All you need to know about how Botox Cosmetic works.

Wondering how Botox works? There are a lot of myths and misconceptions surrounding the safety and effectiveness of Botox, so let’s set the record straight. Ready to get started?

Etiology of the aging face

The aging face has common changes that it experience as the patient matures. From the 30s to 50s, bone and collagen are lost and fat is typically redistributed to other areas. These changes results in different contours, proportion, and symmetry when compared to younger facial structure.

As the face matures, men and women will experience thinner and drier skin, a reduction in collagen, and less elasticity.

Collagen loss is a major change in the aging process. The middle layer of the skin become thinner because collagen does not regenerate at the same rate. Loss of collagen manifests in diminished elasticity and moisture.

As a patient become more mature, fat redistributes and accumulates in different areas of the face. For example, fat in the forehead and cheeks will typically be redistributed around the mouth and the jaw line. In addition, fat may clump and appear as pads.

There is a significant loss of facial bone with age. Aging of the craniofacial skeleton may be due to changes in the relative dynamics of bone expansion and bone resorption. Without the structural support of bone, there are noticeable changes in the other layers of overlying soft tissue and skin.

Rule of thirds
The rule of thirds is a method of analyzing a patient’s facial structure to determine what changes have occurred over time and also which treatments are best for the target area.

Upper Third
This area experiences noticeable wrinkle creases. Dynamic wrinkles (e.g. frowning) become more prominent due to loss of collagen and elasticity.

Middle Third
This area of the face will see a change in fat and bone structure. The fat in the cheek area will migrate lower causing creased nasolabial folds and lowered cheek positioning.

Lower Third
The lower third of the face will see a combination fat loss and wrinkles. Wrinkles may form around the line. Fat loss and diminished elasticity will cause loss of volume in the lips and more prominent marionette lines.

Rules of Symmetry

The objective of neuromodulators and dermal filler treatments is to make the patient’s current facial structure more symmetrical. Every patient has different bone, fat, and collagen distributions and a different optimal symmetrical profile.

When patients are young (20 – 30), they possess, relative to their facial structure, higher cheekbones, fuller lips, and fuller cheeks as well. As the patient matures, changes to the symmetry start taking place. For example, cheeks may experience a loss of fat which causes them to “sag.” Lips may become less filled as well.

Considering these points, the objective of the aesthetic health professional is not to create features that were not there but feature that were once present when the patient was younger. For example, introducing hyaluronic acid filler to cheeks where fat was lost.

Many health professionals will visually superimpose a triangle marker during the consultation to help patients visualize the goal of the treatment. Below you will find a few examples of a typically visualization.

Patients within the age range of 20s – 30s will have certain markers in their facial structure that align with the superimposed triangle that is demonstrated above. The chin is more sharp, the cheek area is fuller and higher.

When a patient’s profile align with these markers, the amount of medication and filler used will be minimal.
Patient’s within the age range of 40s and above will have certain markers in their facial structure that align with the superimposed triangle that is demonstrated above.

As the patient matures the fullness and tissue in the cheeks become redistributed to a lower position. This causes the chin and the cheeks to appear “sagging.” The goal of the aesthetic health professional, in this case, is to move the cheek to a higher position, matching the position that it once was when the patient was younger.

How does Botox work?

The main objective of a neuromodulator medication like Botox Cosmetic or Dysport is to causes paralysis and/or diminish muscle movement. Through this action, the tissue will be relaxed and the lines that are formed are eliminated or softened.

Muscle movement is caused because of the nerves that are triggered at the neuromuscular junction (NMJ). The trigger in this instance is a chemical substance called acetylcholine which is a protein based chin that works as a neurotransmitter.

When a medication like Botox and Dysport are introduced to the NMJ via an injection, it blocks this chemical communication, which ultimately prevents the muscle from contracting.

Indications for Botox and Dysport

  • Upper third of the face (frontalis, corrugulator supercilii and procerus, orbicularis oculi muscle).

  • Middle third of the face (levator labii superioris alaequenasi, nasalis)

  • After facial cosmetic surgery

  • Abnormal muscle hypertrophy

  • In combination with other cosmetic procedures

  • Facial nerve disorders

  • Parotid gland fistula

  • Headaches

  • Temporomandibular joint dysfunction

  • Hyperhidrosis

  • Upper eyelid asymmetry

Which muscles are typically treated with Botox?

Muscles of the forehead
The forehead is very simple in terms of number of muscles. It only has one muscle which is called the frontalis. Although it is just one muscle, it can behave as two. For example, when a patient raises one eyebrow only, then the muscle is behaving like if it was two muscles.

The frontalis is located beneath the skin of our forehead and stretches from temple to temple. At the hairline, the frontalis muscle shades off into an aponeurosis with the thick fascia of the vertex of the skull. Even though the frontalis is a single muscle, it still works on conjunction with other facial muscles. Glabella frown lines

Muscles of the eye
Two muscles are located underneath the eyebrows and above the eyes. These muscles are responsible for a patient’s habitual facial expressions. The muscles located in this area are the orbicularis, the levator palpebrae, and the corrugator supercilii.

The orbicularis starts from the nose and wraps over the orb of the eye, which forms the eyelid. This muscle is a sphincter as it contracts to completely close the eye. When the entire muscle is activated (for example, when you tightly close the eye), the skin of the forehead, temple, and cheek is pulled together.

This causes folds to be visible. As we get older, because of loss of collagen and elasticity, the folds start to become creased and create what is known as crow’s feet.

Muscles of the nasal region
The muscle that is located in this region is known as the procerus which draws up the nose and down the central brow area. The procerus makes transverse squinting, which cause wrinkles across the nose, possible.

Muscles of the mouth: Above the mouth

  • Quadratus labii superioris

  • Levator labii superioris

  • Levator anguli oris

  • Zygomaticus

The muscle located in this areas is called the quadratus labii superioris. It is a broad muscle that extends from the side of the nose and the upper lip to the zygomatic bone, or cheek bone This muscle acts to elevate the upper lip and at the same time pushes them slightly forward.

Some parts of these muscle help form what is known as the marionette lines. These lines extend from the corner of the mouth down to the jaw which gives the patient lines making the look like a puppet.

The movement of the levator labii superioris and levator anguli oris is to raise the angle of the mouth. This assist in forming the nasolabial ridge. As a patient becomes older, the ridge becomes deeper and more pronounced.

Muscles of the mouth: Below the mouth

  • Levator labii inferioris

  • Depressor anguli oris

  • Depressor labii inferioris

The levator labii inferioris acts to raise the lower lip. The depressor anguli oris and the depressor labii inferioris are responsible for the movement of the lower jaw and lower lip.

Muscles of the mouth: Around the mouth

  • Orbicularis oris mentalis

  • Quadratus labii inferioris

  • Risorius

  • Buccinator

The orbicularis circles the mouth and although it may act like a sphincter, it can be much more. The most common action that this muscle is to close the muscles. This muscle can also close the lips and make them protrude.

For example, sucking on a straw. The quadratus labii inferioris draws the lip down and slightly to the side. The risorius is responsible for retracting the angle of the mouth downward.

This expression is commonly seen as a grinning one. The buccinator is responsible for the movement and position that is created when we whistle.

Botox treatment dosing

The following guideline is the typically dosing that is used to treatment certain muscles. Readers must be aware that this is not a diagnose and that patient results may be different.

Forehead and horizontal forehead lines

  • Muscle treated: Frontalis (lifts eyebrows)

  • Number of units: 30 – 60

  • Anatomic landmarks and danger zones: Inject in a gridlike pattern approximately 2 cm above the brow line.

Glabellar complex, vertical glabellar lines, transverse glabellar lines

  • Muscle treated: Corrugator supercilii, procedures, orbicularis, oculi, depressor supercilii (brow depressors)

  • Number of units: 20 – 40

  • Anatomic landmarks and danger zones: Inject in a V shaped pattern. Avoid injection below 0.5 cm of the medial edge of the eyebrows

Bunny lines (side of the nose)

  • Nasalis (transverse portion)

  • Number of units: 2.5 per side

  • Anatomic landmarks and danger zones: Treat only the transverse portion of the nasalis muscle.

Crow’s feet

  • Muscle treated: Orbicularis oculi (brow depressor, cheek elevator)

  • Number of units: 5-15 per side

  • Anatomic landmarks and danger zones: Stay 1 fingerbreadth lateral to the lateral orbital rim and three to four injections in a fan shaped pattern.

Upper third of nasolabial lines

  • Muscle treated: Levator labii superioris

  • Number of units: 2-5 per side

  • Anatomic landmarks and danger zones: Confine the injection to the region between the nasolabial fold and the nasal ala.

Upper lips

  • Muscle treated: Orbicularis oris

  • Number of units: 3-10 units

  • Anatomic landmarks and danger zones: Inject small aliquots in the lower third for lower lip and upper third for upper lip of the orbicularis oris muscle.

Marionette groove

  • Muscle treated: Depressor anguli oris

  • Number of units: 2-5 per side

  • Anatomical landmarks and danger zones: Identify the muscle with the patient actively pursing the lips, then inject 1 cm lateral and 1 cm inferior to the angle of the mouth


  • Muscle treated: chin

  • Number of units: 5-10 units

  • Anatomical landmarks and danger zones: Have the patient project the lower lip and chin upward. Inject at three to give sites intramuscularly into the cobblestoned shin, just inferior to the mental sulcus.

Botox and Dysport treatment techniques The following guideline for the typically techniques that are used to in Botox and Dysport treatments.

Glabella lines
One of the most common areas treated in the USA. The glabella is the area between the eyes. When the area is pulled together, it creates a frown expressions. The lines or lines that are created during the expression are known as number eleven lines. Muscle treated: Frontalis (lifts eyebrows). The main muscles that are targeted for this treatment are the corrugator, the procerus, and the frontalis, and possibly the nasalis.Sex is a variable that is considered in the dosing and the technique. Male patients will need more medication in order to achieve the same results when compared to female patients.Some health professionals use an electromyogram machine to locate the muscle before injecting. However, it is highly recommended to have an understanding of the muscle anatomy and movement for a more flexible and expert approach.During the treatment, the health professional should ask the patient to create a frowning expression in order to understand their muscle movement and where the belly of the muscles are located. The recommended method is to insert the needle into the muscle belly until a pop is heard.The needle should be inserted perpendicular into the belly and the muscle and have the dosing be injected.The most common complication in this area is eyelid ptosis. This happens when the treatment is too low over the brow arch.

Forehead Lines
When a patient lifts their eyebrows towards their hairline, forehead wrinkles will form. Some patient have a lot of wrinkles and others may have very little. These specific wrinkles are performed by the frontalis muscle.Although this treatment, at first glance, looks simple, there exists a lot of variability. This is the reason why thorough consultation is required and highly recommended. Many patients do not fully appreciate how much they use their forehead until they are unable to use it.This treatment will also affect the position of the eyebrow. The eyebrows, after the results, may become more flat or arched.Before beginning treatment, it is important to remember that being conservative with the frontalis is better than aggressive. Since the muscle is susceptible to dosing, overdoing it can cause results that the patient does not want.The treatment will typically require 20 to 30 units and about 50 units for male patients. The first step to have the patient lift their brow and evaluate where the pulls are. Health professionals should be sure that the needle is inserted just below the wrinkle. The next step is to repeat the process but work laterally.Health professionals should not inject close to the eyebrow arch because this may cause ptosis. Massaging the area immediately after may be done. However, the massaging direction is towards the hairline.

Crow’s feet
The muscle that creates the crow’s feet to be formed is called the orbicularis oculi. When treating this muscle it is important that diffusion rate remain minimal since this muscle is small.A high concentration and low volume dilution rate is optimal. There are two routes that injectors may take when treating this area. They are intramuscular and subcutaneous. The intramuscular is the recommended because it allows more consistent results.The subcutaneous method is typically used by beginning injectors as to avoid any bruising. Three to four injection sites are placed about a finger breath from the lateral canthus of the eye.Patients may be asked to wrinkle their eyes in order to observe the formed wrinkles more clearly. The injection sites must be chosen based on the greatest number of lines formed.

Perioral Lines
Perioral lines refers to lines and wrinkles around the mouth area. They are most commonly seen in the upper lips. Many patients know these lines as smoker lines. Botox Cosmetic is a welcome and fast solution to these smoker lines. Smoker lines that are dynamic will have good results with Botox.Smoker lines that are static will not see good result with Botox Cosmetic. If patients are looking to remove the static lines, then most health professionals will recommend a filler.In this specialized area, the Botox concentration should high and the volume should be low. Patients must be aware that treatment in this area may cause flaccidly, which may cause challenges in their daily activities. If too much muscle flaccidly occurs patient will not be able to purse their lips.

Platysmal Bands
This area of the human anatomy and the treatment of it with Botox is typically reserved for specialized health professionals with several years under their belt injecting. Treating platysmal bands can be challenging and must be taken in stages.As a patient ages, the neck can also show signs of the aging. Some of these may include excess skin and fat.In order to locate the platysmal bands, the patient will be asked to grind down on their teeth and at the same time project their jaw forward. The position will expose the bands clearly which will be the central and lateral bands. In order for this specific treatment to be effective, the bands my be tight and the clinician must be able to hold the bands between the clinician’s thumb and forefinger.Once the band is between the index finger and the thumb, the needle will actually be placed horizontally above the finger and the thumb. The muscle should not be penetrated completely.Each area of the platysmal band will receive 5 – 8 units. The total number of units of Botox will be 30 – 50 units. This area can also cause some challenges to the patient’s daily activities. Therefore, it is strongly recommended to treat the platysmal bands in stages. Neck Rings and the Decollete
The decollete area refers to the chest and the lines in the area that can appear due to aging. The lines can only be treated if they are superficial. Lines that are visible due to excessive skin will be see results with Botox Cosmetic or Dysport.

Seeing Great Results with Botox

Botox might seem complicated at first, but the truth is that responsible cosmetic professionals have performed hundreds, if not thousands of Botox treatments over the years.

If you have any questions, please contact us.