Basic Botox Training Program

Anatomy edited by Michael Lin, M.D.,Board Certified Dermatologist

Btoxn- A

Introduction:

There are many ways to achieve great results using Botox. This is one of the best ways that were developed through nearly 20 years of trial and error.

Botox is used as a generic term in this lesson to represent all 5 FDA-approved Btoxn-A. We generally prefer Dysport.

Let’s master this basic framework. Draw and inject at least 20 patients before adding and decreasing injection points. Consider moving the points up and down in different zone for the forehead base on assessment of the anatomy.

General uses of Botox can be used to compliment result of V line series.

To decrease wrinkles
To shape brow position
To contour the facial proportion
To lift the upper and lower face

Micro droplets of Botox have been used to : minimize pores, smooth skin, decrease sweating, jawline tightening, as well as neck and chest rejuvenation, see Advance Botox Course
Other areas that can be beneficial – are lips, chin, and mouth corners.

Joseph, PA, CEO, Creator and Master trainer

Section 1: Natural brow shape

Brow position: Bows rest on the border of the orbital rim for females. For males, it can be a bit lower. Males tend to have flat (non-arched brows).
Medial brows: align with medial canthus and alar of the nose.
Mid brows : Apex should align with a line from the lateral limbus. In many cases it may also align with the temporal crest.
Lateral brows : The tail end of the brow should parallel the medial brow.
There are different patterns of beautiful brows that harmonize into different facial shapes. For example, a rounder face can be complemented by a more arched brow at the tail end. This makes the shape of the face appear more slender. See brow shaping course using fillers, toxins, and threads.

Section 2 : Btoxn-A re-balance.

This basic lesson teaches beginning injectors how to decrease wrinkles while keeping the brow shape natural.

There are two opposing forces acting on the brows. Think of a vertical tug of war. The middle part of the rope is the brow. Once force elevates the brow. The other, depresses the brows. To keep your artwork natural, remember this when designing your injection points. Frontalis elevate the brows, and Procerus Corrugators and Orbicularis Oculi depress the brows. This principle of re-balance applies elsewhere on the face : lips and jaw line. See the figure below

Figure shows elevators and depressors acting on two centers (brows and lip/Jawline). Each center is being acted on like a tug of war, one side is up and another is down. Advanced use of toxin can be used to lift jaw line, forehead, and mouth corners.

Example : Patient’s left medial brow descended a bit. This example demonstrate depressor over powering elevators.

Issue : This photo shows uneven brow position after Btoxn – A injection.

Causes : Superficial injection at medial corrugators leading to frontalis spread.

Solution : Inject deep

Section 3 : How to avoid side effects when injecting frontalis?

Injection Pearl : Some patients have increased low-grade CNS tonality of the frontalis. Do not inject these patients! Injecting these patients unmask pre-existing ptotic brows, as well as slippage of skin down to the orbital rim causing sensation of heavy eyelids. Often double eye lids will be effaced.

How do you assess if brows rely on Tonic Contraction to stay in position?

Below photo shows : Brows and lid positions that predispose to tonic CNS stimulation. Notice upper photo the brows are below the orbital rim. Notice the second photo the lids are ptotic and there is loose skin; Dermatochalasis (or hooding) are apparent. These are high risk cases.

Two tests to see if the frontalis is involved in brow and upper lids elevation.

Do an “eye closure test “to see the position of the brows. If brows are down a bit it is considered a positive test.
Do a “finger isolation test “. Put a finger in supra brow concavity to immobilize the frontalis muscle and ask the patient to raise the eyelids. If eyelid opening is limited, the frontalis muscle is involved in upper eyelid lift. This is a positive test. The patient has Tonic Contraction, risking unmaking brow and upper lids ptosis.

Section 4: Anatomy, and treatments.

What are the main muscle groups?

Frontalis
Corrugators supercili ( depressor supercilli, procerus ), or the glabellar complex.
Orbicularis oculi.

Section 4-A: Frontalis

This is a broad single sheet of muscles that causes horizontal lines or bi-fid (wavy lines), see the figure below. This muscle inserts into Corrugators and Orbicularis oculi, this is the only elevator of brow in the upper face. It is the only depressor of the hairline region. They are vertically arranged. Wrinkles usually appear perpendicular to the direction of muscle arrangement.
The medial portion extends down superficially over the medial corrugators. The lateral frontalis extends down and blends or interdigitates with Corrugator Supercili and Orbicularis Oculi at the orbital rim. Also, it is suggested that no injection is needed in the superior central frontalis where muscle fibers are absent for many patients. Author Swift suggests that there are few muscle fibers, and they should be treated.

Injection Tip:

Inject V pattern for wavy (also for female ). Strait line across for male.

Try to not inject frontalis muscle alone. Always add corrugator injections to prevent eye brow ptosis

Injection Tip : Injecting corrugators medially will decrease lower ⅓ forehead wrinkles in the central region due to diffusion. There is no need to inject the lower ⅓ frontalis wrinkles on its own. This is seen in younger patients with no hooding and large frontalis volume without BTOXN A in the forehead.

Injection Tip :

Frontalis : Male : 10-20u, Female : 5-10u, depending on muscles size, age of patient, and upper eyelid platform. Most difficult to gauge dosage of the three muscles.

Key : Break frontalis in smaller dosage and into two sessions. For example : high risk patients start 5u to 10u then return in 3 weeks for another 5 units.

Options to decrease wrinkles

Minimize brow and lid problems via 3D contour of forehead.

See Figure : Three Hollows of aging represented by 2 arrows and circle in the forehead.

Replacing volume in the suprabrow concavity and Glabella hollow will ease the frontalis workload. This diminishes chronic CNS tonality to the frontalis, and thus, wrinkles, especially wrinkles above brows (rainbow wrinkles, crescent wrinkles). Sculptra, Restylane Contour, Belotero, Voluma are good options for this purpose.
Use small PDO threads (Angel Threads ) to the suprabrow concavity above the superciliary arch. These will improve the wrinkles above the eyebrows and minimize the risk of brow ptosis or the heavy feeling in the lower forehead after Btoxn-A injection.
Use long barb PDO or cone threads to complement fillers for more effectiveness.
The final option is surgical endoscopic brow and lid lift with fat transfer and volumization to the forehead which also diminishes wrinkles as a side benefit due to diminish muscle tone.

Example of 3-D contour of forehead. Instant rainbow wrinkles removal with filler.

0.5cc of Voluma was used to reflate the supra brow concavity.

Assessment : Few things to keep in mind before injecting Btoxn A

Adynamic wrinkles : Often these wrinkles warn the injector of low grade tonic contraction of frontalis to keep the eye brows and droopy eyelids above the orbital rim. These patients are usually over 40 or 50 years old. Injecting Btoxn A unmasks tonic low-grade contraction, increasing brow and upper lid droop.
Orbital platform : diminished and ptotic platform allows loose skin to collect above the rim after relaxation of lower portion of frontalis. Patient experience this as feeling of heaviness.
Roof (retro orbicularis oculi fat ). : Roof moves down as we age. Also genetically, Roofs are usually bigger and lower in Asians, traversing below the orbital rim. One can theorize that these patients may be at higher risk for side effects.
Suprabrow Concavity : is a risk factor for brow mal position.
Oblique creases over upper eyelids : The loss of upper eyelid skin integrity from aging causes oblique lines. These lines are enhanced from sleeping on the side. This is also a risk factor for bros mal position
Extended rainbow wrinkles : passing the temple crest these wrinkles are caused by frontalis fibers. Spock brow risk is increased.
Redundant upper eyelid skin : Dermacholasis suggested by missing double eyelids which were present before.
Age : over 40 years old.
Men with no double eyelids.
Frontalis activation : frontalis activated more than levator palpebral superioris to open eyelids. Press on brow to see if eyelids can still open, and how much. Those who rely on frontalis will have more difficulty opening eyes.

Frontalis “compensation”:

Increasing the strength of adjacent muscle groups by weakening certain regions can help produce natural looking results. For example, when injecting brow elevator, the frontalis medial to the temporal fusion line can strengthen the frontalis lateral to the temple fusion line, therefore elevating the lateral brow.

Design and depth : Frontalis : Inject superficially or mid depth.

For short forehead patients :
- Treat the top ⅓, of frontalis, and do one line to avoid brow ptosis.
For long forehead patients :
- Treat top ⅓, mid ⅓and avoid the last ⅓ which is about 1-2 cm above the brow or superciliary arch. For females, inject in a V pattern. In males, do the strait across pattern. Total 3 to 9 injection points depend on age, size of muscles, orbital platform, present of static wrinkles, degree of supra brow concavity, and Roof.

Section 4-B : Corrugators Supercilia

It draws the brow downward towards the midline.
This muscle begins deep (on bone ) medially but ends up superficially ( dermis ) as it extends laterally to mid pupillary line. See Figure 2. It has a 3-dimensional orientation.

Figure 2 : Source : X medica.com. Free CME Available.

The corrugator is under the frontalis medially and blends with the frontalis laterally at the superficial level.

Injection Tip :

Inject corrugator deep medially and inject superficially lateral 1cm above orbital rim in the mid pupillary line. Deep medial injection avoid mid brow ptosis. Superficial injection laterally avoids brow ptosis ( diffusion into frontalis superior to injection point ) or lid ptosis ( diffusion of toxin inferior to injection site into the orbit affecting lid elevator). Make sure the muscles is firmly pinched between your thumb and index finger. Consider lifting it off the bony rim to avoid diffusion into levator palpebral superioris.

The figure shows levator palpebral superioris and blocking of toxin diffusion using two fingers. Ideally thumb should be at the bottom or inferior rim. Ref: Allergan sponsored facial dissection webinar, performed by Cotafona M.D.. Text and syringe added by Joseph PA, V line series Trainee

Injection Tip. Look for 1. Bulge and 2. Dimpling. Inject more horizontally for transverse pattern and more vertically for oblique corrugators.
Note : Corrugators contraction result in 2 patterns : Horizontal : transverse ( safer )Vertical. : oblique ( riskier )

Injection Tip:

To splay or widen medial brows, inject deep at head of corrugators as well as depressor supercili.
To narrow medial brows inject mid or superficial depth at medial corrugators. 2.5 u only at each side. Swift: AestheticBluePrint.com

Glabella or furrow region wrinkles:

Vertical ones are caused by corrugators.
Horizontal wrinkles are caused by the procerus (and nasalis).
Oblique wrinkles are due to depressor supercili (some people do not have these muscles ).

Corrugators : Put your thumb underneath the superior orbital rim and pinch the muscle up, then inject. The thumbs protect the elevator palpebrae superioris which is an upper eyelid elevator along with Muller’s muscle. Keep the syringe and needle perpendicular to the skin is preferable.

Injection depth :

Head : deep near bone. Half of a pinky nail bed above the medial rim (½ cm) is best.
Body : mid depth.
Tail : superficial 1 pinky nail bed or 1 cm above mid pupillary line is best total 5 to 7 injection points.

Injection Tip : 20 to 30 units. May need up to 50u. Orbicularis Oculi : 10-15 u each side

Section 4-C : Orbicularis oculi consists of three parts

Orbital, preseptal, pretarsal See Figure 4

The orbital part is a powerful brow depressor arranged in a concentric pattern around the eye. They cause radial pattern wrinkles around the eyes laterally—crow’s feet. Its main function is to close the eyelids.

Key concepts : injecting crow’s feet ( brow depressor ) to rid of wrinkles and to lift brows and open eyes as frontalis elevating force takes over. It opens the aperture of the eye as well.

Only the orbital portion, the most outer portion, is injected to decrease wrinkles. Crows feet wrinkles can be improved with blended fillers with low G prime HA. Tarsals rolls can be injected with Botoxn A and fillers can be used for aesthetic purpose.

Gender differences : Avoid injecting too close to the tail end of the brow in males. Most men prefer a flat brow and do not need brow lift usually. Aging already causes the lateral brow to go up due to bony remodeling.
Perform snap test to avoid lower lid lag (ectropion), or sclero show or worsening eye bag (edema)
Steps for Injection:
- Identify orbital rim.
- Inject 1 to 1.5 cm outside the rim.
- Inject superficially to avoid “Lip elevator” Inject 3 points. More units superiorly. Less units inferiorly.

Figure 4

Before / After

How to treat lid ptosis.

Apraclonidine eye drop .05% 1 Gtt 14 -30 days. This is an alpha receptor agonist, a sympathomimetic that acts on Muller’s muscle.
UPNEEQ. FDA-approved eye drops. https://pubmed.ncbi.nlm.nih.gov/25077722/

References

Injection Tip : From 2020 paper by Cotafona : Bi directional movement of frontalis and its clinical relevance from Plastic Reconstructive Surgery.

Author Background

Address: 1569 S Fairway Dr. Suite #226, Walnut CA, 91789

Email: joseph@skinperfectmedspa.com

Clinic: Skin Perfect Brothers. 909 839-0714

With 20+ years of experience in aesthetic medicine, I am a highly skilled and certified practitioner in the field. I hold over 20 certificates in areas such as lasers, injectables, medical weight control, and threads. My team and I at Skin Perfect Brothers and V Line Aesthetics have trained numerous licensed RNs, NPs, PAs, and physicians on aesthetic procedures. My career highlights include working at UCLA School of Medicine in Nephrology/Internal Medicine and with a group of Stanford Physicians. Photos and certifications available upon request.

Education:

PA, Physician Assistant – Charles Drew PA Program (Received double gold seal on PA national exam, Top 5% in the nation)
Clinical training with UCLA medical students through Drew/UCLA college of medicine program | August 31st, 1995
Master of Arts in Theology – Fuller Seminary | March 17, 2012
Bachelor of Science, Physiology – UC Davis | June 18, 1993
General Education – De Anza College, Cupertino, CA | June 15, 1991

Career Summary:

Lead injector and trainer of aesthetic injectables at Skin Perfect Medical Aesthetics, Walnut, California (2004-Current)
CEO of V line Aesthetics consulting/Aesthetics MSO (2019-Current)
V line series master aesthetics trainer
Aesthetic trainer and injector at Advanced Dermatology Skin Cancer Institute, Sherman Oak (1-2 times per month)
Physician Assistant, UCLA Medical Center/Westwood Campus, Los Angeles (2002-2004)
Physician Assistant, M.D. Vista, Cupertino, California (2000-2002)
Physician Assistant, Joshua Medical, Buena Park and Cerrito in California (1997-2000)

Additional Information: