To learn the anatomy of the facial muscles and how they are affected by botulinum toxin.

1.      The website is a very useful resource.

2. Receive training from someone who is willing to give you hands-on experience, and adopt as a starting point whatever toxin and dilution they use.

3. Read and study the literature.

4. Visit experienced practitioners and watch their practice and flow.

5. Set-up a training day in your practice where you offer the treatment for cost to existing patients or staff family members, letting people know you are just starting out. Set up at least 5-10 cases, and ask for them to return after two weeks.

6. Repeat the hands-on training day at cost again after one month. The best way to become good at a procedure is to practice it, and the best way to acquire new patients to the practice is to offer a big discount.

In this series, I am sharing the tips & tricks from my private practice for the Upper Face, in the next series I shall cover the Lower face.

Glabellar Rhytides:

•      3 or 5 point injections

•      Females: 20-25 units

•      Males: 25-35 units

•      Dilution: 2 – 2.5 mL  most common

•      Dilution with preserved saline

•      Needle 30-32 gauge

TIP: Press with one finger inferior to the injection point. This help prevents pain and lessens bruising. The eyebrow should not be considered the landmark for placing injections because the brow itself may be ptotic, plucked, shaped, tattooed, dyed, and otherwise modified

•      Beware of women who pluck or have had permanent tattooing of their eyebrows

•      The peak of the arch should be located just above the lateral limbus of the iris of the eye

•      The tail of the female eyebrow should lie on a horizontal plane 1–2 mm above the lowest point of its medial end.

•      Pre-existing asymmetry of the brow and eyelids should be discussed with the patient before treatment


•      Injections should remain medial to the mid-pupillary line

•      Inject 0.5–1.0 cm above the supraorbital margin, placed deeply into the corrugator supercilii.

Frontal Lines:

•      Typical injection uses about 5 – 12 units

•      Do not treat the bottom line the first time you inject patient.

•      Inject the lateral part of the orbicularis to get the depressor component.

•      Inject higher with more dilution

•      TIP: Before injecting the forehead the patient should be evaluated for brow and lid ptosis, which is especially important in elderly individuals. People with brow and lid ptosis try to correct and compensate the depressed position of their brow/lid by constant contraction of the frontalis. These patients should not be injected because any weakness of the frontalis may compromise their visual field.

•       Identify and document brow or forehead asymmetries prior to treatment.

•      Weaken the frontalis; do not paralyze it


·         The recent trend is to inject the frontalis quite high (at least 2 cm above the orbital rim) to maintain some brow movement and avoid a frozen look. Use a more diluted Botox for better spread.

·         Counteract brow ptosis and elevate the eyebrows by injecting the superficial fibers of the upper orbital portion of the orbicularis oculi with 1–2 units of low-volume BT injected into the medial and lateral aspects of the brow . Otherwise, brow ptosis will remain as long as the current BOTOX® treatment is effective.

Lateral brow Lift:

•      Superior and lateral aspect of orbicularis oculi

•      4-6 units each side, with focal superficial placement at site of maximal orbicularis pull downward


·         Two common techniques for achieving an eyebrow lift are:

(i) injecting the glabella alone and

(ii) injecting the lateral orbicularis oculi (vertical fibers), lateral to the mid-pupillary line.

·         Too medial injection diffusing to orbital septum area risks eyelid ptosis

·         Too superior-medial injection diffusing to frontalis risks lateral brow drop and eyebrow ptosis

Orbicularis Oculi: / Crows Feet:

•      This is a sheet like muscle that wraps the eye.

•      Point needle away from eye.

•      Superficial placement of needle, raise blebs

•      Keep bevel up

•      Typical injection is with 20 units (total)


·         injections should be superficial (because the orbicularis is very thin and superficial), kept lateral (approximately 1–1.5 cm from the orbital rim) and directed ‘outside’ the orbital rim to avoid diffusion to extra-ocular muscles and palpebral portion of the orbicularis oculi which can cause strabismus and lid ptosis


•      Injecting the lateral canthus can produce upper lip asymmetry and cheek ptosis.

•      Lower eyelid injections of BOTOX® produce a ‘wide-eyed’, actively youthful appearance.

•      Older patients will have varying degrees of improvement, depending on the amount of photoaging, redundant skin, and static wrinkling present.


•      Inject well above the superior margin of the zygoma

•       Inject 1–1.5 cm lateral to the lateral canthus (bony orbital rim) to avoid diplopia.

•      Inject only 1–2 U and no more than 3 U of BOTOX® into the lower dermis or the upper subcutaneous tissue in the pretarsal mid-pupillary line.

I hope this series was useful to practitioners of BOTOX..

I would love to hear from you on [email protected] /

And if you are interested in seeing the videos for these procedures, mail me and I shall send you the link.