ANATOMY RELATED TO BOTULINUM TOXIN A INJECTIONS

1. ANATOMY
RELATED TO
BOTULINUM
TOXIN A
INJECTIONS
LEE WALKER BDS MFDS RCPSG
MJDF RCS ENG

2. OBJECTIVES
• To have a practical, interactive session
• To take away something useful that can be applied to your daily
practice
• To understand the anatomy related to botulinum toxin
administration
• To learn strategies to maximize efficacy and minimise the risk of
complications

3. OBJECTIVES

5. FRONTALIS

6. FRONTALIS
• ELEVATES BROW AND LOWERS ANTERIOR HAIRLINE
• BILATERAL /SYMMETRICAL
• AMUSCULAR SUPERIORLY
• ROUGHLY RECTANGULAR IN SHAPE
• MUSCLE FIBRES VERTICALLY ORIENTATED
• THIN MUSCLE 1 – 1.5 MM
• LIES AT A UNIFORM DEPTH BENEATH SKIN 3-5 MM

7. FRONTALIS
• SENSORY INNERVATION VIA SUPRAORBITAL AND
SUPRATROCHLEAR NERVES (RUN DEEP TO
FRONTALIS)
• SUPRAORBITAL HAS SUPERFICIAL BRANCH RUNS
ALONG ORBITAL RIM TO LATERAL SCALP
• MOTOR INNERVATION VIA TEMPORAL BRANCH OF
FACIAL NERVE (FRONTAL NERVE)

8. FRONTALIS
• THE OBICULARIS RETAINING LIGAMENT (ORL) DEEP
BOUNDARY BETWEEN FOREHEAD AND UPPER
EYELID
• ANY TREATMENT WHICH TRANSMITS THROUGH ORL
ENTERS THE SOFT TISSUES OF THE UPPER EYELID
• ORL 2-3 MM ABOVE SUPRAORBITAL RIM
• SUPRAORBITAL NERVE TRAVERSES THE ORL
THROUGH A FACIAL TUNNEL (SUPRAORBITAL
CREASE)
• IMPORTANCE - AVOIDANCE OF EYELID PTOSIS

9. FRONTALIS

10. FRONTALIS

11. FRONTALIS

12. FRONTALIS

13. FRONTALIS

14. FRONTALIS

15. FRONTALIS

16. FRONTALIS

17. FRONTALIS

18. FRONTALIS

19. FRONTALIS

20. OBICULARIS OCULI

21. OBICULARIS OCULI

22. OBICULARIS OCULI
• 3 PARTS – ORBITAL/PRESEPTAL/PRETARSAL
• BROAD/THIN CIRCUMFERENTIAL MUSCLE
• SPHINCTER
• SUPERFICIAL
• UPPER BORDER BLEND WITH
CORRUGATOR/FRONTALIS
• NERVE SUPPLY – TEMPORAL/ ZYGOMATIC
• BLOOD SUPPLY VIA
OPTHALMIC/ZYGOMATICORBITAL/ANGULAR

23. OBICULARIS OCULI
• LOWER BORDER CLOSELY ASSOCIATED WITH
ZYGOMATICUS MUSCLES
• CAN WORK INDEPENDENTLY (REDUCE GLARE)
• DEPRESSES LATERAL BROW
• MOVES EYEBROW MEDIALLY AND SLIGHTLY DOWN
WARDS

24. OBICULARIS OCULI

25. OBICULARIS OCULI

26. PERIORBITAL PERFUSION

27. OBICULARIS OCULI

28. OBICULARIS OCULI

29. OBICULARIS OCULI

30. OBICULARIS OCULI

31. OBICULARIS OCULI

32. OBICULARIS OCULI

33. OBICULARIS OCULI

34. CORRUGATOR
• LIES DEEP TO OTHER MUSCLES
• 5-8 MM UNDER SKIN
• NARROW MUSCLE
• NO BONY ATTACHMENTS LATERALLY
• THICKEST (2-3MM) 199MM FROM NASION
• MININMAL MUSCLE MASS LATERALLY

35. CORRUGATOR

36. CORRUGATOR

37. CORRUGATOR

38. CORRUGATOR

40. CORRUGATOR

41. CORRUGATOR

42. CORRUGATOR

43. MAXIMUM MUSCLE BULK

44. CORRUGATORS
(Benedetto 2005)

45. CORRUGATORS

46. CORRUGATORS
(Mcdonald 1998)

47. CORRUGATOR

48. GLABELLA ‘U’ PATTERN
(Trindade 2012)

49. GLABELLA ‘V’ PATTERN

50. GLABELLA ‘HORIZONTAL’
PATTERN

51. GLABELLA ‘INVERTED
OMEGA’ PATTERN

52. GLABELLA ‘OMEGA’
PATTERN

53. MEDICIS GLABELLA ASSESSMENT
SCALE
MUSCLE MASS MORE IMPORTANT THAN FROWN
SEVERITY
• Wrinkle depth and depression (How deep are the wrinkles and
brow depression at full contraction?)
• Inter-brow space (How much does it change from relaxation to
full contraction?)
• Glabella muscle size and shape (Are the glabella muscles bulging
at the point of maximum frown?)
• Shape and position of the brow (are the glabella muscles
depressed or distorted at the point of maximum frown?)

54. WRINKLE DEPTH

55. INTER-BROW DISTANCE

56. MUSCLE SIZE AND SHAPE

57. BROW POSITION

58. PROCERUS

59. PROCERUS
• DEPRESSES MEDIAL HEAD OF BROW
• RESPONSIBLE FOR HORIZONTAL LINES IN
GLABELLA
• SUPPLIED BY TEMPORAL/ZYGOMATIC AND BUCCAL
BRANCHES (ANGULAR NERVE)
• DEEP NASAL PORTION AND SUPERFICIAL IN
FRONTALIS AREA
• BLOOD SUPPLY VIA SUPRAORBITAL ARTERY

60. PROCERUS
• DEEP INSERTION TO BONE (NASION)
• SUPERFICIAL ATTACHMENT MERGING WITH
FRONTALIS
• LONGER IN WOMEN 19MM – 16MM IN MEN
• THIN, PYRAMIDAL MUSCLE

61. PROCERUS

62. PROCERUS

63. PROCERUS

64. PROCERUS

65. PROCERUS

67. DEPRESSOR SUPERCILII

68. DEPRESSOR SUPERCILII

69. DEPRESSOR SUPERCILI
• ORIGIN – BONY ATTATCHMENT NEAR MEDIAL
CANTHUS
• COURSES DIRECTLY UPWARDS, PARALLEL WITH
PROCERUS TO ATTACH INTO SKIN OF FOREHEAD 14-
15MM

70. LATERAL BROW LIFT

71. BROW SHAPING
FLARED BROW
HORIZONTAL
BROW
ARCHED BROW

72. OBICULARIS ORIS
• BROAD, ELLIPTICAL MUSCLE
• INTERNAL (PARS LABIALIS) EXTERNAL (MARGINALIS)
• INSERTION DEFINES THE WET/DRY BORDER OF LIP
• NERVE SUPPLY BUCCAL BRANCH
(SUPERIOR/INFERIOR)
• BLOOD SUPPLY VIA SUPERIOR/INFERIOR LABIAL
ARTERY

73. OBICULARIS ORIS

74. OBICULARIS ORIS

75. OBICULARIS ORIS

76. OBICULARIS ORIS

77. OBICULARIS ORIS

78. DEPRESSOR ANGULI ORIS
• TRIANGULAR SHAPED MUSCLE
• LIES BEHIND MARIONETTE LINES
• FROM CORNER OF MOUTH TO MANDIBLE BORDER
• DEPRESSES CORNER OF MOUTH
• NERVE SUPPLY MANDIBULAR BRANCH
• BLOOD SUPPLY VIA INFERIOR LABIAL ARTERY

79. DEPRESSOR ANGULI ORIS

80. DEPRESSOR ANGULI ORIS

81. DEPRESSOR ANGULI ORIS

82. DEPRESSOR ANGULI ORIS

83. DEPRESSOR ANGULI ORIS

84. DEPRESSOR ANGULI ORIS

85. DEPRESSOR ANGULI ORIS

86. MENTALIS
• PAIRED CENTRAL MUSCLE FROM DEEP ON
ANTERIOR MANDIBLE
• PROTRUDES LOWER LIP AND DIMPLES CHIN
• NERVE SUPPLY VIA MANDIBULAR BRANCH
• BLOOD SUPPLY VIA INFERIOR LABIAL/ MENTAL
ARTERY

87. MENTALIS

88. MENTALIS

89. MENTALIS

90. MUSCLES INVOLVED IN
‘GUMMY SMILE’

91. ANTERIOR GUMMY SMILE

92. POSTERIOR GUMMY SMILE

93. MIXED GUMMY SMILE

94. INTRADERMAL TOXIN
• LARGE PORES
• OILY SKIN
• SWEATING
• ACTS ON CHOLINERGIC RECEPTOR OF
PILOSEBACEOUS UNIT
• CAN WEAKEN MUSCULAR ACTIVITY
• RESPONSIBLE FOR ‘SHINY’ APPEARANCE
• WEARS OFF QUICKER IF USING FOR ‘BABY BOTOX’

95. MASSETER HYPERTROHY

96. MASSETER ANATOMY

97. FACE SCULPTING USING
TOXIN
• 8 UNITS PER SITE
WITH 12.7MM
NEEDLE
• 3 DIFFERENT
HEADS – DEPTH
ACCORDING
• REPEAT AT 6
WEEKS

98. FACIAL SCULPTING
• RISK OF LOSS OF FULL SMILE DUE TO DIFFUSION
INTO RISORIUS
• ASYMMETRY OF SMILE
• WEAKNESS AND ACHING ON CHEWING- OCCURS
FOR FIRST 8-12 WEEKS
• ‘JOWLING’ DUE TO EXCESS SKIN DROOPING OVER
ATROPHIED MUSCLE – RESOLVES QUICKLY
• BRUISING COMMON

99. DECOLLATAGE
5 UNITS PER
INJECTION

100. DECOLLATAGE
• SUPERFICIAL INTRADERMAL INJECTION
• OVER DILUTE – NEED LARGER DIFFUSION DUE TO
GREATER SURFACE AREA
• WEARS OFF QUICKER THAN FACE
• TAKES LONGER TO ACHIEVE RESULTS
• EXCESSIVE DOSAGE CAN LEAD TO WEAKENING OF
INTERCOSTAL MUSCLES ON DEEP INSPIRATION

101. NEFERTITI LIFT
• Hyperkinetic platysma and
inelastic & saggy skin cause
blunting of the jaw line
• Nefertiti lift redefines the
elegant/sharp lines of jaw and
neck for a tighter more
youthful, contoured look

102. NEFERTITI LIFT
• Inject toxin inferior to the
mandibular border
posterior to the DAO &
anterior to the SCM down
a band or along the mid
portion of the neck
• INJECTION SITES 30 –
60 units per side -2CM
APART

104. NECK TOXIN
COMPLICATIONS
• Asymmetric smile
• Disruption of lip competence
• Incontinence of food and
liquids
• Dysarthria
• (pronunciation)
• Dysphonia
• (pitch of voice)
• Dysphagia
• (cannot swallow