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FIGURE 22-20 Injection points in the crow s feet area The injection technique depends on the eld of effect of the substances used If Reloxin is used, fewer injection sites (two) may be required because of an increased eld of effect Botox should be injected as shown in this diagram The exact placement of injection is determined by the patient s facial anatomy but this is a rough guide of placement
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FIGURE 22-21 To inject Botox in crow s feet, have the patients gently smile Inject at sites of maximal muscle contraction, which will be about 10 to 15 cm lateral to the corner of the eye
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recently by Levy was named the Nefertiti Lift (after the perfect jawline of the ancient queen) 57 This technique releases the downward tension of the depressor effect of the aging platysma and releases the skin to the elevator muscles for lifting action The mini-lift technique requires an injection of 2 to 3 U of BTX-A along and under each mandible and to the upper part of the posterior platysmal band for a total of 15 to 20 U per side57 CHEST The upper area of the chest is a site of predilection for photodamage Textural, pigmented, and photodamage changes are frequently seen in the Vshaped area of the chest Static and dynamic wrinkles are caused by both photodamage and muscular sagging of the upper chest Anatomically, the platysma is known to originate at the second rib; however, it can still present as far down as the fourth rib after which it traverses the pectoralis major and inserts in the mandible58 To date there is no consensus or indication for upper chest injection of BTX-A; however, there are various ways to inject BTX in the upper chest The techniques used are the curved, the V, and the triangular approaches, during which BTX is injected over a curved, V-shaped area, or a triangular area with 5 to 10 sites identified within, each targeted with 2 to 8 U of BTX48
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required by men in comparison to women59 One study compared the muscle mass differences among 468 men and women aged 18 to 88 years and demonstrated a significantly higher amount of skeletal muscle in men than women in the muscles of the face, potentially because of the hypertrophic effect of testosterone60 Moreover, Monks et al found androgen receptors to be abundant in the vicinity of the neuromuscular junction61 They speculated that androgens may even increase the number of junctions The primary author s recommendation is to use a total of 20 U of BTX for glabellar injection in men as a starting dose Five injection sites of 4 U each is the preferred method to preserve a more natural look Significant care must be taken when injecting brows in men so as to avoid cosmetically undesired effects such as feminization of the brow or arching With temporalis and masseter injections, men likely need an additional 25% to 100% as compared to women Furthermore, men need higher doses for orbicularis oculi paralysis owing to its broader circumference
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lack of consensus on dosing considerations for different skin types and there exists a discrepancy regarding which skin type requires higher or lesser doses for an optimal response62 Several variables must be taken into consideration, such as skin thickness, skin musculature, and circumference of bony prominences Skin thickness and texture contribute to dosing decisions Although the injections are generally muscular, the thickness of the dermis might influence the delivery technique For instance, some studies have suggested that the skin of Asians tends to be thicker than that of Caucasians with more collagen fibers, which might demand a higher dose of injection63 However, other studies in Asians have found that lower doses may be needed than in Caucasians64 Arimura et al evaluated the differences in the muscle-relaxing effect of BTX-B using electrophysiologic measurements in 48 Asian and Caucasian volunteers They concluded that the muscle-relaxing effects of BTX-B were similar in both Asian and Caucasian study populations65 Racial differences in BTX responses remain unclear More studies are required to determine any potential variations in the response of different skin types to botulinum toxins The primary author has not noted any consistent differences among the various ethnicities treated in her practice
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