Cosmetic Botox Facial Dosing
For cosmetic facial rejuvenation, the standard starting dose is 20 Units total for glabellar lines (frown lines between the eyebrows), administered as 4 Units per injection site across five intramuscular injection points. 1
FDA-Approved Dosing for Glabellar Lines
- The FDA-approved dose for treating moderate to severe glabellar lines is 0.1 mL (4 Units) injected intramuscularly into each of five sites, totaling 20 Units per treatment session 1
- This represents the only FDA-approved cosmetic indication with specific dosing guidance in the drug labeling 1
Consensus Dosing for Other Facial Areas
While FDA approval exists only for glabellar lines, expert consensus provides guidance for off-label cosmetic treatment of additional facial areas:
Upper Face Treatment Areas
- Horizontal forehead lines: Consensus recommendations suggest starting doses that allow preservation of natural forehead movement, with men typically requiring higher doses than women 2, 3
- Lateral orbital lines ("crow's feet"): Expert panels recommend 12 Units per side as a standard starting dose for lateral periorbital rhytids 2, 4
- Lower eyelid area: 2-4 Units per lower eyelid is recommended, as doses of 8 Units or higher produce unacceptable side effects including lower eyelid edema and incomplete sphincter function 4
Lower Face Treatment Areas
- Perioral area, mentalis muscle (chin dimpling), and depressor anguli oris are now routinely treated in aesthetic practice, though specific unit recommendations vary by individual anatomy 2, 3
- Platysmal bands in the neck represent another common treatment area addressed in consensus guidelines 2
Critical Safety Considerations
- Potency units are NOT interchangeable between different botulinum toxin products (Botox, Jeuveau, Dysport, Xeomin, etc.), as each has distinct potency measurements 1
- Patients with pre-existing neuromuscular disorders may experience exacerbated clinical effects and require dose reduction 1, 5
- Complications increase with higher doses, particularly in patients with severe rhytids requiring more units or those with altered anatomy from previous facial surgery 5
- The boxed warning for all botulinum toxin products emphasizes that toxin effects can spread from the injection site, potentially causing life-threatening swallowing and breathing difficulties 1
Gender-Based Dosing Differences
- Male patients consistently require higher doses than female patients due to increased muscle mass and strength in facial muscles 3
- Conservative initial dosing with upward titration at subsequent sessions minimizes complications while achieving desired aesthetic outcomes 5
Duration and Retreatment
- Clinical effects typically appear within 24 hours to 2 weeks post-injection 6
- Paralytic effects last 3-6 months, after which retreatment is appropriate 6
- The optimal cosmetic dose referenced in dermatology literature is 20 Units as a baseline starting point 6
Key Pitfalls to Avoid
- Using excessive doses in the lower eyelid (>4 Units per side) produces bothersome edema and functional impairment 4
- Failing to account for gender differences leads to under-treatment in men and potential over-treatment in women 3
- Treating multiple facial areas simultaneously without understanding synergistic effects—for example, combining lower eyelid and lateral orbital treatment produces enhanced eye-widening at lower individual doses 4
- Assuming unit equivalency between different botulinum toxin formulations creates serious dosing errors 1