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10 botox mistakes you should avoid when injecting Botulinum toxin

 Undoubtedly, Botox or botulinum toxin holds the title of most demanded non-surgical cosmetic procedure in the world. During the recent years, its use has been combined with dermal fillers which have become a mainstay anti-ageing

botox mistakes you should avoid


Undoubtedly, Botox or botulinum toxin holds the title of most demanded non-surgical cosmetic procedure in the world. During the recent years, its use has been combined with dermal fillers which have become a mainstay anti-ageing treatment for preventing and treating signs of facial ageing[1].

Patients who seek injectable treatments generally want to achieve natural results that are minimally noticeable. However, there is a group of people who think that these treatments give un-natural and even grotesque results. There can be two reasons for this thought:

  1. In few cases, the outcomes of the technique are too paralysing which leads to expressionless face.
  2. In other cases, the unnatural shape of the eyebrow and other tell-tale lines and wrinkles indicate that a patient has undergone a Botulinum toxin treatment.

The administration of Botox treatment depends, for the most part, on the understanding and skill of the practitioner. A physician, who has a good knowledge of facial anatomy, as well as the functionality of facial muscles, can deliver outstanding results of the Botulinum toxin treatment. As doctors attending Botox training courses do have an understanding of facial anatomy and muscles, it is a responsibility of the training institute to help them to blend that knowledge with the right injection techniques to deliver natural and enticing results.

In this article, we will explore the mistakes which Botox injectors should avoid to achieve excellent results from botulinum toxin treatment.

Five action errors

  1. Using excessively high dose of botulinum toxin

The use of high Botox dose usually results in loss of expressions. In some articles and textbooks, the recommended dose of botulinum toxin type A injections is 20-40 Units for the glabella region, 15-30 units for the forehead and 12-30 units for the crow’s feet[2]. But this recommended dose may give un-natural results so we curtail this dosage depending on individual client. For the glabella 30% less, for forehead 50% less dose is used while dose for crow’s feet remains same to give natural looking results. For the lower face, usually 50% less than the recommended dose produces natural results with fewer side effects.

However, it is important to inform patients that the effects of this approach will last for a shorter period (approx. 3-4 months). With this protocol, ask the patient to return for follow-up treatment two weeks following the initial treatment. The practitioner, then, reassesses the patient and makes adjustments. If required, practitioner injects an additional dose of  Botulinum toxin injections in some facial areas. Help your patient, to understand that less is more in the case of botox.

  1. Injecting the Frontalis Muscle Instead of the Corrugator Supercilii Muscle

This action results in creating a Mephisto effect. In most of the textbooks as well as botox training courses show five traditional injection sites of the glabellar region. But practically speaking, the 2 of these superior injection sites are not actually located in the corrugator supercilii muscle, which makes the insertion site nearly at the eyebrow level.

The injection sites are located actually on the frontalis muscle so that the relaxation of this muscle makes the medial eyebrow portion to descend while lifting the lateral brow portion which results from compensatory lateral fibres contraction of the frontalis muscle. This action results in a Mephisto effect or devil brow.

In some cases, a higher concentration of botulinum toxin is used to achieve greater precision and to relax just the corrugator supercilii muscle. With this approach, lesser volume of liquid is injected which decreases the likelihood of diffusion to untargeted muscles (in this instance, the frontalis).

  1. Always Injecting the Superior-Lateral Portion of the Orbicularis Oculi Muscle

This action results in the excessively elevated eyebrows. Botulinum toxin infiltration through the superior-lateral fibres of the orbicularis oculi muscle helps to relax those fibres and also lifts the lateral brow portion. The problem is that the eyebrow position in some patients moves upward with ageing due to physiological contractions of the frontalis muscle.

It was found in one of the study[3] that physiological eyebrows elevation tends to occur with ageing in most of the patients. Therefore, to achieve natural results, superior-lateral fibres of the orbicularis oculi muscle should be injected in case the lateral portion of the brow has dropped among patients.

  1. Injecting the Frontalis Muscle in Patients Who Use it to Raise the Eyelids

This action leads to brow or eyelids ptosis. It has been observed in many patients over the age of 65 years or above that they use frontalis muscle for keeping their eyes open. The relaxation of frontalis muscle in such patients can result in brow or eyelids ptosis. Therefore, while injecting botulinum toxin injections in these patients, the doctor should carefully examine that whether the patient use frontalis muscle for opening eyes or not. If yes, the injection should be avoided in that.

  1. Injecting too low in the crow’s feet

This results in undereye bags exacerbation. Some patients have under eye bags due to herniated fat or retention of fluid. In both cases, if orbicularis oculi inferior muscle fibres are excessively relaxed with the injections of botulinum toxin, it further aggravates the appearance of these bags. Therefore, in patients who have a tendency of developing under eye bags, the most inferior portion of crow’s feet should not be injected to maintain the tone of collateral orbicularis oculi muscle region.

Five Omission errors

  1. Failure to inject lower third portion of the face

This error  results in giving less effective overall results. While administering Botulinum toxin injections, the effect of injections on the whole face of the patient should be considered with the objective of main depressor muscle relaxation in upper as well as a lower third of the face. High doses of botulinum toxin in the lower third of the face can lead to cosmetic and functional problems so it is necessary to inject low doses to avoid any complications.

In the lower third portion of the face, the platysma muscle at the jawline (using a technique called the ‘‘Nefertiti lift’’)[4], the depressor septi nasi muscle (in patients with a plunging nasal tip while smiling)[5], the depressor anguli oris muscle (for lifting mouth corners)[6], the mentalis muscle (for relaxing ‘‘pebbly’’ effect caused by the insertion of this muscle on the skin)[7], etc. can be relaxed.

Some patients have hypertrophy of masseter muscle which causes functional (bruxism) as well as cosmetic (square jaw) alterations. The injection of botulinum toxin into this muscle not just improves bruxism symptoms but also changes the square jaw line into a more oval shape[8].

  1. Failure to inject wrinkles formed due to botulinum toxin

This gives unnatural wrinkles. Due to relaxation of certain muscles with botulinum toxin, the tone of adjacent muscles increases to compensate the inactivity of treated muscles. This action helps in creating a desirable lifting effect but it also causes wrinkles in other areas which should be corrected through botulinum toxin treatment.

  1. Lack of familiarity with the patterns of muscle contractions

This lack of knowledge gives an unnatural appearance. The approach of ‘one size fits all’ does not work in the case of Botulinum toxin treatment. The suitable sites of injection depend on individual patient’s muscles contraction pattern. Therefore, it is necessary for the practitioners to understand the contraction patterns of glabella, forehead and crow’s feet. This information will enable them to custom tailor the injection pattern for each patient giving more natural results with a smaller quantity of botulinum toxin.

  1. Failure to distinguish between eyebrows of males and females

This inability can lead to giving masculine appearance to females and feminine appearance to males. The women’s eyebrows have a classic shape of ‘seagull wing’ while the eyebrows of men are straighter and closer to the upper eyelid. By relaxing frontalis muscle eyebrows can be shaped or by relaxing the orbicularis oculi muscle superior-lateral fibres, the lateral portion of the brow can be lifted. The botulinum injections should be injected into three depressor muscles for lifting the medial eyebrow portion including the procerus, the corrugator supercilii, and the depressor supercilii.

  1. Failure of combining Botulinum toxin with other aesthetic treatments

Botulinum toxin injections offer outstanding results for reducing certain expressions lines and wrinkles however the combination of botulinum toxin with other cosmetic treatments gives excellent overall outcomes and practitioners should explain this to the patients. For instance, along with lines and wrinkles, another clear sign of ageing is a loss of facial volume. This is why dermal fillers and botulinum toxin treatment is often combined to achieve naturally impressive results.

During the botox training courses, these errors should be kept in view and the trainees should be trained to address these errors, competently.


[1] Cartee TV, Monheit GD. An overview of botulinum toxins: Past, present, and future. Clin Plast Surg. 2011;38:409—26.

[2] . Alam M, Dover JS, Klein AW, Arndt KA. Botulinum A exotoxin forhyperfunctional facial lines: Where not to inject. Arch Dermatol.2002;138:1180—5.

Stephan S, Wang TD. Botulinum toxin: Clinical techniques,applications, and complications. Facial Plast Surg. 2011;27:529—39.

[3] Matros E, Garcia JA, Yaremchuk MJ. Changes in eyebrow position and shape with aging. Plast Reconstruct Surg. 2009;124: 1296—301.

[4] . Levy PM. The ‘Nefertiti lift’: A new technique for specific re-contouring of the jawline. J Cosmet Laser Ther. 2007;9:249—52.

[5] Redaelli A. Medical rhinoplasty with hyaluronic acid and botulinum toxin A: A very simple and quite effective technique. J Cosmet Dermatol. 2008;7:210—20.

[6] . Choi YJ, Kim JS, Gil YC, Phetudom T, Kim HJ, Tansatit T, et al. Anatomical considerations regarding the location and boundary of the depressor anguli oris muscle with reference to botulinum toxin injection. Plast Reconstruct Surg. 2014;134:917—21.

[7] Beer K, Yohn M, Closter J. A double-blinded, placebo-controlled study of Botox for the treatment of subjects with chin rhytids. J Drugs Dermatol. 2005;4:417—22.

[8] Klein FH, Brenner FM, Sato MS, Robert FM, Helmer KA. Lower facial remodeling with botulinum toxin type A for the treatment of masseter hypertrophy. An Bras Dermatol. 2014;89:878—84.

Wu WT. Botox facial slimming/facial sculpting: The role of botulinum toxin-A in the treatment of hypertrophic masseteric muscle and parotid enlargement to narrow the lower facial width. Facial Plast Surg Clin North Am. 2010;18:133—40.

Dr Shah studied Biomedical Science at King’s College London, and then graduated with a medical degree from the University of Leicester. His areas of interest include medical science and dermatology. He is fond of coalescing his medical science background with medical aesthetics to provide an all-inclusive approach to the treatments. Being registered with the General Medical Council, and he has also been a member of the Royal College of General Practitioners since 2007.As a General Practitioner, he is a lead in dermatology and diabetes at his practice, and is profoundly involved in teaching student doctors.Dr Shah focuses on skin rejuvenation and the use of botulinum toxin, dermal fillers and counsels his clients on the use of cosmeceuticals to attain effective and natural-looking results. He has a professional approach and enjoys providing evidence-based non-surgical treatments.

  • Sam smith June 6, 2017

    Interesting article however you forgot to reference the original article: Ruiz-Rodriguez R, Martin-Gorgojo A. Diez errores a evitar en la inyección de toxina botulínica. Actas Dermosifiliogr. 2015;106:458–464.