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Botulinum neurotoxin is produced by the gram-negative anaerobic bacterium Clostridium botulinum. Eight serologically distinct botulinum neurotoxins exist, designated as A, B, C1, C2, D, E, F, and G. Seven are associated with paralysis. Types A, B, E and, rarely, F and G are associated with human botulism. Botulism is a bilaterally symmetric descending neuroparalytic illness caused by botulinum neurotoxin. forehead are oriented horizontally. The frontalis muscle originates on the galea aponeurotica near the coronal suture and inserts on the superciliary ridge of the frontal bone and skin of the brow, interdigitating with fibers of the brow depressors (ie, procerus, corrugator supercilii, orbicularis oculi muscle; see Image 5). The medial fibers usually are more fibrous than the lateral fibers, thus requiring less toxin for paralysis. Avoid total paralysis of the frontalis, since this is likely to cause brow ptosis and loss of expression. Injection too close to the lateral eyebrow can cause lateral eyebrow ptosis. Technique Multiple injections of small amounts of toxin create weakness without total paralysis. Inject 3-5 sites on each side of the mid line, usually using 2 units (1-3 U) per site. Separate sites by 1-2 cm. Choose an initial injection site approximately 1 cm above the eyebrow vertical to the medial canthus. Additional sites diverge laterally and upward to the hairline in a "V" configuration, often for a total of 3 sites. Additional sites (1-3) can be added in the mid line or more laterally (1-2) depending on individual and clinical response. If wrinkles extend to the temporal region, lateral injections can be performed. Use caution to prevent injecting lateral to the lateral canthus to avoid inhibiting temporalis function. Use caution when injecting patients in whom the hyperfunctional frontal lines support a ptotic upper eyelid. Injections of the upper face and periocular region usually are performed with the patient seated, and the patient is asked to remain upright for 2-3 hours to prevent spread of toxin through the orbital septum. Some practitioners use EMG guidance, although this usually is not necessary. One technique involves injecting each band at 1.0- to 1.5-cm intervals from the jawline to the lower neck. Approximately 3-10 units may be injected, depending on the thickness of the platysmal band. Another technique involves injecting the bands at the following 3 sites: the curve between the horizontal submental surface and the vertical anterior surface, at points midway between this point and the anterior extent of the band on the submental surface, and the inferior extent of the band on the anterior neck. The 2 large bands can be injected with 20 units each and smaller bands with 5 units each. Most patients require a total of 50-100 units, and some require as many as 200 units. Use caution to inject the platysma muscles and not the muscles beneath them, since this is more likely to cause swallowing weakness. Complications are minimal and may include transient edema and ecchymoses, hematoma formation, muscle soreness, and mild neck weakness.

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