Botox^® Cosmetic is injected using a small, 30-gauge needle. The toxin is injected into the muscles that are to be paralyzed. The muscles that create frown lines run perpendicular to the wrinkles. The skin folds when the underlying muscle contracts. The corrugator muscles are particularly well named, referring to the corrugated appearance of the skin when this muscle contracts, like an accordion.

The muscle that causes a crease at the bridge of the nose is called the "procerus." The "orbicularis oculi" muscles run in a circular fashion around the eyes. The vertically-oriented muscle that produces horizontal forehead wrinkles is the "frontalis". Weakening these muscles removes the force acting on the skin to cause wrinkles from repetitive skin contraction.

By reducing the force pulling down on the eyebrows, it may be possible to achieve a "chemical lift" of the eyebrows- this is highly dependent on the operator's skill and the effect is variable from patient to patient. Toxin is injected on either side of the brow to weaken the forces of the muscles pulling down on the brow, allowing the frontalis to pull up with less opposition. Typically, the frontalis muscle is also intentionally weakened to smooth forehead creases, so this needs to be done judiciously to avoid over treating the frontalis, which might cause the eyebrows to drop rather than elevate.

Who Should Perform Botox^® Procedures?

Botox^®, like liposuction, is a procedure which appears remarkably simple to do. It is done by doctors, nurses, aestheticians, and others in medical offices, spas, and back rooms across the country. For a while, "Botox^® parties" were popular. Indeed, there is nothing difficult about injecting Botox^®.

The fact that administering Botox^® is technically simple does not justify its administration by unqualified operators. How much to inject and where to inject it comes from experience.

What does "Over Treatment" Mean?

Case in point: The Vice Presidential Debate, 2008

In a widely publicized Botox^® debacle, one of the participants was unable to animate with the central portion of his forehead. When he raised his eyebrows, just the lateral portions went up, producing a "devilish" expression. The rest of the brows stayed down. Patients of mine have called this undesirable look "Spock-like" and "like Jack Nicholson."

No one wants to have a motionless or mask-line facial expression. One of my nurses told me her children needed to know when she "meant business." With experience, a reputable operator learns to avoid this appearance, preserve animation, and greatly minimize wrinkles. The goal is a "chemical lift," not paralysis.

Is Botox^® Painful?

Yes. The procedure involves several needle pricks to the forehead, bridge of the nose and crow's feet. The most tender area is between the eyebrows ("glabella") where the corrugator muscles can be quite thick. I usually treat this area first. Fortunately, the upper forehead and crow's feet areas are less painful and the procedure takes just a few minutes.

Anesthesia and Botox^®

Some operators recommend the application of a topical anesthetic before Botox^® injection. To be effective, this should be left on for at least 30 minutes. I have some patients who schedule their appointments such that they have some time to allow the topical anesthetic to work and wait in my waiting room prior to their injection. I also have some patients who prefer the application of an ice pack to their forehead prior to treatment and immediately after. Both of these techniques are probably helpful, but most of my patients have the treatment without any such preparation. Most are disinclined to wait. Botox^® can also be injected while the patient is asleep having other simultaneous cosmetic procedures. It is common for me to perform both Botox injection and injection of filler at the same visit, Botox for the forehead and crow's feet and Juvéderm™ for the nasolabial creases and lips.

Preparing for Botox^®

It is preferable to have no makeup on the area at the time of injection. Otherwise, some makeup may be tattooed under the skin and cause inflammation. I routinely use an antiseptic wipe to clean the skin before the injections.

Avoiding Bruises

There is a small amount of bleeding from these needle pricks. I avoid any superficial veins as much as possible. If I do happen to prick a vein, I immediately apply pressure and have the patient hold pressure for at least a few minutes. This helps avoid bruising.