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How to Inject BOTOX® Cosmetic: a Beginner’s Guide to Botox Certification Training 

What is BOTOX® Cosmetic?

BOTOX® Cosmetic is a purified protein complex derived from the bacterium Clostridium botulinum that smoothes the muscles by blocking nerve impulses.  BOTOX® Cosmetic blocks the release of acetylcholine at the neuromuscular junction thereby preventing the contraction of muscles.  In detail, BOTOX® binds to the nerve terminal, internalizes by receptor-mediated endocytosis, cleaves a cytoplasmic protein called SNAP-25, and blocks the fusion of the vesicles containing acetylcholine with the nerve membrane.  After a time, nerve end plates expand and collateral terminal sprouts appear.  Once the parent nerve terminal regains function, the collateral terminals retract.  

BOTOX® Cosmetic was FDA-approved in 2002 for moderate to severe glabellar lines in patients 18 to 65 years of age.  BOTOX® Cosmetic received FDA approval for crow’s feet in 2013 and horizontal forehead lines in 2017. It should be noted that any other location on the face that BOTOX® Cosmetic is injected for cosmetic purposes is considered off-label use.

As the facial muscles cease to move, the wrinkles will diminish.  Patients will begin to see effects of muscle relaxation within several days, in most patients taking up to 5 – 7 days to see the full effect.  The duration of relaxation of the muscle due to BOTOX® Cosmetic can last up to 3 – 4 months, but rarely up to 6 months.

A common mistake is that BOTOX® Cosmetic is used to fill in wrinkles.  BOTOX® works on dynamic wrinkles and not static wrinkles like a dermal filler.  Also, BOTOX® affects the neuromuscular junction and not the sensory nerves, so you will not numb a patient’s face.  

Basic Botox Injection Training Instructional Video

Contraindication

BOTOX® Cosmetic is contraindicated in the presence of infection at the proposed injection site(s), individuals with known hypersensitivity to any ingredient in the formulation, pregnancy (category C – safety for use during pregnancy has not been established), or breastfeeding. There have been rare reports of adverse events involving the cardiovascular system. Serious and/or immediate hypersensitivity reactions have been reported rarely. These reactions include anaphylaxis, urticaria, soft-tissue edema, and dyspnea. BOTOX® Cosmetic is prepared with an albumin (egg) base and should be avoided if your patient is allergic to eggs. 

The most common side effects following injection of BOTOX® Cosmetic include temporary eyelid droop and nausea. Localized pain, infection, inflammation, tenderness, swelling, redness, and/or bleeding/bruising may be associated with the injection.

Patients with neuromuscular disorders such as ALS, myasthenia gravis, or Lambert-Eaton syndrome may be at increased risk of serious adverse events. Underlying generalized weakness can be exacerbated, and local weakness at injection sites can occur more than otherwise expected. 

Medications, such as aminoglycosides, penicillamine, quinine, and calcium channel blockers, decrease neuromuscular transmission and generally should be avoided in patients treated with botulinum toxin.  

It should be noted that the lethal dose for BOTOX® Cosmetic is 3000 units.  This is 30 vials of Botox® Cosmetic in one day injected into a 70kg individual.  Typically, you will inject 20 units to 100 units in one day.  

Reconstitution and Handling

BOTOX® Cosmetic comes in a vacuum-sealed vial in a powder form at 100 units per vial.  Although the manufacturer, Allergan, recommends using non-preserved 0.9% Sodium Chloride, we recommend using preserved 0.9% Sodium Chloride.  Preserved (Bacteriostatic) 0.9% Sodium Chloride will increase the activity of the BOTOX® Cosmetic protein for up to 6 weeks when stored at 4°C (As recommended by Consensus Recommendations on the Use of Botulinum Toxin Type A in Facial Aesthetics; Plast Reconstr Surg. 2004 Nov;114(6 Suppl):1S-22S). 

Inject 2.5cc of Preserved 0.9% into BOTOX® Cosmetic vial to make the following concentrations in your reconstituted vial of BOTOX® Cosmetic:

100 units per 2.5cc

20 units per 0.5cc

4 units per 0.1cc

This is probably the toughest concept for many to grasp.  However, once you become familiar with it, it will become second nature to you.

However, if you have problems with this dilution recommended by Allergan, then simply reconstitute 1cc per one vial or 100 units of BOTOX® Cosmetic.  This will give you 1 unit of BOTOX® Cosmetic per 0.01cc of solution.  Additional dilution options will be discussed during your hands-on Botox certification and Botox Training class.

Patient Consultation

Before you inject, get a thorough history from your patient and assess for contraindications.  Your patient should sign the informed consent and take “before” photos.  Check your patient for asymmetry and discuss them with your patients.  You must set realistic goals and educate your patients.  Ideally, you should under-promise and over-deliver.

Glogau Wrinkle Scale provides a general overview of the type of wrinkles that you will encounter depending on the age of the individual and the treatments that you will likely recommend. 

Type 1: ‘Early Wrinkles’

Patient age: 20s to 30s, with minimal wrinkles

BOTOX® is typically all you’ll use.  

Type 2: ‘Wrinkles in Motion’

Patient age: 30s to 40s, starts developing smile lines

In addition to BOTOX® you may consider using dermal fillers depending on the location

Type 3: ‘Wrinkles at Rest’

Patient age: 50s & older, Wrinkles even at rest
In addition to BOTOX® you will need to use dermal fillers depending on the location

Type 4: ‘Only Wrinkles’

Patient age: 60s or 70s, 

BOTOX® & dermal fillers alone will not completely eliminate all the wrinkles.  These patients will benefit from a facelift or a laser resurfacing procedure.

Glabella (Frown Lines) Botox Certification

Muscles Involved

The glabellar complex has two main muscles that you will inject: procerus and corrugator.  The procerus originates from the nasal bone and attaches to the medial forehead & skin of the brow.  The action of the procerus draws the medial brow down inferiorly.  The corrugator originates from the medial superciliary arch and inserts into the skin of the medial forehead.  The action of the corrugator draws the brow medially and inferiorly.  

Botox Training Glabellar Injection Pattern

Injection Technique 

Glabellar injections are deep intramuscular injections.  You should insert your needle perpendicular to the skin.  The depth should be deep near the periosteum.  The frontalis muscle overlaps the glabellar complex superficially.  Therefore, a superficial injection can affect the frontalis muscle and cause the patient’s eyebrow to feel heavy.  However, an injection that is too deep will cause the needle to hit the periosteum.  This will cause a headache in your patient and dull the needle for the subsequent injection.  

Landmarks:

Medial corrugator injection = 1 cm above the bony orbital rim and vertical to the medial canthus

Lateral corrugator injections = 1 cm above the bony orbital rim and around 0.5cm medial to the vertical mid-pupillary line

Procerus injection = immediately above the crossing point of the X formed by drawing a line from medial eyebrow to the contra-lateral medial canthus.

20 units is the standard FDA approved injection for the Glabellar lines as found in the BOTOX® Cosmetic package insert.  

Please note that patient with strong glabellar muscles may require 1-2 additional units per injection site.

Clinical Research

A double blind study, 405 patients were injected with BOTOX® Cosmetic and evaluated by investigator and self reported by the subject for efficacy.

Results of the studies show that the severity of glabellar lines was reduced for up to 90 days in the BOTOX® Cosmetic Cosmetic group.

Complication

According to Allergan, Botox® Cosmetic was used on 405 patients and the complication rates are as follows:

•  Facial pain (1%) 

•  Facial paresis (1%) 

•  Eyelid ptosis (3%)

•  Muscular Weakness (1%) 

Please note that injection lateral to the mid-pupillary line may cause brow ptosis.  Also, injection too close to the orbital rim can cause lid ptosis by paralyzing the levator palpebrae superioris muscle.  Usually, complications will be seen in 48 hours to 7 days.  The effects of the complication may last up to 4 – 8 weeks. 

Iopidine 0.5% drop, one drop to affected eye TID is usually prescribed for patients with eyelid ptosis.  Iopidine is believed to stimulate Mueller’s muscle to minimize the ptosis.

For comprehensive, personalized onsite Botox Training with free after training support and a training satisfaction guarantee, call us at (212)470-8059 or email@BotoxMedicalTraining.com.

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Frontalis (Horizontal Forehead Lines) Botox Training

Muscle involved

The frontalis muscle is a single muscle group that varies in size and shape.  It may be narrow or broad, tall or short, and v-shaped or rectangle-shaped.  You cannot just rely on the wrinkle pattern on the skin to know the shape of the muscle.  You must use your fingers to feel the location and strength of the frontalis muscle.  

The frontalis muscle originates at the galea aponeurosis and inserts into the muscles of the glabellar complex. The main action is to lift the eyebrows superiorly and depress the scalp inferiorly.  The fibers of the frontalis muscles are oriented vertically.  

Botox Training Frontalis Injection Pattern

Injection Technique

All injections are intramuscular.  However, since the skin is thin and there is no other major structure on the forehead, you can angle your needle at a 45-degree angle like a subcutaneous injection.  All injections should be at least 2 cm apart.  The lower 3 – 4 cm of the frontalis muscle plays a large role in elevating the eyebrow; therefore, injections here should be avoided.  The medial portion of the frontalis may be fibrous and lack muscle fibers.  

There is great debate about the amount of BOTOX® Cosmetic to inject in this area.  Allergan states in their package insert that 4 units should be injected in 5 injection spots.  An article from 2004 titled “Consensus recommendations on the use of botulinum toxin type A in facial aesthetics” recommends that we start with a lower dose of Botox: 2 units per injection site.  The actual amount truly depends on the patient’s prior experience and the strength of the frontalis muscle.  

Clinical Research

Two multicenter clinical studies show that compared to placebo, BOTOX® Cosmetic demonstrated statistically favorable results.  

Allergan Frontalis Research

Complication

According to Allergan, Botox® Cosmetic was used on 665 patients and the complication rates are as follows:

• Headache (9%)

• Eyelid ptosis  (2%)

• Brow ptosis (2%)

• Skin tightness (2%)

Brow ptosis may happen for many reasons.  Commonly, an injection too low on the frontalis may cause this.  Also, a person who has a hyperfunctional frontalis (a person who always uses the frontalis when opening their eyes) will feel that their eyebrows will feel heavy.  Finally, this can happen if your patient requests that you inject only the frontalis without glabellar treatment.  This will cause unopposed glabellar activity which will depress the eyebrows.  

A Spock brow or Mephisto sign can happen if the lateral fibers of the frontalis muscles have not been properly paralyzed.  Depending on the strength of the muscle, you may inject 1 – 2 units in the area of the greatest muscle activity to smooth out these wrinkles. 

For comprehensive, personalized onsite Botox Training with free after training support and a training satisfaction guarantee, call us at (212)470-8059 or email@BotoxMedicalTraining.com.

Check out our FREE AI-Powered Botox Training App for iPhone or Android.

Orbicularis Oculi (Crow’s Feet) Botox Certification

Muscles Involved

The orbicularis oculi is a purse-string like a single circumferential muscle.  It originates from the medial palpebral ligament and inserts into the lateral palpebral raphe, corrugator, frontalis, and depressor supercili.  The action is to pull the skin of the forehead, temple, and cheek towards the medial angle of the orbit.  

Botox Training Orbicularis Oculi Injection Pattern

Injection Technique

All injections are intramuscular.  However, since the skin is thin and there is no other major structure in this area, you can angle your needle at a 45-degree angle like a subcutaneous injection.  All injections should be at least 2 cm apart in a curving semi-circle like pattern.  You must inject at least 1 cm outside of the bony rim to avoid injecting into the lateral rectus muscle.  

This injection technique is a subcutaneous injection 1cm apart in a slightly curving arch. There is great debate about the amount of BOTOX® Cosmetic to inject in this area.  Allergan states in their package insert that 4 units should be injected in 6 injection spots.  An article from 2004 titled “Consensus recommendations on the use of botulinum toxin type A in facial aesthetics” recommends that we start with a lower dose of Botox: 3 units per injection site.  The actual amount truly depends on the patient’s prior experience and the strength of the orbicularis oculi muscle.

Clinical Research

Two multicenter clinical studies show that compared to placebo, BOTOX® Cosmetic demonstrated statistically favorable results.  

Orbicularis Oculi Allergan Research

Complication

According to Allergan, Botox® Cosmetic was used on 526 patients and the complication rates are as follows:

• Eyelid edema (1%)

Other rare side effects are asymmetrical smile or diplopia due to migration. You can help avoid this by injecting at least 1 cm outside of the bony rim, but not close to the zygomatic arch.  

For comprehensive, personalized onsite Botox Training with free after training support and a training satisfaction guarantee, call us at (212)470-8059 or email@BotoxMedicalTraining.com.

Check out our FREE AI-Powered Botox Training App for iPhone or Android.

Botox Certification & Botox Training Course

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Statement of Responsibility

Botox Medical Training recognizes that many of the techniques and recommendations are for procedures that are considered off-label use.  Our recommendations are based on many textbooks, published articles, seminars, and practical knowledge and experience.  The authors have attempted to maintain up to date knowledge and information in this training manual with the current standard of care.  However, due to the continuing flow of new research and information relating to the drugs being used in this course, we recommend that you check with the manufacturer for any changes in the package inserts, warnings, and precautions.  All information and tools presented within this site are intended for educational purposes. We do not guarantee that the information will be completely accurate and up to date; therefore the authors will not be held responsible for any errors, omissions, or inaccuracies published.  Application of the knowledge is ultimately the responsibility of the practitioner.

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Originally published at Botox Training New York City