Application of botulinum toxin (Botox)

Injecting botulinum toxin (Botox) to smooth facial wrinkles is the most commonly performed aesthetic procedure in the United States, and was one of the first procedures that specialists began using in their practice.

Botox treatments are most commonly applied to the upper third of the face to smooth glabellar lines (between the eyebrows) that give a frown appearance, crow’s feet wrinkles (around the eyes), and horizontal forehead lines. The use of botulinum toxin for aesthetic purposes is a procedure approved by the U.S. Food and Drug Administration due to its minimal risks, side effects, and numerous satisfied patients.

Wrinkles occur due to skin atrophy and constant contractions of the facial muscles. Botulinum toxin (Botox) is a potent neurotoxin. It blocks the release of acetylcholine, which activates muscles and is a major neurotransmitter in the autonomic nervous system. Botox in small amounts (units) injected at specific points in overactive facial muscles causes local muscle relaxation that smooths the skin and visibly reduces wrinkles. Approximately two weeks is the time required to reveal the full effect of botulinum toxin (Botox), and the achieved effect lasts between 4 and 6 months.

Dynamic wrinkles, which appear when the muscles contract, achieve much better results than static wrinkles, which are visible when the facial muscles are at rest. Botox is contraindicated in patients with keloid scars, neuromuscular disorder, allergies to some of the botulinum toxin ingredients, and body dysmorphic disorder. Minimal redness or bruising may occur after Botox injection. Rare side effects are blepharoptosis or eyelid ptosis, which are largely due to the injection technique and their risks would be minimal when the procedure is performed by an experienced professional.

Prior to Botox administration, it is advisable that patients avoid taking aspirin or other medications or dietary supplements that have vasodilating effects and may contribute to hematomas.

How does botulinum toxin work?

As mentioned above, wrinkles appear due to skin atrophy and repetitive muscle contraction. Injecting Botox in small amounts causes muscle relaxation, which smooths the skin and visibly reduces wrinkles.

Botox exerts its effect by releasing acetylcholine, which causes temporary denervation.



Botulinum toxin (Botox) has been used for more than 20 years to treat various conditions such as blepharospasm, strabismus, cervical dystonia, migraines, hyperhidrosis and muscle spasms. The use of botulinum toxin for aesthetic purposes was initially approved by the U.S. Food and Drug Administration (FDA) to treat glabellar fold wrinkles (the lines between the eyebrows), and in 2013 to treat the muscles that contribute to crow's feet wrinkles. Botox treatments have become one of the most desirable treatments for wrinkle removal in the upper third of the face (frown lines, horizontal forehead lines, glabellar lines, and crow's feet). Botox is also applied to the lower two-thirds of the face, but with special care by an experienced professional.



The muscles that express facial expressions are unique in that they are connected by soft tissue to the skin via a superficial muscular aponeurotic system. When the facial muscles move, the skin also moves, forming dynamic wrinkles perpendicular to the muscle movements.

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Facial wrinkles

Glabellar lines or so-called frown lines are vertical lines that appear between the eyebrows. The five depressor muscles between the eyebrows are to blame for the formation of these wrinkles, which cause a frown and sad appearance. To smooth out the frown lines in most cases, Botox is sufficient. If they are too deep, a dermal filler can be placed a few weeks after Botox application to fill them in.Patients with dynamic wrinkles show the greatest improvement after Botox injection and are ideal candidates for the procedure. Patients with static wrinkles that are visible at rest are also suitable for the Botox procedure, but their results are slower and may require two or three consecutive treatments.Deep static wrinkles may not be completely smoothed after the Botox procedure and may require combination therapy with dermal fillers or another aesthetic procedure to achieve optimal results. During your consultation, the experienced specialist will inform you of what results you can expect after a botulinum toxin procedure.

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Facial wrinkles

The first photo shows the ideal candidate for Botox, with mimic wrinkles in the area between the eyebrows, and photo B shows no static wrinkles in the same area when the muscles are at rest.

Contraindications to procedures with botulinum toxin

  • Hypersensitivity;
  • Injection site infection;
  • Blood-muscle diseases /myasthenia, etc./
  • Recently used aminoglycosides, cholinesterase inhibitors, succinylcholine, calcium blockers, lincosamides, polymyxins;
  • Pregnancy;
  • Breastfeeding;
  • Inflammatory/autoimmune diseases/;
  • Age > 65 yrs.
  • Drug and food allergies /eggs/;
  • Diagnosed psychiatric diseases;
  • Easy bruising, bleeding, delayed wound healing, scar enlargement;

Consultation with a specialist

Consultation with a specialist is essential when assessing problem areas. Asymmetries such as unequal brow height, eye opening, etc. are identified, then problem areas are prioritized and treatment options discussed. Expected results and possible side effects are also discussed. Botox is the only method of treating and smoothing mimic wrinkles approved by the Food and Drug Administration. Static wrinkle treatment protocols include other procedures such as laser resurfacing, hyaluronic fillers, mesotherapies, etc. Before and after photos of each procedure are recommended. Photos for dynamic and static wrinkles are usually taken before and two months after the Botox procedure, when the effects of the Botox are finally apparent.

Before botulinum toxin procedure

To minimize the risk of hematomas, discontinuation of aspirin and other medications or dietary supplements with anticoagulant activity two weeks prior to the procedure is recommended. It is usually not necessary to administer an anaesthetic in the form of an anaesthetic cream prior to the Botox procedure.

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Botox injection

The points to be injected are determined. The procedure takes about 15 minutes. It is performed with a very fine needle and the patient should be in a semi-recumbent or sitting position.

After Botox procedure

For 4 hours after the procedure, patients should not occupy a supine position. For a minimum of 48 hours after the botulinum toxin treatment, the area of application should not be massaged or scrubbed. Make-up application should be avoided for at least 4 hours after the procedure. Additionally, forward bending and strenuous exercise, sauna should be discontinued within 7 days after botulinum toxin treatment.


Results and follow-up

Within about 3 days after the Botox procedure, there is a partial reduction in muscle function in the glabellar fold area, with the final result 2 weeks after the procedure. Recovery of muscle function occurs gradually, usually about 3-4 months after the procedure. A follow-up Botox procedure is recommended when the muscle contractions become visible, but before they regain their original state. After several treatments, the effect of the botulinum toxin procedure is usually prolonged, and in some patients the intervals of Botox injection are extended by up to 3-4 months.The photo shows dynamic wrinkles before and 1 month after a botulinum toxin (Botox) procedure.

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