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Neurotoxins such as Botox (Onabotulinum toxinA, Allergan), Dysport (Abobotulinum toxin A, Medicis), and Xeomin (Incobotulinum toxinA, Merz) are now commonplace treatments for consumers, with over five million Botox treatments since its introduction in 2002 for cosmetic procedures. The numbers would rise enormously if treatments outside of the United States were included and treatments with Dysport and Xeomin injections were added. This article will address tips from practitioners as to the “art” as well as potential areas of confusion in the use of these valuable tools by dermatologists and cosmetic surgeons. The tips presented here come from the experience in my practice and from comments by numerous dermatologists around the world.

The Consultation

In the consultation stage, Barry Ginsburg MD (Birmingham, AL), recommends telling patients with deeper lines on the forehead that these will still be visible even after the neurotoxin is injected, but will relax on rest after several injection sessions as long as the muscle isn't allowed to return to activity. As the lines disappear, the time interval necessary between injections will increase.

Dr. Schlessinger's Tip: When confronted with a patient with deep lines, I tell them that the lines will go away very slowly with neurotoxin alone, but if I use both a filler and neurotoxin, then the benefit will be much greater. Additionally, I let them know that the time between treatments increases and filler/neurotoxin combination treatment for the glabellar area rarely has to be done more than once or twice, after which neurotoxin alone is generally enough.

How to Inject

Diane Thaler, MD (Sturgeon Bay, WI) and Karen Maffei, MD (Athens, GA), suggest using an intradermal bleb around the eyes for injection sites rather than injecting deeply into the tissue. This produces less bruising with relatively the same effect.

Emily Altman, MD (Livingston, NJ), suggests having the patient contract their muscles around the time of injection, as that allows the visualization of the area to be injected, especially for the glabellar and periorbital areas. Sometimes, muscles can be anatomically different, causing irregularities if “presumed” injection patterns are followed. While some practitioners prefer to use templates, Dr. Altman (and this author, emphatically) feel this practice leads to less impressive results. Additionally, Dr. Altman prefers to leave at least 2cm (or one fingerwidth, as per Dr. Thaler) between the brows and the most inferior injection above the mid-pupillary line. She also injects 1-2 units of Botox directly below the lower lash line in the mid-pupillary area to improve Denny-Morgan folds and balance out the lower orbicularis muscle. Moreover, Dr. Ginsburg recommends marking treatment injection sites on a map to guide future injections.

Sahar Ghannam MD, PhD (Hawalli, Kuwait), recomdept headline dept byline 24 PRACTICAL DERMATOLOGY september 2012 mends treating the glabellar area initially and waiting two weeks to treat the frontalis in individuals where brow ptosis is a concern. This allows the area of any diffusion from glabellar complex treatment to be ascertained as well as allowing more effective use of neurotoxin in the frontalis area. Jo Herzog, MD (Birmingham, AL), does much the same, and also suggests using Botox for the challenged (nearly ptotic brow) forehead and Dysport for the eyes, as the Botox tends to be more forgiving for those patients with potential brow ptosis. Dr. Herzog also feels that Dysport's spread of action enhances the crows feet area greatly.

Allan Wirtzer, MD (Sherman Oaks, CA), injects Xylocaine into the areas when patients are nervous or unsure about whether neurotoxins should be used. This provides a short (20-minute) effect for the areas and shows the patient the effects that might be possible after the procedure. He reminds us that the innervation nerves lie below the muscle, as opposed to the sensory nerves, which are superficial to the muscle, so it is important to inject deeply in this case. He refers to this as “Nu-Tox.”

Dr. Herzog notes that, if performing this method of Nu-Tox xylocaine injections, it is best to have contact lens wearers remove their lenses, as it may be impossible to remove them after the procedure.

Nina Madnani, MD (Mumbai, India), suggests that, in individuals with thick corrugator muscles, the needle can be inserted from lateral to medial position, with the neurotoxin distributed along the entirety of the muscle (injecting as she withdraws the needle) rather than spot treatment. She also deposits 2 units of Botox on the lateral forehead 2 to 3cm above the brows to prevent Spock-like eyebrows, even if she is only doing the glabellar complex.

Sultan Al-Khenaizan, MD (Riyadh, Saudi Arabia), reconstitutes his Botox with a 20cc for 100 units method for areas around the lateral canthal area of the eyes. This allows him to come much closer than the standard 1cm to the bony area of the ocular region and use very small amounts to treat the finer lines around this delicate area. He terms this “mesobotox.” Dr. Madnani uses this technique for the medial infraorbital lines as well.

Ben Barankin, MD (Toronto, Canada), encourages his patients to close their eyes, as he feels this decreases their perceived fear and ultimately their pain level. He avoids showing patients the needle and cleanses the area in advance, as this makes the injection less painful. Saline with preservative seems to decrease pain of injections as well. Additionally, pain can be diminished by the use of acetaminophen prior to a procedure, accompanied by ice packs for a few seconds prior, as well as squeeze toys, soothing music, and “talkesthesia” during the procedure.

Dr. Al-Khenaizan echoes the point on using preserved saline by mentioning that he once had a patient who had immense pain during injections and it was later revealed that his nurse had used normal saline rather than preservative for the reconstitution.

Dr. Herzog prefers either Becton-Dickinson needles or Braun TB syringes as she feels that these provide the best experience. She also indicates they leak less and hurt less than some of the other needles.

Dr. Schlessinger's Tip: The 30-gauge needles that come with Juvederm Ultra Plus are especially good and almost always come with two per syringe, so I put them aside and use them for my neurotoxin patients.

Dr. Altman removes the cap from the neurotoxin bottles when filling the TB syringes, as this allows the needle to remain sharp. She prefills syringes with 10-unit increments of Botox. In order to decap a vial of neurotoxin, special tools that are suited for these tasks should be used. Dr. Herzog suggests the nurses wrap the bottle in a washcloth initially, as the method can sometimes result in a broken (and very expensive) mess!

Kevin Smith, MD (Niagara Falls, Canada), suggests the use of a 20mm [blue handle] Kebby Decapper tool (www.kebbyindustries. com/crimper-options/vial-decappers-decrimper) for this task for Botox. There are equivalent tools available for Dysport as well.

Pam Basuk, MD (Bay Shore, NY), suggests using less, rather than more, neurotoxins initially, as you can always add more, but it is impossible to take away neurotoxins after the effect has occurred.

Dr. Schlessinger's Tip: Even though there is a small amount of improvement from the use of iodipine after drooping occurs with neurotoxins, the result isn't such that it can be termed an “antidote.” For this reason, it is always important to be careful to not inject too close to the eyebrow centrally and use less, rather than more, neurotoxin. Additionally, be careful with patients where forehead droop is likely to occur, resulting in a brow ptosis.

Follow Up and Post-Operative Care

Dr. Ginsburg suggests following up each new patient in one to two weeks after treatment. The author strongly concurs. This allows for adjustments and also for the ability to point out areas of future opportunity. Many times, this leads to a discussion of full correction should the patient have used less neurotoxin (or filler) than recommended initially.

Dr. Schlessinger's Tip: When discussing neurotoxins, I avoid the terms “paralysis,” “frozen,” or “dead” when referring to the areas treated. Instead, I use “relaxed,” “refreshed,” and “rejuvenated” to promote a happier image. Many times, my patients will use the less preferable terms in a consultation and I will explain that we prefer to use the other terms, as those aren't strictly correct. I also educate my staff that using words such as “paralyzed” isn't something that portrays a good image in patients' minds. This helps to set a positive tone to the consultation and follow-up.


In a cosmetic practice, tips like these can make all the difference between success and failure. It is important to achieve your own style of practice, but avoiding pitfalls like these can only assist in making your patients happier. While these tips may be useful as a beginning point or to refine their craft, the practitioner will encounter situations where additional advice is helpful. For more helpful resources on injections regarding toxins and other aesthetic procedures, visit the Fillers and Toxins channel on DermTube ( Additionally, the 4th Annual Cosmetic Surgery Forum in Las Vegas this year, held from November 29 to December 1 at the Palazzo Hotel (, will offer hands-on opportunities as well as discussion-based learning opportunities for dermatologists and core-cosmetic surgeons.

Please feel free to contact me for clarification of any concept in this article. Additionally, if you want to have the type of collegial interaction that led to this discussion of tips for neurotoxins, consider joining RxDerm, a 1,400-member group of dermatologists across the world.

Joel Schlessinger, MD is Founder and Course Director of Cosmetic Surgery Forum. He practices in Omaha, NE. The 2012 Cosmetic Surgery Forum will be held from Nov. 29 – Dec. 1 at the Venetian/ Palazzo in Las Vegas, NV. For more information and to register, visit Contact Dr. Schlessinger at

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