Multipoint and multilevel injection technique of botulinum toxin A in facial aesthetics

Abstract

Botulinum toxin represents one of the most frequently requested cosmetic procedures. We treated 223 patients with facial wrinkles using a new technique of injection of botulinum toxin A (BTA) called multipoint and multilevel injection technique (MMIT). The aim of MMIT was to relax the muscle and not paralyze it. Patient satisfaction was evaluated by Facial Line Treatment Satisfaction Questionnaire (FTSQ). Treatment with botulinum toxin determined a good response in all patients. Facial rhytids were completely resolved in case of young skin and well reduced in case of aged skin, leaving a natural aspect both in static and dynamic wrinkles. Patient mean overall satisfaction evaluated with FTSQ was 6.4 ± 1.1. In our experience, the use of botulin toxin by MMIT consents a better calibration of action with a soft and natural result. This can be achieved by distributing the BTA dose through various injection points for each area ("multipoint injections"). Furthermore, injections can be performed at different levels ("multilevel injections"). The level of injections regulates the potency of effect on the muscle: if the level is deep (intramuscular), the effect will be strong while if it is medium or superficial (subcutaneous and intradermal), the effect will be soft. This consents a fine calibration of action on muscle activity with a personal aesthetic result.

Clinical Evaluation of the Efficacy of Botulinum Toxin a for Improving Facial Scars (Randomized Clinical Trial)

“…Where the contraction was weak, however, the injection was made at a deep or superficial intradermal level. Depth was also determined by the effect we seek to achieve: intramuscular has a strong effect, while subcutaneous or intradermal has a mild effect (24).…”

Ultrasonographic analyses of Crow's feet and novel guideline for botulinum toxin injection

“…Repeated facial muscle contraction with the expression of smiling and squinting, especially of the orbicularis oculi muscle, leads to the formation of crow's feet, which are classified as dynamic wrinkles. Botulinum neurotoxin has been injected into the orbital part of the orbicularis oculi muscle using multipoint, intradermal, and intramuscular injection methods 1–3 …”

“…Multipoint or multilevel injection techniques can be used to achieve a full zone of treatment, along with different injection methods according to the position of the eyebrows. [1][2][3] Although extensive injection guidelines on BoNT treatment have been reported, most treatments are administered by blind injection. [1][2][3] Furthermore, few studies have investigated the dynamic analyses of the formation of crow's feet, including detailed anatomical investigation of the orbital portion of the orbicularis oculi muscle via ultrasonography, to date.…”

“…(A and B, ultrasound images taken while the face was relaxed and when crow's feet formed, respectively) An illustration showing the injeciton points for crow's feet using the two-line injection technique (LC, lateral canthus; yellow circle, conventional injection into the dermis; red circle, additional inejction into the muscle) Repeated facial muscle contraction with the expression of smiling and squinting, especially of the orbicularis oculi muscle, leads to the formation of crow's feet, which are classified as dynamic wrinkles. Botulinum neurotoxin has been injected into the orbital part of the orbicularis oculi muscle using multipoint, intradermal, and intramuscular injection methods [1][2][3].…”

“…The establishment of various injection guidelines has resulted in intramuscular injection no longer being the only injection method for botulinum neurotoxin administration. The level of injection determines the potency of botulinum neurotoxin into the muscle; intramuscular injection has a strong effect, whereas intradermal injection has a soft effect 2,15. Consequently, we administered the injection intradermally into the relatively thin orbicularis oculi muscle portion (0.7 mm) with a relatively thinner subcutaneous layer (2.0 mm) that was not easy to target at the points 1.5 cm lateral to the lateral canthus under ultrasonographic guidance.…”