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Botulinum Tox for Wrinkles

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Frown Lines

  • Indications

Neurotoxins are commonly used to treat the vertical lines between the brows.

  • Anatomic Considerations

The vertical lines of the glabella result from the contraction of the paired cor­rugator supercilii muscles, and the horizontal lines are caused by contraction of the central procerus muscle. The corrugators originate on the upper eye socket ridge of the frontal bone and in­sert on the skin above the middle third of the eyebrow. The procerus muscle originates on the nose bone and inserts onto the mid-forehead skin.

There are two patterns of corrugator position­ing: either horizontally along the brow, or more vertically in a V shape. The injector should "look through" the skin to imagine the location of the mus­cles and their contribution to the wrin­kles produced during movement.

  • Injection Technique

This injection usually can be tolerated without anesthesia.

Have the patient frown his brow before inject, and look through the skin to determine the size, strength, and location of the procerus and corrugator muscles.

Usual doses for frown lines are 20 to 30 BU (Botulinum tox units); however, some patients can do well with as little as 10 units, and men may need 40 BUs.

Injections should be placed 1 cm above the upper eye socket rim to reduce the risk of upper eyelid droop. Injections should be placed in the muscle belly. The periosteum should not be touched with the needle because periosteal contact can cause a post-injection headache.

  • Precautions

Injection in the brow area can result in upper lid droopiness, which can up to two weeks after an injection and may last for 2 to 4 weeks.

  • Neurotoxin Preparation

Neurotoxins should be reconstituted with preserved saline (0.9% sodium chloride) because preserved saline causes less patient dis­comfort.

Botox Cosmetic-100 BU may be reconstituted with:

1 mL preserved saline, which pro­duces a solution of 10 BU per 0.1 mL

2 mL preserved saline, which produces a solution of 5 BU per 0.1 mL

2.5 mL preserved saline, which produces a solution of 4 BU per 0.1 mL

4 mL preserved saline, which pro­duces a solution of 2.5 BU per 0.1 mL

Botulinum toxin should be stored in a freezer until reconstituted. After reconstitution, botulinum toxin should be kept in a refrigerator.

After reconstitution, botulinum toxin A can be withdrawn from the vial with a 1-mL syringe and a 20-gauge needle, and a 30-gauge needle can then be used for in­jection.

  • Post-Injection Instructions

Patients should not to bend over, push on the injection sites, or lie down for 4 hours after the injection. The patient should not exercise that day or actively move the injected muscles for 90 minutes.

  • Risks

Diffusion of Bo toxin into the eyelid may paralyze the levator palpebrae supe­rioris muscle and result in a transient droop.

  • Pearls of Injection

The patient should frown to demonstrate the size and shape of the muscles. Filler injections may be necessary for deep wrinkles in the brow region. Application of pressure with a thumb along the eye socket rim during in­jection may prevent diffusion of Botox toward the levator palpebrae superioris muscle.


a) More hori­zontal muscles. (b) More vertical V-like muscles.

Fig. Patterns of injection for more horizontal corrugator supercilii muscles.

Fig. Suggested patterns of injection for V-like corrugator muscles.

Fig. Injection sites for horizontal glabellar wrinkles with more con­tribution from the procerus muscle and less contribution from the corrugator muscles.

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