Technique

The most important message concerning the technique of injection into the cheek lines is that the muscular excursion should not be impaired. The muscular contraction should be slightly reduced so that superficial skin wrinkling is softened.

Usually there is no need for any use of topical anesthetics, because the injection on the cheek is not painful. After cleansing, the patient is examined in static and dynamic positions. As the quantity of lines may vary from patient to patient, the marking should also vary from a single row with two injection sites to two rows with four injection sites (Figs. 5.74 and 5.75).

The dynamic analysis should guide the positioning of the injection sites. The first and (if needed) the second row should be on the area with the highest concentration of dynamic lines. Usually the dynamic lines start from 1 to 2 cm from the oral commissure.

Fig. 5.72. a Male patient with thick and oily skin which produces coarse wrinkling. b Nice reduction of cheek wrinkling during animation after treatment with BNT-A
Fig. 5.73a,b. Patient with hyperkinetic cheek lines before and after treatment with BNT-A. Note that skin wrinkling, and muscle excursion strength was reduced. This may be considered a complex case, and a review of the section on asymmetries (Sect. 6.1) is advisable

To proceed with the marking, an imaginary line from the oral commissure to the pre-auric-ular area at the tragal level should be used as a guideline. The first row should be from 1 to 2 cm away from the oral commissure, and two injection sites marked 0.5 cm above and 0.5 cm below the imaginary line. If needed, a second row should be from 1 to 2 cm away from the first row, and two other points marked exactly as on the first row (Fig. 5.76a,b).

After the marking is finished, the needle should be inserted parallel about 2-3 mm into the skin at dermal or sub-dermal level. Deeper injections may result in muscular excursion impairment (Fig. 5.77a,b). A low volume and low dose of BNT-A is also important to avoid diffusion down into the deeper muscle fibers. Initially, 1-3 U Botox or 3-9 U Dysport in total should be injected into each cheek side. If needed, a second treatment after 7-15 days may increase the dose. Of utmost importance is that a papule should be seen at the needle tip to guarantee that the injection is intradermal or maximum sub-dermal. (see Section 6.3. microinjections)

Treatment of cheek lines • One single row to up to two rows of two injection points per side

Fig. 5.75. For stronger muscles, oily and thick skin, or for multiple cheek lines, the two-row technique should be used

Fig. 5.74. Minimal injection sites for intradermal treatment of mild cheek lines. Note that these injections should not reach the muscle layers. The blocking should be targeted at the subdermal muscular fibers that produce skin wrinkling

Fig. 5.75. For stronger muscles, oily and thick skin, or for multiple cheek lines, the two-row technique should be used

Fig. 5.74. Minimal injection sites for intradermal treatment of mild cheek lines. Note that these injections should not reach the muscle layers. The blocking should be targeted at the subdermal muscular fibers that produce skin wrinkling

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