What is the standard protocol for administering Botox (Botulinum toxin) for cosmetic purposes?

Botox Protocol for Cosmetic Use

For cosmetic facial rejuvenation, administer Botox (botulinum toxin type A) using a starting dose of 20 units total for upper face treatment, with individualized dosing per anatomical region, ensuring proper reconstitution and injection technique while screening for absolute contraindications including known hypersensitivity to botulinum toxin and active infection at injection sites. 1, 2

Absolute Contraindications

Before any cosmetic Botox administration, screen for:

• Known hypersensitivity to botulinum toxin – this is an absolute contraindication and patients with documented allergy should never receive treatment 3, 1
• Active infection at the proposed injection site(s) – defer treatment until infection resolves 1
• Pre-existing neuromuscular disorders (e.g., myasthenia gravis, Lambert-Eaton syndrome) – these patients face increased risk of clinically significant effects and require extreme caution 1, 4

Dosing by Anatomical Region

Upper Face Treatment Areas

The consensus approach uses region-specific dosing rather than a single universal dose:

• Glabellar lines (frown lines): Start with 20 units total distributed across 5 injection points in the corrugator and procerus muscles 5
• Horizontal forehead lines: Use fewer units than historically recommended to preserve natural movement; typical range 10-20 units depending on muscle mass 6, 5
• Crow's feet (lateral canthal lines): 12-15 units per side, with careful attention to injection depth and location to avoid complications 5, 7
• Men require higher doses than women due to greater muscle mass – increase doses by 20-50% for male patients 6

Lower Face and Neck (Advanced Treatment Areas)

• Perioral area: Conservative dosing of 2-4 units to avoid lip ptosis 5
• Mentalis (dimpled chin): 4-6 units centrally 5
• Platysmal bands: 15-25 units per band 5
• Bunny lines (nasal sidewall): 2-4 units per side 5

Preparation and Injection Technique

Reconstitution

• Follow FDA-approved reconstitution guidelines using preservative-free normal saline 1
• Standard dilution varies by indication but typically 2.5-4 mL per 100-unit vial for cosmetic use 5
• Use reconstituted product within specified timeframe per manufacturer guidelines 1

Injection Technique Principles

• Inject intramuscularly at the appropriate depth for each facial region 1, 5
• Use small volumes (0.05-0.1 mL) per injection point to minimize diffusion 5
• Maintain at least 1 cm distance from the orbital rim when treating crow's feet to prevent upper lip ptosis from zygomaticus major weakness – this complication, while rare (3 cases per 2000 treatment sides), is preventable with proper technique 7
• Avoid injecting too superficially or too deeply relative to target muscle 4, 5

Onset, Duration, and Retreatment

• Onset of effect: 24 hours to 2 weeks post-injection, with peak effect at 1-2 weeks 2
• Duration: 3-6 months of clinical effect 2
• Retreatment interval: Assess at 2 weeks post-injection; retreat no sooner than 3 months to minimize antibody formation 5
• With repeated treatments, duration may increase and required doses may decrease 7

Critical Safety Warnings

Distant Spread of Toxin Effect

• The FDA black box warning emphasizes that botulinum toxin effects can spread beyond the injection site, potentially causing life-threatening swallowing and breathing difficulties 1
• While this is primarily a concern with therapeutic (non-cosmetic) higher doses, maintain awareness even with cosmetic dosing 1

Product Non-Interchangeability

• Different botulinum toxin products are NOT interchangeable – units of one product do not equal units of another 1
• Always specify the exact product name when prescribing or documenting treatment 1

Common Pitfalls to Avoid

• Over-treatment of the forehead leading to brow ptosis or frozen appearance – use conservative dosing to maintain natural movement 6, 5
• Injecting crow's feet too medially or inferiorly risking zygomaticus major involvement and lip ptosis 7
• Treating patients with unrealistic expectations – counsel patients that results are temporary and natural facial movement should be preserved 5
• Ignoring gender differences – men consistently require higher doses than women 6
• Treating severe rhytids too aggressively – patients with deeper wrinkles require more units but face higher complication rates; consider combination therapy with fillers instead 4, 5

Combination Therapy Considerations

• Botox combined with dermal fillers or laser treatments provides superior aesthetic outcomes compared to monotherapy 6
• Treat dynamic lines with Botox and static lines/volume loss with fillers for comprehensive facial rejuvenation 6