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In the past decade, there has been an enormous rise in the number of cosmetic procedures performed in the United States. As public exposure to the field of cosmetic surgery grows, more and more people are considering facial enhancement procedures than ever before. Aesthetic plastic surgery is no longer restricted to the very wealthy. A large part of this expanding accessibility is due to advances in technology and the boom of both nonsurgical and minimally invasive techniques of facial enhancement. These techniques are typically less expensive and require less recovery time than open surgical procedures. Leading the way since its reinvention as a cosmetic injectable in the early 1990s, botulinum toxin type A (Botox, Allergan, Inc., Irvine, Calif.) injection has remained the most common cosmetic procedure performed in the United States. The American Society for Aesthetic Plastic Surgery maintains a Cosmetic Surgery National Data Bank that is the authoritative source for statistics on cosmetic surgery in the United States. In 2005, almost 11.5 million total cosmetic procedures, both surgical and non-surgical, were performed by the plastic surgeons, dermatologists, and otolaryngologists surveyed. Of these procedures, 9.5 million (83%) were nonsurgical. Botox injections rank at the top of the nonsurgical list, with 3.2 million procedures performed in 2005. Compare these figures to those from 1997 when 65,000 Botox injection procedures were performed comprising only 3.1% of the total 2.1 million procedures. With these trends in mind, it is obvious that Botox procedures are a crucial element in the current armamentarium of the plastic surgeon.


Although Botox is not an injectable filler, it is used in combination with dermal fillers to provide comprehensive treatment of facial laxity and rhytids. The ideal patient has wrinkles in the periocular and glabella region, which can be softened with Botox. Although some dermal regeneration occurs once the dermal fat is lost, a filler is generally needed to diminish the wrinkle depth. Patients with perioral wrinkles, platysmal banding, and mentalis overactivity can also be treated with Botox therapy.

A crucial component of the evaluation is the anatomy and interaction of the facial musculature (Figure 5–1). The Consensus group points out that eyebrow shape is altered with injections into the procerus, corrugators, and orbicularis oculi muscles; therefore, the patient’s desires have to be known before the procedure. This is important because the positions of the brows mold the aesthetics of the face and have different positions between the genders. The same holds true when Botox is injected around the mouth; the position of the mouth shapes the lower portion of the face.

Figure 5–1.

Approximate areas of injection of Botox for the following areas of concern. A: Glabellar creases. B: Transverse forehead furrows. C: Technique for brow elevation in patients with brow ptosis. D: Lateral canthal rhytids (subcutaneous injection).

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