In this popular podcast episode, Dr Adam Cheong sits down with Dr Ahmed El Houssieny, a SkinViva clinician and trainer as well as anesthetist, to discuss a variety of advanced BOTOX® techniques you can use in your practice to achieve great results.
Keep in mind that while the techniques discussed in this podcast can produce great results for your patients, they are also off-label uses, so it is essential that you are trained in and comfortable with the procedures before attempting them due to the risk of diffusion to other muscles. Precision is key.
Top Third of the Face
This is one of the most common areas of concern for clients. A lateral eyebrow lift can be achieved by treating the glabella complex (the frown), injecting BOTOX® into the superior aspect of the orbicularis oculi roughly 1.5 centimeters up from the lateral canthus and 1 centimeter away from the orbital rim. “When you treat a frown, the corrugator and the frontalis and the orbicularis are all intertwined together, so BOTOX® will stop the downward pull on the brow and that should give you the lift necessary
If you simply want to lift the tail end of the brow, you can make just one injection into the superior orbicularis to achieve a nice flare. However, more mature patients may desire an overall eyebrow lift, in which case Dr Ahmed typically treats the glabella and superior orbicularis first, then assesses whether an injection is needed in the frontalis.
Finally, for patients who complain that their forehead feels heavy after a treatment, you may want to counteract the heaviness by making a superficial injection of BOTOX® just under the brow. However, this area can run the risk of ptosis if not performed correctly, so be careful. “Superficial is the key word,” Dr Ahmed says.
Middle Third of the Face
Injecting BOTOX® under the eyes is high-risk because of the potential for diffusion to the muscles around the eyes, which can cause entropion (out-turning of the eyelids). Instead of injecting in this area, Dr Ahmed recommends considering treatment with fillers to replace volume loss.
Nasalis (bunny lines)
These lines around the nose can easily be treated with BOTOX®. Just be cautious and avoid being too lateral when you inject, because if you hit the lip levators, the patient may end up with an asymmetrical smile.
For clients who dislike seeing too much gingiva when they smile, you can inject a small amount of BOTOX® on either side of the nose to depress the levator muscles and the zygomaticus minor. “Again, you have to be a little bit more careful,” Dr Ahmed cautions. Over-injecting in this area can cause a loss of mobility in the upper lip. This is another area where filler could be more effective than BOTOX®, though you may choose to use botulinum toxin as an adjunct treatment.
Nose tip lift
Some clients are uncomfortable that the tip of their nose moves when they talk. To treat this, you can inject a small amount of BOTOX® at the base of the columella, into the depressor nasi.
Bottom Third of the Face
Upper lip lines
Perioral lines are often called “smoker’s lines,” although non-smokers can get them too. This is another area that requires a cautious approach. Since the main issue is typically volume loss, Dr Ahmed again recommends treating with filler first, as BOTOX® may result in difficulty with certain vowels or with drinking from a straw.
One of the muscles around the mouth is the depressor anguli oris (DAO), and treating this muscle with BOTOX® can help to slightly lift the corners of the mouth. As always, precision is necessary, as even a little diffusion to nearby muscles can greatly impact the mobility of the mouth and lips. “Assessment there is key,” Dr. Adam says. If the main issue is fat pad loss, filler may be preferred.
Named after the Egyptian Queen famous for her long, beautiful neck, this treatment will soften the neck muscles to create a sharper contour and lessen the downward pull of the muscles. It is achieved by injecting relatively high doses of BOTOX® all around the neck.
Be sure to assess your patient beforehand, Dr Ahmed says. “You really want to do it with someone where you feel the main issue is the muscle, the downward pull, not skin that’s lost its elasticity or excess fat pad.” The results of a Nefertiti Lift will be subtle rather than dramatic, so be sure to inform your patient of what to expect.
Jawline slimming is especially popular in Asian countries to reduce the appearance of a square jaw. BOTOX® is injected into the masseter muscle, and the muscle then atrophies, which creates a slimmer face. Because the muscle will take some time to atrophy, the results of this treatment may not appear for several weeks.
The risks of masseter BOTOX® include osteopenia of the jaw, hypertrophy of the temporalis as compensation for the relaxed masseter, and worsened marionette lines (more commonly seen in mature clients). It’s important that you and your clients are aware of these risks before starting the treatment.
Injecting BOTOX® into the masseter can also offer great relief to people who suffer from pain and discomfort due to bruxism (teeth-grinding).
Someone with a hyperactive mentalis may experience dimpling of the skin on the chin. BOTOX® can be a great treatment for this, but be careful that it doesn’t diffuse to the muscles around the mouth, causing a drop in the lips.
Medicinal License: Hyperhidrosis
BOTOX® has been approved as a treatment for excess sweating and is offered by the NHS. Because it is a licensed treatment, there are specific dose and technique guidelines to follow. Injections are typically only needed twice a year, and patients tend to be highly satisfied with the results. “I’ve seen it be life-changing for some people,” Dr Adam says.
The only caution here is that because hyperhidrosis can be caused by serious medical conditions, you’ll need to rule out any of those by getting a thorough patient history before starting the treatment. Other than this, the treatment is safe and effective.
In general, when it comes to advanced BOTOX® techniques, Dr Adam says, “Less is more. Accuracy is absolutely key.” It’s essential to be trained in the anatomy of the face and where each of the muscles attach to avoid unwanted side effects, but the first step is becoming familiar with what each of the techniques can achieve. Dr Ahmed and Dr Adam have introduced some of these methods today so that you can assess which ones may be useful to you in your practice.
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