THE TREATMENT of hyperfunctional facial lines with botulinum A exotoxin injection is safe, usually effective, and without serious adverse effects. Millions of individual clinical doses have been delivered without major complications. The average lethal dose, at 40 U/kg (eg, 2800 U for a 70-kg person), is orders of magnitude greater than the average dose delivered for glabellar frown lines (15-50 U).1 Indeed, cosmetic use of botulinum A exotoxin has become routine within dermatology. Initiated by pioneering dermatologists, ophthalmologists, and otolaryngologists during the 1980s, and honed by leaders in dermatologic surgery during the past decade,2- 6 techniques for botulinum injection are now commonly taught in residency and postgraduate education programs. Overall safety and efficacy, however, do not imply that bothersome adverse effects seldom occur. There is understandable reluctance to document these, which are usually mild and time limited.7- 12 Yet adherence to a few simple guidelines can reduce the likelihood that the patient will be dissatisfied and the physician embarrassed. Injecting botulinum toxin without subsequent undesired effects is largely a function of knowing where not to inject.
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Injecting within 1 cm of the middle to lateral aspects of the brow, medial to the temporal fusion line, can cause brow ptosis. In rare cases, eyelid ptosis can occur.
Brow ptosis can be partially corrected by weakening the corresponding brow depressors with small quantities of toxin. For instance, the Carruthers technique entails placement of 10 U of toxin between the brows and 3 to 5 U under each lateral aspect of the brow. An injection into the lateral brow depressors can make the eye appear more open, lift the brow, and accentuate the eyebrow arch.
When injecting glabella frown lines, forceful injections toward the medial canthus can cause eyelid ptosis. Although medial canthus injections are not desirable, injecting the orbicularis under the lateral brow is the correct placement for a lift of the lateral aspect of the brow.
Large volumes should not be injected directly at the lateral canthus because diffusion can rarely cause diplopia, strabismus, and even eyelid droop.
Injection for "bunny lines" should be on the lateral aspect of the nasal wall, not on the medial aspect of the cheek. Injecting the upper cheek deeply below the zygoma can induce a Bell palsy–like appearance.
Do not inject everywhere at once. Diffusion and overlap can result in diminished expressivity or brow ptosis.
Two ways to inject safely and effectively. A, Carruthers eyebrow lift and forehead treatment. B, Klein forehead and glabella treatment. In both cases, place injections outside the bony rim of the orbit.
A "quizzical" or "Jack Nicholson" look can occur if active frontalis muscles are not injected. This can be corrected by injecting 3 U of toxin 2 cm above each brow and medial to the temporal fusion line.
The lines of the lip and the cobblestoning of the chin can be improved with small quantities of toxin. Cobblestoning can be improved by a single injection of 5 to 10 U directly into the point of the chin with massage.
Downward curl of the corners of the lips may be treated by injections at the jaw edge lateral to the first fold. Injecting the orbicularis oris may cause idiosyncratic lip movement.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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