What is botulinum toxin?
DISCLAIMER
Botulinum toxin is a neuromodulator that relaxes the muscles that, when contracted, form wrinkles on the face. This means that to remove a particular wrinkle, you need to inject botulinum toxin into the exact muscle that forms it.
For this reason, we strongly recommend that botulinum toxin injections be performed only by a qualified physician who is familiar with the anatomy of the facial muscles. The information in this article is not intended to be a direct guide and is not a substitute for consultation with a physician.
Table of Contents
Botox or botulinum toxin?
Botox™ is a registered trademark of Allergan, and botulinum toxin is the active ingredient in Botox™. The same botulinum toxin is the active ingredient in all other similar products such as Dysport, Xeomin or Nabota. However, Botox™ was the first drug based on botulinum toxin and, as a pioneer, gained the most popularity. As a result, its name has become a household word. Today, the word “botox” written with a lowercase letter and without the “™” symbol, is often used to refer to all products containing botulinum toxin.
How to store botox?
- As soon as you receive the product, you should put it in the refrigerator.
- Unopened vials of botox should be stored between 2° and 8°C (35.6°F - 46.4°F).
- The shelf life of an unopened bottle is 36 months.
- After diluting the powder with saline solution, manufacturers recommend using the resulting product within 24 hours. However, a number of studies have shown that reconstituted botulinum toxin is stable for up to 5 weeks when stored in a refrigerator at 2-8℃ (35.6°F - 46.4°F).
What is needed for botox injections?
The equipment required for botox injections is not complicated. In addition to the botulinum toxin itself, everything else you can buy in any pharmacy:
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Alcohol wipes
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Rubber surgical gloves
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A syringe with a 20-gauge needle for preparation
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Several 1 ml insulin syringes with 30-31 gauge needles for injections
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Needle disposal container
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Sterile physiological solution - 0.9% sodium chloride solution
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Cosmetic marker/pencil
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Ice packs
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Local anesthetic cream, spray, or gel (optional)
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Any botulinum toxin brand
How should I prepare for botox injections?
Avoid taking blood thinners for 3 days before and 3 days after the procedure. This will reduce the risk of bruising. These substances include, for example, ginkgo biloba products, vitamin E, garlic, alcohol, aspirin, non-steroidal anti-inflammatory drugs, some antidepressants, etc. Consult your physician regarding this matter.
How to properly prepare botox solution for injection?
The botulinum toxin in the vial is in powder form. Therefore, sometimes it may appear that the vial is empty, but it is not. Before use, the powder must be dissolved in saline solution.
The potency of botulinum toxin is measured in conventional units. The most common form in which manufacturers supply botox is in 100 units disposable vials. Vials of 50 units and 200 units are slightly less common.
The table below shows exactly how many units of botox will be in 0.1 ml of the injection solution when a given amount of saline solution is added to the vial (100 units).
The most convenient volume of saline solution in most cases is 2.5 mL. This results in 4 units of botox in 0.1 mL of solution for injection. This is the average dosage needed to inject into a single point.
If you have 200 units of botox in your vial, then the numbers in the right column of the table should be multiplied by 2, and if the vial contains 50 units of botox – divide by 2. That is, to get 4 units in 0.1 mL of solution for injection in a 200-unit vial, you should add 5 mL of saline solution, and in a 50-unit vial, you should add 1.25 mL of saline solution.
Diluting botox step by step:
1. Put on gloves.
2. Remove the protective cap from the top of the vial. You will see a rubber cap underneath.
3. Wipe the rubber cap with an alcohol wipe to ensure sterility.
4. Draw 2.5 mL of saline into a syringe with a 20-gauge needle.
5. Locate the small circle in the center of the vial’s rubber cap. Insert the needle through this circle into the vial.
6. The vacuum in the vial will begin to draw saline solution from the syringe. You can speed up the process by slowly releasing the saline along the inside wall of the vial.
7. Pick up the vial and gently swirl in a circular motion until the powder is completely dissolved. Do not shake the vial to avoid air bubble.
8. The solution should be clear with no visible particles.
9. Take a 1 mL insulin syringe, aspirate 1 mL of air into it and attach it to the needle in the vial cap.
10. Inject 1 mL of air into the vial, then draw 1 mL of the finished solution into the syringe. Injecting air into the vial will help equalize the pressure. It will be easier for you to draw the solution into the syringe.
* Many recommend using a 0.5 mL insulin syringe instead of a 1 mL syringe because after 5-6 standard injections of 0.1 mL (4 units), the needle may become blunt and need to be replaced. 
11. With the needle pointing upward, remove any air bubbles from the syringe by releasing a small amount of solution.
12. The syringe is now ready to inject botox.
How should I prepare my face for botulinum toxin injections?
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Remove makeup.
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Disinfect skin with alcohol wipes.
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Apply local anesthetic gel, cream, or spray.
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Mark the injection sites with a cosmetic marker or pencil. However, botox should not be injected into these marks, but close to them to prevent the dye from getting under the skin along with the needle.
Where to inject botox?
The picture shows the wrinkles that are most often smoothed with botulinum toxin:
Horizontal forehead lines
Frown lines (glabellar complex)
Crow’s feet
Bunny lines
Nasolabial folds
Radial lip lines
Marionette lines
Chin lines
Botox can also be used to soften the contour of the jaw or to correct a gummy smile.
To get great results from botox injections, you need to understand the location and function of each facial muscle. For this reason, botulinum toxins should only be used by physicians who are familiar with facial anatomy. In addition, large muscles such as the glabellar complex can be visually identified by asking the patient to frown hard.
How deeply should botox be injected?
The main task is to get into the muscle tissue that lies under the skin and fat layer. However, different areas of the face require different depths of injection. For example, around the eyes, the skin and fat layer is very thin, so the muscles are much closer to the surface than on the forehead. In general, however, it is not recommended to inject more than 4-5 mm deep.
It takes experience to determine the correct depth of injection. The more botox injections a doctor performs, the better he or she understands the mechanics of the process. A good way to determine if the needle has reached the muscle is to feel it advance. The connective tissue of the epidermis and dermis is quite tough and resists needle movement well. But when the needle enters the fat layer, this resistance disappears. Then comes the target muscle layer – when you enter it, you feel elastic resistance. If you go through the muscle, the needle will hit hard bone and will not penetrate any further.
How much botox should be injected to get the best results?
The volume of injections is chosen by the physician based on the individual characteristics of the patient and the area to be injected. On average, there are 3-5 units of botox per injection. Therefore, 4 ml of saline solution per bottle of 100 units of botox is the optimal dilution. This gives us 4 units of botulinum toxin in 0.1 ml of ready-to-use solution – just enough for one injection, which is very convenient for dosing.
These issues are discussed in more detail in our separate article “Where and how much botox to inject for optimal results“. It explains how to calculate the dosage of botulinum toxin and inject it with great accuracy, without affecting neighboring muscles and minimizing the risk of side effects.
What happens after the botox injections?
When will I see results?
The first results will be noticeable 2-3 days after the botox injection. However, the wrinkles will be maximally smoothed after 10-14 days.
How long does the effect last?
Our body processes botulinum toxin gradually. Therefore, the achieved results are maintained for 3-4 months, maximum six months. After that, botox injections can be repeated.
Tips and Tricks
- Make sure that it is the muscle contractions that are causing the wrinkles. If the wrinkles are caused by age-related sagging of the skin or loss of volume, botox will be useless, but dermal filler injections will work well.
- Check the correct dilution of the powder with saline solution. Too few units of botox will not produce results, and too many units will increase the risk of a stiff face or, for example, drooping eyebrows (ptosis).
- Take a picture of your face before the botulinum toxin injection. This will help you visualize the result.
- Use only sterile medical equipment for injections.
- After the botox injection, follow the doctor’s recommendations. This will help you maintain the results longer.
Please remember that botulinum toxin products are for professional use only. They should only be administered by certified specialists, and unprofessional use by yourself can be harmful to your health.
List of scientific sources used:
- Brennan R, Wells JSG, Van Hout M. "Saving Face": An Online Study of the Injecting Use of DIY Botox and Dermal Filler Kits. Plast Surg (Oakv). 2018;26(3):154-159. doi:10.1177/2292550318767432
- Biello A, Oney R, Zhu B. Botulinum Toxin Treatment of the Upper Face. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
- Padda IS, Tadi P. Botulinum Toxin. In: StatPearls. Treasure Island (FL): StatPearls Publishing; November 6, 2023.
- Kaplan JB. Consideration of Muscle Depth for Botulinum Toxin Injections: A Three-Dimensional Approach. Plast Surg Nurs. 2019;39(2):52-58. doi:10.1097/PSN.0000000000000265
- Swift A, Green JB, Hernandez CA, et al. Tips and Tricks for Facial Toxin Injections with Illustrated Anatomy. Plast Reconstr Surg. 2022;149(2):303e-312e. doi:10.1097/PRS.0000000000008708
- Small R. Botulinum toxin injection for facial wrinkles. Am Fam Physician. 2014;90(3):168-175.
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