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  • The most popular dermatologic uses of BTX include the reduction of facial rhytides, facial contouring, and treatment of focal hyperhidrosis. It is commonly used for the following areas of the face:

    • Upper face

      • Glabellar lines

      • Lateral canthal lines

      • Horizontal forehead lines

      • Bunny lines

      • Infraorbital region

    • Lower face

      • Nasal tip droop

      • Nasal flare

      • Perioral rhytides

      • Depressor anguli oris

      • Hypertrophic masseters

      • Excessive gum show

      • Wrinkled chin

image Beginner Tips

  • Expert consensus guidelines recommend that a vial of BTX can be refrigerated or refrozen for at least 4 weeks before injection without significant risk for contamination or decreased effectiveness, and that a single vial can be used to treat multiple patients, assuming appropriate handling.

  • Using preservative-containing sterile normal saline for reconstitution significantly reduces subsequent injection pain and is therefore recommended.

image Expert Tips

  • Variations in muscular patterns in the upper face are well established, and studies have demonstrated that targeted individualized treatment delivers superior outcomes.

  • Due to the interrelationship between the facial musculature, it is useful to conceptualize the upper and lower face as global treatment regions rather than focus on a specific area such as the glabella or lateral canthus. This mindset promotes the goal of achieving a harmonious, balanced, natural, and aesthetically pleasing outcome.

image Don’t Forget!

  • Simple mechanical distraction administered by an assistant tapping on the patient’s shoulder or forehead during injections is a highly effective and efficient way to decrease injection pain.

  • Brow ptosis is especially common in those with smaller foreheads, naturally low brows, minimal frontalis bulk, or with a tendency to overutilize the frontalis muscle for brow elevation during facial expressions.

image Pitfalls and Cautions

  • Cultural and ethnic norms should also be taken into account when tailoring individual treatments, as desires and expectations can vary significantly between these diverse populations.

  • Inferolateral extension of lateral canthal lines down toward and across the zygoma should not be “chased” with BTX due to the risk of facial asymmetry.

image Patient Education Points

  • Important areas to consider include: establishment of realistic goals, assessment of desired treatment area, understanding of expectations and potential side effects, written informed consent, and photographic documentation.

  • Photographic documentation is highly recommended for both pre- and posttreatment status.


Botulinum toxin (BTX) is one of the most widely used aesthetic treatments available to dermatologists and dermatologic surgeons. When appropriately applied, its safety, efficacy, reproducibility, and overall satisfaction are exceptional.

Although the toxin itself was isolated in the 1940s, early work with BTX for medical purposes began in the 1970s and 1980s with the pioneering research of Dr. Alan Scott on strabismus and blepharospasm. Experiments in monkeys1 laid the groundwork for successful clinical trials in humans.2,3 In 1989, BTX received Food and Drug Administration (FDA) approval for blepharospasm and nystagmus.

In parallel with ...

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