Cosmetic Use of Botulinum Toxin

Grant S. Gillman

Since receiving approval from the U.S. Food and Drug Administration for the treatment of glabellar rhytids, the cosmetic use of botulinum toxin A (Botox) has become perhaps the most popular nonsurgical treatment of the aging face. The safety profile is very high, and complications are few; nonetheless, there are technical considerations that must be considered in order to maintain a high degree of patient satisfaction while minimizing adverse outcomes. Although the range of applications of Botox continues to expand, this chapter will focus only on the most common cosmetic facial applications: the treatment of glabellar rhytids (frown lines), transverse forehead rhytids, lateral periorbital rhytids (crow’s-feet), and the adjustment of brow contour and position (chemical brow lift).

• Pregnant women or nursing mothers
  
• History of other neuromuscular diseases (multiple sclerosis, Eaton-Lambert syndrome, myasthenia gravis)
  
• Known hypersensitivity to Botox
  
• Human albumin allergy

• Drugs that may potentiate the effect of Botox include aminoglycosides, cyclosporine, neuromuscular blockers, d-penicillamine, quinidine, magnesium sulfate, and lincosamide.
  
• Aminoquinolines (chloroquine, hydroxychoroquine) can inhibit the activity of Botox.

• Reconstitution should be carried out with preservative-free saline.
  
• Higher concentrations will result in injections of a lesser volume, which minimize the risk of inadvertent diffusion to muscles adjacent to the treatment area.
  
• Botox is supplied in 100 unit treatment vials. Dilution with 2 cc of saline will yield 5 units of Botox per 0.1 cc. Dilution with 2.5 cc of saline with yield 4 units per 0.1 cc. In practical terms, this facilitates easy injection of either 5.0 and 2.5 units, or 4 and 2 units, respectively—doses frequently used in facial cosmetics.
  
• Once reconstituted, Botox can be refrigerated. The manufacturer recommends use within 4 hours of reconstitution, although many have found Botox to retain potency beyond that time period.