Botox Injection Technique
A half-inch 32-gauge needle (Air-Tite Products) minimizes injection discomfort. In the periorbital areas we inject in an oblique manner to the skin to lessen the chance of deep injections or even injury should a patient suddenly move. Pinching upward or gently rubbing the adjacent skin during injection minimizes patient discomfort by distracting the patient during the injection and “confusing” the sensory sensation of the injection (Figure 95.1). We recommend premarking the areas to be injected, and utilizing bright lighting and wearing magnification to avoid injury to eyelid vessels. We seldom use topical anesthetics, and some suggest a reduced duration of effect in patients treated with topical anesthetic prior to injection.1 We inject into the subcutaneous tissue planes to avoid the underlying muscle and neurovascular structures. This reduces patient discomfort and lessens the risks of bruising and deep dissemination. In general the injections can be given obliquely or perpendicular to the skin, but in the orbicularis areas it is critical to inject at as flat an angle as possible because of the thinness of the eyelid skin and to point away from the eye. It is also helpful when injecting the lower orbicularis areas to put the skin on stretch, which helps with placing the Botox in the subcutaneous plane. Botox must be avoided in the central upper eyelid to prevent ptosis and over the inferior oblique in the lower eyelid to avoid diplopia.
KeywordsTopical Anesthetic Bright Lighting Lower Eyelid Neurovascular Structure Underlying Muscle
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