Botulinum Toxin Type A

Botox Cosmetic is supplied in 100-U vials, which must be kept between 2°C and 8°C until used.Additionally, the sterile vacuum vial contains albumin and sodium chloride but does not contain a preservative. The 100-U vial is reconstituted with 2.5 ml of normal saline (0.9% NaCl), resulting in a final concentration of 4 U/cc of Botox Cosmetic. Due to the absence of a preservative, Botox Cosmetic should be stored in a refrigerator and used within 4 h. Small quantities are injected directly into the muscles to be treated (Table 5.5) using a 30- to 32-gauge needle and a calibrated syringe [14]. The injections may cause some discomfort manifested as mild stinging or burning. Patients should avoid physical activity or exercise for the remainder of the day.

Table 5.5. Treatments and injection sites   Region   Type of correction   Injection site   Additional Information   Facial asymmetry   Hemiparesis: naturally occurring or consequence of medical conditions such as Bell’s palsy [30]   Contralateral muscles [30]       Upper face   Glabellar creases   Corrugator/supercilli/procerus   Orbicularis oculi: pretreatment snap test and Schirmer documented tear secretion       Forehead lines   Frontalis           Forehead and brow shaping   Frontalis, depressor supercilii, lateral orbicularis oculi           Periorbital rhytids or crow’s feet   Inferior ciliary margin of the orbicularis oculi [31]           Eye shaping to increase the palpebral aperture           Midface [32]   Nasalar radix (bunny lines), nasolabial folds   Levator alaeque nasi Levator labii superioris   Causes upper lip ptosis       Nasal flare Gummy/canine smile           Lower face [32]   Marionette lines or mouth frown   Depressor anguli oris   Potential side effect includes asymmetric relaxation of the oral commissure       Perioral rhytids and mouth shaping   Orbicularis oris           Peau d’orange (pebbly chin)   Depressor labii inferioris Mentalis muscle       Neck [32]   Horizontal neck creases   Intradermal along the transverse neckline   Possibility of dysphagia       Platysmal bands   Platysma       Below the neck   Décolleté creases [33]   Subcutaneous muscle fibers running over the third intercostal spaces and over the presternal area [33]           Breast lifts