Consensus Statement on the Use of Botulinum Neurotoxin in the Middle East

Figures & data

Table 1 FDA-Approved Indications and Manufacturer-Recommended Dosages of Botulinum Neurotoxin Products^24–26

Non-Proprietary Name	FDA-Approved Indication	Dosage
AbobotulinumtoxinA	Glabellar lines	Total dose of 50 U divided among five sites (10 U each); retreatment no more frequently than every 12 weeks
OnabotulinumtoxinA	Glabellar lines	Total dose of 20 units divided among five injection sites (4 U each); repeat treatment every 12–16 weeks
	Lateral canthal lines	Total dose of 24 U divided among three injection sites on each side of face (4 U), six total injection points.
	Horizontal forehead lines	Total of 40 U divided among five forehead line sites (4 U each) and five glabellar line sites (4 U each).
IncobotulinumtoxinA	Glabellar lines	Total dose of 20 units divided among five sites; repeat no more frequently than every 12 weeks
	Lateral canthal lines	Total dose of 24 U divided among three injection sites on each side of face (4 U), six total injection points.
	Horizontal forehead lines	Total dose of 10–20 U divided among five horizontally aligned injection sites (2 U, 3 U, or 4 U, per injection point).

Table 2 Injection Techniques for On-Label Indications

Indication	Dose Range	Injection Plane	Technique
Medial glabellar complex	8–10 U 1U/side	Deep (corrugator supercilii and depressor supercilii). Superficial (corrugator tail)	Inject deep targeting both the corrugator supercilii and depressor supercilii muscles. Diffusion from these injection sites takes care of the procerus muscle. The latter is only injected when there is a deep horizontal line and heavy central bulging of procerus. In this case the procerus is injected with 4–8 U. The tails of the corrugators are also injected laterally, very superficial almost intradermally 1 U each side.
Frontalis	16–20 U (2–3 U per site)	Intramuscular	Tailor according to pattern of wrinkles and muscle strength. Avoid injecting lower half of frontalis, especially above the lateral third of brows. If necessary to inject, use 0.25 U or less.
Crow’s feet	12–14 U/side	Superficial	Mark the skin according to the movement pattern. Dose reflects strength of orbicularis oculi muscles: full fan pattern, upper fan pattern, lower fan pattern or single line radiating from the lateral canthus. Start by injecting upper fibers of orbicularis oculi, where medial two-thirds of the brow meets lateral one third and inject 2–3U. 3–4U is injected on the line joining lateral canthus with the orbital bone (injection point is 1 cm lateral to the bone). Upper fan needs 2–3U, lower fan pattern also needs 2–3U.

Table 3 Injection Techniques for Popular Off-Label Indications

Indication	Dose Range	Depth	Technique
Nasal rhytids (bunny lines)	3–4 U	Superficial	Inject high up on the nose, to the sides of the bridge of the nose and into the area of maximum wrinkling. Inject superficially into skin overlying nasalis muscle.
Cobblestone chin	3–4 U	Deep	Inject two points adjacent to midline close to origin of mentalis muscle.
Changing eye silhouette to almond shape	1 U	Superficial	Inject into the center of the lower lash-line into the pretarsal section of the orbicularis oculi muscle. This creates widening of the eye. As the muscle relaxes, the eye becomes more oval or almond shaped.
Changing brow shape	2–3 U per injection point	Superficial	Inject 3 points on the orbicularis oculi: (1) First injection site medial two thirds of brow meeting lateral third of brow (3 U); (2) second injection site 2–3 cm lateral and 1 cm inferior to first injection point, just under hairy part of eyebrow (2U); (3) third injection point on line joining lateral canthus with orbital bone, 1 cm lateral to the bone (3–4U). Also inject two to three points on uppermost fibers of the frontalis muscle close to the hairline (1U each injection site) to induce the compensation force of the lower lateral frontalis muscle fibers.
Raise corners of mouth	3–4 U/side	Muscular	Inject origin of depressor anguli oris muscle at the level of the mandible.
Platysmal bands	3–5 U per injection point	Deep	Inject 3–5 U into each injection site tracing the bands from mandible to the clavicle.
Improving skin quality	0.25 U or less per injection point	Intradermal	Hyperdilute by mixing 10 U neurotoxin with 1–2 mL normal saline or lidocaine. Inject intradermally avoiding areas of origin or insertion of muscles of facial movement.