Keywords

Review with the patient the exact aesthetic goals and whether the patient is abstinent from all blood thinners for a week. The physician wipes all makeup off the patient with a makeup removal pad followed by chlorhexidine solution to minimize methicillin-resistant Staphylococcus aureus (MRSA) before botulinum toxin (BTX) injection. With the makeup removed and the skin cleaned, the physician should carefully study the patient’s anatomy in repose and in animation. Proper illumination is used to determine the presence of major vessels around the eyes that could be punctured, which can lead to massive and sustained ecchymosis. Preoperative asymmetry and wrinkle distribution are determined. An eyebrow crayon can be used to mark out the injection sites since it can be easily removed without need for an alcohol prep pad or other solution. Gentian violet should never be used due to its persistence.

At the end of the session, the patient is reminded not to disturb the treated area for a minimum of 3–4 h. It is not necessary to actively contract the muscles, but there is no harm in doing so. Evidence that supports the claim that the muscle needs to be moved repetitively immediately following an injection to improve the results has not been well established and only further encourages unnecessary habitual movements that worsen wrinkles in the first place. The patient should not lie down for the prescribed 3–4 h for fear that pressure applied to the treated areas might cause unwanted migration of the toxin.

Meticulously record all patient concerns, anatomy, and injection points on a treatment record. Document that the patient had all questions answered and give written instructions. The lot number and expiration on the BTX bottle may be recorded.

There are two principal methods to charge for BTX: per treatment area or per unit. I prefer the former method for two reasons. First, I charge slightly more for the first treatment area and less for subsequent areas if performed the same day so as to encourage more complete treatment. I also like to give touch-up treatments without a charge to promote good will and patient rapport. The reader is encouraged to follow the standards of one’s community when deciding on pricing preferences.

I recommend every patient to schedule their next treatment session because if not, they can easily forget, and the 3-month window slips quickly to 9–12 months. Scheduling patients for the next session also helps a busy practitioner avoid a phone call to establish a last-minute treatment when the practitioner may not be able to accommodate the request. I always say that I would rather cancel an appointment than for someone to forget and not show up on a well-timed interval. Thus, the patient would not receive the benefits of consistent usage that would include long-term wrinkle reduction and skin healing.

BTX therapy has become a valuable and effective method of periocular rejuvenation and a mainstay of a youthful maintenance regimen. Often, patients who are the best candidates think they do not need it because they are too young. Dissemination of knowledge that BTX is intended to prevent or minimize the onset of static wrinkles will help in achieving increased patient satisfaction.