effective at relaxing the muscle. Although you still get some result, it’s neither pleasant for the patient nor efficient for achieving optimal outcomes.

To find the ideal depth for frontalis injection, pay careful attention to the resistance you feel. As your needle passes through the skin, you’ll notice substantial resistance at the beginning that gradually eases off and then almost disappears. At this point, if you advance slightly further, you’re likely right at the boundary of the muscle—potentially between the muscle and fat, or maybe just underneath the muscle. This is where most botulinum toxin receptors are located, making it the optimal target for frontalis injection.

Most experienced injectors prefer this depth because going deeper risks touching the periosteum. While gentle contact with periosteum can be acceptable, it often blunts your needle and makes subsequent injections more painful for the patient.

To visualize this process: you’ll feel resistance as you pass through the dermis, then as you enter the hypodermis, injection becomes much easier. The goal is to estimate the distance at which you’re fully through the dermis but not touching the periosteum. Beneath the periosteum lies a small amount of loose areolar tissue underneath the frontalis muscle, which is not your target for effective treatment.

Procerus: Depth Makes All the Difference

When injecting the procerus muscle (referred to as “braceis” in the transcript), understanding its unique anatomy is crucial. This muscle runs from the bridge of your nose into the forehead, originating at the periosteum and extending upward toward the dermis. Because of this orientation, injection depth makes a tremendous difference to treatment effectiveness.

Similar to the frontalis, the most superficial injection would be in the dermis, but this approach would miss the bulk of the muscle. This is because underneath the dermis lies a relatively thick layer of fat before you reach the muscle itself. The ideal level for procerus injection is just beyond the hypodermis, at the surface of or within the muscle itself.

Going too deep presents another challenge. Beneath the procerus lies the galeal fat pad, a deep fat pad that runs underneath the muscle. Injecting at this depth will produce minimal effect on the muscle, wasting product and delivering suboptimal results.

To improve your depth accuracy when treating the procerus, angle your needle toward the origin of the muscle. As long as you feel minimal resistance for 4-5 millimeters while pointing down toward the muscle’s origin, you should be in the optimal zone where most acetylcholine receptors are concentrated. This technique allows you to relax the muscle effectively with the least amount of product.

Orbicularis Oculi: Surprisingly Superficial

The orbicularis oculi is perhaps the most incorrectly treated muscle in the upper face. Based on clinical observation, the depth of this muscle is poorly understood by many practitioners. The key insight is that this muscle is incredibly superficial, lying just beneath a very thin layer of dermis.

This superficial position often confuses injectors, making them think they need to go deeper—which is precisely where complications occur. The correct approach requires understanding the layers you pass through when targeting the orbicularis oculi.

If you inject beneath the muscle, you’re no longer treating the orbicularis oculi but instead placing product in the deep cheek fat, which will be relatively ineffective. More concerning, going deeper puts important structures at risk, including the lateral rectus muscle (which turns the eye laterally) and the lacrimal gland. Hitting the lateral rectus muscle can cause lateral rectus palsy, while affecting the lacrimal gland can impair tear production.

This is why depth awareness is so critical when treating the eye area. Additionally, maintaining superficial injection technique in this region helps minimize bruising—a benefit your patients will certainly appreciate.

Lateral Corrugator: Where Depth Equals Safety

The lateral corrugator area is most associated with eyelid ptosis, and this complication is almost entirely about injection depth. To safely treat this muscle, we must understand that it runs from the periosteum medially to the dermis laterally. Injecting at the correct level keeps treatment safe, but going underneath the muscle puts the eye at risk.

The lateral portion of the corrugator is where the eye is most vulnerable. For this reason, when treating this area, aim your needle in a more superficial direction. The layers you’ll encounter include a thin layer of dermis before entering the muscle directly when injecting laterally.

As you move medially, the anatomy becomes more complex. You may pass through either the frontalis muscle or a portion of the orbicularis oculi before reaching the corrugator supercilii. The correct approach is to angle your injection from lateral to medial, pointing toward the muscle’s origin.

Going too deep in this region brings serious risks. Beneath the orbicularis oculi, you’re dangerously close to the orbital rim, small foramina, and the eye itself. These structures, when affected by botulinum toxin, can lead to eyelid ptosis and superior rectus palsy—one of the most severe complications in aesthetic medicine. This complication results directly from the needle penetrating too deeply.

Bunny Lines: Finding the Sweet Spot

When treating bunny lines by injecting the levator labii alaeque nasi muscle, depth awareness remains crucial. If you prefer to inject just above the piriform fossa, note that this muscle typically sits supported by a deep fat pad.

Injecting too superficially places you in the dermis, where you’re more likely to affect parts of the orbicularis oris rather than your target muscle. Conversely, going all the way to the periosteum likely positions you underneath the muscle entirely. The ideal position is intermediate—neither too superficial nor too deep.

Developing Your Depth Awareness

The next time you perform botulinum toxin injections, pay careful attention to the depth at which you’re working. Begin thinking with greater precision about where your needle tip is likely positioned and how you can optimize results through adjustments in depth, angle, or technique.

This heightened awareness is key to becoming a more proficient and confident injector. By understanding what’s happening beneath the skin’s surface, you’ll develop the ability to visualize the three-dimensional anatomy you’re treating. This skill represents one of the core elements of mastering botulinum toxin injections.

Conclusion: The Third Dimension of Injection Excellence

Mastering injection depth transforms your approach to botulinum toxin treatments. While most training focuses on the two-dimensional aspect of where to inject, adding the third dimension of depth awareness elevates your technique to a truly advanced level.

This understanding allows you to:

• Achieve more consistent results
• Minimize complications like eyelid ptosis
• Optimize product placement for maximum effect
• Enhance patient comfort during treatment
• Reduce bruising and other side effects

For practitioners serious about perfecting their botulinum toxin technique, comprehensive training that addresses these nuances is essential. The most successful injectors understand not just where to place product, but exactly how deep to position it for optimal results.

By applying these principles of depth awareness across your upper face treatments—from frontalis to procerus, orbicularis oculi to corrugator, and even bunny lines—you’ll develop the confidence and skill that defines truly masterful injectors.

Free Guide to Neurotoxin Injection Patterns

Want to learn the best toxin patterns for the upper face based on your patients unique anatomy? Get our comprehensive guide to neurotoxin injection patterns to inject based on anatomy, not just points.

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.